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Year 3 Surgery block > Peri-operative Medicine/Anaesthesia > Flashcards

Peri-operative Medicine/Anaesthesia Flashcards

1
Q

What is Virchows triad

A

Abnormal blood flow- stasis
Abnormal blood components- hypercoagubility
Abnormal vessel wall- endothelial injury

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2
Q

What are risk factors for VTE?

A 
older age 
previous VTE 
smoker 
malignancy 
pregnancy 
recent prolonged immobility
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3
Q

How may a DVT present?

A 
Unilateral calf swelling 
Tender 
Painful
Low grade pyrexia 
Pitting oedema 
65% are asymptomatic
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4
Q

How do you investigate a possible DVT?

A

Ultrasound
D-dimer
Wells score
d-dimer is not specific to DVT

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5
Q

Explain the wells score

A 
Each is worth one point 
Clinical signs of DVT 
Heart rate > 100bpm 
Recent surgery or immobilisation 
Previous PE or DVT 
Haemoptysis 
Malignancy 
Alternative diagnoses less likely than PE

Less than or equal to one- DVT is unlikely and need a D-dimer to exclude

Greater than 1- DVT needs to be confirmed using ultrasound

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6
Q

How would you treat a patient with a confirmed DVT

A

DOACs, however in some cases vitamin K antagonist. Patients with a provoked DVT will need it for 3 months .
Unprovoked DVT or recurrent DVT may need lifelong anticoagulation

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7
Q

Which drugs need to be stopped pre-op?

A

CHOW:
Clopidogrel- stop 7 days pre-op
Hypoglycaemics- most sto pped 24 hours before. Metformin stopped the morning of . Sub cut insulin, stopped, reduce dose by 1/3 and omit morning insulin
Oral Contraceptive pill or HRT- stop 4 weeks before
Long term steroids- may be switched to IV to reduce risk of Addisonian crisis

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8
Q

What drugs do you start pre-op

A

LMWH
TED stockings
Abx prophylaxis

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9
Q

What is the ASA score?

A

Determine if a patient is healthy enough to tolerate anaesthesia

ASA1: normal, healthy patient
ASA2: A patient with mild systemic disease e.g. obesity, well controlled DM/HTN, smoker
ASA3: A patient with severe systemic disease e.g. poorly controlled DM,HTN, COPD morbid obesity,
ASA4: A patient with a severe systemic disease that is a constant threat to life e.g. recent MI, TIA, sepsis, ESRD not undergoing regular dialysis
ASA5: Moribund patient, not expected to survive without the op e.g.ruptured AAA, massive trauma
ASA5: A declared braindead patient who’s organs are being donated

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10
Q

What investigations would you do pre-op?

A

Bloods- FBC/ U+Es/LFTs/ condition specific e.g.TFTs, HbA1c, clotting

ECG- if hx of cardiac disease or major surgery

Spirometry e.g. COPD and asthma patients

Urinanalysis- identify a UTI

MRSA swab

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11
Q

Briefly outline the WHO pain ladder

A

Simple analgesics: paracetamol–> NSAIDS

Weak Opiates: codeine and tramadol

Strong opiates: fentanyl and morphine

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12
Q

What are the two types of fluids available?

A

Crystalloid, colloid.

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13
Q

For each patient, what should you consider when prescribing fluids?

A

Age, weight, cardiac function, co-morbidities. Reason for admission. Electrolytes recently given?

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14
Q

What is the aim of maintenance fluids?

A

To hydrate - all distribute into all compartments.

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15
Q

What is the aim of resuscitation fluids?

A

To improve tissue perfusion - will stay in intravascular space.

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16
Q

What are the 5R’s of fluid prescribing?

A

Resuscitation, Routine maintencence, Replacement, Redistribution, Reassess.

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17
Q

A patient is depleted of fluids. What signs should you look for when assessing fluid status?

A

Dry mucous membranes, reduced skin turgor, decreased urine output, orthostatic hypotension, increased cap refill time, tachycardia, hypotension.

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18
Q

A patient is overloaded with fluids. What signs should you look for when assessing fluid status?

A

Raised JVP, sacral odema, peripheral oedema, pulmonary oedema.

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19
Q

In what circumstances may you replace ongoing losses?

A

Third space losses (i.e. fluid losses into spaces that are not visible e.g. bowel lumen in bowel obstruction). In diuresis. When pt is tachypnoeic or febrile. When pt is losing electrolyte-rich fluid.

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20
Q

In what conditions are electrolyte imbalances common?

A

Dehydration - high urea:creatine ratio.
Vomiting - low K+, low Cl-, alkalosis,

Diarrhoea - low K+ and acidosis.

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21
Q

What fluids would you prescribe for patient with sepsis?

A

Fluids that get into intravascular space

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22
Q

What is the 4, 2, 1 rule regarding paediatric fluid maintenance?

A

First 10kg = 4ml/kg/hr. Next 10kg = 2ml/kg/hr. Thereafter = 1ml/kg/hr.

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23
Q

Why is hyponatremia so important to correct?

A

Can lead to transient or permanent brain damage due to cerebral oedema.

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24
Q

How do you manage a patient on long term oral steroids in the peri-operative period?

A

Switch oral steroids to 50-100mg IV hydrocortisone
If any associated hypotension, fludrocortisone can be added
Minor ops- oral prednisolone can be restarted immediately post op. If surgery is major than they may require IV hydrocortisone for up to 72 hours post op

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25
Q

What might you find on physical examination of a pt in pain?

A

Tachycardia, tachypnoea, hypertensio, sweating, flushing, agitation, unwilling to mobilise

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26
Q

Why is the WHO pain ladder used?

A

To titrate analgesia

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27
Q

A pt is already on NSAIDs and they are not aiding in their role as pain relief. What would you think of prescribing next? (on who pain ladder)

A

Weak opiates - codeine, tramadol.

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28
Q

What is the mechanism of action of NSAIDs?

A

Inhibit COX enzymes needed to convert arachidonic acid to downstream products in the prostanoid pathway. This stops the synthesis of prostaglandins so reeduces inflammatory response

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29
Q

Name 3 side effects of NSAIDs

A 
I-GRAB
Interactions with other meds (e.g. warfarin)
Gastric ulceration
Renal impairment 
Asthma sensitivity (trigger!)
Bleeding risk
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30
Q

How do NSAIDs increase the bleeding risk of a pt?

A

Reduce platelet function (they stop prostacyclin which usually promotes platelets)

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31
Q

If you are worried of a patient having NSAIDs for a long time due to side effects, what can you prescribe alongside it?

A

PPI

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32
Q

Why do NSAIDs cause renal impairment?

A

Prostaglandins are inhibitied in this pathway. Usually, prostaglandin cause vasodilation of the afferent arteriole of the kidney to help maintain GFR. When your pt takes NSAIDS, they inhibit this vasodilation. SO you get poor renal perfusion - and kidney is more unable to respond to a reduced GFR

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33
Q

What are two side effects of opiates?

A

Constipation, nausea, sedation, confusion, pruritus, respiratory depression

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34
Q

What can you prescribe alongside opiates if a pt suffer with their side effects?

A

Laxatives and anti-emetics

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35
Q

Why wouldn’t you co prescribe a weak opiod with a strong opiod?

A

They inhibit the same receptor !! (Mop u)

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36
Q

Which opioids would you consider giving to someone who had eGFR of 50?

A

Oxycodone or Fentanyl as pt has renal impairment

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37
Q

What is patient controlled analgesia?

A
  • Used when analgesia required exceeds the capacity of the nursing staff.
  • So, an IV pump is used to provide a bolus of analgesia when a button on the pump is pressed.
  • This allows the analgesia to be tailored to the pt’s requirements.
  • The device records the opiod being administered.
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38
Q

Why may a pt present with neuropathic pain after an operation?

A

Irritation to a nerve or nerve injury during the procedure.

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39
Q

What drugs can be used to manage peri-operative neuropathic pain?

A

Gabapentin, Amitriptyline, Pregabalin

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40
Q

How can pain be assessed?

A

Subjectively - use SQITARS/SOCRATES. Objectively - HR, HTN?, Sweating, flushing? Agitiated, unwilling to mobilise?
Can assess in multiple environments - in bed, when taking a deep breath in, when mobile.

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41
Q

How does surgery affect the stress response?

A

Heightens it !! Huge increase in stress hormone and sympathetic response.

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42
Q

What hormones are involved in stress response? Describe this process

A

Increase in adrenaline, ACTH, cortisol, glucagon, GH = all catabolic (to create more glucose). Insulin tries to counteract this.

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43
Q

What are risks of a diabetic pt having anaesthesia and surgery?

A
  • During surgery: Stress of surgery/trauma/infection can make hyperglycaemia harder to control as there is insensitivity to insulin
  • Before and after surgery:GA/NBM before surgery/ post surgery vomiting means keeping glucose in normal range is challenging
  • Increased risk of hospital infections
  • Renal impairment
  • MI and cardiac ischamia can be painless in a DM pt.
  • Ketoacidosis can be mistaken
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44
Q

What is the target blood glucose in peri-operative /anaesthesia management?

A

Target capillary blood glucose 6-10mmol/L (for DM pt).

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45
Q

What three groups are DM pt divided into peri-operatively?

A

Insulin dependent, oral hyperglycaemic managed, diet controlled.

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46
Q

How do you (peri-operatively) manage insulin dependent DM pt?

A
  • Establish good diabetic control before the operation.
  • Give insulin as a continuous iv infusion during operative period
  • Give infusion of dextrose through op (to balance the insulin or to make up dietary intake)
  • Add potassium to dextrose
  • Monitor blood glucose and electrolytes in op and after.
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47
Q

How do you manage DM pt’s who have oral hyperglycaemia?

A

Stop metformin - risk lactic acidosis. Stop Sulphonylureas can be stopped on the day of the op.
If blood glucose rises a little bit, can do sub-cut insulin to control insulin.

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48
Q

If patient has diet controlled DM, how would you manage them peri-operatively?

A

Do blood glucose. May not need intervention.

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49
Q

How do you manage poorly controlled DM on emergency admission?

A

Risk of DKA. Aim is to control glucose with rehydration and infusion of insulin, glucose and potassium.

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50
Q

What should be given alongside VRIII?

A

IV glucose, K, NaCl substrate solution

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51
Q

What is the aim of a pre-assessment before an operation?

A
  • Assess good glycaemic control <8.5% Hba1c.
  • Determie safest anaesthetic
  • Timing of operation on the list (i.e. do they need to be first to limit starvation)
  • VTE assessment risk
  • Need for home support after surgery
  • Assess other co-morbidities and complications
  • Bloods
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52
Q

Regarding blood sugar, what are your aims whilst in the operating theatre?

A
  • Regular blood glucose measurements.

- Feet visible, limit pressure sores, ensuring fluids are given.

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53
Q

What are post theatre aims for pt with DM?

A
  • Maintain blood glucose.
  • Maintain electrolyte balance
  • Optimise renal and cardiac function
  • Anti-emetics
  • Fluids - Hartmann’s
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54
Q

What is the half life of IV insulin?

A

6mins. Some are 15 mins.

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55
Q

Why is insulin having a fast half life an advantage in surgery?

A

Fast half life = easy to adjust in surgery where there can be haemodynamic changes,

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56
Q

How many kcal in 1L of 5% dextrose?

A

170 kcals

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57
Q

Why are anticoagulants used in surgical patients?

A

Prevention of stroke, VTE embolism, PE, DVT, non-valvular AF

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58
Q

With regard to warfarin, what measurements mean a patient is fit for surgery?

A

INR of 1.5 or below.

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59
Q

Why might a surgical pt be on warfarin?

A

May have a mechanical heart valve. May have had a recent VTE?

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60
Q

How is warfarin reversed in emergency surgery?

A
  • IV Vit K if surgery can be delayed by 6-12hrs and INR is >1.5.
  • If surgery can not be delayed, human prothrombin complex (1 hr reversal).
  • Fresh frozen plasma if HPC not available. FFP- contraindicated in fluid overload
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61
Q

A high risk pt usually on warfarin has had it reversed for surgery. What do you prescribe to ensure their blood does not clot?

A

LWMH for high risk pts. Can be stopped shortly before surgery then restarted after.

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62
Q

A pt on rivaroxiban is due to have surgery soon. When should they stop taking it?

A

24-72hrs before surgery. This depends on their kidney function, half life and the surgical procedure

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63
Q

What is the name of the antidote for dabigatran?

A

Idarucizumab - rapid reversal for emergency surgery or bleeding

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64
Q

What is the name of the antidote for apixaban?

A

Andexanet alfa

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65
Q

When should he COCP be stopped before surgery?

A

4 weeks before

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66
Q

Why should COCP be stopped before surgery?

A

Risk of VTE

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67
Q

What is commonly used as DVT prophylaxis?

A

Dalteparin

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68
Q

How is dalteparin administered?

A

Subcut injection

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69
Q

What should be given alongside LWMH prophylaxis?

A

Graduated compression stockings

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70
Q

Why should you wait 4 hours after inserting an epidural anaesthetic before giving LWMH?

A

Risk of epidural haematoma - blood accumulates in the epidural space which mechanically compresses the spinal cord - not good.

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71
Q

Which surgical procedures would need extended dalteparin/lwmh prophylaxis after surgery?

A

Major procedures such as orthopaedic (THR/TKR) as they have a higher risk of VTEs —> DVT/PE

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72
Q

A pt is already taking prednisolone. How should they be managed during surgical procedures (including pre and post)?

A

IV Hydrocortisone at induction AND immediately post op for first 24 hours.
Double normal steroid dose once eating/drinking fro 24-72 hours depending on the operation

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73
Q

What happens when a pt’s (who has been taking steroids) steroids are stopped suddenly?

A

Addisonian crisis

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74
Q

Describe what happens in addisonian crisis?

A 
Reduced glucocorticoid and mineralcorticods. 
Hyponatraemia 
Hyperkalaemia 
Hypoglycaemia 
Reduced consciousness
Low BP/blood vol
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75
Q

Why is addisonian crisis hard to detect post surgery/in surgery?

A
  • Manifestations = hypotension, tachycardia, hypoxia and fever. These mimic common post op complications
  • Can present as nausea, vomiting, diarrhoea = similar to effects of anaesthetic drugs
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76
Q

What are the 7 sources of pyrexia (7 C’s)?

A 
Chest (infection)
Cut (wound infection)
Catheter (UTIs)
Collections (abdo, pelvic)
Calves (DVT)
Cannula (infection)
Central line
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77
Q

When should prophylactic abc be given?

A

Before clean surgery involving prosthesis or implants.
Clean-contaminated surgery
Contaminated surgery

78
Q

How are abx given for a surgical procedure?

A

Single dose IV 60mins before first incision

79
Q

What is involved in the safe use of abx in surgical procedures?

A

Check pt details, check allergies, check the surgery being done. Given prophylactically to counter the high risk of wound infection or where infection causes severe infections (prosthesis)

80
Q

Define septic shock

A

Sepsis with hypotension despite adequate fluid resuscitation or requiring use of inotropic agents to maintain a normal systolic BP

81
Q

How is septic shock managed?

A

Aggressive fluids resusc and abx therapy. Need to involve the critical care team

82
Q

Distinguish between inotropes and chronotropes

A

Inotropes increase contractility whereas chronotropes increase heart rate

83
Q

What investigations would you do to ID source of infection in septic patient?

A 
Stool culture
Cerebrospinal fluid sample 
Operative site assessment - US or CT
Swabs of surgical wound 
CXR
Urine dip and cultures
84
Q

What should be done after you have completed sepsis 6?

A

Escalate to seniors.

85
Q

What are involved in sepsis 6?

A

GIVE Oxygen, IV fluids, IV abx.

TAKE Routine bloods and lactate, urine output, blood cultures

86
Q

In sepsis 6, how much urine are you aiming for per kg/hr?

A

0.5ml/kg/hr

87
Q

With regard to sepsis 6, when should blood cultures be taken?

A

BEFORE abx are given

88
Q

What are you ordering in routine bloods for sepsis6?

A

FBC, U&Es, LFTs, clotting, CRP, glucose

89
Q

What is the SOFA score used for?

A

To monitor treatment for sepsis

90
Q

What is involved in the SOFA score?

A

Respiration, Coagulation, Liver function, CVS function, CNS, Renal function

91
Q

What clinical signs might you see with pt with suspected sepsis?

A

RR>22, altered mental state, SystBP <100mmHg

92
Q

What are blood products?

A

Any part of the blood that is collected from a donor for use in a blood transfusion

93
Q

What are blood products?

A

Any part of the blood that is collected from a donor for use in a blood transfusion

94
Q

How is haemolytic disease of the newborn caused?

A

Second child - who is RhD+.
Mum is RhD-. Exposed to RhD+ blood antibodies produced in pregnancy.
Rhesus D- antibodies cross placenta and cause haemolytic disease of the newborn - as child is RhD+

95
Q

How is haemolytic disease of the newborn caused?

A

Second child - who is RhD+.
Mum is RhD-. Exposed to RhD+ blood antibodies produced in pregnancy.
Rhesus D- antibodies cross placenta and cause haemolytic disease of the newborn - as child is RhD+

96
Q

What is the purpose of doing a group and save blood test?

A

Determines patients ABO and Rh status.

Screens blood for atypical antibodies.

97
Q

What is the purpose of doing a cross match blood test?

A

Mixing patients blood with donor blood to ID an immune response.
If there is no immune response, can issue the blood to the patient.

98
Q

Who MUST be given cytomegalovirus (CMV) negative blood? And why?

A

WHO - Pregnant women, intra-uterine transfusing, neonates (up to 28days).
WHY - CMV is a common congenital infection which can cause sensorineural deafness and cerebral palsy.

99
Q

Why are irradiated blood products used (i.e. blood from 1st or 2nd degree relatives)

A

To reduce the risk of graft-vs-host disease in at risk populations.

100
Q

For administering blood products, when should observations be taken?

A

Before administering, 15-20mins after administration of blood, at 1 hour then at completion of administration. (However, NICE say give 1 unit in a surgical pt with no active bleeding then reassess).

101
Q

What are the four types of blood products that can be given?

A

Packed red cells
Platelets
Fresh frozen plasma
Cryoprecipitate

102
Q

In what circumstances should packed red cells be given?

A

In acute blood loss

In anaemia where Hb<70g/L or <100g/L in pts with CVD.

103
Q

When should platelets be given?

A

In haemorhagica shock, profound thrombocytopenia, bleeding with thrombobytopenia, pre-op platelet feels of <50 x10(9)

104
Q

What does fresh frozen plasma contain?

A

Clotting factors

105
Q

What does Cyroprecipitate contain?

A

Fibrinigen, vWF, FVIII, Fibronectin.

106
Q

When is FFP used?

A

DIC, haemorrhage secondary to liver disease, all massive haemorrages

107
Q

When is cyroprecipitate used?

A

DIC with fibrinogen, vWF disease, massive haemorrhage

108
Q

What are the three main categories of haemorrhage?

A

Primary bleeding, reactive bleeding, secondary bleeding

109
Q

What clinical features would you look for in suspected haemorrhage?

A

Tachycardia, elevated RR, reduced urine output, increased cap refill, hypotension (v late sign)

110
Q

What does NEWS2 measure?

A 
RR, 
Oxygen sats, 
Systolic BP, 
Pulse rate, 
Level of consciousness or new onset confusion,
Temperature
111
Q

Why is NEWS2 score used?

A

Improve detection and response to clinical deterioration to critically ill patients

112
Q

A pt has a score of 3 in one parameter of the NEWS2 score. What is your next management step?

A

Urgent review by ward based doctor to determine cause and decide on changing frequency of monitoring the patient./Escalate to critical care.

113
Q

A patient is said to be high risk from their NEWS2 score. What score must they be on/above?

A

7 or above.

114
Q

In initial resuscitation, what is involved in A of A-E assessment?

A

Talk to pt - if can talk - airway is patent. Examine the oropharynx - if liquid is present, can suction liquid out.
Can do jaw thrust. Use airway adjuncts

115
Q

In initial resuscitation, what is involved in B of A-E assessment?

A

Listen to chest.
Sats?
RR?
Cyanosis
Chest deformity/chest asymmetry
O2 therapy - 15L/min through non-rebreath mask.
ABG/VBG
CXR
Wheeze? Give nebuliser salbutamol 5mg and ipratropium 500mg. Wheeze can be due to HF - so check fluid status.
Resp arrest - call cardiac team and use bag valve mask to oxygenate patient until they arrive

116
Q

In initial resuscitation, what is involved in C of A-E assessment?

A

Cap refill, BP, pulse, assess limb temp, oliguria, 12 lead ECG.
Insert wide bore cannula and take blood from cannula.
Start IV fluid replacement - 500ml in less than 15mins of warm crystalloid solution

117
Q

In initial resuscitation, what is involved in D of A-E assessment?

A

Check pupils, temp, blood glucose, AVPU. Electrolyte status - especially hyponatraemia

118
Q

What can pin point pupils demonstrate, if seen during A-E?

A

Opiod toxicity

119
Q

What is anisocoria a sign of?

A

Increasing intracranial pressure

120
Q

When is naloxone used?

A

Opiod induced resp depression, bradypnoea or coma.

121
Q

A patient has N&V post op. What are possible differentials?

A 
Post op N&V due to anaesthesia 
Rising ICP (pls add more if you thought of something different
pain 
opiate use 
infection 
ileus
122
Q

In your A-E assessment, the patient you see is having a seizure. What is your 1st line treatment?

A

10-20mg PR diazepam (benzodiazepines)

123
Q

What is main sign/symptom of post op fever?

A

Core body temp>38 degrees for 2 consecutive days
or
>39 degree for 1 day

124
Q

What are 5Ws ? (causes of post op fever)

A 
Wind - chest infection 
Water - urine infection 
Walking - VTE 
Wound - surgical site infection 
Wonder drugs - abx, anaesthesia, analgesia
125
Q

Name a differential for post op fever?

A

Pyretic stress response of surgery

126
Q

What are SIRS?

A

Systemic inflammatory response syndrome - an exaggerated defense response of the body to a noxious stressor.

127
Q

What is involved in SIRS criteria?

A

Temp >38 0r <36.
HR > 90bpm
RR>20/min
WCC >12 or <4

128
Q

How many of the SIRS criteria is required to diagnose SIRS?

A

At least 2.

129
Q

How can severe sepsis be defined?

A

SIRS + Source of infection + organ dysfunction

130
Q

complication of long term mechanical ventilation in trauma patient?

A

Trachea-Oesophageal fistula formation

131
Q

How long before op should patient stop drinking fluids?

A

Can have clear fluids up to 2 hours before the op.

132
Q

Presentation of malignant hyperthermia?

A

Often seen following administration of anaesthetic agents.
Hyperpyrexia
Muscle rigidity

Management
dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum

133
Q

Investigations of malignant hyperthermia?

A
  • CK - will be raised

- Halothane caffeine contracture test (google this to find out how to do this)

134
Q

Management of malignant hyperthermia?

A

Dantrolene sodium - given by rapid IV.
2-3mg/kg initially, then 1mg/kg repeated if needed (max of 10mg/kg per course)

This drug prevents Ca2+ release from the sarcoplasmic reticulum (as in malignant hyperthermia, get excessive release of Ca2+ which leads to contraction - i.e. muscle ridigity)

135
Q

Causative agents of malignant hyperthermia?

A
  • halothane
  • suxamethonium
  • other drugs: antipsychotics (neuroleptic malignant syndrome)
136
Q

Pathophysiology of malignant hyperthermia?

A
  • Caused by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle
  • Associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, which controls Ca2+ release from the sarcoplasmic reticulum
  • Susceptibility to malignant hyperthermia is inherited in an autosomal dominant fashion
137
Q

Where are the following regional anaesthetic techniques administered?

  1. Spinal
  2. Epidural
  3. Field
A
  1. Spinal - injected into intrathecal space in the lower lumbar region usually at L3/L4
  2. Epidural - L4/5 epidural space via catheter and left for at least duration of surgery
  3. infiltrated into the inguinal region - e..g inguinal hernia surgery
138
Q

What is the principal difference between general and regional anaestheisa?

A

General - agents that induce general anaesthetic act on the brain and therefore - “abolishes consciousness”

Regional anaesthesia- effect is limited to a region of the body. often give sedative drugs so not ‘awake’

139
Q

Regional anaesthetic agents DO have an effect on the central nervous system - TRUE / FALSE

A

FALSE

DO NOT have an effect on CNS unless they are combined with a spinal anaesthesia.

140
Q

What is the most commonly used local anaesthetic in regional anaethetics?

A

Bupivacaine

trade name Marcaine - long duration of action.

141
Q

What is a peri-op assessment?

A

Used to determine pt’s ability and capacity to undergo stress of surgery
A time to optimise physiological condition by reversing or minimising effects of co-existing morbidities/ primary pathological process

142
Q

What is included in peri-op assessment?

A
  1. General assessment:
    History - comorbidites/PMH, previous surgery, tooth extractions
    SH - religion and cultural practice
    DH and allergies
    Examine - pallor, dehydration, previous surgical scars, petechiae, purpura
    Investigations e.g. U+Es etc
  2. Haematological assessment:
    O2 capacity of blood. Hb, anaemia check
    Platelet count, peri-op bleeding before, FHx of bleeding disorders, blood thinners
    VTE risk assessment
    Cellular immune competence - is pt neutropenic?
143
Q

What pre-op investigations are done to aid peri-op assessment?

A

FBC - Hb, platelets, WBC, Oxygen carrying capacity

Group and Save. Cross match (if high bleeding risk)

144
Q

Why is it important to investigate for anaemia before surgery?

A

Anaemia = bleed more during surgery.

Poor wound healing

145
Q

Name surgeries that are high bleeding risk?

A 
Vascular 
Cardiothoracic 
Polypectomy 
Liver or spleen op
Urological procedures
146
Q

What is Group and save?

A

Blood sample taken from patient - confirms blood group and ant antibodies on the RBC.
Info is saved if needed for transfusion

147
Q

What is Cross match?

A

Patient’s sample is mixed with sample from actual blood unit in the stock fridge = ensures compatibility.

148
Q

How is haemostatic competence assessed?

A

Need to know whether a pt’s blood will clot in good time when surgeon makes cut.
Need to know Hx of bleeding/bruising (spontaneous) and of any bleeding disorders or unusual bleeding (e.g. menorrhagia)
Need to know current medications - DOAC, warfarin, aspirin, clopidogrel, steroids.
Need to know FBC, platelet count.

149
Q

Which patient groups need a coagulation screen (PT, APTT, TT, Fibrinogen) before surgery?

A
  • PMH of unusual bleeds
  • post surgical or post-dental procedure bleeding
  • unexplained persistent menorrhagia
  • FHx of bleeding disorder
  • Unexplained thrombocytopenia
  • Emergecny Ops including pts with severe sepsis
150
Q

What is involved when assessing need for post-op thromboprophylaxis ?

A

Patient factors

  • Pt age
  • BMI
  • Personal or FHx of VTE
  • Personal or FHx of thrombophilia

Factors related to the procedure

  • Orthopeddic op
  • plaster cast immobilisation
  • spinal surgery
  • pelvic operations
  • prolonged anaesthesia
  • op for malignancy
151
Q

When are red cells used for transfusion?

A

In symptomatic and/or actively bleeding patients

152
Q

What does red cell transfusion do in terms of Hb?

A

Increases oxygen carrying capacity

Replaces blood loss

153
Q

When are platelets used for transfusion?

A

Prophylactically in non-bleeding pts with thrombocytopenia

154
Q

Describe storage of red cells?

A

Stored at 4 degrees celcius
Stored for up to 35 days from collection
No platelets or coag factors

155
Q

Describe storage of platelets?

A

Stored at room temp

Stored up to 7 days

156
Q

Describe storage of FFP and Crytoprecipitate?

A

Stored at -30 degrees Celsius for 2 years

157
Q

Use of FFP?

A

Contains clotting factors! Used in general coagulation factor deficiencies e.g. DIC

158
Q

Use of Cryoprecipitate?

A

Source of fibrinogen and factor VIII

159
Q

Dose of FFP?

A

10-15ml/kg

160
Q

Dose of Cyroprecipitate?

A

10 units for adult

161
Q

In blood, where are antigens present?

A

Red cells

162
Q

In blood, where are antibodies present?

A

In plasma.

163
Q

If a pt is blood group A, what antigens on RBC? What antibodies will be present in plasma?

A

Antigen A on RBC

Anti-B antibody in plasma

164
Q

Antigens present on RBC for blood group AB?

A

Antigens A and B

165
Q

Antibodies in plasma of pt with blood group ABO?

A

Anti-A and Anti-B

166
Q

Clinical significance of ABO blood group?

A

ABO incompatible blood transfusion can be life threatening.
Causes intravascular haemolysis
A never event.

167
Q

What does production of Alloantibodies depend on?

A

Immunogenicity
Recipients immune repsonse capability
Amount and frequency in transfusion

168
Q

In what circumstance is all antibodies (Alloantibodies) produced ?

A

When pt is exposed to blood of a different group via transfusion in pregnancy

They are immune antibodies only produced following exposure to foreign blood cell antigens

169
Q

How is sensitisation to Rh D and risk of haemolytic disease of the foetus and newborn prevented?

A

D negative (and K negative) girls and women of child bearing potential are NOT transfused with D or K positive red cells.

Note: this rule is overriden in an emergency

170
Q

What is universal blood that can be given in emergency?

A

Group O negative

171
Q

What are critical points in the blood transfusion process?

A 
Decision to transfuse
Prescription/request 
Pre-trasnfusion sampling of blood 
Lab testing on blood 
Collection of blood from storage site 
Bedside administration
172
Q

Symptoms and signs of acute haemolytic transfusion reaction?

A 
Fever
Chills
Hypotension 
Tachycardia 
Pyrexia 
Flank pain 
Haemoglobinuria
173
Q

S+S of allergic reaction to foreign plasma proteins or antibodies to IgA?

A

Urticaria, pruritus, wheezing, hypotension, angiodema

Anaphylaxis reaction

174
Q

What happens in febrile non-haemolytic transfusion reaction?

A

> 1˚C temp rise with no other medical explanation.

175
Q

S+S of transfusion related acute lung injury (TRALI)?

A

Dyspnea, hypoxia, non-cariogenic pula oedema

176
Q

Transfusion reaction symptoms?

A 
Increase in temp 1.5˚C<
Collapse
Pain - chest, loin, back, extremities 
Rigors 
Anaphylaxis
Shivering 
Hypotension 
Flushing 
SOB 
Burning  or pain at the drip site 
Bleeding from drip site
Non-specific deterioration 
Dizziness
177
Q

How to manage acute transfusion reactions?

A 
Based on S+S, and severity 
Stop the transfusion 
Do rapid clinical assessment - A-E
Check pt ID and compatibilty 
Then assess whether mild, moderate or severe reaction and manage accordingly
178
Q

How to optimise pt’s Hb before a scheduled surgery?

A

Oral iron
EPO
Consider stopping anticoagulant/antiplatelets

179
Q

How to optimise pt’s Hb in surgery and post-op?

A

Cell salvage

Meds - tranexamic acid

180
Q

What long term treatment to give pt with if they have VTE and no cancer?

A

ACCP guidance 2016 - DOAC !!

181
Q

What long term treatment to give pt with if they have VTE and cancer?

A

LMWH

instead of DOAC

182
Q

How to manage pre-op anaemia in pre-op clinic?

A
  • correct any cause - B12, iron replacement, EPO injection
  • may not need correction - B that or in minor op
  • investigate underlying cause
  • specialist pre-op anaemia clinic
  • liaise with GP and other specialists and delay surgery
183
Q

What needs to be considered in management of pre-op anaemia in an emergency setting?

A

Need to consider:

  • current physiological state
  • rate of fall in Hb
  • anticipated blood loss
  • underling co-morbidity e.g. cardiac disease.
184
Q

Options for red cell transfusion in an emergency?

A

Packed red cells
Group specific (but non-crossmatched) blood
Group O- red cells

185
Q

When should G&S be sampled within 28 days?

A

If patient has:

Never previously transfused
Last transfusion >3months ago
Not pregnant
No known red cell antibodies.

186
Q

ASA 1 means?

A

ASA1: normal, healthy patient

187
Q

ASA 2 means?

A

ASA2: A patient with mild systemic disease e.g. obesity, well controlled DM/HTN, smoker

188
Q

ASA 3 means?

A

ASA3: A patient with severe systemic disease e.g. poorly controlled DM,HTN, COPD morbid obesity,

189
Q

ASA 4 means?

A

ASA4: A patient with a severe systemic disease that is a constant threat to life e.g. recent MI, TIA, sepsis, ESRD not undergoing regular dialysis

190
Q

ASA 5 means?

A

ASA5: Moribund patient, not expected to survive without the op e.g.ruptured AAA, massive trauma

191
Q

ASA 6 means?

A

ASA6: A declared braindead patient who’s organs are being donated

Year 3 Surgery block (66 decks)

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