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Year 3 - Anaesthetics and Perioperative Medicine > Post-operative > Flashcards

Post-operative Flashcards

1
Q

What is early postoperative fever likely to be due to?

A

Early postoperative fever (within the first 24 hours after surgery) is most likely to be due to the systemic inflammatory response to surgical trauma.

–> symptom management e.g. antipyretic

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2
Q

If a patient still has a fever 4 days post-op, what investigations should you do?

A
  • Take blood cultures
  • Urinalysis for MC&S - UTI can be asymptomatic post-op
  • Clinical resp exam and sputum culture
  • Inspect surgical wound

DO NOT GIVE CEF - routine use of cephalosporins has been shown to increase rates of MRSA + C Diff so should be avoided.

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3
Q

What are the two types of hypovolaemia in peri-operative patients?

A

Absolute - due to blood loss and preoperative starvation

Relative - due to vasodilating effects of anaesthetic and inflammatory response to surgery

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4
Q

What does low BP in healthy patients signify? What about a slow HR?

A

Hypovolaemia

A slow heart rate is unlikely to be the cause of hypotension unless the rate is very slow (less than 50/min).

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5
Q

If you suspect low BP is due to hypovolaemia what should you do?

A

Elevate the legs - this will increase venous return to the heart and increase stroke volume which in turn increases BP

NB: pain increases BP

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6
Q

What is the equation for:

  • MAP
  • pulse pressure
A

Mean arterial blood pressure (MAP) = diastolic pressure + 1/3 (pulse pressure)

Pulse pressure = systolic pressure–diastolic pressure

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7
Q

Why is MAP important?

A

MAP is considered to be a useful number to represent the perfusion of organs. MAP above 60 is required to sustain adequate organ perfusion in a fit patient. Patients who are hypertensive may require a higher MAP.

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8
Q

What dose of morphine should you start with?

A

10mg ampules - start with this in case you start respiratory depression.

1-2mg for an elderly person

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9
Q

Causes of illeus.

A
  • peritonitis
  • electrolyte abnormalities
  • opioid medication (so shoudl give epidural for a laparotomy)
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10
Q

What is atelectasis?

A

Alveolar collapse - may be caused by lying on our backs when sleeping. Collapses the bases of the lung.

Things that increase this are pain (–> splinting of the diaphragm)

Giving 100% oxygen can cause atelestasis quickly - nitrogen usually fills alveoli but is not absorbed across the membrane but oxygen is

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11
Q

When giving 40kPa of oxygen to a patient and their kPaO2 is 13 is this good?

A

They should have a kPa of about 30 so they are actually hypoxic.

You should never interpret the kPa of oxygen on ABG without knowing how much oxygen they are getting.

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12
Q

Why is metformin often stopped pre-op?

A

Can cause a lactic acidosis.

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13
Q

What is the difference between sedation and general anaesthesia?

A

Sedation is a component of general anaesthesia. The patient is sleepy but conscious.

In general anaesthesia, the brain is “switched off” and the patient is unconscious.

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14
Q

What parameters are measured in recovery? (NEWS)

A

NEWS: - if a patient deteriorates use SBAR

  1. Resp rate - assess airway, resp rate/regularity/symmetry. Look out for respiratory depression.
  2. Oxygen saturation - should be >95% unless lung disease
  3. Temperature - Bair Hugger if cold, antipyretics if too warm. Monitor as drop could mean bacterial infection
  4. Systolic BP - if SBP lowered and tachycardia could mean haemorrhage/shock
  5. HR - tachycardia could mean pain
  6. GCS (take into consideration that they have been sedated)

Also monitor fluid balance.

Observed for signs of :

  • haemorrhage
  • shock
  • sepsis
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15
Q

What are the NEWS score ranges for low, medium and high risk?

A
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16
Q

How often should you monitor a patient with a NEWS score between 0 and 4?

A

0 - min 12hourly

1-4 - min 4-6 hourly - inform registered nurse who must assess pt and she can assess need for more frequent monitoring.

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17
Q

How often should you monitor a patient with a NEWS of >4 or 3 in one parameter

A

Min 1hourly monitoring and

  • nurse to inform medical team
  • urgent assessment by clinician with core competencies to assess acutely ill patient
  • clinical care in an environment with monitoring facilities
18
Q

How often should you monitor a patient with a NEWS score >6 and what is the next course of action?

A

Continuous monitoring AND

  • registered nurse to immediately inform medical team caring for pt - this should be an SpR (specialist registrar at least)
  • emergency assessment by clinical team with critical care competencies which also includes practitioners with advanced airway skills
  • consider transfer of critical care to level 2 or level 3 care facility ie. higher dependacy or ITU
19
Q

List the criteria for safe discharge from recovery.

A

Summary: to be discharged from recovery patients must

  • be able to breathe properly without assistance
  • have stable vital signs
  • be awake and orientated (exc children)

Consciousness - patient responds to verbal stimulation, can move all 4 limbs, cough when asked, be easily roused by voice

Respiration - adequate gas exchange, maintain airway, cough and breathe deeply, RR 10-20, SpO2 >95%

Circulation - adequate perfusion of all organs, measure BP + HR, urine output and skin colour/temp. BP should be within 10-20% of pre-op baseline. UO should be 0.5-1ml/kg/hr

Pain control - comfortable+ sedated but still responsive to verbal stimulation; multimodal analgesia should be used; deep breaths, coughing without pain.

N&V - should not return to ward; may be due to drugs

Fluid balance - if significant bleed remain in recovery until further assessment by surgeon and anaesthetist.

Heat conservation - note peripheral and core temperature (shivering with elevated temp could mean infection)

Wound site, drains and dressings - keep them intact and dry. Check pulses.

From: https://www.nursingtimes.net/clinical-archive/public-health-clinical-archive/criteria-for-the-safe-discharge-of-patients-from-the-recovery-room-23-09-2003/

20
Q

When can the patient leave recovery?

A

Once the effects of anaesthesia have worn off and the patient is stable.

This varies from 30mins to several hours depending on their state and the type of procedure done.

21
Q

What types of surgeries are suitable for day case procedures? (give 4 examples)

A

They represent about 70% of all surgery in the UK

22
Q

What criteria must be met for a surgery to be considered appropriate for day case?

A

For a surgical procedure to be considered for day case surgery, it must meet the following criteria:

  • Minimal blood loss expected
  • Short operating time (<1 hour)
  • No expected intra-operative or post-operative complications
  • No requirement for specialist aftercare
23
Q

List 5 points on the discharge criteria for day cases.

A

Discharge Criteria – all criteria should be met

  • Vital signs stable for at least one hour
  • Correct orientation as to time, place and person
  • Adequate pain control and has supply of oral analgesia
  • Understands how to use oral analgesia supplied and has been given written information about these
  • Ability to dress and walk where appropriate
  • Minimal nausea, vomiting or dizziness
  • Has at least taken oral fluids
  • Minimal bleeding or wound drainage
  • Has passed urine (if appropriate)
  • Has a responsible adult to take them home
  • Has agreed to have a carer at home for next 24 hours
  • Written and verbal instructions given about postoperative care
  • Knows when to come back for follow up (if appropriate)
  • Emergency contact number supplied
24
Q

What is the difference between HDU and ICU?

A
  • HDU has one nurse for every 2 patients
  • ICU has one nurse per patient
25
Q

What are the levels of adult critical care services?

A

Level 0 - normal acute ward care

Level 1- acute ward care, with additional advice and support from critical care team

Level 2 - more detailed observation or intervention - HDU (they may have single failing organ system or require post-op care)

Level 3 - advanced respiratory support alone, or basic respiratory support together with support of at least 2 organ systems. For complex patients requiring support for multi-organ failure.

26
Q

What does SBAR stand for?

A
27
Q

Describe the anaesthetic handover to recovery.

A
28
Q

What is sepsis?

A

Infection and 2 or more of…

  • temp
  • HR
  • RR
  • WCC
29
Q

If you suspect sepsis what are the steps you should take within 3 hours?

A

Give 2 take 2

1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L “Time of presentation” is defined as the time of triage in the emergency department

30
Q

If you suspect sepsis what 3 additional steps should be taken within 6 hours?

A

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) ; maintain a mean arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion.
7. Re-measure lactate if initial lactate elevated.

31
Q

How is oxygen prescribed? What are the modes of delivery?

A

Prescribing as below

Modes of delivery:

  • Nasal cannulae
  • Facemask - Hudson, Venturi
32
Q

What are the goals of oxygen therapy? (4) How is it monitored?

A
  1. Relieve hypoxaemia + maintain tissue oxygenation - assessed by SpO2/SaO2 and clinical signs (NEWS2)
  2. Reduce work of breathing e.g. CPAP.
  3. Prevent excess CO2 accumulation - done by appropriate flow rate and delivery device selection
  4. Ensure adequate clearance of secretions and limit adverse effects of hypothermia and insensible water loss by use of optimal humidification (depends on mode of dleivery)
33
Q

What % oxygen can nasal cannulae deliver? When is it used?

A
  • Deliver 24-30% oxygen
  • Flow rate is 1-4L/min
  • Used in non-acute situations and mild hypoxia
34
Q

How much oxygen is delivered by Hudson mask?

A
  • Delivers 30-40% oxygen
  • Flow rate 5-10L/min
35
Q

How much oxygen is delivered by Venturi mask? What are the flow rates? When are they often used?

A
  • Delivers 24-60% oxygen
  • Different colours deliver different rates
  • Flow rate: varies with colour
  • Often used in COPD
36
Q

When is a non-rebreather mask used? How much oxygen does it deliver?

A
  • Used for acutely unwell patients
  • Delivers 60-90% oxygen
  • 15L/min flow rate
  • valve stops rebreathing of expired air
37
Q

What are the two types of non-invasive ventilation?

A

CPAP - continuous positive airway pressure

BiPAP - bilevel positive airways pressure

38
Q

Describe CPAP. When is it used?

A

CPAP (continuous positive airways pressure)

  • High pressure oxygen with tight-fitting mask
  • Positive pressure all the time (to splint airways open)
  • Used in type 1 respiratory failure (hypoxia) e.g. pulmonary oedema/OSA
39
Q

Describe BiPAP. When is it used?

A

BiPAP (bilevel positive airways pressure)

  • High positive pressure on inspiration and lower positive pressure on expiration
  • Used in type 2 respiratory failure e.g. COPD exacerbation
40
Q

Post-operative complications: explain the assessment and management of post-operative complications,including

  • pain
  • tachycardia
  • hypotension
  • low urine output
  • confusion
  • low oxygen saturation
  • reduced conscious level
A
41
Q

What is the pain relief ladder?

A

Year 3 - Anaesthetics and Perioperative Medicine (12 decks)

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