Perioperative care

Question 1

Why is D-dimer unreliable as an indicator of PE in the post-operative phase?

Answer 1

D-dimer is an acute phase protein and often raised post-op

Question 2

Post-op complication in which alveolar collapse leads to respiratory difficulty

Answer 2

Atelectasis

Question 3

When does VTE usually present post-op?

Answer 3

Between 5-10 days post op

Question 4

Causes of early post-op pyrexia? (5

Answer 4

Blood transfusion
Cellulitis
UTI
Physiological systemic inflammatory reaction
Pulmonary atelectasis

Question 5

Causes of late post-op pyrexia? (4)

Answer 5

Pneumonia
VTE
Wound infection
Anastamotic leak

Question 6

Lack of respiratory effort following extubation?

Answer 6

autosomal dominant mutation where suxamethonium (muscle relaxant used for intubation) is not broken down; therefore effects are prolonged

Question 7

How should diet/tablet controlled diabetics be managed perioperatively?

Answer 7

First on the list

Medications may be omitted with regular checking of blood glucose levels

Question 8

How should people with poor diabetic control or who are on insulin be managed?

Answer 8

Variable rate insulin infusion + potassium supplementation

Question 9

Risks of a) metformin b) sulfonylureas in surgical patients?

Answer 9

a) lactic acidosis risk esp. if poor kidney function/IV contrast agents
b) hypoglycaemia when fasting- should be omitted on day of surgery

Question 10

Blood products:

Used for transfusion in chronic anaemia and cases where whole blood transfusion might cause heart failure

Answer 10

Packed red cells

Question 11

Blood products:

Used for thrombocytopenic patients

Answer 11

Platelet rich plasma or platelet concentrate

Question 12

Blood products:

Contains clotting factors, albumin and Ig

Answer 12

Fresh frozen plasma

Question 13

Blood products:

Formed from supernatant of FFP, rich source of Factor VIII and fibrinogen

Answer 13

Cryoprecipitate

Question 14

Management of patients on warfarin requiring urgent surgery

Answer 14

Stop warfarin

Vitamin K + Human prothrombin complex (bereplex)

Question 15

Guidelines for warfarinised patients undergoing elective surgery?

Answer 15

Stop 5 days prior; if INR less than 1.5 surgery can go ahead

Question 16

Unwell post-op patient with low sodium, high potassium?

Answer 16

? Adrenal insufficiency e.g. Addison’s disease

Question 17

Reversal of heparin?

Answer 17

Protamine sulfate

Question 18

VTE risk:

When should combined oral contraceptives be stopped prior to surgery?

Answer 18

4 weeks

Question 19

VTE risk:

Risk factors for VTE

Answer 19

Active cancer
Age more than 60
Dehydration
Known thrombophilia
Obesity
HRT/Combined oral contraceptives
Reduced mobility
Pregnancy
One or more significant medical co-morbidities
Varicose veins with phlebitis

Question 20

VTE risk:

Particular surgical risks for VTE?

Answer 20

Total anaesthetic + surgery time greater than 90 minutes
Pelvis/lower limb surgery
Acute surgical admission with inflammatory or intra abdominal condition

Question 21

VTE prevention? (3)

Answer 21

TED stockings
Early mobilization
Prophylactic fragmin (LMHW)

Question 22

Fluid challenge in patients with a) normal cardiac function b) clinical signs or documentation indicating possible heart failure

Answer 22

a) 500mls 0.9% saline STAT

b) 250mls 0.9% saline STAT

Question 23

Which blood product is most likely cause a gram-positive iatrogenic septicaemia?

Answer 23

Platelets- stored at room temperature