Pre/post operative care Flashcards
When should you stop ferrous sulphate prior to colonoscopy
7 days as can effect purgative effectiveness
Bowel regime for bowel imaging
ERCP- Clotting, antibiotics, Vitamin K if jaundiced
Diagnostic OGD- Nil by mouth for 6 hours
Flexible sigmoidoscopy- Phosphate enema 30 minutes pre procedure
Colonoscopy- Check U+E and if normal, prescribe oral purgatives e.g. picolax
Fluid management of surgical patients
Hartmann’s when a crystalloid is needed for resuscitation or replacement of fluids.
Avoid 0.9% N. Saline (due to risk of hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids.
Causes of pyrexia post op
Actelectasis - abdo surgery, mild pyrexia, chest signs- within 48hrs
UTI- indwelling catheter,
Wound infection- erythema, mild pyrexia- 5-7 days
Anastomotic leak- swinging fevers, ileus -7d
Surgical patients requiring thromboprophylaxis
Surgery greater than 90 minutes at any site or greater than 60 minutes if the procedure involves the lower limbs or pelvis
Acute admissions with inflammatory process involving the abdominal cavity
Expected significant reduction in mobility
Age over 60 years
Known malignancy
Thrombophilia
Previous thrombosis
BMI >30
Taking hormone replacement therapy or the contraceptive pill
Varicose veins with phlebitis
What reduces the effectiveness of local
Infected tissue
Acidotic environment- ionise in alkaline
Doses of local
Agent Dose plain Dose with adrenaline
Lignocaine 3mg/Kg 7mg/Kg
Bupivacaine 2mg/Kg 2mg/Kg
Prilocaine 6mg/Kg 9mg/Kg
Optimal fluid management pre op for elective
Avoid solids 6 hours
Clear fluids until 2 hours
Carb loading drink in between
Avoid IV fluids
Monitoring of heparin
APTT
No need for LMWH
Different types of central lines and there uses
Central tunnelled- Hickman, good for long term therapeutic
Non tunneled
PICC- less complications on insertion
More prone to infection
Thromboprophyaxis in paediatric cases
None
Chemical types of local
All amino amide
Apart from procaine and benzocaine- Amino ester
Absolute CI to tourniquet
AV fistula
Severe peripheral vascular disease
Previous vascular surgery
Bone fracture or thrombosis at the site of tourniquet application
Physiological effects of inflating then deflating the tourniquet
Post inflation
Increased systemic vascular resistance, increased CVP and increased BP
Slower gradual increase in BP over time
Induced hypercoagulable state
Slow increase in core temperature
Post deflation
Fall in CVP, BP and SVR
Increased end tidal carbon dioxide
Enhanced fibrinolysis
Fall in core temperature
Raised serum potassium and lactate levels
Factors effecting wound healing
Mnemonic to remember factors affecting wound healing: DID NOT HEAL
D iabetes
I nfection, irradiation
D rugs eg steroids, chemotherapy
N utritional deficiencies (vitamin A, C & zinc, manganese), Neoplasia
O bject (foreign material)
T issue necrosis
H ypoxia
E xcess tension on wound
A nother wound
L ow temperature, Liver jaundice
CI of lidocaine
Any cardiac rhythm disorders
Urine sodium in dehydration
<20mmol
Biochem features of dehydration
Hypernatraemia
Rising haematocrit
Metabolic acidosis
Rising lactate
Increased serum urea to creatinine ratio
Urinary sodium <20 mmol/litre
Urine osmolality approaching 1200mosmol/kg
Closure for peri anal abscess
Secondary closure
Dyes or injections prior to surgeries
Parathyroid surgery; consider methylene blue to identify gland.
Sentinel node biopsy; radioactive marker/ patent blue dye.
Surgery involving the thoracic duct; consider administration of cream.
Metallic heart valves anticoagulants prior to surgery
Bridge to heparin
Stop this 6 hrs prior to surgery
Local used in regional block
Prilocaine
Due to less cardiotoxic
Use of lidocaine vs bupivacaine
It has a much longer duration of action than lignocaine and this is of use in that it may be used for topical wound infiltration at the conclusion of surgical procedures with long duration analgesic effect.
Lidocaine faster onset
Presentation of atelectasis post op
w/i first 48hrs
Mild pyrexia
Dyspnoea
Dull bases ̄c ↓AE
Mx of wound dehiscence
Replace abdo contents and cover ̄c sterile soaked gauze
IV Abx: broad spec
Opioid analgesia
Call senior and arrange theatre
Repair in theatre
Wash bowel
Debride wound edges
Close ̄c deep non-absorbable sutures (e.g. nylon)
May require VAC dressing or grafting
RF for wound dehiscence
Pre-Operative Factors
↑ age
Smoking
Obesity, malnutrition, cachexia
Comorbs: e.g. BM, uraemia, chronic cough, Ca Drugs: steroids, chemo, radio
Operative Factors
Length and orientation of incision
Closure technique: follow Jenkin’s Rule Suture material
Post-operative Factors
↑ IAP: e.g. prolonged ileus → distension Infection
Haematoma / seroma formation
Mx of post op ileus
IV fluids and NGT
TPN if prolonged
Cause of reduced urine output post op
Post-renal
Commonest cause
Blocked / malsited catheter Acute urinary retention
Pre-renal: hypovolaemia
Renal: NSAIDs, gentamicin
Anuria usually = blocked or malsited catheter
Oliguria usually = inadequate fluid replacemen
When is heparin given in vascular and cardiac bypass surgeries
Vascular- 3,000 units of systemic heparin 3-5 minutes prior to cross clamping
Bypass- 30,000 units is given prior to going on cardiopulmonary bypass
A thin bluish - white margin appears around the graft
Re epithelierisation
LA for scalp lesions
Lidocaine with adrenaline
Wound healing process
Haemostasis
Inflammation- Typically days 1-5
Neutrophils migrate into wound (function impaired in diabetes).
Growth factors released, including basic fibroblast growth factor and vascular endothelial growth factor.
Fibroblasts replicate within the adjacent matrix and migrate into wound.
Macrophages and fibroblasts couple matrix regeneration and clot substitution.
Regeneration
Typically days 7 to 56
Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells.
Fibroblasts produce a collagen network.
Angiogenesis occurs and wound resembles granulation tissue.
Remodelling
From 6 weeks to 1 year
Longest phase of the healing process and may last up to one year (or longer).
During this phase fibroblasts become differentiated (myofibroblasts) and these facilitate wound contraction.
Collagen fibres are remodeled.
Microvessels regress leaving a pale scar.
How should DM be managed intra operatively
Cases operated on first
Sliding scale for insulin or poorly controlled- K supplementation
Options for surgical nutrition and when they are used
Nutrition requirements < 4 wks:
Fine bore NG tube as well as oral diet
(bike accident, head injury, comatose, no basal skull #; slow recovery;)
Naso-jejanal for acute severe pancreatitis
Nutrition requirements > 4 wks :
PEG (most case)
NCJ (Needle Catheter Jejunostomy);
Use after major GI surgery; Small bowel stoma done
TPN use
Pre-operative pt. & needs to be optimized prior 2surgery
Low BMI & Low albumin
Projectile vomiting due 2PS occurred due to obstructing tumor(excludes oral /NG route) Post operative entero-cutaneous fistula
Patients identified as being malnourished
BMI < 18.5 kg/m2
* unintentional weight loss of > 10% over 3-6/12
* BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12
Parenteral nutrition guidelines
for feeding < 14 days consider feeding via a peripheral venous catheter
* for feeding > 30 days use a tunneled subclavian line
* continuous administration in severely unwell patients
* if feed needed > 2 weeks consider changing from continuous to cyclical feeding
* don’t give > 50% of daily regime to unwell patients in first 24-48h
Those at risk of referring syndrome
BMI < 16 kg/m2
- Unintentional weight loss >15% over 3-6 months
- Little nutritional intake > 10 days
- Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
Kcal aim for refeeding syndrome risk and those are who aren’t
10/kcal/kg per day- RS
25- not as risk
When is cell salvage CI
Malignancy
Physiological response to surgery
Neuro- sympathetic
Acute phase response- TNF-α, IL-1, IL-2, IL-6, interferon and prostaglandins are released
Endocrine
Increases ACTH and cortisol production:
increases protein breakdown
increases blood glucose levels
* Aldosterone increases sodium reabsorption
* Vasopressin increases water reabsorption and causes vasoconstriction
Causative agents of malignant hyperthermia
Halothane
Suxamethosium
Cause, ix and mx of malignant hyperthermia
Excessive release of Ca
Hyperpyrexia and rigidity
CK raised
Dantrolene
Spinal anaesthesia SE
hypotension, sensory and motor block, nausea and urinary retention.
Epidural use and disadvantages
preferred option following major open abdominal procedures
- Disadvantages of epidurals is that they usually confine patients to bed, especially if a motor block is present. In addition an indwelling urinary catheter is required. Which may not only impair mobility but also serve as a conduit for infection. They are contraindicated in coagulopathies.
When TAP blocks are used, which LA
extensive laparoscopic abdominal procedures
Bupivicaine
What do you prepare skin with
skin with alcoholic chlorhexidine (Lowest incidence of SSI)
When do prophylactic antibiotics needs to be given
placement of prosthesis or valve
- clean-contaminated surgery - (e.g resp GI)
contaminated surgery - If a tourniquet is to be used, give prophylactic antibiotics earlier
Types of wound contamination
Clean : Non-infected skin with no hollow organ is cut
Clean-contaminated : Cut of hollow organ except COLON (e.g. GB, unruptured Appendix)
Contaminated : Colon incision; open #; animal/ human bites; colon insion ē minimal spillage.
Dirty : Perforation; wounds made in presence of pus; perforated viscus/traumatic wound>4hrs
Mx options for wound dehiscence
Resuture- wound edges healthy- deep tension sutures used
Wound dressing- granulation tissue, high output bowel fistula
Bogota bag-if wound cannot be closed- need theatre return
+ diagnostic peritoneal lavage
-RBC>100000/mm .
- WBC> 500/mm3
- Gm staining showing organisms
Indications of preoperative steroid cover
Pituitary or adrenal surgery
>10mg 3m
Evidence of cushing
Mx of pts on pre op steroids
For patient on >10mg pred for 3m
Usual dose +
Minor surgery- 50mg pre op HC IV
25mg every 8hrs for 24hrs
Intermediate- 50mg pre op and 25mg every 8h for 24 hrs
Major- 100mg pre, 200mg infusion >24hrs
Warfriin before surgery
Stop 3-5d before
Heparin bridge
INR <1.2 open surgery, 1.5 invasive procedures
Antiplatelets before surgery
Stop 7d-14 before
When to stop LMWH before surgery
6hrs
Metformin before surgery
Stop 48 hours before
In what timeframe should you delay surgery if there’s been a CVA
<6w
Aim to wait for 6m
What is a ring block
Field block in digit or penis
Levels where brachial plexus block is performed
Intersclaene- trunks
supra/infraclavicualr - divisions
axillary - cords
Femoral block
1cm lateral to pulsation of femoral artery at inguinal ligament
Sciatic block
Lateral, anterior or posterior
2cm lateral to ischial tuberosity
Intercostal nerve block
Feel posterior angle of rib
Insert needle just below edge of rib
Complications of epidural
Post dural tap headache
Infection
Haematoma
Urinary retention
When should spinal catheters be removed when anti coagulated
12 hours post LMWH
Then can restart AC after 2 hours
ASA classification
1- normal
2- mild disease
3-severe that limits activity but not incapacitating
4- constant threat to life
5- not expected to survive
DIfferent inductive agents
Thiopental sodium - negative inotrope, cheaper, not used with laryngeal
Propofol - antiemetic effect, used if using laryngeal mask
Etomidate- better for CV unstable pats- induces adrenal suppression
Muscle relaxants
Suxamtheonium- depolarising- hydrolysed slower than Ach
Non depolarising- slower onset, longer duratioon
Acracurium, vecuronium
GA maintainence drugs
Halothane
Enflurane
Isolfurance
NO
Antidote for prilocaine
Methylene blue
May be used in piere block
Which surgeries would be scarless
Fetal
Formation of scar
Haemastasis- mins to hours- vasospasm, fibrin clot- platelets
Next stages can happen concurrently
Inflammation Days, neutrophil, macrophage, fibroblast
Regen 7d-2m- weeks - fibroblast- produce collagen, endothelial cells, macrophages
Remodelling 1m-1y- myofibroblasts, vessels regress
Hypertrophic vs keloid scar
Hypertrophic- stay within scar limit- can be excised
Keloid- do not respect limit- cannot be excised - steroids, silicone
Which factors is affected by warfarin
2,7,9,10 protein C
What increases vs inhibits warfarin
Increase- by inhibiting CYP450
Cipro/cimetidine
Omeprazole/ Fluconazole/metronidazole
Valproate
Erythromycin
Inhibit
Rifampicin
Barbituates
Carbmazepine
CI for caudal anaesthesia
Spina bifida
Meningitis
RICP
Spinal anaesthesia location, dose, how quickly the effect
L1/2
In subarachnoid
2.5-3.5 buvi
2-5 mins
Block more dense
Headache more common
Hypotension more rapid
Epidural anaesthesia location, dose, onset
Between dura mate and ligaments flavum
15-20 of buvi
15-20 mins
Hypotension low
Headache not as common
Patient has bone mets not controlled on medication what to do
Radiotherapy
Patient has pancreatic mets not controlled on medication what to do
Coeliac block
Patient with oesophectomy that’s unsafe to swallow mx
Jejunostomy as stomach now intrathoracic
Nasaljujenal benefits and placement
Less food pooling
Less aspiration risk
Placed surgically
Long term TPN effect on liver
Fatty liver
Derranged LFT
A calculi cholecystitis
Feeding for perforated oesophagus
TPN
Pancreatitis with poor appetite feeding
Nasal jejenostomy
Head injury no signs of skull base fracture feeding
NG tube
Subtotal colectomy with poor appetite feeding
NG tube
High output fistula feeding
TPN
Crohns disease with multiple fistula
TPN
When is TAP block administered
During operation
When is a tracheostomy performed
If requiring ventilation over roughly 1m- long term
Useful for slow wheaning
To reduce dead space
When is a laryngeal mask used and what risks
Short day surgery
Swift onset anaesthesia - fluranes, no muscles relaxants needed
Used in paediatric
Poor control of reflux
Fever and diarrhoea in leukaemia post transfusion
GVHD- immunocomprismed
What day after transfusion does GVHD occur
4-30d GVHD
Cells found in TRALI
Neutrophils
Non immune SE of blood transfusion
Hypocalcaemia
Hyperkalaemia
CCF- TACO
Plts storage temp, days stored and bacteria associated
Room temp
Must be used in 5 days
Gram +
RBC storage temp, days stored and bacteria associated
4 degrees
50-60 d
Gram -
Which blood product most likely to cause urticaria
FFP
Which blood product most likely to cause pyrexia
RBC
What condition is cryoprecipitate used
vWD
As lots of factor 8 and vWF
What can be used for vWD if undergoing minor/MAJOR procedure
TXA- minor
Desmopressin- major
Types of inotropes, the receptors and effects
Noradrenaline- a- vasopressor
Adrenaline- a and b- increase output and PVR
Dopamine- B1- CO
Dobutamine- B1+2- increase CO, reduce PVR
Milrinone- PDE inhibitor- cAMP icnrease- short half life- PVR reduces, increase contractility- reduces pulmonary resistance - vasodilator
Phenylephinephrine- a1- increase PVR and pulmonary
Isoprenaline- B1+2- increase CO reduce PVR- bradycardia
Etmodiate SE
Adrenal Suppressor
Negative inotrope- good for heart
No analgesic properties
Which agent is used for rapid induction
Sodium thiopental
Which muscles relaxants cause histamine release
Actracurium and other tetras
Vercuronium and sux do not
What does TPN not contain in preliminary
Fibre
What monitoring do you measure for TPN
Weight: daily if fluid balance concerns, otherwise weekly reducing to monthly
BMI: at start of feeding and then monthly
If weight cannot be obtained: monthly mid arm circumference or triceps skin fold thickness
Daily electrolytes until levels stable. Then once or twice a week.
Weekly glucose, phosphate, magnesium, LFTs, Ca, albumin, FBC, MCV
levels if stable
2-4 weekly Zn, Folate, B12 and Cu levels if stable
3-6 monthly iron and ferritin levels, manganese (if on home parenteral regime)
6 monthly vitamin D
Bone densitometry initially on starting home parenteral nutrition then every 2 year
Enzyme deficiency in malignant hyperthermia
Pseudocholinesterase
Which anaesthetic agent has strongest anti emetic
Propofol
New AF and fever 5d post resection
Anastomotic leak
Pulmonary oedema CVP
> 18mmHg
When do anti platelets need to be stopped before surgery
5-7d before
Etomidate pros and cons
Good is CV unstable
Can cause adrenal suppression
No analgesia
Vomitting after is common
Muddy brown casts in urine
Acute tubular necrosis
CI to suxamathonium
If extensive tissue necrosis e.g in burns
Can cause hyperkalaermia due to muscle contractions leading to cardiac arrest in these patients
Complication of Dextrans
Anaphylaxis
They inhibit platelet aggregation and leucocyte plugging- improving flow in sepsis
Halothane SE
Hepatotoxicity
Pulmonary function test results
Obstructive lung disease
FEV1- reduced
FVC- reduced
FEV1/FVC- <70%
Asthma
COPD
Bronchiectasis
Restrictive
FEV11- reduced
FVC-sig reduced
FEV1/FVC- normal or high
Fibrosis
Sarcoidosis
ARDS
Scoliosis
NMD
Post haemorrhoidectomy analgesia
Caudal Block
Part of ERAS
Optimise pre existing conditions and nutrition pre admission
Minimise starvation- carb loading drink 2hrs pre procedure- omitted in diabetics with complex insulin
Avoid excess IV during procredure
Post op- early movement, drain removal, catheters, oral nutrition
What is used for intubation in small children
Uncuffed endotracheal tube- reduce risk of tracheal injury
ARDS physiology
Loss of surfactant and increased eleastse release from neutrophils
Fluid accumulation and reduced diffusion
CI to epidural
Active infection- e.g appendicitis
SOFA scoring use and factors
Organ dysfunction in sepsis
PaO2
Plts
Bilirubin
MAP, dopamine/nor/adrenaline use
GCS
Creatinine
Urine output
Test for brain death
Fixed pupils which do not respond to sharp changes in the intensity of incident light
No corneal reflex
Absent oculo-vestibular reflexes - no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the caloric test)
No response to supraorbital pressure
No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation
No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes)
Cardiogenic shock PAOC, CO and SVR
PAOC- high- fluid overload
CO- low
SVR- high
Septic shock PAOC, CO and SVR
POAC- low
CO-high
SVR-low
Hypovolaemic shock PAOC, CO and SVR
POAC- low
CO-low- due to low preload
SVR-high
What is used to reverse depolarising NM blockers and what adverse effects can they cause
Neostigmine
Bradycardia
Where do inotropes have to be administered and what is the exception to the rule
Central line
Metaraminol can be peripheral
Treatment of burning post amputation
Pregabalin or amitriptyline
Pain relief for trigeminal neuralgia
Carbamazepine
What electrolyte disturbance does suxamethonium cause
Hyperkalaemia
Due to the Na/K not keeping up with K efflux from contractions
Major abdo surgery- when can patient resume eating
If malnourished and safe swallow and post op caesarean, gynaecological or abdominal surgery, aim for oral intake within 24h
Analgesia post op for child following ochidoplexy
Caudal
Tx of acute diatonic reaction
Procyclidine
SE of amitriptyline
Orthostatic hypotension
TPN in liver failure
Fatty acids removed
Kcal per day in TPN and in acute unwell
25-35 per day
More in acutely unwell
Amount in 1% lidocaine
100mg in 10ml
As 1% means 1g/100ml
Max lidocaine in adult
200mg
3mg/kg below that
Preservation of what would prevent dumping syndrome
Pylorus
Repair technique of bladder laceration
In layers with absorbable sutures
Protein intake for surgical patient
0.8-1.5
Ventilation with laminar flow reduces wound infection by
2x
Incision for renal tumours
Upper pole- thoracolumbar
Lower- flank incision
Order of ligation of vessel in nephrectomy and is adrenal gland removal necessary
Artery then vein
Adrenal removal is not required unless CT suggests involvement
Homan vs Charles vs thompson technqiue
Charles- excision of lymph tissue with skin graft
Homan- removal of skin and subcut with primary closure
Thompson- excision of subcutaneous and tunnel of dermal flap into muscle compartment of leg
Ladd procedure steps
Usually rotates 270 Anticlockwise
DJ normally to left
This doesn’t occur
Urgent laparotomy
Rotate volvulus anticlockwise
Return small bowel to right and caecum and colon to left and perform appendectomy
Reason for laparoscopic surgeries causing difficult oxygenation in COPD patients
Increased IAP
Reduce FRC, VC and pul compliance
Increase peak airway pressure
In COPD prone to collapse
Often require positive end expiratory pressure in order to achieve adequate gas exchange
Patient with metabolic alkalosis secondary to NG output with ileus- what fluid replacement
Saline
Most common complication of laparoscopic surgery
Haemorrhage
Sterilisation method for medical equipment
Sterilisation of surgical instruments typically takes place in an autoclave which uses pressurised steam at a temperature of 134 degrees
Or using ethylene or formaldehyde
Endoscopy- glutaldehyde for 22 hrs
Gamma radiatio- disposable products- needles, syringes
Short bowel syndrome symptoms
Weight loss
Diarrhoea
Dehydration
High output stoma
Store length of platelets and in humans
5 days
10 days in human
Suspended in plasma
Lipids effect on Na
Pseudo hyponatraemia
When should a drain be removed
If has stopped or decreased to <25ml/day
Which diseases are screening in blood donations
HIV
Hep B, C
Syphilis
Epidural in situ- patient complaining of worse neuro symptoms ix
MRI spine
Who is a pre op ECG required for
Undergoing major surgery
Poor exercise tolerance
MI hx
HTN
Rheumatic fever or other heart conditions
Consent forms
1- adult consent where consciousness will be impaired eg GA
2- parental- used even if child has capacity
3- consciousness not impaired
4- lack capacity
Order of splenic vessel division and prophylaxis
Artery before vein and offer lifelong penicillin prophylaxis
Sign in , sing out and timeout
Sign in - before induction of anaesthesia, check identity, procedure, consent, risks, blood loss
Time out- just before operation
Correct ID, location and schedule, check antibiotics, allergies, medical implants
Sign out- discuss procedure done, counts of instruments, any equipment problems, post op plan
ABPI for TED stockings
08-1.3 safe class 2
0.5- 0.8- class 1
<0.5- not safe
Patient with severe pitting oedema, what mx of thrombophrophylaxis
Flowtron boots
TED CI
Bleeding time definition
Time between making a wound and bleeding to stop
Usually 1-9mins
Test of plt function
Can diathermy be used with a pacemaker in situ
Bipolar yes
Monopolar- pad has to be well away from pacemaker
Cutting vs coagulation diathermy
Cutting- continuous current
Coagulation- interrupted
How long is aspirin stopped before surgery
7 days
Pressure and time for tourniquet in proximal arm
50 mmHg above systolic and 60 mins
ECG changes with swans Ganz catheter and resolution
RBBB in 5%
Resolves in 24 hrs
Feed cause of diarrhoea
Hyperosmolar feed
Bacterial contamination
Low temp feed
Reduced intestinal absorptive capacity
Essentials of TPN
Nitrogen
Carbs
Fat
Ca, Mg, Fe, Zn, Mn, Copper, fluoride, iodine, chloride
Vitamins
Most useful marker of nutritional recovery status
Serum albumin
Venous line left open on insertion complication
Venous air embolism
DIC levels
Low plts
low fibrinogen
prolonged PT
Increased D dimer
Max amount of blood collected for autologous transfusion of pre collected blood
4-5 units
Insulin levels after surgery
Low in Ebb
High in flow - but resistant
Shrinking of split vs full thickness graft
Full intiially shrinks more due to more elastin in dermis
Split contract considerably more after
Retractor used when converting laporasopic to open
Bookwalter
Fiochietto retractor
Rectractor used to separate ribs in thoracic surgery
Weinlager retractor
Self retaining- usually used in herniotomy, FP bypass, plastic, joint procedures
Gelpi retractor
Self retaining
Orthopaedic and spinal
Sweetheart retractor
Heart shaped
Used for cheeks, tongue and lips
Max time for tourniquet
2 hrs
% of TG digested in saliva
10-30%
Current, frequency and voltage of diathermy
Current and voltage low
Frequency high
% of patient requiring conversion to open cholecystectomy and those who can go home same day
5% converted
60% go home sam day
Venous access for TPN
<14 d peripheral
>14 central
Electrolyte abnormalities low Mg can contribute too and symtpoms
Low Ca and K
Low ca so muscle weakness, twitching
Function of factor XIII
Stabilising factor
Cross links fibrin
Not a serine protease like other factors
Position on table for left thoracotomy
Right lateral position
DAPT for MI scheduled for elective surgery what mx
Delay surgery
Major haemorrhage definition
Loss of >50% volume in 3hrs
> 100% in 24
> 150ml per minute
Long acting insulin before surgery
80% before
All others stopped
Storage and use time of FFP
-25
Once thawed sued within 24h at 4 degrees
36 months storied
Suture for vascular anastomosis
Polypropylene 6-0
Mono non absorbable
Needle for tendon repair
Round bodied needle
First signs of large blood loss
Tachycardia
Normal fluid regime for 70kg man
500ml NaCL with 20mmol K 8 hrs
1L dextrose with 20mmol 8 hrs
500ml Dextrose with 20mmol K 8 hrs
Best way to assess fluid status
Urine output
When should a trachy tube be changed
3 days post op
Principals of diathermy pad placement
Close to op site
Away from prosthetics
Well vascularised
Shaved
Good contact
Blade used for minor cutaneous lesions, abdomen and arrteriotomy
Number 15- abdomen
10- skin, muscle, cutaneous
11- arteries - pointy
Calories required per day for surgical patient
25-30
2000 for 70kg
Protein fat glucose ratio for surgical patient
20:30:50
SE of Mg infusion
Cardiac arrhythmia
Nausea
Thirst
Hypotension
Resp depression
Confusion
Loss of reflexes
Muscle weakness
When to give chlorpropamide with surgery
Stopped once the insulin infusion is commenced and not restarted until the patient is eating and drinking normally.
Sulfonulurea
When to use alginate vs foam vs hydrogel vs hydrocolloid vs iodine dressings
Alginate- wound producing fluid
Foam- wet
Hydrogel- dry
Hydrocolloid- clean
Iodine- infected and exudate
What can be a haem SE of TPN
Acute folate def if not given as well
Megaloblastic
Emergency surgery, MRSA +, what to do
Continue surgery
Cover with appropriate Abx
Side room
Class 2 haemorrhage shock sx
15-30
Tachycardia
Lower pulse pressure due to symp vasoconstriction
Agitated but oriented
Use of drains
Detect post op bleeds, remove pus or fluid
Doesn’t help healing
What size of trachy correlates to
Internal diameter
Those requiring U+E before surgery
> 60
CV disease
Renal disease
Diabetes
Steroids/ACEi
Urinary osmolality, sodium and creatine of pre renal vs renal cause
Pre renal
Osm >500
Na <20
Creatinine >40
Renal
Osm <350
Na >40
Creatinine <20
Sign for middle lobe consolidation
Indistinct right heart border
Third space loss definition and constituants
Temporary internal loss of extracellular fluid into space not participating in normal transport
Composition similar to interstitial fluid
Patient post embolectomy, pulse not findable on same leg, what next ?
Measure compartment pressure
Effect of tourniquet on nerves
Neuropraxia
CEPOD classification
1- immediate- life threatening
2- urgent- acute onset- appendectomy, compund fracture- washout within 6 hrs
3-expidited- early treatment- acute cholecystectomy
4- elective
Zinc function intracellularly
RNA and DNA synthesis
When is a post op MI most likely to occur
Day 1
When should pre op ECG and lung function be conducted
ASA 1 over 65
ASA 2
Resp disease lung functions
Class of Nd YAG laser and protection
Class 4
Glasses
Wave length determines penetration
Most effective way of reducing heat loss in pateint
Heated blanket
Imaging radiation risk
Limb 0.01 apart from hip 0.3
Then chest 0.02 3 days BG
Then abdo 0.7 4months
Lumbar spine x ray 1.2 8 months
CT head 2 1 yr
CT chest 8 3.6yrs
CT AP 10 4.5 yrs
When is artificial nutrition required
Oral intake absent or likely to be absent for 5-7d
What time period is a prev MI CI for major surgery
Within 6m
Metabolic complications of TPN
Hyper/oglycaemia
High/low Na
High/low K
High/low Ca
Def in folate, Zn, P , Mg
Anastomosis of free flap construction of breast
Internal mammary
DIEP- deep inferior episode
SGAP- superior gluteal artery
Cause of hypotension in spinal
Reduction in symp
Splanchnic vasdoialtion and pooling
Op max length of time for spinal
<2hrs
Patient chewing gum when NBM how long to wait for surgery
2 hrs
Ventilation support for ARDS
Low tidal volumes
Also give nutritional supplementation NG
Medications stopped before surgery and timings
Lithium- 24hrs
ACEi- 24 hrs
K sparing- day of
Aspirin- 7-14d
Warfarin- 5d
Oestrogen- 4w
