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Year 3 - Surgery > Peri-operative management > Flashcards

Peri-operative management Flashcards

1
Q

What information would you need from a patient before a surgery? (In a pre-op appointment)

A
  • History of presenting complaint
  • Past medical history - CVS, Respiratory, Renal, Endocrinological (diabetes and thyroid)
  • Pregnant?
  • Past surgical & anaesthetic history
  • FADOS
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2
Q

Recall the ASA grades?

A

I - Healthy

II - Mild systemic disease

III - Severe systemic disease

IV - Severe systemic disease that is a constant threat to life

V - Moribund

E - Emergency

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3
Q

What is the difference between a group and save and a crossmatch?

A

A group and save is defining a patients blood group.

A cross match is crossing the patients blood with the donors blood to ensure there is no reaction.

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4
Q

When is an ECG indicated before surgery?

A

When the patient has a significant cardiovascular history or for any major surgery

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5
Q

When is a CXR indicated before a surgery?

A

In any patient with a respiratory pathology who has not had a CXR for over 12 months

Present cardiorespiratory symptoms

Recent travel to a location with endemic TB

Significant smoking hx

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6
Q

Which medications should be stopped before a surgery?

A

“CHOW”

C - Clopidogrel

H - Hypoglycaemics

O - Oral contraceptive pill

W - Warfarin

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7
Q

At what point should Clopidogrel be stopped before a surgery?

A

7 days prior

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8
Q

At what point should hypoglycaemic be stopped before a surgery?

A

On the morning of the surgery

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9
Q

At what point should the oral contraceptive pill be stopped before a surgery?

A

4 weeks prior to minimise the risk of a DVT

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10
Q

At what point before a surgery should Warfarin be stopped?

A

5 days prior and the patient should be started on therapeutic dose of LMWH

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11
Q

How would you decide whether a patient required intra operative steroids?

A

If they have been on steroids for more than 2 weeks then you would run a short synacthen test before the surgery to find out whether the patient had suppression of their HPA axis.

If this was the case you would consider steroids. Dose is dependent on the type of surgery

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12
Q

When is LMWH indicated?

A

In all patients undergoing major GI surgery

In all patients under going lower limb joint replacements

All of these patients should be diagnosed 28 days of LMWH post operatively and TED stockings

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13
Q

How would you manage a patient pre-operatively with T1DM?

A

You would admit the night before or on that morning.

Reduce the insulin dose by one third the night before the srugery

Omit the morning dose of insulin and commence VRII - 5% dextrose infusion 125ml/hr with BM checked every 2 hours to change accordingly

Post-operatively, give SC rapid acting insulin one hour before their meal and stop IV infusion 30-60 minutes after they have eaten.

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14
Q

How would you manage a T2DM patient pre-operatively?

A

Metformin should be stopped on the morning of their surgery with other hypoglycaemic being stopped 24 hours beforehand.

The latter patients may need VRII

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15
Q

How much water does a patient require per day?

A

25ml/kg/day

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16
Q

How much sodium does a patient require a day?

A

1mmol/kg/day

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17
Q

How much potassium does a patient require a day?

A

1mmol/kg/day

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18
Q

How much glucose does a patient require a day?

A

50g/day

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19
Q

What is a fluid challenge?

A

250ml-500ml is administered IV over the course of 15-30 minutes with regular ob checks.

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20
Q

What are third space losses and name two examples?

A

A loss of fluid into spaces that you cannot see/observe.

Eg. into the bowel lumen during bowel obstruction and retroperitoneal fluid losses in pancreatitis.

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21
Q

How can a haemorrhage be classified into different types?

A

Primary bleeding - intra-operatively. Usually resolved in theatre

Reactive bleeding - occurs within 24 hours of the operation

Secondary bleeding - 7 to 10 days post op. Often due to erosion of a vessel in reaction to an infection

22
Q

Most sensitive sign to haemorrhagic shock?

A

Tachypnoea

23
Q

What are the clinical features of pain?

A

Tachycardia, tachypnoea, hypertension, sweating, flushing

24
Q

What is the risk of poor pain control following abdominal surgery?

A

Reduced mobilisation and hypoventilation

Hypoventilation will resolvedly lead to atelectasis and hospital acquired pneumonia.

25
Q

Describe the WHO ladder for analgesia?

A

1) Simple analgesics such as NSAID’s or paracetamol
2) Weak opiates such as codeine or tramadol
3) Stronger opiates or morphine
4) Consider alternative methods other than PO. Eg - IV, PR. Or consider alternative pain management if suspected neuropathic pain

26
Q

What pain medication should be prescribed for neuropathic pain?

A

Amitryptilline or Gabapentin

27
Q

What are the side effects of NSAID’s?

A

IGRAB mnemonic

I - Interactions with other medication

G - Gastric ulceration

R - Renal impairment

A - Asthma sensitivity

B - Bleeding risk due to alteration of platelet function

28
Q

Where in the brain is the vomiting centre located?

A

The lateral reticular formation of the medulla oblongata

29
Q

Where in the brain is the chemoreceptor trigger zone?

A

Below the fourth ventricle

30
Q

Which neurotransmitters stimulate the chemoreceptor trigger zone?

A

Dopamine and serotonin

31
Q

Which neurotransmitters stimulate the GI tract?

A

Dopamine

32
Q

Which neurotransmitters stimulate the vomiting centre?

A

Histamine and serotonin

33
Q

What can you add to the induction regime of anaesthesia to prevent PONV?

A

Dexamethasone

34
Q

What is pyrexia of unknown origin?

A

A temperature of >38oC for over 3 weeks without an obvious source

35
Q

What is the most common clinical presentation of an anastomotic leak and at what point does it usually present?

A

Abdominal pain and pyrexia

Usually presents 5-7 days post operatively

36
Q

What imaging would you use to diagnose an anastomotic leak?

A

CT with contrast (abdo and pelvis). You would also use chest CT if it was a thoracic leak

37
Q

Initial management of an anastamotic leak?

A

Catheter - monitor fluid balance

IV access and fluids

NBM
(drip and suck)

IV Abx

38
Q

Definitive management of an anastamotic leak?

A

Collections of <5cm usually self resolve so manage conservatively

Percutaneous drainage of collection is an option.

Surgical explorative laparotomy is an option in patients with multiple collections.

39
Q

How would you manage paralytic ileus?

A

Daily bloods

Correct any underlying cause if possible

Encourage the patient to mobilise

NBM

Reduce opiate analgesia

40
Q

How would you manage an uncomplicated bowel obstruction?

A

Manage conservatively - administer IV fluids and analgesia. Keep px NBM.

Tube decompression may be indicated.

41
Q

When is surgery indicated in small bowel obstruction?

A

When ischaemia or perforation is indicated.

When conservative management fails

42
Q

How would you define constipation?

A

<3 stools per week that may appear hard and dry.

43
Q

Name some examples of osmotic laxatives?

A

Movicol and lactulose

44
Q

Name an example of a stimulant laxative?

A

Senna

45
Q

Name an example of a bulk forming agent and what is its MOA?

A

Ispaghula husk - it keeps water in the bowel space ensuring that the stool retains more water

46
Q

What is the first line investigation in suspected urinary retention?

A

Post voiding USS

47
Q

How would you manage acute urinary retention?

A

Initially - manage conservatively. Many cases of post operative retention resolve alone.

Severe acute retention - catheterise patient at least overnight. Then commence a TWOC.

TWOC fails? Place a catheter and repeat TWOC every 1 to 2 weeks.

48
Q

How would you define an acute kidney injury?

A

Any of the following:

A 50% rise in creatinine from the baseline in the past 7 days

A rise of creatinine levels of >26.5mmol/L in the past 48 hours

Oliguria (<0.5mmol/kg/hr) for at least 6 hours

49
Q

What are the causes of pre-renal AKI?

A

Sepsis

Haemorrhage

Dehydration

Heart failure

Liver failure

Renal artery stenosis

50
Q

What are the two causes of intra-renal AKI?

A

Parenchymal issues - eg. glomerulonephriditis, myoglobinaemia

Nephrotoxins

51
Q

What are the causes of post-renal AKI?

A

Ureteric obstruction

Bladder obstruction

Urethral obstruction

Year 3 - Surgery (3 decks)

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