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MRCS A - Clinical > Pre-op, Peri-op and Post-op Mx > Flashcards

Pre-op, Peri-op and Post-op Mx Flashcards

1
Q

What type of analgesia do we need to be careful with using anticoagulants?

A

Spinal epidural > Spinal epidural haematoma can occur

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2
Q

What do we do with HRT/OCP pre-op?

A

Stop it 4 weeks before major surgery

Restart 2-weeks after if mobile

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3
Q

NBM prep for elective surgery?

A

Not > 2 hours for clear fluids
not > 6 hours for solids

2-3 hours before surgery = carbohydrate rich drink + avoid IV fluids

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4
Q

How much blood to order for gastrectomy and AAA?

A

Gastrectomy = 4 units

AAA = 6 units

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5
Q

What prophylactic ABx for GI / vascular / MRSA +ve surgery?

A 
GI = Ceftriaxone and met
Vasc = co-amox

MRSA+ve = vancomycin

Give all 1 hour prior to surgery

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6
Q

Management of insulin dependents pre-surgery?

A

Atop long acting night before
Omit AM insulin
First in to surgery

Sliding scale until tolerating food post op

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7
Q

How to manage steroid dose pre-surgery?

A

Major surgery = hydrocortisone 50-100mg IV pre-surgery, then TDS for 3/7 after

Minor surgery = just the one off dose

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8
Q

Managing warfarin pre-surgery?

A

If low risk e.g. AF - stop 5 days prior, restart next day

If high risk, stop 5 days prior.
Bridge with LMWH until 12 hours prior
Restart this and warfarin next day

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9
Q

ASA grades for surgery?

A 
1 = localised surgical pathology, no systemic affect 
2 = mild systemic disease
3 = severe systemic that limits activity 
4 = severe systemic disease that is constant threat to life
5 = moribund, wot survive without surgery
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10
Q

Disinfection vs sterilisation ?

A

Disinfection = reduction in numbers of viable organisms

Sterilisation = removal of all organisms and spores

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11
Q

Autoclaving vs glutaraldehyde vs Ethylene oxide ?

A

Autoclaving = air removed and high temp pressures

  • Most re-usable surgical equipment
  • must be cleaned first

Glutaraldehyde = for endoscopes and laparoscopic stuff
- staff can develop allergies

Ethylene oxide = 3% gas with CO2
- for package materials that can’t be heated

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12
Q

Benefit and downfall of femoral lines?

A 
Benefit = easy
Risk = higher infection rates
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13
Q

Pulmonary arterial lie - what does it measure, what does this essentially measure and interpretation?

A

Measure pulmonary artery occlusion pressure = LEFT ATRIAL PRESSURE

Interpretation:

normal = 8-12mmHg
Low <5 = hypovolaemic
Low with pulmonary oedema = ARDS
High > 18 = overloaded

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14
Q

Airway management - oropharyngeal?

A

Easy to use
No paralysis
Short procedures

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15
Q

Airway management - LMA?

A

Easy, no paralysis
Sits in pharynx
Poor control against gastric reflux, not suitable for high pressures

Useful in day surgery

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16
Q

Airway management - tracheostomy?

A

Reduces work of breathing and anatomical dead space
Useful In weaning from mechanical
needs humidified air

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17
Q

Airway management - ET tube?

A

Optimal control
High pressures can be used

Errors in insertion = oesophageal intubation, so measure CO2 tidal volume

Paralysis needed

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18
Q

5 general principles of anaesthesia?

A 
Induction = propofol 
Muscle relaxation = suxamethonium
Airway control
Maintenance = halothane
End = switch to 100% oxygen
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19
Q

Anaesthetics - Propofol

A

Rapid onset, pain on IV
Rapidly metabolised = little metabolites

Anti-emetic

Moderate cardiac depression

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20
Q

Anaesthetics - Sodium thiopentone?

A

RSI
Metabolites build up quickly

Little analgesic effect

Marked myocardial depression

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21
Q

Anaesthetics - Ketamine?

A

Induction

Moderate - strong analgesic
Little myocardial depression = good in unstable patients

May induce dissociative state = nightmares

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22
Q

Anaesthetics - Etomidate?

A

No analgesic

Favourable cardiac safety profile

Cannot be used for maintenance as prolonged use = adrenal suppression

Post-op vomiting common

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23
Q 
Anaesthesia related complications of:
Propofol
Suxamethonium
Intubation
Loss of pain sensation
Loss of muscle power
Pseudocholinesterase deficiency
A

Propofol = cardiorespiratory depression
Suxamethonium = Malignant hyperthermia (Mx = dantrolene)
Intubation = trauma or oesophageal intubation
Loss of pain = Retention, pressure sores and nerve palsies
Loss of power = corneal abrasions and atelectasis

Pseudocholinesterase deficiency = increased duration of muscle relaxants

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24
Q

Malignant hyperthermia - mechanism, cause, Ix and Mx?

A

Due to the excessive release of calcium from sarcoplasmic reticulum of skeletal muscle
= Pyrexial and rigidity

Halothane and suxamethonium

CK raised

Dantrolene

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25
Q

why is pain management necessary?

A

Causes increased autonomic activation = arteriolar constriction = reduced would perfusion = reduced healing

Reduced mobility = DVT

Reduced cough = atelectasis and pneumonia

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26
Q

How does paracetamol work, how is it absorbed and metabolised.

A

Inhibits prostaglandin synthesis
Orally absorbed
Metabolised by LIVER

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27
Q

How do NSAIDs work and contraindications?

A

Inhibit cox which usually catalyses arachidonic acid to prostaglandins

Peptic ulceration, bleeding, renal disease and asthma

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28
Q

How does morphine get metabolised and SE’s?

A

Metabolised by liver = reduced clearance in liver disease / elderly

SE’s = N+V, constipation, resp depression

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29
Q

Pethidine - how is it metabolised?

A

By kidneys

In renal failure can accumulate = twitching and convulsion

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30
Q

Local anaesthetics - lidocaine > mechanism, metabolism and excretion.

A

Blocks sodium channels - although. activated first = pain

Hepatic metabolism
Protein bound
Renal excreted

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31
Q

Local anaesthetics - lidocaine toxicity?

A 
CNS overactivity
Cardiac arrhythmias = contraindicated in:
- Current flecainide Mx
- 3rd degree HB no PPM
- Severe SAN
- Accelerated idioventricular rhythm
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32
Q

Local anaesthetics - bupivacaine = mechanism, duration compared to lidocaine and SE’s?

A

Binds to intracellular portion of Na channels = blockage influx
Longer duration vs lidocaine. So used at end of surgery to infiltrate the wound
SE’s = cardiotoxic so contraindicated I regional blockade

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33
Q

Local anaesthetics prilocaine - Mechanism, use, and toxicity?

A

Binds to intracellular portion of Na channels = blockage influx

Regional blocks e.g. biers blockade

Can cause methaemoglobinaemia = cyanosis and dyspnoea
Mx&raquo_space; Methylene blue

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34
Q

What kind of amino group do procaine and benzocaine have?

A

Amino-ester group

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35
Q

Doses with and without adrenaline of BLP?

A

Bupivicaine = 2mg and 2mg with adrenaline. Toxicity is related to protein binding and adrenaline won’t change this

Lidocaine = 3mg then 7mg

Prilocaine = 6mg then 9mg

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36
Q

Symptoms and management of local anaesthetic OD?

A

Circumoral paraesthesia
Tinnnitus and low GCS

Mx = stop anaesthetic, high flow oxygen and lipid emulsion e.g. intralipid 20% bolus

If prilocaine = methylene blue

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37
Q

Spinal anaesthesia - use, benefit and SE’s?

A

Used in lower half of body surgery

Pain relief can last many hours after surgery

SE’s = nausea, hypotension, retention, sensory and motor block

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38
Q

Epidural anaesthesia - Use, SE’s?

A

Used for major abdominal surgery, helps prevent post-op respiratory compromise

SE’s:
Confined to bed
Need urinary catheter = immobile and infection
Contraindicated In coagulopathies = haematoma

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39
Q

TAP - Mechanism, use and disadvantage?

A

USS to find correct muscle plane, inject local and it diffuses and blocks spinal nerves

Used in extensive laparoscopic surgery. Provides wide block with no post-op motor impairment

disadvantage = limited by half-life of agent chosen

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40
Q

Neuropathic pain Mx?

A

First line = amitriptyline or gabapentin
2nd line = combine the 2

Diabetic neuropathic = duloxetine

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41
Q

Muscle relaxants - only depolarising type?

A

Suxamethonium

42
Q

Muscle relaxants - Suxamethonium - Mechanism and SE’s?

A

Inhibits ratio of Ach at NMJ
Degraded by cholinesterase and ACh

Fastest onset and shortest duration
Generalised muscle contraction prior to paralysis

SE’s = malignant hyperthermia, hyperkalaemia, delayed recovery

43
Q

Muscle relaxants - Atracarium - Mechanism, duration, excretion, SE’s and reversal?

A

non-depolarising neuromuscular blocking drug
30-45 minutes
Generalised histamine release = facial flushing, tachycardia and hypotension

Not excreted by liver or kidney = hydrolysis in tissue

neostigmine

44
Q

Muscle relaxants - Vecuronium = Duration, excretion and reversal?

A

non-depolarising neuromuscular blocking drug
30-40 mins

Excreted by liver and kidneys

neostigmine

45
Q

Muscle relaxants - Pancuronium - Onset, duration and reversal

A

non-depolarising neuromuscular blocking drug

2-3 mins
2 hours

neostigmine

46
Q

Tourniquets - post inflation effects?

A

SVR, BP and CVP increase
Core temperature increases
Hyper-coagulable

47
Q

Tourniquets - post deflate effects?

A

Decrease in CVP, SVR and BP + core temperature
Increase end tidal volume
Fibrinolysis
Raised serum K and lactate

48
Q

Tourniquets - contraindications?

A

AV fistula
Severe PVD
Previous vascular surgery
Current # or thrombosis

49
Q

Tourniquets - local side effects?

A

Damage to muscle, vessels and skin

neuropraxia - risk increased by besmirch bandage tourniquet

50
Q

Management of bleeding - superficial dermal bleeding?

A

Usually. ceases
Troublesome = diathermy
Scalp = mattress sutures

51
Q

Management of bleeding - Superficial arterial vs major arterial?
Major venous?
Raw surfaces?

A

Superficial arterial = clip and ligate
Major arterial = clip and ligate, but if can’t identify it, pack first !

Major venous:
Apply digital pressure
Divided veins need ligation
Incomplete laceration = stinky clamp + 5/0 prolene

Raw surfaces:
Spray diathermy or Argon coagulation
Splenic injury = specifically argon coagulation

52
Q

Diathermy - what is used in colonoscopic polypectomy?

A

Mixture of cutting and coagulation

53
Q

Diathermy - cutting mode?

A

non-modulated sinusoidal
High power and current
Vaporisation

54
Q

Diathermy - Coag?

A

Modulated current, intermittent dampened sine waves
High peak voltage
Evaporation

55
Q

Diathermy - Desiccation?

A

Low current, high voltage

Loss of cellular water but no protein damage

56
Q

Diathermy - fulguration?

A

Spray affect
Local superficial tissue destruction
Low amplitude and high voltage

57
Q

How does a CUSA device work?

A

High frequency US oscillations
Seal and coagulate tissue
e.g. brain resection

58
Q

Sutures - How are absorbable ones broken down?

Which surgeries dow we always use non-absorbable?

A

Macrophages hydrolyse material

Cardiac and vascular

59
Q

Sutures - braided vs monofilament?

A

Braided = better handling, but higher bacterial count

Unsuitable for vascular as potentially thrombogenic

60
Q

Sutures - silk - type, durability, use?

A

Braided biological
Theoretically permanent
Use = anchoring devices and skin closure

61
Q

Sutures - Polydiaxone (PDS) - Type, durability and use?

A

Synthetic monofilament
3 months
Widespread surgical use = visceral anastomoses, dermal closure and abdominal wound closure

62
Q

Sutures - Polyglycolic acid (Vicryl and Dexon) - Type, durability and use?

A

Synthetic braided
6 weeks
Most tissues

63
Q

Sutures - Polypropylene (Prolene) - Type, duration and use?

A

Synthetic monofilament
PERMANET
Vascular anastomoses

64
Q

Sutures - Polyester (ethibond) - Type, durability and use?

A

Synthetic braided
PERMANENT
Laparoscopic surgery

65
Q

Complications of surgical drain?

A

Infection + fistula

66
Q

What drain is used in CNS?

A

Low suction / free drainage

e.g. subdural haematoma

67
Q

What drain for cardiothoracic stuff?

A

Underwater seal

Can put on suctions if there is some air leak

68
Q

Why are drains used in GI surgery?

A

To prevent or drain abscesses

To turn anticipated complication e.g. bile leak, into a manageable one

69
Q

What is a redivac?

A

Suction type drain
Propylene
Closed system
High pressure

70
Q

Example of a low pressure drain?

A

Wallace Robinson

These have lower risk of fistulation = used in abdo surgery
Can be emptied and repressurised

71
Q

When do you use latex drains?

A

CBD exploration
Come In T-shape or straight
Used if want to generate fibrosis along the tract

72
Q

Wound closure - primary vs delayed primary vs vacuum assisted

A

Primary = surgical wound, clean, primary intention

Delayed primary = if infection and primary not achievable

Vacuum assisted - sponge on wound, negative pressure applied. Removes exudate but risk of fistulation

73
Q

Split thickness graft. - what is taken, how does the remaining skin regenerate, how can size be increased + can donor site be reused?

A

Superficial dermis using Watson knife
Remaining epithelium regenerates from dermal appendages

Coverage can be increased by mesh, but decreases cosmesis

Donor site can be reused

74
Q

Pre-tibial laceration - how to close wound?

A

Heal poorly

Need split thickness skin graft

75
Q

Full thickness graft - common use, what layers removed?

A

Commonly for facial reconstruction
Whole dermal layer used
Donor site morbidity

76
Q

Types of flaps?

A

Viable tissue with own blood supply
Pedicles = more reliable but limited with range
Free = > range but increased risk of breakdown as need vascular anastomoses

77
Q

Some examples of immediate, early and late surgical complications?

A

Immediate = intubation issues, surgical trauma and bleeds

Early = VTE, Infection, retention, ABx associated colitis

Late = Scarring, neuropathy and recurrence / failure

78
Q

2 big causes of post-op retention?

A

Drugs - opioids + Anti-ACh

Pain = sympathetic activation = sphincter contraction

79
Q

Post-op pyrexia causes - early vs late?

A

Early = up to 5 days
Blood transfusion, physiological, pulmonary atelectasis + infection

Late > 5 days:
Pneumonia, VTE, wound infection, collection and anastomotic leak.

80
Q

Post-op pyrexia:
Swinging fevers post ileal resection
Abdo pain
Inflamm markers up

A

Anastomotic leak

81
Q

Post-op pyrexia:
Post midline laparotomy and GA
Dull at bases

A

Atelectasis = alveolar collapse

Mx = analgesia and chest physio

82
Q

Post-op pyrexia:
oozing wound and raising inflammation markers

Classification?
Mx?

A

Wound infection, commonly S. Aureus

Clean = doesn’t break viscus
Clean and contaminated = breach viscus not colon
Contamiated = breach viscus and colon

83
Q

Post-op pyrexia:

Malaise, swinging fevers with a localised peritonitis?

A

Collection

needs antibiotics and drainage

84
Q

Post-op pyrexia:

Pain, swelling and warmth
Where cannula had been inserted

A

Cellulitis
B-haemolytic strep

Antibiotics

85
Q

Pink serosanguinous fluid is coming from wound 10 days post op?
Mx options?

A

Wound dehiscence

On ward = IV Abx, IVF, Analgesia and covered in saline impregnated gauze

Then to theatres:

  1. Re-suture if healthy tissue
  2. Wound manager - if some granulation tissue or high output fistula with wound
  3. Bogota bag - as a temporary measure until surgery, clear plastic bag cut and sutured to edges
  4. VAC dressing
86
Q

Who would get thromboprophylaxis for surgery?

A

> 90 mins or > 60 for LL/pelvis surgery
Thrombophilia, malignancy, known varicose + phlebitis
Acute admission with inflammation of abdomen
Expected reduced mobility
Previous DVT
Age >60, BMI > 30

87
Q

How does LMWH work vs unfractionated vs. dabigatran

A

LMWH = binds to antithrombin to inhibit Xa

Unfract. = Binds antithrombin 3 = affects thrombin and Xa

Dabigatran = Direct thrombin inhibitor

88
Q

causes and Mx of post op reduced urine output?

A 
Pre-renal = hypovolaemic
Renal = commonly drugs e.g. NSAIDs or gentamicin 
Post-renal = retention or blocked catheter 
Mx:
Fluid status
Check catheters and stomas etc
Check drug chart
Flush all instruments 
Fluid challenge
89
Q

Specific surgical complications:

Cholecystectomy?

A

5% converted to open
Bile leak
Retained stones needing ERCP
Fat intolerance / loose stool

90
Q

Specific surgical complications:

Appendicectomy?

A

Abscess
Damage to fallopian tubes
Right heme-colectomy

91
Q

Specific surgical complications:

Inguinal hernia?

A

Early = haematoma, retention and infection

Late = chronic pain, ischaemic orchitis, recurrence

92
Q

Specific surgical complications:

Colonic surgery?

A

Early = ileus, anastomotic leak, fistula, abscess

Late = Adhesions causing obstruction, incisional hernia

93
Q

Specific surgical complications: Ileus

Symptoms, causes and Mx?

A

Distension, constipation / vomiting + absent bowel sounds
Causes:
Bowel handling, infection, hypokalaemia, metoclopramide, pancreatitis

Mx:
NGT, drip and suck
NBM
IVF

94
Q

Specific surgical complications:

Anorectal?

A

Incontinence
Stenosis
Annal fissure

95
Q

Specific surgical complications:

Vascular?

A 
Anastomotic leak
Ischaemia 
Thrombosis / emboli
Infection
Aorto-enteric fistula
96
Q

Specific surgical complications:

Splenic surgery?

A

Thrombocytosis = VTE
Gastric dilation secondary to small bowel ileus
Infection with encapsulated. bugs

97
Q

Specific surgical complications:

Thyroid?

A

Recurrent laryngeal nerve
Tracheal obstruction secondary to haematoma
Hypoparathyroid

98
Q 
Specific nerve injuries in surgery:
Hypoglossal
Accessory
Long thoracic
Recurrent laryngeal
Ulnar + median
Sciatic 
Superior gluteal
Common peroneal
A

Hypoglossal - carotid endarterectomy
Accessory - posteiror triangle LN biopsy
Long thoracic - Axillary node clearance
Recurrent laryngeal - thyroid surgery
Ulnar + median - Upper limb # repairs
Sciatic - Posteiror approach
Superior gluteal - anterolateral approach
Common peroneal - legs In Lloyd Davies position

99
Q 
Specific visceral / structural injuries in surgery:
Thoracic duct
Parathyroid glands
Ureters
Bowel perforation 
Bile duct injury
Facial nerve injury 
Tail of pancreas 
Testicular vessels
Hepatic veins
A

Thoracic duct - any thoracic surgery
Parathyroid glands - difficult thyroid surgery
Ureters - colonic / gynae surgery
Bowel perforation - use of Verres needle
Bile duct injury - not delineating clots triangle
Facial nerve injury - parotidectomy
Tail of pancreas - legating splenic hilum
Testicular vessels - re-do ope inguinal repair
Hepatic veins - liver mobilisation

100
Q

What is post-op cognitive deterioration, and early vs late. causes?

A

Deterioration in. performance on battery of tests expected in <3.5% of controls

Early = Duration of anaesthesia, GA, re-op, post-op infection, increasing age

Late = increasing age, emboli, biochemical disturbance

101
Q

Prepping for endoscopic procedures?

A 
ERCP = clotting, antibiotics 
OGD = NBM 6 hours prior
Flexi-sig = enema 30 mis prior
Colonoscopy = stop ferrous fumerate 7 days prior. If U+E's okay give PO laxatives

MRCS A - Clinical (4 decks)

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