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7118 - Clinical Therapeutics for Core Conditions > Pharmaceutical Care in General Surgery > Flashcards

Pharmaceutical Care in General Surgery Flashcards

1
Q

What do surgeons use to stain glands in thyroid surgery

A

methylene blue

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2
Q

What adverse effect can methylene blue cause

A

serotonin toxicity - Needs to be highlighted if patients are taking other serotinergic drugs that carry the same risk e.g. anti-depressants.

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3
Q

potential complications of thyroidectomy or parathyroidectomy?

A

thyrotoxic crisis, hypothyroidism, hypoparathyroidism, recurrent thyrotoxicosis

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4
Q

If a patient has thyroidectomy for example what pharmaceutical issues can we think about?

A
  • stop cinacalcet
  • review bisphosphonate
  • start thyroxine, Ca, Vit D - depends on biochemistry results
  • Review the possibility of chelation of Ca with other meds
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5
Q

If a patient has lymph nodes removed under armpits what sort of things should we think about?

A
  • risk of lymphodema & patient cannot have injectables into that arm
  • review IV meds as now limited access to one arm
  • lifestyle education - cuts or graze may be at increased risk of infection
  • review duration of tamoxifen and anastrozole.
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6
Q

Hepatobilary surgery involves

A

liver, gallbladder, bile ducts and pancreas

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7
Q

ERCP

A

Endoscopic retrograde cholangiopancreatography - This is usually a diagnostic procedure however they can widen the gallbladder to allow stones to go through.

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8
Q

Gall stones cause….

A

bilary colic, cholecystitis and if they migrate to the common bile duct can lead to jaundice, cholangitis and pancreatitis.

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9
Q

cholecystectomy is

A

removal of the gall bladder

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10
Q

Procedure specific pharmaceutical interventions for cholecystectomy may be….

A
  • stop ursodeoxycholic acid
  • stop meds for binary colic e.g. hyoscine butyl bromide
  • check cholesterol and consider if lipid lowering therapy is required (although some can actually cause gallstones) GP can initiate this.
  • Lifestyle advice - weight loss and exercise, diet low in saturated fats, good control of T2DM
  • oestrogen preparations have also been known to cause gallstones so these may need to be removed.
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11
Q

Pharmaceutical considerations post gastrectomy for example

A
  • PPI’s would be stopped. no use. Depending on the UGI procedure they may be increased or decreased.
  • Eratic drug absorption as drugs not in the stomach for a long time.
  • NG placement? for drugs or drainage only
  • swallowing problems - liquids
  • Vit B12 injections - will need if antrum is removed since this releases intrinsic factor which is needed for B12 absorption.
    lifestyle - alcohol, smoking, eating little and often
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12
Q

What part of the bowl is an ileostomy/jejunostomy

A

the formations of a stoma from the small intestine.

indicated for chrons disease or ischemic bowel disease

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13
Q

colectomy is

A

removal of the colon/large intestine

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14
Q

Things to think about in ileostomy/jejunostomy

A
  • loperamide prescribed PRN for when stoma starts to function incase of loose stool (inpatient and on discharge)
  • if short bowel and high output then review all medicines in light of absorption issues
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15
Q

Things to consider post low gastric surgeries

A

cancer - VTE prophylaxis

IBD - review medicines - is rectal route still available?

colectomies - lactulose needed few days post op

Review meds that may drive stoma output e.g. laxatives or pro kinetic

nutrition and lifestyle

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16
Q

cystoscopy

A

to investigate haematuria, loss of bladder control, urinary blockage and growth.

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17
Q

TURP

TURBT

A

transurethral resection of prostate

transurethral resection of bladder tumour

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18
Q

When is it best for patients to have mitomycin in a bladder tumour

A

within 24 hours

not ok for all patients - may go through bladder lining and into systemic circulation

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19
Q

Angioplasty

A

Revision of blood vessels, widens narrowed or obstructed vessels. Balloon inflates and pushes plaque into the wall. A stent may also be placed.

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20
Q

Femoral popliteal bypass

A

bypass graft from the blocked artery to allowed blood o flow though
Indicated to treat acute limb ischemia. allows blood to bypass a blocked artery.

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21
Q

Carotid endarterectomy

A

indicated to treat atherosclerosis and reduces risk of stroke/TIA
Remove plaque from artery feeding the brain

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22
Q

AAA repair

A

Abdominal aortic aneurism
- Aorta is the main artery carrying blood to the rest of the body. Usually symptomless however if it ruptures it can be fatal. If it is less that 5cm it is usually ok. If it is greater than 5cm then needs to have surgery.
One method is the part with the aneurism is removed and graft inserted.

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23
Q

Pharmaceutical interventions for vascular procedures

A
  • bleeding risk higher with vascular surgery. Re-assess ate assessment every day post op.
  • infection risk with stent insertions - micro plan?
  • in case of angioplasty and carotid endarterectomy - is there any long term secondary prevention e.g. statin or aspirin?
  • lifestyle advice - smoking, BP, reduce cholesterol
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24
Q

Orthopaedic surgery - pharmaceutical concerns

A
  • smoking - delays wound healing and pt won’t be very mobile consider NRT.
  • Trauama vs pathological - pathological will need Ca and Vit D
  • Any implants or metal plates - do they need ABX cover?
  • VTE prophylaxis
  • NSAIDS indicated? some trusts say no due to effect on bone healing. PPI cover if so?
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25
Q

ASA score

A

physical status of a patient prior to surgery.
1 being healthy
5 would not survive 24 hours without the op

26
Q

when is it best to give prophylactic ABX before surgery

A

30 mins prior to skin incision.

>3 hours after makes it less effective

27
Q

why are patients NBM before surgery?

A

risk of regurgitation of stomach contents when under aesthetic which can cause aspiration pneumonia.
Todd should be stopped 6 hours pre-op. Pt may take oral tabs with water.

28
Q

how long should anti-platelet be stopped prior to surgery

A

7/7

29
Q

How long before surgery should warfarin be stopped and what INR so we like to see

A

3-4 days pre surgery

<1.5

Then treatment dose LMWH when INR <2-2.5 then stop this 24 hours pre op

30
Q

Drugs to stop pre-op….

A
  • loop diuretics - omit morning of op - risk of dehydrations, full bladder and hypotension is continued. Monitor for worsening heart/renal failure
  • potassium sparing diuretics - omit morning of up - risk of hyperkalaemia if renal perfusion impaired or tissue damage if continued. Monitor for worsening HF or ascites whilst withheld
  • ACE- ARB - discontinue 12-24 hours pre-op - evidence of profound hypotension on induction of anaesthesia REL (ramipril, enalapril and lisinopril) stop 24 hours pre-op.
  • MAOI’s - serious anaesthetic drug reactions. stop 2 weeks before
  • herbal remedies - 2 weeks pre-op. lack of evidence. Garlic, ginseng and ginko may increase the risk of bleeding.
    Ginseng may also cause hypoglycaemia
    Valarian - sedative effect
    st johns wort - drug interactions
31
Q

Drugs which are continued pre-op….

A
  • beta-blockers - reduced cardiac morbidity and mortality if continued due to post op complications such as HTN, AF, TIA, stroke. rebound effects if withdrawn such as tachycardia, MI, arrhythmia, sudden death.
  • Statin - stopping may cause rebound pro-thrombotic effect hence are usually continued.
  • TCA’s - continue with caution. risk of cardiac effects.
  • SSRI’s - withdrawal symptoms common if stopped. risk of serotonin syndrome with pethidine, tramadol etc.

Steroids - depends on route. patients on long-term systemic steroids are likely to have impaired adrenocorticol response to stress. steroids must be continued and then the dose increased in the immediate post-op period. abrupt withdrawal can cause acute adrenal insufficiency, hypotension or death.

32
Q

What oral diabetic drug can be continued as normal

A

pioglitazone

33
Q

What oral diabetic meds should be omitted if the patient is fasting?

A

metformin, acarbose, sulphonylureas, repaglinide/nateglinide

34
Q

What oral diabetic meds should be omitted day of surgery?

A 
DPP4 inhibitors (gliptins)
GLP-1 analogues  (liraglutide, taspoglutide)
35
Q

What do we do with metformin if patient is receiving contrast media and eGFR <50ml/min

A

stop days of procedure and for the next 48hours

36
Q

VRII includes

A

glucose
insulin
potassium

37
Q

Which area of the hospital is a documented risk factor for VTE prophylaxis?

A

Critical Care

38
Q

Does appendectomy require prolonged VTE prophylaxis post discharge?

A

No

39
Q

List contra-indications to picolax (bowel prep)

A
  • congestive heart failure
  • ileus
  • acute appendicitis
  • concomitant diuretics
  • active inflammatory bowel disease
40
Q

How many hours should a patient be help NBM before an op?

A

6 hours

41
Q

True or false

A PPI may be prescribed to reduce the risk of pulmonary aspiration?

A

True

42
Q

what is the WHO pain ladder

A

mild pain - non opioid with/without adjuvant

mild-mod = opioid plus non-opioid (e.g. para) with or without adjuvant

mod - severe = opioid plus non opioid with to without adjuvant

43
Q

When a patient has a PCA how often should we monitor ops?

A

every hour for four hours and then every four hours after that

44
Q

what shall we make sure is always prescribed for a patient who is receiving a PCA?

A

oxygen

45
Q

What do epidurals contain and what benefits do they have over PCA’s?

A

bupivacaine +/- opioids

  • improved analgesia
  • improved respiratory and lung function
  • less nausea and vomiting
  • no significant depression of conscious level
  • lower DVT rates
  • better wound perfusion
  • better compliance with dressing, physiotherapy and treatments,
  • opioids used as adjuvant therapy hence lower doses required via epidural so patients experience a lower incidence of opioid related side effects such as sedation, nausea and vomiting and prolonged ileus
46
Q

What risks come with epidurals

A

local anaesthetic toxicity can cause refractory cardiac arrest.

a lipid emulsion such as intralipid 20% can be used as rescue therapy.

Epidurals also carry risk of spinal haematoma which can result in permanent paralysis. Anticoagulants and anti platelets need to be reviewed in this context.

47
Q

LMWH prophylaxis timing with epidural catheter

A

wait at least 12 hours after last dose to insert and wait 4 hours for next dose after removal

48
Q

Warfarin and timing with epidural catheter

A

INR should be less than 1.5 when the epidural is inserted/removed.

49
Q

clopidogrel/aspirin/dipyridamole with epidural

A

epidural should be avoided in pt who recently taken clopidogrel

epidural is fine with pt on aspirin or dipyridamole

50
Q

Apfel score to predict pt N&V

A

Female = 1
motion sickness/ pre PONV = 1
non-smoker = 1
post op opioids = 1

0=10%
4=80%

51
Q

Potential causes of constipation post-op

A
  • immobility
  • dehydration
  • changed in diet
  • electrolyte imbalance (low K, low Mg, high Ca)
  • opioid use
  • general anaesthetic
52
Q

What is post op ileus and what are its symptoms?

A

it is a predictable delay in gastrointestinal motility that occurs after abdominal surgery.

symptoms include:

  • belching
  • abdominal distention
  • abdominal discomfort
  • constipation
  • lack of flatulence
  • N&V especially after oral intake
  • May be accompanies my faecal vomiting in some cases
53
Q

How do we diagnose and treat post op ileus?

A

IT is diagnosed by CT scan and should be done so and treated quickly as it can cause bowel perforation or peritonitis.

Make pt completely NBM (not even meds like pre-op)

Pro kinetics used - metoclopramide, domperidone, erythromycin

Hiccups are a tell-tale sign of files developing. Whilst they can be treated with haloperidol 1.5mg TDS or chlorpromazine 25-50mg TDS it is prudent to inform surgical team if pt complains of hiccups.

54
Q

Is vascular pain a type of neuropathic pain?

A

Yes

55
Q

How does the frequency of IV paracetamol change if patients eGFR <30ml/min

A

Reduce frequency to 6 hourly rather than 4 hourly

56
Q

Amitriptyline is C/I in pt with history of MI

A

True

57
Q

Which NSAID is said to have the best cardiac safety profile?

A

Naproxen

58
Q

Which is more constipating? ondansetron or cyclizine?

A

ondansetron

59
Q

Can prochlorperazine be given both IM and IV?

A

No just IM

60
Q

When should an epidural be taken down ?

A

About 24-48 hours after oral analgesia has been started

7118 - Clinical Therapeutics for Core Conditions (31 decks)

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