Peri- operative care Flashcards
1
Q
How long should a pt not eat or drink dairy products for before surgery?
A
6hrs
2
Q
How long before surgery should a pt stop drinking clear fluids?
A
2hrs
3
Q
Why should a pt go into surgery with an empty stomach?
A
to reduce risk of aspiration when they put the pt under general anaesthetic and try to intubate
4
Q
What causes the pt to reflux gastric contents when under general anaesthetic?
A
Many of the medications (propofol, sevoflurane, opioids) decrease lower oesophageal sphincter tone and the cough reflex is inhibited
5
Q
In emergencies, how is risk of gastric reflex reduced?
A
NG tube and stomach drainage + rapid sequence induction (press on coracoid, minimal ventilation time)
6
Q
What drugs need to be stopped prior to surgery? (4)
A
CHOWD Clopidogrel Hypoglycaemics Oral contraceptives Warfarin DOACs
7
Q
How long before surgery does clopidogrel need to be stopped?
A
7 days before, cover with aspirin if minimal bleeding risk
8
Q
Describe the management of a pts warfarin as they prepare for surgery (how long before should you stop it, what is INR needed, how do you restart)
A
- stop it 5 days before
- make sure INR <1.5 before op
- if INR now low enough night before, give PO Vit K
- restart at normal dose the evening/ day after surgery and continue with LMWH until INR in range as warfarin prothombotic initially
9
Q
What should be given to a pt on warfarin who needs emergency surgery?
A
- check INR
- give Vit K and FFP as needed
10
Q
How should DOACS be managed pre op? (for high/ low risk sugery and for good and bad renal function)
A
- If normal renal function and low risk procedure stop them 24 hrs before and restart 6-12 hrs after
- if higher risk, stop 48her before and start 48 hrs later
- check factor Xa levels if eGFR <50, for dabigatran check PT and APTT
- if abnormal renal function, seek guidance
- Give LMWH for VTE prophlaxis as normal
11
Q
Should aspirin be stopped prior to surgery?
A
Not unless the surgical bleeding risk is very high, in which case stop 3 days before and start 7 days after. Give tranaxaemic acid in emergencies.
12
Q
How should pts on dural antiplatelet therapy be managed pre op?
A
- if low bleeding risk surgery= continue both
- if high risk= defer surgery or continue with aspirin only
13
Q
Why are oral contraceptives stopped pre op and how long before surgery should they be stopped?
A
As they increase VTE risk
Stop 4 weeks before
14
Q
What prescriptions are need before most operations? (3)
A
- LMWH
- anti emolic stockings
- antibiotic prophylaxis
15
Q
Give 3 contra indications of LMWH and for what surgeries may they not be given?
A
Acute bacterial endocarditis, major trauma, epidural anaesthesia, haemophilia, peptic ulcer (not absolute), recent cerebral haemorrhage
Dont give for most neck or endocrine surgery
16
Q
What dose of dalteparin is given for medium risk surgeries?
A
2500 units, 6pm night before surgery and then every evening theyre in hospital for
17
Q
What dose of dalteparin is given for higher risk surgery? (eg general, vascular or oethopaedic surgery)
A
- 5000 units if renal function is good
- on night before surgery and then thereafter
18
Q
How long should LMWH be continued for, for hip and knee replacements?
A
hip= 28 days knee= 14 days
19
Q
Why do you not give dalteparin before and until at least 4 hrs after a spinal epidural?
A
risk of spinal epidural haemoatoma which can cause cord compression, ischaemia and infarction
20
Q
Which surgeries require a phosphate enema on the morning of surgery? (4)
A
- left hemicolectomy
- anterior resection
- sigmoid colectomy
- abdo peroneal resection
21
Q
What bloods need to be done pre op?
A
- FBC (make sure not anaemic or infection)
- U&E (check renal function for clearance of anaesthetics and other drugs)
- INR (if on warfarin)
- Group and save (X match if hgiher risk surgery)
- LFTs (for metabolism of some drugs)
- clotting screen (pick up any clotting disorders)
22
Q
What important anaesthetic complication should you ask the pt if they have a FHx or PMH of pre op?
A
malignant hyperthermia
23
Q
What imaging may be requested pre op? (2)
A
- ECG (everyone- for baseline incase of post op ischaemia and to check for arrhythmias which may complicate anaesthetic)
- CXR (if resp illness, any cardio resp symptoms, smoking history or from TB endemic areas)
- any diagnostic/ or assessment images such as CT or MRI
24
Q
Other than bloods and imaging, what other investigations may be requested pre op? (4)
A
- pregnancy test
- sickle cell test (if hx, fhx or afrocarribbean descent)
- MRSA swab nostils +/- perineum
- urinalysis (not routine)
25
What may increase insensible losses (water losses through sweating, respiration, faeces- normally accounts for 1L per day)
- febrile
- tachypnoeic
- diarrhoea
- sepsis
26
Why are pts with bowel obstruction very fluid deplete? What blood results will indicate dehydration in this context?
- 3rd space losses (increase osmitc gradient causes litres to be lost into peritoneum and bowel)
- vomiting
- will cause raised haematocrit and urea
27
what electrolyte changes does vomiting cause?
- Loss of H+ and Cl- from stomach
- causes metabolic alkalosis
- also hypokalaemia as kidneys excrete K+ and cells take up K+ to preserve intravascular H+
28
What is the daily requirement for water?
25ml/kg/day - 1.75 L in 70kg person
29
What are daily requirements for Na, K and glucose?
Na and K= 1mmol/kg/day (70mml in 70kg person)
| Glucose= 50g/ day
30
What is the difference between hartmans and normal saline?
Hartmans has slightly less Na and Cl- and so has a slighly lower osmotic pressure
Hartmans has 5mmol/L K+
31
Outline a fluid maintenance regime for the 70kg pt with no significant comorbities?
- 500ml NS with 20mmol K+ over 8 hrs
- 1L 5% dextrose with 20mmol/l K+ over the next 8hrs
- 500ml 5% dextrose with 20mmol K+ over 8 hrs
32
What pt factors may mean you need to design a bespoke fluid regime?
- renal pts
- pts with cardiac impairment
- elderly, frail cachectic pts
33
What is the definition of a reduced urine output?
urine output <0.5ml/kg/hr
34
How should a reduced fluid output be managed?
- check the catheter is working properly// chart is filled in correctly
- A-E assessment
- give fluid challenge of 250 or 500ml over 15-30 mins and see how they respond
- give repeated challenges up to 2L or until BP/ output is restored
- If 2L given, seek expert help
35
What may cause a fluid deficit// reduced fluid output?
- third space losses (usualy bowel obstruction or pancreatitis)
- diuresis
- tachypnoeic
- febrile
- diarhhoea
- vomiting
36
What biochemical disturbance does diarrhoea cause? (3)
- loss of HCO3-, K+ and Na+ in stool
| - leads to hyponaturaemia, hypokalaemia and acidosis
37
Why do you often get decreased urine output and sodium retention post op?
- sympathetic activation-> cortisol release -> raas activation -> retain Na+
- also retain K+ so DONT give K+ in 1st bag post op
38
When may an NG tube be used to feed?
- unable to take sufficient calories orally despite lots of encourangement
- dysfunction swallow
39
When may a pt be PEG fed (into stomach)
- oesophagus blocked or dysfunction
40
When is jejunal feeding (jejunostomy) used?
- stomach inaccessible, dysfunctional or outflow obstruction
41
When may parenteral nutrition be used?
jejunum inaccessible or intestinal failure
42
what screening tool is used to asses malnutrition?
- MUST tool
43
What can cause low albumin?
- chronic inflammation
- protein losing enteropathy
- proteinurea
- hepatic dysfunction
- NOT MALNOURISHMENT (very very rarely)
44
When can general and non general surgery start tolerating enteral feeding?
- non GI surgery= almost immediatly
| - GI- within 24hrs
45
How can enterocutaneous. high fistula (jejunal) and lower fistula be managed?
- enterocutaneous (most heal spontaneously, some need surgery)
- high fistula (jejunal)- needs enteral or parenteral support
- lower fistula can be treated with low fibre diet
46
How are high output stomas managed?
- if long distance between the DJ flexure and the colostomy/ jejunostomy then then get parenteral feeding + supportive
- if not supportive only, reduce oral hypotonic fluid intake to 500ml/day, give loperamide and codeine, PPIs and low fibre diet (constipate them basically)
47
What may cause a high output stoma?
- gastric acid hyper secretion
- infection (pre stomal ileitis)
- bacterial overgrowth
48
How can pain be assesed?
- subjective: pain scale (mild, mod, severe)
| - objective: tachycardia, tachypnoea, hypertension, sweating, flushing, unwilling to mobilise, agitation
49
Describe the WHO pain ladder
1: non opioid (parcetamol) + adjunct (ibuprofen)
2: weak opioid (codeine-> tramadol) + non opioid adjunct (naproxen, diclofenac)
3: stong opioid (oral morphine-oxycodone, IV morphine- methadone- diamorphine-> fentanyl) + non opioid
4: nerve blocks, epidurals
- Neuropathic pain better managed with amitryptyline or gabapentin/ pregablin
50
What are the cautions/ side effects of using NSAIDS? (5)
I GRAB
- Interactions (warfain)
- Gastric ulceration (add PPI if long term)
- Renal impairment
- Asthma (triggers 10% asthma pts)
- Bleeding risk (due to effect on platelet function)
51
give 4 side effects of opioids
- constipation (give laxative- lactulose)
- nausea (antiemetic- cyclizine)
- sedation
- confusion
- resp depression
- pruritis
- tolerance and dependence (rare)
52
What should you use instead of morphine in renal impairment?
Oxycodone or fentanyl
53
How long dose IV, oral and IM morphine take to work?
```
IV= 2-3 mins
IM= 15 mins
Oral= 20mins
```
54
How should t1 diabetics insulin be managed pre, intra and post op?
- on night before reduce SC inslulin by 1/3
- omit morning insulin and start IV variable rate insulin of 50mls NS and 50 units actrapid
- while nil by mouth (and intra op) give 5% dextrose at 125ml/hr and check BMS every 2 hrs
- continue until can eat and drink, give SC insulin 20 mins before meal and then stop IV infusion 30-60 mins after
55
How should a t2 diabetic on oral hypoglycaemics be managed perioperatively?
- stop metformin on morning of surgery and other hypoglycaemics 24 hrs before
- put on variable rate insulin and 125ml/hr dextrose same as for t1 if theyre poorly controlled or theyll miss >2 meals
56
Why is it important to monitor BMs intra op?
They cannot report symptoms of it and signs are hidden by anaesthetic. May get hypoglycaemic from starvation. It also helps avoid them getting ketoacidosis.
57
What usually happens to BMs post op? what should the post op BM target be?
they increase as cortisol release suppresses insulin release
target 6-12
58
How should pts on steroid be managed preoperatively?
- swap them to IV hydrocortisone (roughly 20mg for every 5mg po pred they normally have)
- post op increase IV hydrocort dose (no guidelines on how much by)
59
Why is addisonians crises hard to detect intra and post op? What should you look out for on the biochemistry?
- lethargy, N+V, confusion and reduced GCS are signs of addisonians but can also be due to anaesthetic and analgesia
- look out for LOW SODIUM, LOW GLUCOSE, HIGH POTTASSIUM
60
What abx should be given for GI surgery?
- gentamicin single dose 30 mins before op
| - add metronidazole if colon resection
61
What abx should be given for open biliary surgery? what for ERCP?
- IV cefuroxime and IV metronidazole 30 mins before
| - IV gent for ERCP
62
What abx should be given for joint replacement surgery?
- Iv cefurozime or IV fluclox and gent 30 mins before
63
What abx should be given for closed # surgery and open # admission, debridement and surgery?
- closed: IV fluclox 30 mins before
- open: IV co amox (1.2g within 1 hr of admission and until operation, clindamycin if allergic)
- Iv cefuroxime and met and gent at first debridement and IV gent again 30 mins before skeletal stabilisation and closure
64
What is pre op hb aim? What is done if it is less than aim?
aim for >70g/L
| if below this give RBC transfusion, should increase it by about 10
65
How long dose Xmatch and G&S take? What is involved in each and when is each done?
```
G&S= 40 mins, determines blood group and screens for atypica antibodies, use if no blood loss anticipated
Xmatch= 80 mins, does blood group, antibodies and also mixes blood to see if theres a reaction, done if anticipate blood loss
```
66
What is irradiated blood and when is it used?
Where leukocytes have been destroyed to reduce risk of graft vs host reactions. Used if pts with hodgkins lymphoma, familly members, stem cell transplants, purine analogue chemo or intrauterine infusions
67
When must a pt have obs done if theyre getting a transfusion?
At start, 20 mins in, 1 hr in and at completion
68
What is atelectasis? What causes it?
partial collapse of small airways, most pts get it post op to some degree, its thought to be due to airway compression, alveolar gas resorbtion intra op and impairment of surfactant production
69
How does atelectasis present?
- varying degrees of airway compromise
- usually increased RR, reduced O2 sats, fine crackles
- sometimes low grade fever but no other infective signs
70
How is atelectasis managed?
- deep breathing exercises and chest physio
- pain control may help them to breath deeply
- broncoscopy may be needed to suction out pulmonary secretions but this is rare
71
What is acute respiratory distress and what can cause it
- acute lung injury w/ severe hypoxaemia and no cardiogenic cause, due to inflammation and subsequent pulmonary odema
- causes inc pneumonia, aspiration, fat embolism, polytrauma, smoke inhalation, acute pancreatitis, sepsis
- many of which occur around surgery (hence the relevance)
72
How does acute respiratory distress present?
- worsening dyspnoea, acute onset (<7 days) w/ identifable cause
- hypoxia, tachycardia, tachypnoea, inspiratory crackles
- bilateral infiltrates on CXR
73
How is ARDS managed?
- ITU admission as will likely need intubation
- maintain minimum intravascular pressure you can for perfusion of tissues to reduce odema
- treat cause
- corticosteroids are being used less and less
74
How should post op pneumonia be managed?
- bloods, ABG, sputum and blood cultures, d dimer (think PE), CXR, ECG (MI)
- O2 therapy
- IV abx (co amox likely as HAP)
- ? aspiration pneumonia and chemic pneumonitis- will require ITU as difficult to treat
75
Why are DVT/ PE risk increased by surgery?
- long period of immobolisation
- surgery--> trauma--> stress response--> prothombotic
- cancer, sepsis etc frequently alongside
76
What is the use in doing a WELLS score for DVT?
directs investigations:
- if 0= unlikely DVT
- if 1= maybe DVT do d dimer
- if >1 probably DVT do duplex USS
77
How is DVT treated?
DOAC such as apixaban for 3 months
78
What may cause hyperkalaemi post op? (3)
- AKI
- blood transfusions
- diuretics or ACEi
- excessive K+ treatment
79
How may hyperkalaemia present?
blood abnormality, paraesthesia, weakness, N+V, palpitations, cardiac arrest
80
What may cause hypokalaemia post op? (5)
- excessive diuretic use
- gi losses (vomiting, diarrhoea)
- steroids
- excessive insulin
- too many salbutamol nebs
- inadequate replacement when pt NBM
81
How may hypokalaemia present?
- usually asymptomatic
| - may get cramps, muscle weakness, paraesthesia, constipation or tetany
82
What changes are seen on ECG of hypokalaemia?
- prologed PR
- T wave flattening/ inversion
- U wave
- ST depression
83
When correcting significant hypokalaemia with IV fluids, why should the K+ be run with normal saline and NOT dextrose?
dextrose causes glucose and so insulin spike which can make hypokalaemia worse
84
What may cause hypovolaemic hypernaturaemia post op?
- diuretics (usually loop)
- dehydration/ fluid restriction (usually due to burns, D+v or sweating, poor oral intake)
- ATN or HHS
85
What is most likely cause euvolaemic hypernaturaemia post op?
- diabetes insipidus usually after pituitary surgery
86
What may cause hypervolaemic hypernaturaemia post op?
- giving them too many bags of normal saline or hartmans
| - steroid dose too high
87
How is hypernaturaemia managed? what is risk of rapid correction?
- find cause and replace fluid deficit if hypovolaemic
- oral water or 5% dextrose if unconscious
- 0.9% saline if hypovolaemic
- aim to reduce sodium by 10mmol/L/ day, doing it too quick can lead to cerebral odema
88
What could cause hyponaturamia?
- post op hyponaturamia is common due to stress response and if they get given lots of dextrose before it'll dilute the sodium
- vomiting or diarrhoea (low urine conc)
- diuretics (high urine conc)
- SIADH (high urine conc, euvolaemic)
- acute fluid overload
- heart failure or liver cirrhosis
- ATN
89
How should hyponaturamia be managed? What is risk of rapid correction?
- close fluid monitoring
- Iv fluids- dont correct too rapidly due to risk of central pontine demyelination
- monitor renal function
- treat cause
90
What may cause post of hypoglycaemia?
- accidental insulin OD
- lat gastric dumping syndrome (large scale movement of gastric contents, usually after gastric bypass)
- liver disease
- adrenal insufficiency
91
How is gastric dumping syndrome managed?
- small volume, more frequent meals
| - avoid simple carbs
92
What factors increase risk of anastomotic leak?
- steroids
- smoking
- diabetes
- obesity
- malnutrition
- emergency surgery
- peritoneal contamination
- oesphageal gastric or rectal anastamosis
93
How do anastomotic leaks present?
- abdo pain + fever 5-7 days post op
| - usually peritonism, sepsis
94
How should anastomotic leaks be investigated?
CT CAP with contrast, urgent bloods inc lactate, G&s and blood cultures
95
How are anastomotic leaks initially managed?
- A-E resus
- sepsis 6
- urgent senior r/v
- NMB
- work up for surgery depending on CT results
96
What is the definitive management for anastomotic leaks?
- If <5cm- conservative with abx
- if >5cm, percutaneous drainage, exploratory laparotomy.
Colorectal anastomosis usually need stomas
97
How may bowel adhesions present?
- many asymptomatic
- may cause bowel obstruction
- may cause chronic pain or infertility
98
How should bowel obstruction due to adhesions be managed?
- A-E assessment
- tube decompression if uncomplicated
- keep NMB
- IV fluids and analgesia
- If they get ischaemia, peforation or failed conservative management then need laparoscopic (or open) adhesionolysis +/- removal of affected bowel
99
What are RFs for incisional hernias?
- smoking
- infection
- obesity
- midline incision
- pre op chemo
- pregnancy
- advanced age
- chronic cough
- diabetes
- steroids
- connective tissue disease
- emergency surgery
100
How are incisional hernias managed?
You can do laparoscopic or open mesh (for larger) or suture repairs (for smaller), but this causes pain, seroma formation or bowel injury and so tend to be avoided as only 6-15% incarcerate and 2% of these strangulate
101
What causes post op constipation?
- low fibre diet
- low fluid intake
- less activity/ movement
- opioids
- iron supplements
- BOWEL OBSTRUCTION PANIC
- hypercalcaemia
- hypothyroid
- multifactoral
- post op ileus
102
How is constipation managed?
```
- if absolute and features of bowel obstruction-> CT + contrast
If not:
- laxatives
- enemas
- manual evac
```
103
What laxatives are best for opioid induced and soft stool constipation?
- stimulants like senna or picosulphate
104
What laxatives are best for hard stool and chronic constipation?
- softeners: lactulose, movicol, ispahgula husk
105
What is post op ileus?
Arrest of decellaration in intestinal motility so is a functional bowel obstruction.
106
What are the clinical features of post op ileus?
- failure to pass flatus or faeces (absolute constipation)
- bloating
- distension
- N+V (usually later)
- high NG tube output
- absent bowel sounds
107
How is post op ileus managed?
- bloods (esp U&E as fluid shift can cause AKI)
- CT with contrast to diagnose and rule out leaks/ adhesions/ collections
- daily bloods
- encourage mobilitsation
- stimulate (senna, picosulphate) laxatives
- reduce opioids
- NG tube on free drainage
- wait for the bowel to start up again
108
Give 3 risk factors for keloid scars
- black or asian
- age 20-30
- burns
- previous keloid scars
109
Whats the difference between keloid scars and hypertrophic scarring?
- hypertrophic scarring stays within the boarders of the wound margin
- hypertrophic scarring appears soon after injury and then regresses
- hypertrophic scars tend to improve on surgical intervention
110
How can keloid scars be managed?
- intralesional steroids
- silicone gel
- radiation therapy
- wont do any harm so can just leave it
111
Give 5 risk factors for surgical site infections
- old or young age
- poor nutrition
- DM
- smoking
- immunosurpression
- pre op shaving
- foreign material in site
- insertion of surgical drainage
- poor or no wound closure
- procedures at skin creases
- long post op stay
They tend to happen 3-7 days post op
112
How should surgical site infections be managed
1 remove suture/ clips so pus can drain
2 drain pus
3 empirical abx
4 monitor closely for systemic infection
113
How is superficial wound dishiscence managed?
wash with saline and then pack, wound will have to heal by secondary intention and may take weeks. Vacuum assisted closure can speed this up.
Infection prevention becomes v important
114
How is full thickness wound dishiscense managed?
IV fluids, broad specturm abx, analgesia, cover wound in saline soaked gauze, return to theatre for reclosure with large interrupted sutures
115
What may cause an AKI in the peri-op setting?
- sepsis
- dehydration
- haemorrhage
- nephrotoxins
- urinary retention or blocked catheter
116
What drugs should be stopped or reduced if a pt develops an AKI? (7)
- NSAIDS
- ACEi
- ARBs
- aminoglycosides
- K+ sparing diuretics (reduce risk of hyperkalaemia)
- reduce metformin (risk of lactic acidosis)
- reduce LMWH
117
What causes urinary retention in the peri op setting?
- uncontrolled pain
- constipation
- infection
- anaesthetic agents (epidurals)
- blocked catheter
118
How is urinary retention managed in post op setting?
- most will recover spontneously
- catheterise overnight and TWOC next day
- if TWOC fails look for other causes and give 1-2 week catheter
- discharge and TWOC in community setting
119
Describe the clinical features of anaphylaxis
- sudden hypotension which is unresponsive to a fluid challenge
- airway compromise
- facial angiodema
- urticial rash
- feeling of impending doom
120
What is the immediate management of anaphlyaxis? (5 drugs, inc doses)
- A-E assessment
- often need intubation so call anaesthetists
- high flow O2
- bronchodilators (salbutamol nebs 2.5mg, aminophylline 500mg IV)
- IM adrenaline 1:1000 0.5mg
- chlorphenamine IM or IV 10mg
- hydrocortisone IM or IV 200mg
121
What is the longer term management after an anaphylactic reaction? (5)
- monitor every 15 mins until stable
- then 4 hrly
- review drug and food chart for allergens
- measure mast cell tryptase ASAP after recovery, 1-2 hrs and 24 hrs later
- make sure theyve got an epipen
122
What is involved in the CAM ICU score for delirium?
Acute onset change in mental status + inattention + altered consciousness or disorganised thinking
123
Give 3 risk factors for post op delirium?
- >65
- dementia
- sensory impairment
- male
- renal impairment
- emergency surgery
124
List 8 common causes of delirium
HICUPEDD
- Hypoxia
- Infection (kidney, bladder, lungs, wound)
- Constipation
- Urinary retention
- Pain
- Endocrine abnormalities
- Drugs (benzos, diuretics, opioids, steroids)
- Dehydration
125
How should delirium be investigated initially? give a reason for each
- FBC (? infection)
- U&E (? electolyte abnormalities- esp Ca2+, AKI)
- TFTs (derangement can cause)
- Glucose (hypo or hyper can cause)
- B12 and folate (can cause)
- blood cultures (?infection)
- wound swabs ?infection
- urinalysis ?infection
- CXR, CT head if appropriate
126
Other than managing the specific cause, would should delirium be managed?
- quiet area
- regular routines
- clocks
- photos
- relative visits
- sleeping pattern
- oral intake
- analgesia
- haloperidol if need sedative
127
What are the 3 types of peri op haemorrhage
Primary: intraop bleeding, resolved in surg but needs monitoring
Reactive: within 24 hrs of op, usually from ligature slip or missed vessel (due to hypotension and vasoconstriction)
Secondary: 7-10 days post op due to erosion of vessel from spreading infection
128
Describe the clinical features of class 1 (15%) and class 2 (15-30%) haemorrhage?
1: HR <100// BP normal// RR 14-20// urine output normal
2: HR 100-120// BP normal// RR 20-30// urine output 20-30 ml/hr
129
Describe the clinical features of class 3 (30-40%) and 4 (>40%) haemorrhage?
3: HR 120-140// BP decreased// RR 30-40// urine output 5-20
4: HR >140// BP decreased// RR >40// urine output <5
130
How is post op haemorrhage managed?
- A-E
- IV access and fluid resus, activate major haemorrhage protocol for RBC, FFP and platelet transfusions as appropriate
- Direct pressure to bleeding site if visible
- urgent senior r/v
- imaging as appropriate (usually contrast CT)
131
What may be needed for neck surgery reactive bleeding and why?
- bedside airway rescue: take out suture and suction haematoma
- the neck fascia only distends so much, so can close trachea and cause resp distress
132
What vessels are most often injured in laparoscopic surgery and why?
- inferior epigastric vessels (arise from external iliac and run up in front of rectus muscle)
- often injured by port insertion and isnt noticed at the time due to gas inflation keeping them compressed
133
Give 4 risk factors for post op N+V (PNOV)
- Previous PNOV
- motion sickness
- use of opioids
- intercranial surgery
- prolonged surgery
- inhalation anaesthetic
- intra op dehydration or bleeding
- overuse of bag and mask ventilation (due to gastric dilation)
- young
- female
134
What may cause PNOV?
- surgery and anaesthetic itself
- post op ileus
- bowel obstruction
- infection
- metabolic (hypercalcaemia, uraemia, DKA)
- raised ICP
135
How can PNOV be avoided?
- use minimal amounts of opioid, volatile agents and spinal anaesthetic
- prophylactic anti emetic therapy
- dexamethasone at time of induction
136
How should PNOV be managed if its caused by metabolic/ biochem imbalance, opioids and by impaired gastric emptying?
Metabolic= Metoclopramide (dopamine antagonist)
Opioid: Ondansetron (serotonin antagonist) or cyclizine (histamine antagonist)
Impaired gastric emptying: Metclopramide or domperiodone
137
How many days post op are urinary, resp and surgical site/ abscess/ central line infections most common?
Day 1-2 most likely resp
3-5= urinary
5-7= surgical site/ abscess/ central line
138
What may cause a post op fever?
- infection
- drugs (abx or anaesthetics)
- transfusion reactions
- VTE (can cause low grade fever but very rare not to have other clinical features)
- prosthesis implantation (can cause low grade fever with no other signs of infection)
139
Define pyrexia of unknown origin and state what they most commonly end up being?
- fever for 3 weeks with no obvious cause despite 1 week of inpatient investigations
- 30% infection unknown cause, 30% lymphoma or other malignancy, 30% vasculitis, ct disease or drug reactions, 10% idiopathic
140
What abx are used for central line infections
flucloxacillin
141
What abx are used for intra abdominal infections
cefuroxime + metronidazle
