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Gen surg > Pre-op assessment > Flashcards

Pre-op assessment Flashcards

1
Q

Oral fluids/fasting requirements for surgery

A

May drink clear fluids until 2 hours before their operation

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2
Q

Purpose of drinking clear fluids before the operation

A

Can help reduce headaches, nausea and vomiting afterwards

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3
Q

How long must patients fast for prior to surgery

A

Generally advised to fast from non-clear liquids/food for at least 6 hours before surgery

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4
Q

Potential complications of poorly managed diabetes during surgery

A

Undetected hypoglycaemia whilst a patient is under GA

increased risk of wound and resp infections

Increased risk of post-op acute kidney injury

Increased length of hospital stay

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5
Q

Which grading system can be used to classify patients to indicate risk of absolute mortality

A

American Society of Anesthesiologists Grade (ASA)

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6
Q

What is Group and Save

A

Determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies(takes around 40 mins)

Recommended if blood loss is not anticipated, but blood may be required if greater blood loss occurs

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7
Q

What is cross-match

A

Involves physically mixing the patient’s blood with donor’s blood, in order to see if any immune reaction takes place –> transfusion if not

Should be done pre-emptively if blood loss is anticipated

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8
Q

What happens if an MRSA sample is isolated from a patient prior to surgery

A

Decontamination hair and body wash, along with topical ointment applied to the nostrils, will be given

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9
Q

What might high-risk patients undergoing major surgery be referred for

A

Cardiopulmonary exercise testing(CPET)

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10
Q

What is CPET

A

Involves a graded intensity period on a stationary bicycle whilst wearing a mask, as well as ECG monitoring

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11
Q

Purpose of CPET

A

Provides VO2max and anaerobic threshold, which can be used to risk-stratify patients for post-op complications and need for higher level care environments

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12
Q

How long before surgery should a patient ideally have a pre-op assessment

A

2-4 weeks

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13
Q

What classification is used to assess the potential difficulty of a patient’s airway for intubation

A

Mallampati score stratifies the difficulty of endotracheal intubation based on anatomic features

Also Wilson’s score

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14
Q

Rules regarding use of antihypertensives and antiarrhythmics in patients undergoing surgery

A

ACE inhibitors should be withheld on the morning of major surgery

Beta-blockers should be continued as per prescription

Digoxin will need an ECG and blood tests to exclude hypokalaemia

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15
Q

Rules regarding use of antiplatelets in patients undergoing major surgery

A

Aspirin and NSAIDs can be continued

Clopidogrel causes irreversible platelet inhibition and therefore should be stopped 7 days before surgery and/or neuraxial intervention

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16
Q

How long before surgery should warfarin be stopped

A

Last dose of warfarin should be given 6 days before procedure

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17
Q

How long before surgery should heparin be stopped

A

Unfractionated heparin is short-acting and administered IV so must be stopped 4 hours before neuraxial block with evidence of a normal APTT

LMWH is longer acting and administered subcut so a neuraxial block cannot be performed for 12 hours following a prophylactic dose and 24 hours following a treatment dose

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18
Q

Oral hypoglycaemic agents in patients undergoing major surgery

A

Agents such as metformin should be omitted on the day of surgery

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19
Q

Use of hormonal therapies in patients undergoing surgery

A

OCP can increase risk of DVT so should be stopped

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20
Q

Why are antacids given prior to surgery

A

Ranitidine or omeprazole given to minimise stomach acid and reduce risk of aspiration during induction

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21
Q

Purpose of giving glycopyrrolate prior to surgery

A

Anti-sialogogue which reduces oral secretions prior to airway instrumentation

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22
Q

What are the three phases of an operation identified by the WHO checklist

A

1) Before the induction of anaesthesia (sign in)
2) Before the incision of the skin (time out)
3) Before the patient leaves the operating room (sign out)

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23
Q

Appropriate ix in IHD prior to surgery

A

Bloods
Urine
ECG
Treadmill/myocardial perfusion scan/angiography

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24
Q

Important blood parameter to check prior to thyroid surgery

A

Calcium

TSH

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25
Q

Anticoagulant to cover warfarin during surgery

A

Prophylactic tinzaparin

IV unfractionated heparin if mechanical heart valve

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26
Q

IX for respiratory disease patients prior to surgery

A

Peak Flow/FEV1 FVC/6 min walk

Peri-op - saline nebulisers, bronchodilators, chest physiotherapy, ABG

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27
Q

Important imaging ix prior to surgery for rheumatoid arthritis patients

A

Cervical x-ray - risk of Atlanta-axial subluxation

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28
Q

What is primary bleeding

A

bleeding that occurs within the intra-operative period
This should be resolved during the operation, with any major haemorrhages recorded in the operative notes and the patient monitored closely post-operatively

29
Q

What is reactive bleeding

A

Occurs within 24 hrs of op

30
Q

What are most reactive bleeding case slinked to

A

A ligature that slips or a missed vessel. These vessels are often missed intraoperatively due to intraoperative hypotension and vasoconstriction, meaning only once the blood pressure normalises post-operatively will this bleeding occur

31
Q

What is secondary bleeding

A

occurs 7-10 days post-operatively
Secondary haemorrhage is often due to erosion of a vessel from a spreading infection.

Secondary haemorrhage is most often seen when a heavily contaminated wound is closed primarily

32
Q

Which artery is vulnerable to laparoscopic ports

A

Inferior epigastric artery

33
Q

Which artery is vulnerable during angiography

A

The puncture site is often the external iliac artery, above the inguinal ligament. Therefore, any bleeding from this artery will go into the retroperitoneum.

34
Q

General mx of post op haemorrhage

A 
Review operation notes 
Rapid fluid resus(18G minimum for IV) 
Direct pressure 
Urgent senior surgical review 
Urgent blood transfusion

Prep for theatre after senior review

35
Q

Risk factors for post-op nausea and vomitng(PONV)

A

Female
Hx of pONV
Opioids
Non-smoker

36
Q

Prophylactic measures for post-op nausea and vomiting

A

Anaesthetic measures – reduce opiates, reduce volatile gases, avoiding spinal anaesthetics
Prophylactic antiemetic therapy
Dexamethasone* at induction of anaesthesia

37
Q

Conservative measures for post-op nausea and vomiting

A

Adequate fluid hydration
Adequate analgesia
Consider nasogastric tube insertion to aid gastric decompression

38
Q

Pharmaceutical measures for post-op nausea and vomiting

A

Impaired gastric emptying or gastric stasis should be trialled on prokinetic agent(metoclopramide) unless bowel obstruction

Hyoscine to reduce secretions

Ondanstron or cyclising for opioid induced nausea and vomiting

39
Q

What can nausea and vomiting after operation indicate

A

May be a sign of post-op complication such as ileum

40
Q

Likely aetiology of pyrexia - day1-2 post op

A

consider a respiratory source (or body’s routine response to surgery)

41
Q

Likely aetiology of pyrexia - day3-5 post op

A

consider a respiratory or urinary tract source

42
Q

Likely aetiology of pyrexia - day5-7

A

Surgical site infection or abscess/collection formation

43
Q

Other causes of pyrexia post op

A

Iatrogenic(drugs/transfusions)
VTE(low grade fever)
Prosthetic implantation

44
Q

Causes of pyrexia of unknown origin

A

infection of unknown source (30%), malignancy (classically B-symptoms from lymphoma, 30%), connective tissue diseases or vasculitis (30%), or drug reactions

45
Q

Mx of LRTI post op

A

Co-Amoxiclav 1.2g IV +/- Amikacin

46
Q

Mx of UTI catheter associated

A

Co-Amoxiclav 1.2g IV +/- Amikacin

Nitrofurantoin 50mg PO + Change of Catheter

47
Q

Mx of surgical site infection

A

Flucloxacillin 1g IV

48
Q

Mx of central line infection

A

Replace line (trial antibiotic line lock with vancomycin if not able to replace line)

49
Q

Interpretation of SOFA score

A

greater than or equal to two indicates sepsis; the SOFA score can also be used to monitor and quantify a patient’s clinical course and response to treatment for sepsis.

50
Q

qSOFA criteria

A

Respiratory Rate ≥ 22/min (1 point)
Altered Mental State (1 point)
Systolic Blood Pressure ≤100mmHg (1 point)

51
Q

Risk factors for anastomotic leak

A

Medication (such as corticosteroids and immunosuppressants)
Smoking or alcohol excess
Diabetes Mellitus
Obesity or malnutrition

52
Q

Clinical features of anastomotic leak

A

Abdo pain and fever 5-7 days post op

Delirium

Prolonged ileus

Tachycardia

Signs of peritonism

53
Q

IX for anastomotic leak

A

CT contrast of abdomen and pelvis

FBC/CRP/U&Es/LFTs and clotting screen

VBG

Repeat group and save

54
Q

Initial mx of anastomotic leak

A

A-E
NBM
Broad spectrum ABX
IV fluids and urinary catheter

55
Q

Definitive mx of anastomotic leak

A

Collections <5cm managed conservatively

Larger ones drained percutaneously

Exploratory laparotomy if septic or multiple collections

56
Q

Risk factors for post-op ileus

A

Increased age
Electrolyte derangement (e.g. Na+, K+ and Ca2+ derangement)
Neurological disorders (e.g. Dementia or Parkinson’s Disease)
Use of anti-cholinergic medication

57
Q

Surgical factors which increase risk of post-op ileum

A

Use of opioid medication
Pelvic surgery
Extensive intra-operative intestinal handling
Peritoneal contamination (by free pus or faeces)
Intestinal resection

58
Q

Clinical features of post-op ileus

A

Failure to pass flatus or faeces
Sensation of bloating and distention
Nausea and vomiting (or high NG output)

Abdominal distension and absent bowel sounds

59
Q

Ix for post-op ileus

A

FBC and CRP
U&Es
Electrolytes

CT abdo and pelvis

60
Q

Mx of post-op ileus

A

NBM
Daily bloods to monitor AKI
Encourage mobilisation
Reduce opiate analgesia

61
Q

Prophylactic measures for post-op ileus

A

Minimise intra-operative intestinal handling
Avoid fluid overload (causing intestinal oedema)
Minimise opiate use
Encourage early mobilisation

62
Q

What are adhesions

A

fibrous bands of scar tissue. Many occur secondary to previous surgery or intra-abdominal inflammation (particularly pelvic)*, however they can also be congenital.

Common cause of SBO

63
Q

Clinical features of bowel adhesions

A

Asymptomatic
Obstruction
Infertility
Chronic pelvic pain

64
Q

Mx of bowel adhesions

A

Conservative mx with tube decompression

NBM

IV fluids

Adequate analgesia

65
Q

Surgical mx of bowel adhesions

A 
Adhesiolysis 
Laparoscopic mx(mainstay)
66
Q

Risk factors for incisional hernia

A 
Emergency surgery 
BMI > 25 
Midline incision 
Post-op wound infection 
DM
Steroids
Age 
Smoking
67
Q

Clinical features of incisional hernia

A

reducible, soft and non-tender swelling at or near the site of a previous surgical wound. If the hernia is incarcerated, it can become painful, tender, and erythematous.

68
Q

Mx of incisional hernia

A

Suture repair for small hernias

Laparoscopic mesh repair/open mesh repair

Abdominal wall reconstruction

69
Q

Iatrogenic causes of post-op constipation

A

medications such as opioid analgesia, anticonvulsants, iron supplements, or antihistamines

Gen surg (24 decks)

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