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Anaesthetics, ED and Plastics > Pre-Op > Flashcards

Pre-Op Flashcards

1
Q

What can the trauma of surgery lead too

A 
Stress
Fluid shift in body 
Blood loss 
CVS / respiratory / renal failure 
Decreased FRC due to GA so post-op oxygen
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2
Q

What is pre-op important for

A 
Assess and identify high risk patients and minimise risk
Establish baseline
Establish severity of disease
Exclude any serious issue that will affect analgesia 
Dx unknown or suspected conditions
Inform and support patient decisions
Get consent
Guide management
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3
Q

What do you want to know in the Hx

A

Known co-moridities
- Exacerbations / Ax / home oxygen / use of steroid

Unknown co-morbid

Ability to withstand stress

  • ETT
  • Cardio / resp disease

Drugs and allergy

Previous surgery and anaesthesia

FH - malignant hyperthermia or cholinesterase

SH - drug / smoke / alcohol

Potential anaeshteitc problems - is neck / jaw immobile / teeth stable

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4
Q

What increases likelihood of airway issue

A

Reflux
Obesity
Pregnancy
FH

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5
Q

What do you want to confirm before op

A

How have they been in time leading up
Confirm drug and allergies
Fasting

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6
Q

What happens for an elective operation

A

Assess CVS system and exercise tolerance
Bloods
- FBC, U+E, LFT, finger tip blood glucose in most
- G+S
- DO clotting in liver / renal / DIC / anti-coagulation
- Blood glucose if DM
Drug levels as appropriate
Urinanalysis
Pregnancy test
Sickle cell if from area
TFT if thyroid disease
Assess for DVT risk
Thromboprophylaxis plan
MRSA screen - decolonize carrier
CXR = not routine - if cardiorespiratory disease
ECG if >65 / DM / renal or poor ETT
Lateral Spine X-ray if RA / Down’s / AS as risk of atlanto-axial instability

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7
Q

Risk assessment tools

A

OK

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8
Q

What are NICE guidelines for risk

A

ASA grade
Surgery grade
Co-morbid

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9
Q

ASA 1

A

Otherwise healthy

No smoking or alcohol

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10
Q

ASA 2

A

Mild - mod systemic disturbance
No functional limitation
Current smoker / social alcohol / obesity / well controlled DM or high BP

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11
Q

ASA 3

A 
Severe systemic disturbance / disease 
Functional limitation
Poor controlled DM / BP 
COPD / asthma / end stage renal
Previous MI
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12
Q

ASA 4

A

Life threatening

Recent MI / CVA or severe reduction n EF

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13
Q

ASA 5

A

Moribund
Not expected to survive without operaiton
Rupture AAA / ischaemic bowel

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14
Q

ASA 6

A

Organ retrieval

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15
Q

What does cardiac risk index look at

A 
High risk surgery
IHD
CCF
Cerebrovascular
DM
Renal failure
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16
Q

If cardio procedure what do you get / what other tests can be done

A 
ECG
ETT
ECHO +- stress
May have angio prior
PFT
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17
Q

If CVS issue what are options

A

GA = high risk of myocardial depression
Regional - may not cover
Spinal - watch for CI

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18
Q

If resp procedure what do you get

A 
O2 sats
ABG
CXR or CT chest - not routine 
Peak flow
FVC and gas transfer
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19
Q

E+D prior to surgery

A

Foods / solid >6 hours

Clear fluid >2 hours

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20
Q

What do you do if DM prior to surgery

A

If diet or tablet controlled = omit and check BG regularly
If poor control or insulin = sliding variable rate IV insulin infusion
Put first on list
May need K supplementation
Treat as hypo if <4

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21
Q

Pre-op meds

A

Most continue as normal

esp inhalers / angina / epilpesy

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22
Q

If on steroids what do you need to do

A

Supplement with hydrocortisone as surgery will increase stress

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23
Q

What do you do if on anti-coagulant

A

VTE risk assessment
Withhold warairn
Use short acting e.g. LMWH
Withold LMWH the evening before and use TEDS

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24
Q

Anaemia pre-surgery

A

Blood transfusion to correct
IV iron will take too long
If refuse then can give IV iron
Oral iron is possible but will take 2-4 weeks to work

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25
Q

Operations with high risk of transfusion needing X-match 4-6 units

A 
Total gastrectomy
Oophorectomy
Oesophagectomy
Elective AAA reapir
Cystectomy
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26
Q

Operations which may need transfusion so X-match 2 units

A

Salpingectomy for rupture

THR

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27
Q

Operations unlikely to need transfusion so G=S

A 
Hysterectomy
Appendectomy
Thyroid
ELective LSCS
Lap chole
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28
Q

How does paralytic ileus present post surgery

A

Vomiting
Absent bowel
CRP raised anyway as post surgical response

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29
Q

What causes and what is associated

A 
No peristalsis
Chest infection
MI
Stroke
AKI
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30
Q

What are nutrition options post surgery

A 
Oral - early feeding good 
NG 
- If entubated soon 
NJ
Feeding jejunostomy
PEG
TPN
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31
Q

What is CI in head injury

A

NG as risk of worsening

32
Q

What is benefits of NJ over NG

A

Insertion is more complicated but avoids risk of aspiration / food pooling in stomach

33
Q

What can be used long term

A

Feeding jejunostomy
1st line in most if longer term
Low risk of aspiration

34
Q

What is main risk

A

Displacement

Leakage = peritonitis

35
Q

Risk of PEG

A

Aspiration

36
Q

When do you use TPN

A

If enteral CI

37
Q

What are SE

A

Phlebitis
Fatty liver
Deranged LFT

38
Q

What are early causes of post op pyrexia

A

Blood transfusion
Infections - Cellulitis / UTI - have low threshold
Pulmonary atelectasis - needs prompt physio
Physiological

39
Q

What are later causes

A

VTE
Pneumonia
Wound infection
Anastomotic leak

40
Q

How do you avoid surgical complications

A

WHO checklist
Ax
DVT risk + prophylaxis

41
Q

When do you carry out checklist

A

Prior to induction
Incision
Patient leaves operation room

42
Q

What does checklist involve

A 
Site marked
Confirm identity
Confirm procedure
Confrim consent
Anaesthesia check complete
Pulse oximeter on 
Allergies
Airway / aspiration risk
>500ml blood loss risk
43
Q

What are complications of surgery

A 
Bleeding
Haemorrhagic shock
Infection  
Confusion 
Arrhythmia following cardiac
Electrolyte imbalance
Ileus
Fluid and electrolyte loss
Pulmonary oedema
Anastomotic leak
MI
Nerve damage
44
Q

What can cranial surgery cause

A

SIADH = hyponatraemia

45
Q

Who is very sensitive to oedema

A

After pneumonectomy as lose lung volume

46
Q

What are baseline investigations in any acutely unwell

A

Bloods- FBC, U+E, LFT,, CRP, Ca, clotting
Blood culture
ABG
ECG +- enzyme
Urinanalysis
Consider CXR / USS / CT depeniding on finding

47
Q

What ae specialist test

A 
CT for abscess / leak
Gastrograffin enema for rectal leak
Doppler for DVT
CTPA for PE
Peritoneal fluid
ECHO if effusion
48
Q

What is a CI to thrombolysis

A

Recent surgery

49
Q

What is thermoregulation in perioperative period

A

Temp management 1 hour prior to 24 hours after

50
Q

When is hypothermia more common

A 
If under anaesthesia
ASA 2+
Major surgery 
LBW
Large volume of unwarmed infusion 
Unwarmed blood
51
Q

If temp <36 pre op

A

Active warming before induction

Do not move to there unless time critical

52
Q

How do you measure temp intra op

A

Oesophageal probe

Axillary / sublingual

53
Q

What should be used if high risk of >30 minutes

A

Forced air warming device

54
Q

If fluid >500ml

A

Warm all

55
Q

What happens post-op

A

Document temp every 15 minutes till in ward
Do not transfer if <36
May develop hyperthermia due to fever

56
Q

What are complications of hypothermia

A 
Coagulopathy - reduced clotting so increased loss
Prolonged recovery 
Reduced wound healing as constriction
Infection
Shivering increases metabolic rate
57
Q

What increases risk of VTE

A 
Surgery >90 mins or >60 if LL
Abdominal inflammation 
Reduction mobility 3+ days 
Hip / knee replacement or fracture 
60+ 
Known malignancy 
Thrombophilia
Previous thrombosis
BMI >30
HRT / OCP
Varicose veins
58
Q

What are general RF

A

Dehydration
Co-morbid
Critical care
Pregnant or <6 weeks post partum

59
Q

What is mechanical prophylaxis

A

Early amputation

Compression stocking

60
Q

When is compression CI

A

PAD

61
Q

What is options for therapeutic

A

LMWH SC daily
Unfractioned heparin IV
Dabigatran

62
Q

Benefits of unfractioned

A

IV

Rapid onset and decline on stopping infusion

63
Q

How do you measure

A

APTT

64
Q

How do you reverse

A

Protamine sulphate

65
Q

When is dabigatan used

A

Hip and knee

No active monitoring required

66
Q

CI

A

If risk of active bleeding

67
Q

What do you have as prophylaxis if RF

A

Mechanical and therapeutic

68
Q

How long

A

Stat 6-12 hours after op
Elective hip = 28 days
Elective knee = 14 days
Hip fracture = until mobile / 28 day s

69
Q

If patient N+V post op what should you think

A

Any mechanical obstruction
Ileus ?
Emetic drugs - opiates / anaesthesia

70
Q

What should you consider

A

AXR

NGT

71
Q

What should you aim for UO post op

A

> 30ml / hr in adults

72
Q

If UO decreased what do you look for

A

Blocked or malted catheter
Incorrect fluid replacement
Urinary retention
AKI

73
Q

What do you do

A 
Review fluid chart
Examine fluid status
Examine bladder 
Fluids to establish normovolaemia
Cathterise for accurate monitoring 
Correct issue
74
Q

If dyspnea or hypoxia post op what do you do / what tests

A

Sit patient up and give O2
Monitor sats
Examine for evidence of pnuemonia / collapse / aspiration / LVF / PE
Do FBC, ABG, CXR, ECG and enzymes

75
Q

What can cause LVF post op

A

MI

Fluid overload

76
Q

What are risks of surgery in jaundice patient

A

Coagulopathy - decreased vit K
Sepsis
Renal failure

77
Q

What should you do prior

A

ERCP to relieve

Anaesthetics, ED and Plastics (14 decks)

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