Post Operative Flashcards
What kind of electrolyte disturbance occurs when accessive amount of sodium chloride is replaced
Hyperchloraemic acidosis that’s why R/L is preferred
Which type of fluid can cause acute renal injury
Dextran 70
Cryo precipitate is trans fused how
As 6 unit pool
Constituents of cryoprecipetate
Factor VIII
Fibrinogen
von Willebrand factor
Factor XIII
Suxamethonium may cause
Malignant hyperthermia
Hyperkalemia
Muscular pain
Prolonged apnea
Names of depolarizing and nondpolarizing muscular relaxence
D: Suxamethonium
Non D: Atracurium,Vecuronium, Pancuronium and Rocurunium
Quickest onset muscular relaxant
Suxamethonium
Suxamethonium can be used in
Rapidl intubation
Short procedures
Atracurium vs Vecuronium
A is not cleared by liver or kidney
V does
Atracurium Side effects
Histamine release and allergic reactions
Which non depolarising drug used for rapid intubation
Rocurunium as it’s reversedby suggamedex which is widely available
Which drug reverses effect of nondepolarusing drug effects
Neostgmine
ward based analgesianot working then whatto do for metastatic disease of spine
Radiotherapy for lumbar spine
Side effects of spinal anaesthesia include:
hypotension, sensory and motor block, nausea and urinary retention.
preferred option analgesic post op major surgeries
Epidural
preferred technique analgesia when extensive laparoscopic abdominal procedures are performed
Transversus Abdominal Plane block (TAP)
Clearance of morphin versusPethidine
M bby liver
P by kidney
Rx of neuropathic pain
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid morphine)
Clopidogrel should be stopped before surgery around
stopped around 5-7 days prior to surgery
Dose of Clopidogrel
75mg
Clopidogrel MOA
decreases ADP induced platelet aggregation persisting for 120 hours after the final dose
Which anaesthetic has strongest antiemetic properties
Propofol
muscle relaxants is an agent that is degraded by hydrolysis and may produce histamine release?
Atracurium
Which muscle relaxants is least likely to result in histamine release?
Vecuronium and suxamethonium
Which inotrope can be guven via the peripheral intra venous route in the non cardiac arrest setting?
Metaraminol is an alpha receptor agonist
A patient with locally advanced pancreatic cancer has persistent back pain
Rx
Pancreatic cancer can cause severe pain as a result of retroperitoneal nerve infiltration. It can be managed with chemical neurectomy/ nerve blocks.
Improve
Wh8ch anaesthetic agents has the strongest analgesic effect?
Ketamine
agent of choice for rapid sequence of induction
Sodium thiopentone
Side effects of neostigmine
Bradycardia thus atropine is given simultaneously
First line management of neuropathic pain in patients with orthostatic hypotension
pregabalin not amitriptylline as ami has a side effect of Ietho hypo
If diabetic neuropathic pain
Duloxetine
Orchidopexy
Pain relief through
Caudal block
Immediate pain reliefost hemmoidectomy
Caudal block
Which anesthetic is hepatotoxic
Halothane
adrenocortical depression by which anesthetic agent
Etomidate
Which anesthetic is used in neurosurgical procedures
Sodium thiopentone
agent of choice for rapid sequence of induction
Sodium thiopentone
Marked myocardial depression may occur by which anesthetic agent
Sodium thiopentone
dissociative anaesthesia resulting in nightmares caused by
Ketamine
Why we should avoid excessive IV fluid during surgery
Can cause ileus
carbohydrate loading drink in enhanced recovery program should be given
carbohydrate loading drink is given 2 hours pre procedure.
first line investigation vs gold standard for PE
CTPA 1st line
Gold standard is pulmonary angiography
Which artery can be missed by CTpa
peripheral emboli affecting subsegmental arteries may be missed
ARDS
bilateral pulmonary infiltrates
severe hypoxemia (PaO2/FiO2 ratio < 200) in the absence of evidence for cardiogenic pulmonary oedema
Capillary wedge pressure <18
Stages of ARDS
Early stages consist of an exudative phase of injury with associated oedema.
Later stage is one of repair and consists of fibroproliferative changes. Subsequent scarring may result in poor lung function
Causes of ARDS include
Sepsis
Direct lung injury
Trauma
Acute pancreatitis
Long bone fracture or multiple fractures (through fat embolism)
Head injury (causes sympathetic nervous stimulation which leads to acute pulmonary hypertension)
only treatment found to improve survival rates in ARDS
Low tidal volume ventilation
Rx of ARDS
Treat cause Like give
Ab if sepsis
Diuretics to get rid of fluids
PEEP, prone ventilation
Low tidal volume ventilation
Pulmonary artery occlusion pressure in ARDS vs pulmonary edema 2° overload
ARDS: Low pressure <5 with edema
Overload: High pressure >18mmHg
Cutfed vs uncuffed ETT
Cuffed prevents air Leaks thus needs to be given where chances of regurg are high
Uncuffed in children to prevent tracheal injury
which airway device can and cannot be used for high pressure ventilation
ETT can
Laryngeal mask cannot
Rx of malignant hyperthermia
Dantrolene - prevents Ca2+release from the sarcoplasmic reticulum
malignant hyperthermia is caused by defect in
Chromosome 19. encoding ryanodine receptor
Acute dystonic reaction is causedby
antipsychotics (haloperidol) and metoclopramide.
marked extrapyramidal effects can be caused by
antipsychotics (haloperidol) and metoclopramide
Serotonin syndrome symptoms
syndrome of agitation, tachycardia, hallucinations and hyper-reflexia.
Benzodiazepines affect on Post operative cognitive impairment
Use of benzodiazepines preoperatively reduces long-term POCD (9.9% vs. 5%)
Drug for post opt cognitive dysfunction
Haloperidol
Complication of TPN
sepsis, re-feeding syndromes and hepatic dysfunction.
Till how much BP surgeries can be performed
There is no evidence to support cancellation when blood pressure is below 180/110 mmHg.
most frequent clinical indications for TPN
•Undergone massive resection of the small intestine
•Who have intestinal fistula
•Who have prolonged intestinal failure for other reasons.
If opioid analgesia is required in a patient with renal impairment
consider using oxycodone or fentanyl rather than morphine
Time taken by morphine to act
Remember, morphine takes approximately 2-3 minutes to work if given intravenously, 20 minutes if taken orally, and 15 minutes if given intramuscularly
Yellow /sulfor granules
Actinomycosis
Rx of acute dystonic reaction
benzhexol and procyclidine
Myoglobinuria and haemolysis result in
Necrosis
aminoglycosides and radiological contrast media induce
apoptosis
Post operative renal failure occurs by which mechanism
tubular cell death
RIFLE Criteria of Kidney injury
Key points : Renal injury and acute renal failure: RIFLE Classification.
R=Risk (Serum Creatinine x1.5)
I=Injury (Serum Creatinine x 2)
F=Failure (Serum Creatinine x3)
L=Loss (Loss of renal function >4weeks)
E=End stage kidney disease
Pro op bowel preparation can cause
post op dehydration
AKI diagnosis
≥50% rise in serum creatinine from baseline within last 7 days
Increase in serum creatinine by ≥26.5mmol/l within 48 hours
Urine output <0.5mls/kg/hour (oliguria) for more than 6 hours
proximal to renal artery aortic clamp applied for too long causes
Renal Artery Stenosis
Nephrotoxic drugs
NSAIDs, ACEi (or ARBs), antibiotics (such as aminoglycosides), or chemotherapy (such as cisplatin
Most imp Postrenal cause of AKI post op
Acute urinary retention
Blocked catheter
pre-renal and intrinsic causes of AKI
Urine specific gravity and osmolality values will be higher in pre-renal causes, whilst urine Na excretion will be lower, due to the kidney actively conserving Na and water in pre-renal cases, compared to intrinsic causes.
Drugs to be potentially stopped: if suspected AKI
ACEi and ARBs
NSAIDs
Aminoglycoside antibiotics
Potassium-sparing diuretics (due to increased risk of hyperkalaemia)
How to check whether the ETT is not in esophagus
Check End tidal CO2
highest incidence of PONV in children due to
squint surgery
which surgeries have greater risk of post-op nausea
Intra-abdominal laparoscopic surgery
Intracranial or middle ear surgery
Gynaecological surgery, especially ovarian
Squint surgery
Anesthetic causes of PONV
Opiate analgesia or spinal anaesthesia
Inhalational agents (e.g. Isoflurane, nitrous oxide
Which Drug at anesthesia to prevent ‘PONV
Dexa 8mg
Antiemetic drugs in different situations
1. Impaired gastric emptying
2. Bowel obstruction
5. Opiod induced
- prokinetic agent, such as metoclopramide (dopamine antagonist) or domperidone (dopamine antagonist)
- Hyoscine (anti-muscarinic) can help to reduce secretions
- ondansetron (5-HT3 receptor antagonist) or cyclizine (H1 Histamine receptor antagonist)
Brain death criteria
Deep coma of known aetiology.
Reversible causes excluded
No sedation
Normal electrolytes
There are two criteria both required for a diagnosis of sepsis
Presence of a known or suspected infection
Clinical features of organ dysfunction
SOFA score’
is a means by which clinicians can quantify the level of organ dysfunction
What SOFA and qSOFAscore indicates sepsis
score greater than or equal to two indicates sepsis
What is present in q SOFA score
Respiratory Rate ≥ 22/min (1 point)
Altered Mental State (1 point)
Systolic Blood Pressure ≤100mmHg (1 point)
Septic shock
Septic shock is defined as sepsis with hypotension, despite adequate fluid resuscitation or requiring the use of inotropic agents to maintain a normal systolic blood pressure.
Lactate >2
Criteria of ICU shift in sepsis
Evidence of septic shock
Lactate > 4.0mmol
Failure to improve from initial management
Resuscitation goals in sepsis
CVP 8-12mmHg
MAP >65mmHg
Urine output >0.5ml/kg per hour
Superior vena cava oxygen saturation >70%
Normal lactate
Does TPN affects in 1 week
Yes
On TPN
What to perform 6 mont9vs 1 year
Vit D in 6 months
Bone densitometry
If on TPN.
what to check in 2-4 weeks after stable
and 3-6 months
2-4 weeks: Zn, Folate, B12 and Cu levels if stable
3-6months: iron and ferritin levels, manganese
If on home TPN regime then what needs tobe checked apart from others
Magnese in 3-6 months
What tests to perform in unstable TPN patients weekly
Weekly glucose, phosphate, magnesium, LFTs, Ca, albumin, FBC, MCV
Benzodiazepines/ Midazolam reversal by
Flumanezil
antagonises the effects of benzodiazepines by competition at GABA binding sites.
suitable agent for anaesthesia in those who are haemodynamically unstable
Ketamine
Which anesthetic has antiemetic properties
Propofol
Criteria of Malnourishment
BMI < 18.5 kg/m2
unintentional weight loss of > 10% over 3-6/12
BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12
What line of administration for TPN in 14 days vs 30
In 14 give via IJV
In 30 give via subclavian tunnel line
if feed needed > 2 weeks, which pattern of feeding
Cyclical instead of continuous
How to prevent refeedimg syndrome,e
don’t give > 50% of daily regime to unwell patients in first 24-48 hours
Complication of TPN
sepsis, re-feeding syndromes and hepatic dysfunction.
Composition of TPN
glucose, lipids and essential electrolytes,
NO fibers
Which fluid causes ana0hylaxis the most between dextran and gelatin
Dextran 70 the most
outside hospital anesthetic for E R surgery
Ketamine
How to check NG
Aspiration and pH
post pyloric tubes are checked for their placement by
AXR
Gastric feeding via NG vs gastrostomy
NG for < 4weeks
Gastrostomy for >4 weeks
In an ICU patients
How to feed
Continuously for 16 to 24 hours
PEG canbe used after how long post insertion
4 hours post insertion
PEG shouldn’t be removed for how much post insertion
Atleeast 2 weeks
Enteral vs parenteral
Both can be given for Malnourished, Unable to swallow people
Now look for intact GI for absorption
if yes then enteral otherwise parenteral
If delayed gastric emptying post op then Rx is
1St antimotility agents
If this doesn’t work then try post pyloric feeding or parenteral feeding.
Marked Myocardial depression occurs by which anesthetic agent
Na Thiopentone
Which anesthetic is known antiemetic vs emetic
Propofol is antiemetic
Etomidate is emetic
Propofol usage
maintaining sedation on ITU,
total IV anaesthesia and
for daycase surgery
first and most common finding in hyperkalaemia.
Peaked T waves
ECG findings in Hyperkalemia
Peaking of T waves (occurs first)
Loss of P waves
Broad QRS complexes
Ventricullar fibrillation
Pethidine points
is much more lipid soluble than morphine. It produces less biliary tract spasm than morphine.
Can be given IM
Metabolized by liver
Weak opiod vs strong
Codeine and dextropropoxyphene are weak
Morphine is strong
Pyrexia of Unknown Origin (PUO
recurrent fever (>38oc) persisting for >3wks without an obvious cause, despite >1wk of inpatient investigation.
Post operative Pyrexia causes based on days
Day 1-2 – respiratory source (or body’s routine response to surgery)
Day 3-5 – respiratory or urinary tract source
Day 5-7 – surgical site infection or abscess/collection formation
Any day post-operatively – consider infected IV lines or central lines as a source
Post op ileuw caused by
Opiates
Reactive Bleeding
Within 24 hours of operation
Absolute vs relative contraindication of Epidural
A: Coagulopathies
R: INFECTION
Most popu drug in Patient Controlled Analgesia (PCA)
Morphine
Which drugs are Class C controlled substances
Pregabalin and gapapentin
Thus chk for addiction hx before starting it
Airway in long term weaning
Tracheostomy
Which airway Reduces the work of breathing (and dead space)
Tracheostomy
Which airway is used as bridge to more definitive airway
Oropharhngeal airway
If a patientis biting down then which airway
Nasopharyngeal airway
Most common type of hypovolemia
Covert compensated
Covert compensated hypovolemia is which SHOCK
Type 1
Diagnosis of Covert compensated hypovolemia
By urinalysis
Have high urine osmolality and Dec Na concentration
If uncomplicated surgery of abdomen (even colectomy)
When to start oral diet
Within 24 hours if SAFE SWALLOW
When to start oral feeding in uncomplicated abdominal, gynecological and c section
Within 24 hours of operation
Only after fulfilling the oral feeding criteria
Effect on light diet and liquid on anastomosis
Administration of liquid and even light diet does not increase the risk of anastomotic leak.
Thus start feeding 24 hours post op
Airway device used in day case procedure like inguinal repair
Laryngeal mask
Laryngeal mask few points
•In day case surgeries
•Paralysis not required
•Chances of reflux
•Not suitab for high lress ventilation
Which tests for PE are highly sensitive but bad specific
Means if negative then the disease is ruled out
D Dimer
V/Q mismatch
CT for Pulmonary embolism
If negative for PE then no need for MRI
Dosage of midazolam
2-5mg
Midazolam 0elimination by
cytochrome P450 pathway in the liver. I
Best advantage of midazolam
Amnesia
muscle relaxants will tend to incite neuromuscular excitability following administration?
Suxamethonium
Which one is Fastest onset and shortest duration of action of all muscle relaxants
Suxamethonium
Kyphoscoliosis causes which pulmonary disease
Restrictive
Restrictive causes of lung
Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis
Neuromuscular disorders
Worsening renal function plus muddy brown casts
ATN sec to myoglobinuria
ATN with myoglobinuria
If any injury which can raise potassium levels then what anesthetic agent not tongive
Suxamethonium as it can cause hyperkalemia
Which drugs don’t release histamine at all
Suxa
Vecuronium
If any surgical procedure in infants
What to give for pain
Paracetamol
Codeine in neonates
Contraindicated
phosphodiesterase inhibitor
Milirinone
first-line for trigeminal neuralgia
carbamazepine
