pre + post op mx Flashcards
You are asked to review a 45-year-old man on the surgical ward by the nursing
staff. Checking through the notes, you observe that he is 1 day following an
open anterior resection for rectal carcinoma. He describes severe central abdominal pain associated with dyspnoea. The abdomen is soft but generally tender
throughout. His symptoms have occurred despite an epidural that was inserted
prior to surgery. What is the most effective form of analgesia in this setting?
A. Four-hourly intramuscular morphine
B. Patient-controlled opiate analgesia (PCA)
C. Intravenous paracetamol
D. Per rectum diclofenac
E. Intravenous oxycodeine hydrochloride
B Patient-controlled opiate analgesia (PCA)
This patient is 1 day following a major bowel resection. The best form
of analgesia in this setting is an epidural; however, this appears not to
be functioning. Hence, a PCA system is indicated. This mode of delivery has been shown to be effective for control of postoperative pain. In
addition, it reduces the risk of development of basal atelectasis and other
respiratory complications. The drawback with PCA is that it requires a
level of patient cooperation and understanding, and the patient has to
be able to use the device.
Intravenous oxycodeine hydrochloride and intramuscular morphine are
strong and effective analgesics. The rationale for preferring PCA is that
it has been shown to provide a superior background of analgesia, with
fewer episodes of breakthrough pain. The parental opioid administration is preferred in patients who are less suitable for PCA, that is those
unable to understand instructions, those under sedation and those with
vision impairment or mobility/coordination issues. Paracetamol and
diclofenac are simple analgesics, which you are told have not relieved
the patient’s pain. These drugs may be appropriate to use in conjunction
with a PCA system or other morphine analgesia, although candidates
must be aware that PR drugs should be strictly avoided in patients with
a recent low rectal resection.
Postoperative urine output decline
A 64-year-old man undergoes a laparoscopic gastric bypass for obesity. His baseline blood pressure is 150/80 mmHg. Intraoperatively, there was a small serosal
tear which was sutured laparoscopically. The patient had some bleeding during
the dissection of the lesser omentum, which was controlled with diathermy. The
patient did not require intraoperative transfusion. Postoperatively on return to
the high dependency unit, the patient is mechanically ventilated and his blood
pressure is 80/40 mmHg. His urine output is 15 mL/h. Which of the following is
the best means of improving his urine output?
A. Commence an infusion of furosemide
B. A trial of dobutamine
C. O-negative blood transfusion
D. Insert a Swan–Ganz catheter
E. Give a fluid challenge and monitor the clinical response
2 E Give a fluid challenge and monitor the clinical response
In a surgical patient, it is typically safe to assume that the cause of postoperative hypotension is hypovolaemia until proved otherwise. This
patient may be suffering from a reactionary haemorrhage from a vessel within the lesser omentum. The most appropriate management plan
would be to give a fluid challenge and monitor the clinical response
while simultaneously checking the full blood count and clotting.
Inotropic support with drugs such as noradrenaline and dobutamine
is the reserve of patients who are fluid replete but who still struggle to
maintain their urinary output. Use of these drugs might be indicated
once there is confirmation that the patient is adequately filled. There is
little value to be gained from inserting a Swan–Ganz catheter, unless
there is a clear cardiac cause for shock. Insertion of pulmonary artery
catheters is controversial and some studies even suggest their use is
associated with increased mortality. Furosemide may play a role in the
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30 Section 2: Pre- and postoperative management
management of a patient with low urine output and fluid overload but
not in cases of hypovolaemia.
Right upper quadrant pain
A 46-year-old woman re-presents to the emergency department 48 hours following an ‘uncomplicated’ laparoscopic cholecystectomy and on-table cholangiogram. She describes a history of progressive, constant, right upper quadrant
pain radiating to the shoulder tip since the surgery. The pain is worse on coughing and moving. On direct questioning, she describes a 24-hour history of nausea and vomiting. The abdomen is rigid. Her liver function tests are abnormal
as follows: bilirubin 60 μmol/L, alkaline phosphatase 550 IU/L and alanine
20 Pre- and postoperative management
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Questions 21
aminotransferase 220 IU/L. Her international normalized ratio is <1.5. Which
single investigation is more likely to be diagnostic?
A. Endoscopic retrograde cholangiopancreatography
B. Computed tomography scan of the abdomen and pelvis
C. Erect chest radiograph
D. Amylase or lipase levels
E. Urine Ketostix to detect ketonuria
3 A Endoscopic retrograde cholangiopancreatography
This question requires careful consideration because of its wording:
‘Which single investigation is more likely to be diagnostic’. An urgent
CT scan of the abdomen and pelvis will reveal a small amount of free air
secondary to the recent laparoscopy and free fluid; however, it would
not be able to determine the source of the fluid. In this setting, ERCP
would be required to determine the site of a leak and a CT would help in
the assessment. If the question had asked which investigation is likely
to be performed first, the correct answer might be a CT or ultrasound
scan. Optimal care would be for a scan to confirm a collection followed
by an operation to identify a cause.
The most likely diagnosis in this case is of a biliary leak (commonly
secondary to either slipped Ligaclip, a high pressure ductal system, or a
duct of Luschka). An erect chest plain film radiograph is an appropriate
investigation in the work-up of a patient with an acute abdomen, but in
this setting it is likely to reveal a small amount of free air secondary
to the recent laparoscopic cholecystectomy. Urgent amylase or lipase
levels should be performed as a matter of routine to exclude pancreatitis secondary to the on-table cholangiogram. However, pancreatitis is
unlikely to be the cause of this patient’s peritonism or subphrenic irritation. Urine Ketostix to detect ketonuria should be performed as part of
the assessment. It is likely to show dehydration-associated ketonuria,
but this will not aid the diagnosis.
Postoperative breathlessness
You are called urgently to see a 67-year-old man who is 24 hours following uncomplicated laparoscopic cholecystectomy. The patient is human immunodeficiency
virus-positive and has a past history of thrombocytopenia and at pre-assessment
his platelet count was 60 × 109/L. He is complaining of chest pain and breathlessness and his abdomen is noticeably more distended than in the initial postoperative
period with significant peri-umbilical tenderness. His postoperative electrocardiogram shows lateral ischaemia and his current haemoglobin level is 7.5 g/dL. He is
tachycardic and his blood pressure is 115/75 mmHg. The next appropriate step is
A. Bleep the on-call cardiologist
B. Start treatment dose heparin
C. Start an infusion of glyceryl trinitrate
D. Start blood transfusion
E. Return the patient to operating theatre for re-look laparoscopy
4 D Start blood transfusion
It is likely that this patient has had an umbilical port-site bleed/
haematoma (not uncommon following laparoscopic procedures).
Subsequent blood loss and anaemia are the likely precipitant of the
angina-like chest pain and dyspnoea. Note that atherosclerosis is more
common in retroviral-positive individuals, and they are therefore at
increased risk of underlying undiagnosed cardiovascular disease.
Treating the cause of the anaemia is likely to be the most important step.
It may be appropriate to call a cardiologist and ultimately commence
a GTN infusion, although GTN should be avoided in haemodynamic
compromise as it can cause profound hypotension. Heparin should be
used cautiously in patients with thrombocytopenia and the advice of a
haematologist should be sought.
The nursing staff asks you to review an erect chest radiograph of a 60-year-old
woman who has undergone open colonic surgery for a pelvic mass 3 days ago.
She is comfortable at rest. Her abdomen is distended, with absent bowel sounds.
Free air under the hemi-diaphragms is likely to be due to
A. Perforated peptic ulcer
B. Anastomotic leakage
C. Perforated sigmoid diverticulum
D. A normal finding 4 days post laparotomy
E. A diaphragmatic injury
Abdominal distension
5 D A normal finding 4 days post laparotomy
The presence of free air under the diaphragm is not uncommon following open and laparoscopic surgery and is the most likely explanation
for this finding. This represents a normal finding 3 days post laparotomy. Other less likely causes of free intraperitoneal air in this setting
include anastomotic leakage, perforated sigmoid diverticulum and perforated peptic ulcer; however, these are extremely unlikely in a patient
who is otherwise well.
A 22-year-old woman with known Crohn’s disease is about to undergo an emergency subtotal colectomy with ileostomy. Prior to surgery the patient has been
on 30 mg of prednisolone daily for more than 3 months. The best management to
prevent an addisonian crisis would be
A. Additional steroid cover is not required
B. Usual preoperative dose only (30 mg oral prednisolone)
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22 Section 2: Pre- and postoperative management
C. 50 mg of hydrocortisone intravenously preoperatively, followed by
50 mg of hydrocortisone intravenously 8-hourly for 72 hours
D. 25 mg of hydrocortisone intravenously preoperatively, then resume
the normal steroid dose postoperatively
E. 25 mg of hydrocortisone intravenously preoperatively, followed by
25 mg of hydrocortisone intravenously for 24 hours
Perioperative steroid therapy
6 C 50 mg of hydrocortisone intravenously preoperatively, followed by
50 mg of hydrocortisone intravenously 8-hourly for 72 hours
The amount of steroid cover required perioperatively relates to the
duration of preoperative steroid use, the amount used and the nature of
the surgery. The following table shows a guide to pre- and postoperative
steroid regimens for different types of surgery.
You are asked to assist your consultant who is operating on a 43-year-old human
immunodeficiency virus-positive man involved in a road traffic accident. The
following precautions have been shown to decrease risk of HIV transmission,
with the exception of
A. Gowns
B. Double glove with indicator system
C. Protective eye wear
D. Laminar flow ventilation
E. Surgical masks
Health and safety in the surgical environment
7 D. Laminar flow ventilation
The US Centers for Disease Control and Prevention recommends wearing gloves and surgical masks for all invasive procedures. Protective
eyewear or face shields should be worn for procedures that commonly
result in the generation of droplets, splashing of blood or other body
fluids, or the generation of bone chips. Gowns or aprons made of materials that provide an effective barrier should be worn during invasive
procedures that are likely to result in the splashing of blood or other
body fluids. There is no evidence that laminar flow ventilation reduces
the risk of contraction of HIV.
Preoperative
steroid use
Nature of
surgery Suggested steroid regimen
<10 mg daily Minor No cover required
>10 mg daily Minor 25 mg intravenous hydrocortisone preoperatively
Resume normal steroid use postoperatively
>10 mg daily Intermediate 25 mg intravenous hydrocortisone preoperatively
25 mg intravenous hydrocortisone every 8 hours for
24 hours then resume normal steroid dose
>10 mg daily Major 50 mg intravenous hydrocortisone preoperatively
50 mg intravenous hydrocortisone every 8 hours for
72 hours then resume normal steroid dose
You are called to the ward to review a 72-year-old man who is pyrexial at
38.0°C, 8 hours following an anterior resection for rectal adenocarcinoma without defunctioning stoma. He is asymptomatic and pain-free with an epidural.
A urinary catheter inserted in theatre is draining concentrated urine. He has a
history of chronic airways disease controlled with inhalers. He has no respiratory distress, but both lung bases sound quiet. The most likely explanation for
the patient’s pyrexia is
A. Epidural abscess
B. Systemic response to surgical trauma
C. Basal atelectasis
D. Infective exacerbation of chronic airways disease
E. Urinary sepsis
Health and safety in the surgical environment
7 D. Laminar flow ventilation
The US Centers for Disease Control and Prevention recommends wearing gloves and surgical masks for all invasive procedures. Protective
eyewear or face shields should be worn for procedures that commonly
result in the generation of droplets, splashing of blood or other body
fluids, or the generation of bone chips. Gowns or aprons made of materials that provide an effective barrier should be worn during invasive
procedures that are likely to result in the splashing of blood or other
body fluids. There is no evidence that laminar flow ventilation reduces
the risk of contraction of HIV.
Preoperative
steroid use
Nature of
surgery Suggested steroid regimen
<10 mg daily Minor No cover required
>10 mg daily Minor 25 mg intravenous hydrocortisone preoperatively
Resume normal steroid use postoperatively
>10 mg daily Intermediate 25 mg intravenous hydrocortisone preoperatively
25 mg intravenous hydrocortisone every 8 hours for
24 hours then resume normal steroid dose
>10 mg daily Major 50 mg intravenous hydrocortisone preoperatively
50 mg intravenous hydrocortisone every 8 hours for
72 hours then resume normal steroid dose
You are called to see the same patient 7 days postoperatively as he has become
unwell and pyrexial with a temperature of 39.0°C. The patient has generalized
abdominal discomfort. The abdomen is tender with generalized guarding and
rebound. The chest is clear to auscultation. The patient’s catheter and epidural
were removed 2 days ago. The most likely explanation for the patient’s pyrexia is
A. Deep vein thrombosis
B. Infective exacerbation of chronic airways disease
C. Pulmonary embolus
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Questions 23
D. Anastomotic leakage
E. Pre-existing chest infection
8 B Systemic response to surgical trauma
This patient is only 8 hours following major abdominal surgery. The
pyrexia is likely to be due to the systemic response to surgical trauma.
The patient is at risk of pulmonary atelectasis, but this would be a more
likely answer 24–48 hours postoperatively. An infective exacerbation
of chronic airways disease is less likely in the absence of respiratory
symptoms or signs and more commonly occurs as a consequence of pulmonary atelectasis between 3 and 7 days postoperatively. The urinary
catheter was inserted in theatre, making urinary catheter sepsis less
likely. While an epidural abscess is a recognized cause of postoperative
pyrexia, it is unlikely to be responsible for early postoperative pyrexia.
A 62-year-old man is admitted to the emergency department with abdominal
pain. The patient has a past history of ischaemic heart disease and atrial fibrillation. Computed tomography scan features are highly suggestive of ischaemic
bowel. The patient’s blood gases are as follows:
• pH = 7.25
• paO2 = 10
• paCO2 = 2.8
• HCO3 = 18
• Base excess = –8
Which of the following best describes the patient’s acid–base status?
A. Metabolic acidosis
B. Metabolic acidosis with respiratory compensation
C. Respiratory acidosis with metabolic compensation
D. Metabolic acidosis with inadequate respiratory compensation
E. Cannot be sure without a serum lactate level
Postoperative pyrexia (2)
9 D Anastomotic leakage
The patient is 7 days following an anterior resection without a defunctioning stoma. The patient has generalized peritonitis. The most likely
answer is an anastomotic leakage. Pulmonary embolus and deep vein
thrombosis are recognized causes of postoperative pyrexia and should
be excluded but are less likely. Pre-existing chest infection and infective exacerbations are common in patients with COPD but are less likely
to be responsible for increasing abdominal pain and peritonitis
