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MRSA theory > Post-operative medicine > Flashcards

Post-operative medicine Flashcards

1
Q

What is pulmonary artery occlusion pressure?

A

indirect measure of left atrial pressure, and thus filling pressure of the left heart.

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2
Q

What is a normal PAOP?

A

8-12mmHg

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3
Q

what does low PAOP mean?

A

<5
hypovolaemia

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4
Q

What does low PAOP with pulmonary oedema mean?

A

<5 ARDS

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5
Q

What does high PAOP mean?

A

> 18
overload

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6
Q

What does ASA I mean?

A

No organic physiological, biochemical or psychiatric disturbance. The surgical pathology is localised and has not invoked systemic disturbance

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7
Q

What does ASA II mean?

A

Mild or moderate systemic disruption caused either by the surgical disease process or though underlying pre-existing disease

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8
Q

What does ASA III mean?

A

Severe systemic disruption caused either by the surgical pathology or pre-existing disease

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9
Q

What does ASA IV mean?

A

Patient has severe systemic disease that is a constant threat to life

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10
Q

What does ASA V mean?

A

A patient who is moribund and will not survive without surgery

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11
Q

Which anaesthetic agent is associated with hepatotoxicity?

A

Halothane

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12
Q

How is TPN best administered?

A

Internal jugular vein via central venous catheter

for feeding < 14 days consider feeding via a peripheral venous catheter
for feeding > 30 days use a tunneled subclavian line

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13
Q

Which patients are at risk of malnutrition?

A

eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
poor absorptive capacity
high nutrient losses
high metabolism

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14
Q

which patients are malnourished?

A

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

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15
Q

ECG features in hyperkalaemia?

A

Peaking of T waves (occurs first)
Loss of P waves
Broad QRS complexes
Ventricullar fibrillation

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16
Q

What does TPN contain?

A

glucose, lipids and essential electrolytes, the exact composition is determined by the patients nutritional requirements.

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17
Q

Complications of TPN?

A

sepsis, re-feeding syndromes and hepatic dysfunction.

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18
Q

Pulmonary function tests in obstructive lung disease?

A

FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced (less than approx. 70%)

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19
Q

Pulmonary function tests in restrictive lung disease?

A

FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased (over approx. 70%)

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20
Q

Examples of obstructive lung disease?

A

Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans

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21
Q

Examples of restrictive lung disease?

A

Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis
Neuromuscular disorders

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22
Q

Which muscle relaxant is an agent that is degraded by hydrolysis and may produce histamine release?

A

atracurium

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23
Q

Negative side effects of etomidate?

A

adrenal suppression
Post operative vomiting is common

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24
Q

Complications of using dextran?

A

Dextran 40 and 70 have higher incidence of anaphylaxis than either gelatins or starches

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25
What is typically used to monitor cardiac output?
Swan Genz catheter Swan-Ganz catheter can measure several variables it can be used to calculate: Stroke volume Systemic vascular resistance Pulmonary artery resistance Oxygen delivery (and consumption)
26
MOA of noradrenaline?
alpha agonist
27
Effect of noradrenaline?
Vasopressor action, minimal effect on cardiac output
28
MOA of adrenaline?
α and β receptor agonist
29
Effect of adrenaline?
Increases cardiac output and peripheral vascular resistance
30
MOA of dopamine?
β1 agonist
31
Effect of dopamine?
Increases contractility and rate
32
MOA of dobutamine?
β1 and β2 agonist
33
Effect of dobutamine?
Increases cardiac output and decreases SVR
34
MOA of milrinone?
Phosphodiesterase inhibitor
35
Effect of milrinone?
Elevation of cAMP levels improves muscular contractility, short half life and acts as vasodilator
36
Causes of ARDS?
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)
37
Clinical features of ARDS?
Acute dyspnoea and hypoxaemia hours/days after event Multi organ failure Rising ventilatory pressures
38
Management of ARDS?
Treat the underlying cause Antibiotics (if signs of sepsis) Negative fluid balance i.e. Diuretics Recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes may cause lung injury (only treatment found to improve survival rates)
39
wHY does ARDS cause hypoxaemia?
loss of surfactant and increased elastase release from neutrophils, results in fluid accumulation. This leads to reduced diffusion, which is the main reason for hypoxaemia.
40
How to calculate nutrition prescription for those at risk of refeeding syndrome?
-Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days -Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements -Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)
41
How to calculate nutrition prescription for those at risk of refeeding syndrome?
-Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days -Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements -Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)
42
Main side effect of neostigmine?
bradycardia
43
Management 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) If diabetic neuropathic pain: Duloxetine N.B. SE of amitriptyline is orthostatic hypotension
44
Criteria for brainstem death testing?
Deep coma of known aetiology. Reversible causes excluded No sedation Normal electrolytes
45
How to test for brainstem death?
-Fixed pupils which do not respond to sharp changes in the intensity of incident light -No corneal reflex -Absent oculo-vestibular reflexes - no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the caloric test) -No response to supraorbital pressure -No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation -No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes)
46
Who can test for brainstem death?
two appropriately experienced doctors on two separate occasions at least 5y post grad experience one must be consultant not member of transplant team
47
which variables are required for calculation of SOFA score?
PaO2, platelet count, creatinine level, and bilirubin level, GCS, Cardiovascular MAP
48
Which variables are required for a quick (qSOFA) score?
Respiratory rate 22/min Altered mentation (<15) Systolic blood pressure 100 mm Hg
49
Which variables are required for a quick (qSOFA) score?
Respiratory rate 22/min Altered mentation (<15) Systolic blood pressure 100 mm Hg
50
What does a SOFA score >=2 indicate?
A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection
51
What are the goals of resuscitation?
CVP 8-12mmHg MAP >65mmHg Urine output >0.5ml/kg per hour Superior vena cava oxygen saturation >70% Normal lactate
52
What is septic shock?
sepsis with persisting hypotension requiring vasopressors to maintain MAP 65 mm Hg and having a serum lactate level >2 mmol/L (18mg/dL) despite adequate volume resuscitation (mortality >40%)
53
What should be monitored before and during administration of TPN?
Weight BMI: at start of feeding and then monthly If weight cannot be obtained: monthly mid arm circumference or triceps skin fold thickness Daily electrolytes until levels stable. Then once or twice a week. Weekly glucose, phosphate, magnesium, LFTs, Ca, albumin, FBC, MCV
54
What should be monitored if stable on TPN?
- 2-4 weekly Zn, Folate, B12 and Cu levels if stable -3-6 monthly iron and ferritin levels, manganese (if on home parenteral regime) -6 monthly vitamin D -Bone densitometry initially on starting home parenteral nutrition then every 2 years
55
Why should suxamethonium be avoided in extensive poly trauma and tissue necrosis?
may induce hyperkalaemia as it induces generalised muscular contractions cardiac arrest
56
Which operations carry higher chance of anastomotic leak?
rectal resections
57
Which signs may indicate a new anastomotic leak?
new AF and raised inflammatory markers 5 days post resection
58
Enteral feeding of ITU patients?
ITU patients should have continuous feeding for 16-24h (24h if on insulin)
59
When can a PEG be used and removed?
PEG can be used 4 hours after insertion, but should not be removed until >2 weeks after insertio
60
Side effects of spinal anaesthesia?
hypotension, sensory and motor block, nausea and urinary retention.
61
Preferred anaesthetic technique for extensive laparotomy?
Transversus Abdominal Plane block (TAP)
62
What is pethidine?
Synthetic opioid which is structurally different from morphine but which has similar actions. Has 10% potency of morphine.
63
Differences between pethidine and morphine?
Short half life and similar bioavailability and clearance to morphine. Short duration of action

MRSA theory (20 decks)

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