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Junior surgery > Pre and Post op care > Flashcards

Pre and Post op care Flashcards

1
Q

Which 5 things need to be monitored on patients who are on TPN?

A
  1. Blood Glucose (TPN has high sugar content and can develop blood sugar derrangement)
  2. Daily Electrolytes
  3. Fluid balance input and output
  4. Daily inspection of line and dressing - for infection
  5. 4 hourly temperature and observations - again looking for signs of infection
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2
Q

Why are patients on TPN given IV Pabrinex before TPN is started?

A

Patients are at risk of Wernicke’s encephalopathy as they will have been in a state of starvation so thiamine levels are low and will be depleted even further as feeding recommences

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3
Q

What is pseudomembranous colitis?

A

Acute diarrhoea after antbiotic therapy often due to Clostridium dificile organisms

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4
Q

When does Warfarin need to be stopped pre-surgery?

A

5 days prior and bridged with LMWH

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5
Q

What does a patients INR need to be before surgery?

A

<1.5

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6
Q

How can warfarin be reveresed if still high before surgery?

A

PO vitamin K

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7
Q

How long before surgery does Clopidogrel need to be stopped before surgery?

A

7 days

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8
Q

In elective surgery, how long before should patints stop any OCP or HRT? Why?

A

4 weeks before

due to DVT risk

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9
Q

How should subcutanous insulin be modified before surgery?

A

Night before: reduce subcutanous basal insulin dose by 1/3rd

Switch to IV variable rate insulin on day of surgery

Whilst patient is NBM prescribe infusion of 5% dextrose and check BM ever 2hrs

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10
Q

How should patients on long term steroids be managed pre-op and why?

A

MUST CONTINUE due to the risk of Addisonian crisis

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11
Q

What should patients undergoing major GI surgery or lower limb joint replacement be discharged home with? (VTE prophylaxis)

A
  • TED stockings
  • 28 days of prophylactic LMWH (unless contraindicated)
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12
Q

Most patients recieved enoxaparin (LMWH) prophylactically to reduced risk of VTE. Which surgeries is this not indicated in?

A
  • Neck
  • Endocrine
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13
Q

What are some contraindications to the use of TED stockings?

A
  • Peripheral vascular disease
  • Peripheral neuropathy
  • Recent skin graft
  • Severe eczema
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14
Q

How should oral hypoglycaemics used in T2DM be altered before surgery?

A
  • Metformin - stop the morning of surgery
  • All others - stop 24hrs before
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15
Q

Which factors increase risk of aspiration under anaesthesia?

A
  • Diabetes
  • Diagnosed hiatus hernia
  • Symptoms of acid reflux
  • High BMI
  • Not starved before theatre
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16
Q

How can the need for giving donated blood be decreased in surgical patients?

A
  • Correct any preoperative anaemia before surgery
  • Adhere to guidelines for postoperative blood transfusions
  • Perform surgery under regional rather than general aneasthesia if possible
  • Use intra-operative cell salvage techniques (transfusion of own blood back into patient)
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17
Q

Which type of blood should be transfused in anaemic patients?

A

Packed red blood cells

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18
Q

How do you manage pre-op aneamia?

A
  • Correct any cause e.g. iron replacement, EPO injection, B12
  • May not need correction if congenital
  • Investigate any underlying cause
  • May be a pre-op anaemia clinic at hospital to refer to
19
Q

Do all patients need pre-op clotting status testing?

A

No - as not predictive of bleeding risk

only needs doing in those with positive bleeding history or in patients where you think they will have a reduced ablity to clot (sepsis, trauma, on anticoagulants, metastatic cancer, liver cirrhosis)

20
Q

In which surgeries is bowel prep required pre-op?

A

Left hemicolectomy, sigmoid colectomy or abdoinal-perineal resetion - phosphate enema on day of surgery

Anterior resection - 2 sachet of picolax day before or phosophate enema morning of surgery

21
Q

Why are irradiated blood products used? Which patient groups are they used in?

A

To reduce the risk of graft vs host disease

Used in:

  • Patient’s recieving blood from 1st/2nd degree relative
  • Hodgkin’s Lymphoma patients
  • Recent haematopoietic stem cell transplants
  • After anti-thymocyte globulin or alemtuzumab therapy
  • Recieving purine analgoues for chemo (e.g. fludarabine)
  • Intra-uterine transfusions
22
Q

Which cannulas must blood products be given by and why?

A

Green (18G) or Grey (16G) cannulae only

Otherwise cells haemolyse due to sheering forces in the narrow tube

23
Q

In what situations are packed red blood cells used?

How much does 1 unit of blood increase a patient’s Hb by?

A
  • Acute blood loss
  • Chronic anaemia (Hb <70g/dl) or symptomatic anaemia
  • 1 unit of blood increased Hb by 10g/L
24
Q

In what situations are platelet transfusions used?

What is the duration 1 unit should be delivered over?

A
  • Haemorrhagic shock in a trauma patient
  • Profound thrombocytopenia (<20 x109/L)
  • Bleeding with thrombocytopenia
  • Pre-op platelet level is <50 x109/L
  • Administer over 30 minutes
25
Q

Over what period should packed red blood cells be administered over?

A

Between 2-4hrs

Must be completed within 4 hours of coming out of stores

26
Q

In what situations is fresh frozen plasma given for? (FFP)

Over what duration should it be administered?

A
  • DIC
  • Any haemorrhage secondary to liver disease
  • All massive haemorrhages - commonly given after 2nd unit of packed red blood cells
  • Administer over 30 minutes
27
Q

What is cryoprecipitate?

What situations is it given in?

A

Blood product containing fibrinogen, Von Willebrands factor (vWF), Factor VIII & fibronectin

Given in:

  • DIC with fibrinogen <1g/L
  • von Willebrands disease
  • Massive haemorrhage
28
Q

What are risk factors for developing atelectasis in a surgical patient?

A
  • Age
  • Smoking
  • Use of general anaesthesia
  • Duration of surgery
  • Pre-existing lung or neuromuscular disease
  • Prolonged bed rest
  • Poor post op pain control
29
Q

What is the mainstay of treatment in post of atelectasis?

A
  • Chest physiotherapy
  • Deep breathing exercises
  • Pain control to allow deep breathing
  • Bronchoscopy may be needed if conservative measures are unsuccessful (not routine)
30
Q

What is post op fever defined as?

A

A temperature of >38oC for 2 consecutive post op days

Or >39oC for 1 day

31
Q

What are some of the differentials for post op fever?

A

5 W’s

  • Wind - possible chest infection (roughly post op day 2), general anaesthetic and ventilator can cause air stasis, not breathing deep enough
  • Water - UTI (roughly post op days 3-5), consider especially if catheter in place
  • Walking - possible VTE (occurs day 5-7), stress response to surgery and immobilisation
  • Wound - surgical site infection (post op day 10), consider intra-abdominal / thoracic collection
  • Wonder about drugs - check all IV cannulae sites, tranfusion reaction to blood?
    *
32
Q

What factors indicate severe sepsis?

A
  • SBP <90mmHg or MAP <65mmHg
  • Drop in BP >40mmHg
  • Lactate >2 (indicates poor tissue perfusion)
  • Urine output <0.5/mls/kg/hr for 2 consecutive hours
  • Drop in GCS or AMTS
33
Q

What is septic shock?

A

Severe sepsis that is hypotensive despite fluid resucitation

34
Q

What bloods would you request in a patient with post op fever?

A
  • FBC - for WCC and differential (look at the trend), Hb (may be anaemic 2ndry to blood loss), platelets can indicate stasis or DIC
  • U&Es - any element of AKI or pre-renal renal failure
  • LFTs - assess HPB system/ liver injury as source of sepsis
  • Blood cultures - preferably pre-abx
  • Wound swab
  • Urine MC&S
  • Sputum culture (if producing any) - may need to ask chest physio for assistance
  • If suspecting line sepsis take blood culture from that line and send tip of line to lab
35
Q

What imaging should be requested in post op patient with surgery?

A
  • CXR
  • AXR if had abdominal surgery
  • Early CT to evaluate for any collections
36
Q

Give some patient risk factors for post op nausea and vomiting

A
  • Female
  • Age (younger patients affected more)
  • Previous PONV
  • Suffers with motion sickness
  • Non-smokers
37
Q

Give some surgical risk factors for post op nausea and vomiting

A
  • Intra-abdominal laparoscopic surgery
  • Intracranial or middle ear surgery
  • Squint surgery
  • Gynaecological surgery
  • Prolonged operative time
  • Poor pain control post op
38
Q

Give some anaesthetic risk factors for post op nausea and vomiting

A
  • Opiate analgesia or spinal anaesthesia
  • Inhalation agents (nitrous oxide, isoflurane)
  • Prolonged anaesthetic time
  • Intraoperative dehydration or bleeding
  • Over use of bag and mask ventilation
39
Q

What pre-op measures can be taken to reduce the risk of post operativ nausea and vomiting?

A
  • Anaesthetic measures - reduce opiates, reduce volatile gases, avoid spinal anaesthetic
  • Prophylactic antiemetics
  • Demamethasone at induction of anaesthesia (8mg)
40
Q

How can you manage post-op nausea and vomiting?

A

Conservative measures:

  • adequate fluid hydration
  • adequate analgesia
  • consider NG tube to aid gastric decompression

Pharmaceutical measures:

  • Impaire gastric emptying/ stasis - try prokinetic agent (metoclopramide D antagonist) or domperidone (dopamine antagonist)
  • Hyoscine (anti-muscarinic) can help to reduce secretions
  • Opiod induced N+V responds well to ondansetron (5HT3 receptor antagonist) or cyclizine (H1 receptor antagonist)
41
Q

How do you distinguish between demetia and delerium?

A

Dementia:

  • insidious
  • constant
  • can have good attention span
  • delusions and hallucinations less common

Delerium:

  • acute onset
  • fluctuating time course
  • poor attention span
  • delusions and hallucinations more common
42
Q

Give smome risk factors for developing delerium

A
  • Male
  • Age >65 yrs
  • Multiple co-morbidities
  • Underlying dementia
  • Renal impairment
  • Sensory impairment (hearing or visual)
43
Q

What are some of the common causes of delirium?

A
  • Hypoxia
  • Infection (UTI/ LRTI post op)
  • Drug induced (benzodiaxepines, diuretics, opiods, steroids) or drug withdrawl
  • Dehydration
  • Pain
  • Constipation
  • Urinary retention
  • Electrolyte imbalance
44
Q

What investigations form part of the confusion screen in patients with post op delerium?

A
  • Bloods - FBC, U&E, Ca2+, TFTs, glucose
    • B12, folate
  • Blood cultures
  • Wound swabs
  • Urinalysis
  • CXR
  • CT head (if relevant)

Junior surgery (8 decks)

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