Perioperative medical management

Question 1

What drug type most commonly causes anaphylaxis in surgery? Specific drug?

Answer 1

Antibiotics

Teicoplanin

Question 2

What agent is second most likely to cause anaphylaxis?

Answer 2

Chlorhexidine

Question 3

Define malignant hyperthermia? What causes it?

Answer 3

progressive, life threatening hyperthermic reaction causing tachycardia, increased HR, sweating, increase end tidal volume
Triggered by volatile anaesthetic gas or suxamethonium

Question 4

What is the presentation of malignant hyperthermia? If it is left untreated what happens?

Answer 4

Increased HR
Sweating
Increased temperature
Increase end tidal volume
Muscle rigidity
Untreated then increased metabolic rate leading to hypercapnia, increased muscle breakdown, acidosis, hyperkalaemia, arrhythmia, cardiac arrest

Question 5

What is the treatment for malignant hyperthermia?

Answer 5

Dantrolene

Question 6

What type of drug is suxamethonium

Answer 6

Muscle relaxant

Broken down very quickly, fast acting

Question 7

What breaks down suxamethonium?

Answer 7

plasma cholinesterase

Question 8

What genetic abnormal physiology can lead to a personal suffering suxamethonium apnoea?

Answer 8

Due to change in cholinesterase structure meaning the drug isnt broken down for a prolonged period

Question 9

Define post operative nausea and vomiting?

Occurence overall in patients? in high risk?

Answer 9

Any nausea of vomiting up to 48 hours post op

Occurs in 30% of all patients and 80% of high risk

Question 10

3 patient associated risks to developing post operative nausea and vomiting?

Answer 10

Female
Non-smoker
Decrease risk with increase age

Question 11

Give 4 anaesthetic related risks and 3 types of surgeries that are more likely to suffer post operative nausea and vomiting?

Answer 11

Volatile anaesthetic use
NO
Perioperative use of opioids
Duration of surgery
ENT, gynae and opthalmology

Question 12

What anaesthesia methods can you put in place to reduce the chances of post operative nausea and vomiting?

Answer 12

Use an neuraxial anaesthetic

Total IV anaesthetic (propofol infusion)

Question 13

What is Total IV Anaesthetic and why is it useful in combating post operative nausea and vomiting?

Answer 13

Propofol
Short acting
Decreases consciousness and limits memory

Question 14

What 3 antiemetics are used first line in post operative nausea and vomiting and what receptors do they act on?

Answer 14

Ondansetron (serotonin antagonist)
Dexamethasone (corticosteroid)
droperidol (dopamine antagonist)

Question 15

What 4 antiemetics are used second line in post operative nausea and vomiting? what receptors do they act on?

Answer 15

Cyclizine (Histamine antagonist)
Metaclopromide
Prochlorperazine (D2 receptor antagonist)
Hyoscine (mAch receptor antagonist)

Question 16

Which antiemetic should not be used in Parkinsons?

Answer 16

Dopamine antagonists - droperidol

Question 17

What is the major side effect of serotonin receptor antagonist anti-emetics?

Answer 17

QT prolongation and potential torsades de pointes

Question 18

what 4 receptors can be found in the vomiting centre?

Answer 18

Histamine
Serotonin
Dopamine
Acetylcholine

Question 19

What monitoring is need post operatively?

Answer 19

HR/BP - any MI?
RR, WOB, O2 sats - any post oper pulmonary complications?
Fluids - any ongoing losses? electrolytes replacement needed?

Question 20

What do you want to try and remove ASAP after surgery?

Answer 20

Remove drains, NG and catheters ASAP

Start oral fluids ASAP

Question 21

Importance of analgesia post op?

Answer 21

Allows quicker return to baseline functioning, increase oral intake, mobilise sooner

Question 22

Importance of mobilization early post op? How can you do this?

Answer 22

Maintains muscle strength and joint mobility, less VTEs, less PPCs
Encourage deep breathing, incentive spirometry, chest physio, mobilise with physio

Question 23

Why is post operative nutrition important? What can dietician advice on?

Answer 23

Important to prevent catabolism state with muscle breakdown and weight loss, wound dehiscence
Dietician - do they need TPN? NG? prevent re-feeding syndrome.

Question 24

Simple interventions you can put in place post operatively to ensure no complications occur?

Answer 24

Early mobilisation
Nutrition
Monitor for sepsis 
VTE prophylaxis
Prevent skin breakdown

Question 25

What does enhanced recovery after surgery refer to?

Answer 25

Protocols that are put in place perioperatively in order to decrease hospital stay, rates of readmission and time to full recovery
Multimodal perioperative care pathways

Question 26

How is ERAS fulfilled both pre, intra and post op?

Answer 26

Pre op = organ function maintained, analgesia, nutrition, counselling, carb drinks
intra op = Standardised anaesthetic, analgesia pathway, actively warmed above 36 degrees, conservative IV fluids
Post op = nutrition, remove drains/NG, early mobilization, analgesia that is opioid sparing

Question 27

What type of nutrition is given to patients pre op and how does this help post operatively?

Answer 27

Carbohydrate filled drinks which help reduce post op nausea and vomiting, pain and diarrhoea as well as wound dehiscence

Question 28

Why are conservative IV fluids intraoperatively part of the ERAS pathway?

Answer 28

Every litre of fluids used increases the hospital stay by 24 hours