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Perioperative Flashcards

1
Q

Which heparin regime should the surgeon ask for prior to cross clamping in vascular surgery?

A

3,000 units of systemic heparin 3-5 minutes prior to cross clamping (prevent intra-arterial thromboses)

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2
Q

Advantages of LMWH?

A

Better bioavailability
Lower risk of bleeding
Longer half life
Little effect on APTT at prophylactic dosages
Less risk of HIT

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3
Q

Complications of LMWH?

A

Bleeding
Osteoporosis
Heparin induced thrombocytopenia (HIT): occurs 5-14 days after 1st exposure
Anaphylaxis

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4
Q

Features of lidocaine toxicity?

A

Initial CNS over activity then depression as lidocaine initially blocks inhibitory pathways then blocks both inhibitory and activating pathways. Cardiac arrhythmias.

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5
Q

What does lidocaine interact with?

A

Beta blockers, ciprofloxacin, phenytoin

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6
Q

How does bupivacaine work?

A

Bupivacaine binds to the intracellular portion of sodium channels and blocks sodium influx into nerve cells, which prevents depolarization.

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7
Q

difference between bupivacaine and lidocaine?

A

longer duration of action than lignocaine and this is of use in that it may be used for topical wound infiltration at the conclusion of surgical procedures with long duration analgesic effect.

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8
Q

When is bupivacaine contraindicated?

A

regional block as cardiotoxic

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9
Q

What is the LA of choice for regional anaesthesia?

A

prilocaine (non cardiotoxic)

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10
Q

lignocaine dose plain and with adrenaline?

A

3mg/Kg, 7mg/Kg

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11
Q

Bupivacaine dose plain and with adrenaline?

A

2mg/Kg, 2mg/Kg

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12
Q

Prilocaine dose plain and with adrenaline?

A

6mg/Kg, 9mg/Kg

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13
Q

What are adult maintenance fluid requirements?

A

Na 50-100 mmol/day and K 40-80 mmol/day in 1.5-2.5L fluid per day.

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14
Q

When should patients for elective surgery be given carbohydrate rich drinks?

A

Patients for elective surgery should be given carbohydrate rich drinks 2-3h before. Ideally this should form part of a normal pre op plan to facilitate recovery.

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15
Q

Which drugs impair wound healing?

A

Non steroidal anti inflammatory drugs
Steroids
Immunosupressive agents
Anti neoplastic drugs

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16
Q

what are the stages of wound healing?

A

Haemostasis,
Inflammation,
Regeneration
Remodelling

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17
Q

Keloid vs hypertrophic scar?

A

Keloid extends beyond boundaries of wound
Hypertrophic confined to boundaries of original wound

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18
Q

Factors affecting wound healing?

A

DID NOT HEAL

D iabetes
I nfection, irradiation
D rugs eg steroids, chemotherapy

N utritional deficiencies (vitamin A, C & zinc, manganese), Neoplasia
O bject (foreign material)
T issue necrosis

H ypoxia
E xcess tension on wound
A nother wound
L ow temperature, Liver jaundice

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19
Q

What can reverse IV heparin?

A

protamine sulfate

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20
Q

How long does it take UFH to be cleared from circulation?

A

2h

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21
Q

When will patients with metallic heart valves stop UFH?

A

6h before surgery

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22
Q

administration of what may help to identify parathyroid glands?

A

methylene blue IV

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23
Q

Which vessel is the best conduit for a coronary artery bypass?

A

internal mammary artery

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24
Q

indication for cardiopulmonary bypass?

A

Left main stem stenosis or equivalent (proximal LAD and proximal circumflex)
Triple vessel disease
Diffuse disease unsuitable for PCI

The guidelines state that CABG is the preferred treatment in high-risk patients with severe ventricular dysfunction or diabetes mellitus.

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25
cardiopulmonary bypass procedure?
Aortic root cannulated Right atrial cannula Circuit primed and patient fully heparinised (30,000 Units unfractionated heparin) as the circuit is highly thrombogenic Flow established through circuit Aortic cross clamp applied Cardioplegia solution instilled into the aortic root below cross clamp Heart now asystolic and ready for surgery
26
cardiopulmonary bypass complications?
Post perfusion syndrome: transient cognitive impairment Non union of the sternum; due to loss of the internal thoracic artery Myocardial infarction Late graft stenosis Acute renal failure Stroke Gastrointestinal
27
What Pre-operative checks needs to be considered in all patients?
OP CHECS Operative fitness: CVS comorbidities Pills Consent History Ease of intubation (neck arthritis, dentures, loose teeth) Clexane Site (correct and marked)
28
OCP/HRT and surgery?
stop 4w prior restart 2w post op if mobile
29
Beta blockers and surgery?
continue as usual
30
AED and surgery?
continue as usual postop give IV or via NGT if cannot tolerate oral
31
How many units of blood XM for AAA/gastrectomy?
AAA: 6U Gastrectomy: 4U
32
duration NBM?
>=2h clear fluids >=6h SOLIDS
33
When are prophylactic Abx given before surgery?
15-60mins before
34
When are prophylactic abx used ?
GI surgery Joint replacement
35
Common surgical antibiotic prophylactic regiments?
Biliary: 1.5g cef + met500mg IV CR/appendicetomy: cef + met TDS Vascular: co-amoxiclav 1.2g IV TDS MRSA +ve: vancomycin
36
When should platelet transfusion be considered prior to surgery?
thrombocytopenia. Aim for: >50x10^9 for most patients 50-75 if high risk of bleed >100 if critical site surgery
37
When is platelet transfusion contraindicated?
Chronic BM failure AI thrombocytopenia Heparin induced thrombocytopenia TTP
38
How to manage insulin prior to surgery in IDDM?
Reduce dose by 20% day prior to surgery +/- stop long acting the night before Omit AM insulin if surgery in the morning Start sliding scale -> 5% Dex/20mmol Kcl 125ml/hr, infusion pump 50u actrapid, check CPG hourly (aim 7-11)
39
Post-op how is insulin managed in IDDM?
Continue sliding scale until tolerating food Switch to SC around meal
40
How to manage NIDDM prior to surgery?
if fasting >10Mm treat as IDDM Omit oral hypoglycaemics on day of surgery (am)
41
How to manage NIDDM post surgery?
If eating resume oral hypoglycaemics with meal If not eating check fasting glucose on AM of surgery, start insulin sliding scale,, consult specialist team
42
Risks of perioperative steroids?
poor wound healing infection adrenal crisis
43
when to consider steroid cover?
if high dose steroids within last year Major: hydrocortisone 50-100mg IV pre-med then 6-8hourly for 3d Minor: as above but for 24 h
44
Risks of operating on jaundiced patients?
increased risk post oprenal failure coagulopathy increased infection risk
45
Pre-op Mx of jaundiced patients?
avoid morphine check clotting and consider pre-op vitamin K Give 1L NS pre-op (unless CCF) urinary catheter Abx prophylaxis (cef +met)
46
General considerations in anticoagulated patients?
avoid epidural, spinal and regional blocks continue aspirin/clopiidogrel unless high risk of bleed (then stop 7d before) very minor surgery can happen without stopping warfarin if INR <3.5
47
Protocol for emergency surgery if on warfarin?
discontinue warfarin vit K 0.5 mg slow IV Request FFP or PCC to cover surgery
48
How to manage anti coagulated patients with low thromboembolic risk e.g. AF
Stop warfarin 5 days pre-op Need INR <1.5 Start next day after surgery
49
How to manage anti coagulated patients with high thromboembolic risk e.g. valves/recurrent VTE
need bridging LMWH Stop warfarin 5d pre-op and start LMWH Stop LMWH 12-18h pre-op Restart LMWH 6h post op Restart warfarin next day Stop LMWH when iNR >2
50
Operative risks COPD / smoking
basal atelectasis aspiration chest infection
51
Pre-op management for smoking/COPD
stop smoking 4w prior physio for breathing exerfises PFTs CXR
52
Examples of immediate surgical complications?
Intubation (oropharyngeal trauma) Surgical trauma to local structures Primary or reactive haemorrhage
53
Examples of early surgical complications (1d-1mo)
secondary haemorrhage VTE Urinary retention Atelectasis and pneumonia Wound infection and dehiscence Antibiotic association colitis
54
Examples of late surgical complications?
Scarring neuropathy failure recurrence adhesions
55
Common organisms causing wound infection?
S.aureus coliforms
56
Causes of post-operative ileus?
bowel handling anaesthesia electrolyte imbalance
57
Mx of post-op ileus?
IV fluids and NGT TPN if prolonged
58
Early causes of post-operative pyrexia?
0-5d Blood transfusion Physiological (SIRS from trauma) Pulmonary atelectasis Infection (UTI, cellulitis, thrombophlebitis) Drug reaction
59
Delayed causes of post-operative pyrexia?
>5d post op pneumonia VTE(5-10d) Wound infection (5-7d) Anastomotic leak (7d) Collection (5-20d)
60
Minimum UO, Na requirement and K requirement a day
UO- 0.5ml/kg/h Na - 1.5-2mmol/kg/d K - 1mmol/kg/d
61
Contents Na in a L bag NaCl
0.9% NaCl =9g/L 154mM NaCl

MRSA theory (20 decks)

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