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FRACS study > Pharmacology, devices, perioperative care and nutrition > Flashcards

Pharmacology, devices, perioperative care and nutrition Flashcards

1
Q

Smoking cessation

A

At least 3 weeks before surgery

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2
Q

Warfarin

A

Vitamin K antagonist

  • Inhibits factors II, VII, IX, X

Reversal

  • Vit K
  • Prothrombinex 25u/kg
  • FFP
  • Time
    • 3-5/7
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3
Q

Dabigatran

A

Direct Thrombin inhibitor

Half life 12-14 hours in normal renal function

Reversal

  • Praxbind 5g in 2 doses
    • Half life 47minutes
      • but biphasic decay so some efficacy for 10 hours
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4
Q

Rivaroxiban

A

Direct factor Xa inhibitor

Half life 5-9 hours in normal renal function

  • May be longer in older individuals (~12 hours)

Reversal

  • Recombinant factor 10a
  • Dialysis won’t work (high protein binding)

Pre operative cessation

  • Recommend 48-72 hours cessation (the longer for high risk surgery)
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5
Q

Aspirin

A

Irreversible non selective COX inhibitor

Life of a platelet is 7 days

Reversal- Platelet transfusion (but never needed)

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6
Q

Clopidogrel

A

Antiplatelet agent

Irreversible inhibitor of P2Y12

Reversal: none specific

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7
Q

Ticagrelor

A

Antiplatelet agent

Reversible inhibitor of P2Y12

Reversal:

  • specific antidote created, not available
  • High protein binding in plasma
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8
Q

Unfractionated heparin

A

Activates antithrombin III

  • Antithrombin III then inactivates thrombin and factor Xa

Half life- 1-2 hours

Reversal- Protamine

  • 1mg per 100units received in the past 4 hours
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9
Q

Low molecular weight heparins

(Enoxaparin)

A

Antithromin III activator

higher ratio of inactivation of factor Xa (over thrombin) compared with unfractionated heparin

Partially reversible with protamine (the Xa effect is not reversed)

Half life (Enoxaparin)- 4.5 hours

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10
Q

Bowel prep before colorectal surgery

A

There is no strong evidence to support bowel prep in major colorectal surgery

additional considerations:

  • Ease of laparoscopic approach
  • loop ileostomy and leaving a laden colon
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11
Q

Thromboprophylaxis very high risk vs high risk surgeries

What is the recommended duration for anticoagulant thromboprophylaxis for each group

A

Very High- 28-35 days

  • Hip or knee arthroplasty
  • Major trauma

High- 5-10 days

  • Major surgery >40 years
    • Major surgery defined as any surgery >45 minutes OR any intrabdominal surgery
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12
Q

VTE in pregnancy and puerparium

A

Increased risk

Continue VTE for 4/52

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13
Q

Recommendations on the use of oestrogen preparations in the perioperative period

A

These increase the VTE risk

  • OCP should be stopped pre op
    • alternative methods of contraception should be advised
  • HRT should be stopped for 6/52 at least
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14
Q

NSAIDS in anastomoses

A

Multiple studies with conflicting results

Effect is small if at all present

Effect on pain is also probably minimal

“my approach is a single dose of long acting NSAID given intraoperativey and then discontinued”

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15
Q

Post op NG tubes

A

Remove in theatre all but those for oesophageal surgery

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16
Q

Assessing perioperative risk:

Severity of surgery

A

NICE surgical severity grading

Grade 1

  • Endoscopy
  • Vasectomy
  • dental
  • Skin

Grade 2

  • Heamorroidectomy
  • Varicose veins
  • Adenoidectomy
  • Reduction of dislocated joint

Grade 3

  • Amputation
  • Mastectomy
  • thyroidectomy
  • Prostatectomy

Grade 4

  • Colectomy
  • Gastrectomy
  • Renal transplant
  • Hip replacement
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17
Q

Assessing perioperative risk:

NELA calculator

A

NELA calculator

  • Age
  • ASA
  • Gender
  • Cardiac
  • Respiratory
  • ECG
  • SBP
  • Pulse
  • WCC
  • Urea
  • Creat
  • Sodium
  • Potassium
  • GCS
  • Operation type (major vs minor)
  • Number of procedures
  • anticipated blood loss
  • peritoneal contamination
  • malignancy
  • Urgency
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18
Q

Assessing perioperative risk

what are the components of the possum score

A

Possum score

  • Age
  • Cardiac
  • Respiratory
  • ECG
  • SBP
  • Pulse
  • Hb
  • WCC
  • Urea
  • Creatinine
  • Sodium
  • Potassium
  • GCS
  • Operation type (minor, moderate, major, complex)
  • Number of procedures
  • EBL
  • Peritoneal contamination
  • Malignancy
  • Urgency
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19
Q

Assessing perioperative risk

ASA

A

Initially five point system (later revised to six)

  1. Normal healthy patient
  2. Mild systemic illness
  3. Severe systemic illness
  4. Severe systemic illness that is a constant threat to life
  5. Moribund patient not expected to survive without the operation
  6. Brain dead, pertinent only in organ harvest
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20
Q

CPEX testing

A

Is the gold standard measure of cardiorespiratory function

Cardiopulmonary exercise testing (CPET) is a dynamic, non-invasive assessment of the cardiopulmonary system at rest and during exercise using a closed respiratory circuit, cardiac monitoring and a variable resistance exercycle

Outcome measures of Anaerobic threshhold, peak O2 consumtion and ventillatory efficiency for CO2 are associated with poor perioperative outcomes

  • An anaerobic threshold (AT) of <11 oxygen.ml/min/kg is associated with an increased risk of perioperative mortality (18% vs <1%)
    • “8 is shithouse, 10 is borderline”
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21
Q

Assessing frailty

A

Edminton frail scale

  • Cognition
  • Hospitalisation
  • independance
  • support
  • meds
  • nutrition
  • mood
  • continence
  • performance of “stand up, walk three meters, turn around and come and sit back down”
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22
Q

Goal directed therapy

A

A principle of balanced resuscitation

Aim is to achieve adequate tissue perfusion without fluid overload of the extravascular compartment

  • Basic parameters are restoration of normal blood pressure, pulse, mentation and urine output.
    • these may not be possible to achieve so surrogate markers of tissue perfusion can be used
      • Echo for estimation of central volume
      • Base deficit
        • Lactic acid consumes base creating a base deficit
      • Lactate level
      • Central venous SPO2
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23
Q

Trauma metabolic phases

A

Ebb

  • Decreased resting energy expenditure
  • Increased glycogenolysis
  • Increased Gluconeogenesis

Flow

  • Increased resting energy expenditure
  • pyrexia
  • increased muscle catabolism and wasting, loss of body nitrogen
  • increased fat breakdown and decreased fat synthesis
  • increased gluconeogenesis and impairment of glucose tolerance
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24
Q

What effects does sepsis have on the metabolism of protein, carbohydrate and lipid

A

Protein: high skeletal muscle breakdown and nitrogen loss

Carbohydrate: hyperglycaemia from increased gluconeogenesis and glycogenolysis

Lipid: decreased peripheral uptake causes hypertriglyceridaemia

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25
Q

Hypoglycaemia in sepsis

A

Conveys very poor prognosis, usually associated with mortality

Sepsis disrupts the inner membrane of hepatocyte mitochondria

  • resultant marked decrease in aerobic metabolism of carbohydrate and fatty acids
  • metabolism relies on anaerobic glucose metabolism.
  • hypoglycaemia results from loss of glycogen reserves without adequate gluconeogenesis commencing- a late sign of hepatic dysfunction
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26
Q

Protein RDI

A

0.8g/kg/day

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27
Q

What are the three most improtant “non essential” amino acids in sepsis

A

Alanine

Glutamate

Aspartate

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28
Q

Metabolic energy by substrate

A

Fat- 39kJ/g

Glucose- 17.1kJ/g

Protein- 17.7kJ/g

Alcohol- 29.7 kJ/g

29
Q

kcal per kJ conversion

A
  1. 2 kcal per kJ
  2. 24 kJ per kcal
30
Q

What is the baseline resting metabolic expenditure?

what is the goal nutrition rate in critical illness

A

25-30kcal/kg/day

105-125kJ/kg/day

This is the goal rate of nutrition in critically unwell patients but should not be given in the first week as it may worsen outcomes.

8-10kcal/kg/day (34-42kJ/kg/day) is used for initial feeding in critically unwell patients

31
Q

Additional metabolic energy requirements in disease states

A
32
Q

Nutritional assessment

A

Historically divided into:

  • Anthropometric
    • BMI
    • sub cut. fat thickness
    • bioelectrical impedance
  • Biochemical
    • albumin
    • urinary nitrogen losses
  • Function
    • immune competence
      • low WCC
    • muscle function
      • grip strength

All combined maybe of some use in assessing perioperative risk but not reliable for nutrition assessment.

The MUST score is endorsed by the NHS for routine use in all hospital admissions

33
Q

Refeeding syndrome

A

A syndrome of fluid and electrolyte shifts in refeeding, potentially fatal

Starvation depletes the normal concentration gradients across membranes

When energy is provided massive electrolyte shifts may occur

Most notably Potassium, phosphate, magnesium

34
Q

What vitamin is crucial to provide prior to refeeding and why

A

Thiamine

Thiamine is an essential cofactor in oxydative phosphorylation of glucose, without thiamine glucose is metabolised to lactic acid

Wernicke-Korsakoff syndrome may occur if not replete before refeeding

35
Q

Thymine vs Thiamine

A

Thymine is a DNA base.

Thiamine is a B vitamin (B1)

36
Q

Effects on the intestine from lack of enteral feeding

A

Loss of height of vili

Loss of cellular proliferation

Mucosal atrophy

Translocation of bacteria and toxins

Lack of hormonal stimulation

37
Q

Elemental diet

A

Used in patients with out normal capacity of enzymatic digestion

  • short gut
  • pancreatic insufficiency
38
Q

Tranexamic acid

A

Synthetic lysine analogue

Antifibrinolytic

39
Q

Apache II score

A

An ICU severity-of-disease classification system (Knaus et al., 1985)

Applied within 24 hours of admission of a patient to an intensive care unit (ICU): an integer score from 0 to 71

higher scores correspond to more severe disease and higher mortality

12 physiological parameters

  1. AaDO2 or PaO2 (depending on FiO2)
  2. Temperature (rectal)
  3. Mean arterial pressure
  4. pH arterial
  5. Heart rate
  6. Respiratory rate
  7. Sodium (serum)
  8. Potassium (serum)
  9. Creatinine
  10. Hematocrit
  11. White blood cell count
  12. Glasgow Coma Scale
40
Q

Perioperative optimisation and specific considerations in cirrhosis

A

Local expertise

  • Anaesthetic
  • ICU
  • Surgical
  • Nursing

Varices

  • Pre operative decompression with shunting

Transplantation

  • Rescue transplantation should be discussed if MELD >15 in case decompensation occurs

Nutrition

41
Q

Steps in a management plan for malignancy

A

Preoperative

  • Complete assessment
    • Stage
    • Nutrition
    • Fitness
  • MDT
  • Optimise
    • Refer to other specialists

Operative

Post operative

  • Psychosocial support
  • Follow up
42
Q

Clindamycin

A

Lincosamide antibiotic

Reversibly binds to 50S ribosomal subunits preventing peptide bond formation thus inhibiting bacterial protein synthesis

Important actions;

  • Bacteriostatic or bacteriocidal depending on organism and concentration
  • Suppresses toxin production
  • Decreases penicillin binding protein production
    • thereby increasing the ratio of beta lactam antibiotic to receptor

Important negatives

  • Relatively high rates of C.diff
43
Q

Suture choice:

Elective laparotomy, fascial closure

A

2-0 PDS on a CT-2 needle

44
Q

Suture choice:

Handsewn bowel anastomosis

A

3-0 PDS on RB-1 or SH-2 needle

45
Q

NTLC staple height:

Blue

A

Narrowest

1.5mm

46
Q

NTLC staple height:

Gold

A

Medium:

1.8mm

47
Q

NTLC staple height:

Green

A

Widest

2.0mm

48
Q

Choice of stapler device:

Ileotransverse anastomosis

A

Ethicon NTLC 75 linear cutting:

Blue or Gold firing depending on tissue thickness

Ethicon TX60 linear non cutting:

Blue

49
Q

Stapler choice: Division of rectum

A

Ethicon Contour.

Green load

50
Q

Choice of stapler:

Stapled colorectal anastomosis

A

Ethicon ECS 29

(also available in 21,25,33mm)

51
Q

Tachyphylaxis

A

Rapidly diminishing response to successive doses of a medication

  • e.g somatostatin analogues (SSA) in carcinoid syndrome
52
Q

What is PRRT

A

PRRT is the use of radiolabeled somatostatin analogues for the treatment of neuroendocrine tumours

  • 2 agents are available, none in NZ
    • Yttrium- 90 Dotatoc
    • Lutetium-177 Dotatate
      • Lutetium is FDA approved in the USA
  • Several trials have shown survival advantage
  • Continued use of octreotide before, during and after seems to be a standard part of that treatment.

Susceptibility is determided by somatostatin based imaging (PET or scintigraphy)

53
Q

Serious side effects of antithyroid medications

A

Aplastic anaemia

Agranulocytosis

54
Q

What antithyroid medication is used in pregnancy, why not the other one

A

Propylthiouracil is used in pregnancy

Carbimazole crosses the placenta and causes cretinism

55
Q

How does carbimazole work

A

Carbimazole is converted to methimazole

Methimazole inhibits thyroid peroxidase

  • prevents iodination of, and tyrosine coupling to, thyroglobulin
56
Q

How should a patient with a genetic predisposition to cancer be followed up if there are no clear surveillance recommendations

A

Regular follow up with a primary care physician with an interest in genetic disorders and a low threshold for investigation of symptoms where they arise

57
Q

How is weight adjusted for BMI in patients for nutritional goals of enteral and parenteral nutrition

A

BMI 18.5-30 should use current weight.

in obesity weight should be calculated as Ideal Body Weight (IBW) + 0.4x excess body weight

58
Q

What is the role and rationale for protein provision in enteral and parenteral nutrition in critical illness

A

There is no evidence that early provision of protein improves outcomes.

Protein is provided in the hope that it may prevent muscle catabolism

carbohydrate is the dominant energy source in critical illness

  • fat metabolism is impaired
59
Q

How might haemostatic agents be grouped

what are examples of each

A

Passive Topical

  • oxidised regenerated cellulose based
    • SurgiCel
    • SurgiCel fibrillar
  • gelatin based
    • Gelfoam

Active topical

  • thrombin impregnated gelatin
    • Floseal
  • fibrin and thrombin sealants
    • Tisseel

Systemic agents

  • antifibrinolytic
    • tranexamic acid
  • activation of extrinsic pathway
    • Novoseven (recombinant activated factor VII)
      • use only in trials or in established factor VII deficiency
        • possible use for reversal of rivaroxiban/apixaban
60
Q

Floseal

A

Gelatin matrix with thrombin impregnated

active topical haemostatic agent

mixed and prepared in the operating room

61
Q

Tisseel

A

Active topical haemostatic sealant agent

pooled human plasma compound, stored frozen

contains thrombin, fibrin, antifibrinolytic agents, factor XIII

62
Q

SurgicCel

A

passive topical haemostatic gauze

Oxidised regenerated cellulose product

promotes activation of the bodys normal coagulation cascade and a site for platelet adherence

63
Q

SurgiCel Fibrillar

A

passive topical haemostatic fleece

oxidised regenerated cellulose product

promotes activation of the bodys normal coagulation cascade and a site for platelet adherence

64
Q

PerClot

A

Topical passive haemostatic powder

absorbent plant starch

activation and concentration of platelets and coagulation factors

65
Q

Bioglue

A

Two component surgical adhesive

Purified bovine serum albumin and glutaraldehyde

66
Q

Basics of radiation safety

A

The portable x-ray machine is comprised of 2 components

  • the columnator
    • generates the x-rays
  • the image intensifier
    • receives the image
  • patient should be positioned as close to the intensifier as possible

the dose of radiation received is subject to the inverse square law

  • intensity = 1/distance2​
  • this applies to the patient and staff

As an operator

  • always ensure PPE
  • ensure all staff do the same
  • wear a dosimeter
  • wear x-ray eye protection
67
Q

late complications of bariatric surgery

A

Anaemia

  • B12 defiency due to no intrinsic factor
  • Iron defiency due to high pH

Osteoporosis

  • bypass of duodenum causes loss of calcium and vitamin D absorption

Weight loss

  • inadequate weight gain and maintenance
68
Q

Fogarty catheter sizes

A

The size of a fogarty catheter is measured by the inflated balloon in the french system

  • in the range of these catheters the inflated balloon size in mm is approximately twice the french size

FRACS study (13 decks)

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