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Perioperative Care > Preoperative Care > Flashcards

Preoperative Care Flashcards

1
Q

List the common medications that should be stopped prior to surgery

A
  • COCP (4 weeks prior to major surgery)
  • Tamoxifen (4 weeks prior to major surgery)
  • HRT (4 weeks prior to major surgery)
  • Antiplatelets (stop 7-14 days prior)
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2
Q

List the common drugs that should be held of the day of surgery

A
  • ACE-i
  • ARBs
  • Diuretics
  • Diabetic treatment (alternative should be arranged)
  • Warfarin/Aspirin/Clopidogrel (unless coronary stent)
  • Lithium
  • NSAIDs
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3
Q

How should oral medications be given on the days of surgery

A

With a sip of water even if NBM

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4
Q

Which patients should receive perioperative steroid cover

A
  • Adrenal insufficiency on steroids
  • Undergoing pituitary or adrenal surgery
  • On systemic steroid therapy >7.5mg/day for >1 week prior to surgery
  • Those who have received >1 month steroid course in the past 6 months
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5
Q

What are the mineralocorticoid side effects of steroids

A
  • Sodium and water retention
  • Potassium loss
  • Metabolic alkalosis
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6
Q

What are the Prednisolone and Dexamethasone equivalent doses of 100mg Hydrocortisone

A
  • Prednisolone 25mg

- Dexamethasone 4mg

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7
Q

What does Warfarin inhibit

A
  • Vitamin K-dependent clotting factors (2, 7, 9, 10)

- Protein C and S

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8
Q

How do you reverse warfarin:
A) >24 hours
B) Immediately

A

A) Vitamin K 10mg

B) FFP 15ml/KG

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9
Q

How should Warfarin be managed perioperatively

A
  • Stop 3-5 days before

- Replace with heparin

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10
Q

INR targets for:
A) Open surgery
B) Invasive procedures

A

A) <1.2

B) <1.5

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11
Q

Mechanism of action of Heparin

A
  • Binds to antithrombin 3

- Inhibits factors 2a, 9a, 10a, and 12a

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12
Q

How often should APTT be checked whilst on heparin infusion

A

6 hourly

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13
Q

How is LMWH reversed

A

Protamine 1mg per 100 units

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14
Q

Describe the Lee Index

A

Individual predictor of cardiac risk based on 6 parameters

  1. History of IHD
  2. History of CVA
  3. HF
  4. T1DM
  5. Impaired renal function
  6. High risk surgery
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15
Q

List the cardiac effects of general anaesthetic

A
  • SVR decreases (20-30% at induction)
  • Tracheal intubation reduces BP by 20-30mmHg
  • Myocardial depression
  • Increased cardiac irritability
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16
Q

What is the minimum interval between MI and elective surgery

A

6 months

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17
Q

How should T2DM be managed prior to surgery

A

Continue normal oral hypoglycaemics until the morning of surgery, except Metformin and Chlorpropamide which may need to be stopped earlier due to risk of lactic acidosis

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18
Q

Risk of MI if surgery performed within 3-6 months of previous MI

A

16%

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19
Q

What is the minimal accepted urine output guiding adequate renal perfusion

A

0.5ml/kg/hr

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20
Q

What is the best blood marker for assessing response to nutrition supplementation

A

Serum transferrin

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21
Q

Criteria for malnourishment

A
  • BMI <18.5
  • Unintentional weight loss >10% over 3-6 months
  • BMI <20 and unintentional weight loss >5% over 3-6 months
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22
Q

List the risks associated with TPN

A
  • Hyperosmolarity
  • Lack of glycaemic control
  • Micronutrient deficiencies
  • Liver dysfunction
  • Pancreatic atrophy
  • Fluid overload
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23
Q

What scan should be performed prior to commencing home TPN

A

Bone densitometry

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24
Q

In whom should gastrostomy be considered for nutrition

A

If gastric feeding likely required for >4 weeks

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25
Q

How does pancytopenia occur when using TPN

A

B12/Folate deficiency

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26
Q

How many mg/ml in a 1% solution

A

10mg/ml

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27
Q

Maximum dose of Lidocaine with and without adrenaline

A
  • Without = 3mg/kg

- With = 7mg/kg

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28
Q

Maximum dose of Bupivicaine with and without adrenaline

A
  • Without = 2mg/kg

- With = 2mg/kg

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29
Q

Maximum dose of Prilocaine with and without adrenaline

A
  • Without = 6mg/kg

- With = 9mg/kg

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30
Q

What are the symptoms of systemic local anaesthetic toxicity

A
  • Perioral tingling
  • Anxiety
  • Tinnitus
  • Drowsiness
  • Seizures
  • Coma
  • Apnoea
  • CV collapse
  • Paralysis
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31
Q

What is the reversing agent for local anaesthetics

A

Lipid emulsion (intralipid 20%) at 1.5ml/kg over 1 minute

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32
Q

How is prilocaine toxicity treated

A

Methylene blue

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33
Q

How is a field block performed for inguinal hernia repairs

A

Direct infiltration of the ilioinguinal nerve above the ASIS

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34
Q

When should a heparin infusion be stopped prior to surgery

A

6 hours

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35
Q

What type of block should be used for the fingers and how is this performed

A
  • Ring block
  • NO ADRENALINE
  • Inject either side of the digit at the level of the webspace
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36
Q

When might a sciatic block be used

A

Foot and ankle surgery

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37
Q

How is a sciatic block performed

A

Injection 2cm lateral to the ischial tuberosity at the level of the GT

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38
Q

Outline how a Bier’s block is performed

A
  1. IV access in both arms
  2. Exsaguinate limb with Eschmark bandage
  3. Apply double cuff touniquet
  4. Inflate upper cuff to 300mmHg
  5. Inject 40ml of 0.5% Prilocaine
  6. Inflate lower cuff
  7. Release upper cuff
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39
Q

Which dural space is used for spinal anaesthesia

A

Subarachnoid

40
Q

What level is the needle inserted for spinal anaesthesia

A

L1-2

41
Q

What dural space is used for epidural anaesthesia

A

Extradural space

42
Q

What precautions must be taken with spinal catheters and anticoagulation

A

Catheters must not be removed whilst anticoagulated (remove 12 hours post low-dose LMWH and delay two hours before next dose)

43
Q

What type of drug is Lidocaine

A

Amide local anaesthetic (also antiarrhythmic)

44
Q

What is the primary precaution with Bupivacaine

A

Cardiotoxicity

45
Q

What is the mechanism of action of Bupivicaine

A

Binds to the intracellular portion of sodium channels and blocks sodium influx into nerve cells to prevent depolarisation

46
Q

Why is bupivicaine contraindicated in regional blockage

A

Due to its cardiotoxicity in the event that the tourniquet fails

47
Q

What is the local anaesthetic of choice for IV regional anaesthesia

A

Prilocaine

48
Q

At what pH do local anaesthetics become less effective

A

Acidic environments e.g. abscess

49
Q

Which drugs contraindicate the use of adrenaline

A
  • TCAs

- MAOIs

50
Q

What is the major side effect of Prilocaine

A

Methaemoglobinemia

51
Q

Why do spinal anaesthetics cause hypotension

A

Cause loss of sympathetic tone

52
Q

Outline ASA grading

A
  1. Normal healthy individual
  2. Mild systemic disease
  3. Severe systemic disease that limits activity but is not incapacitating
  4. Incapacitating disease that is a constant threat to life
  5. Moribund patient not expected to survive
53
Q

What are the aims of anaesthetic premedication

A
  • Anxiolytic
  • Enhances hypnotic effect of GA
  • Amnesia
  • Dries secretions
  • Antiemetic effect
  • Increases vagal tone
  • Modifies gastric contents
54
Q

Agent to reverse Benzodiazepines

A

Flumazenil

55
Q

Side effects of Hyoscine

A
  • Bradycardia
  • Confusion
  • Ataxia
56
Q

What is the agent of choice for rapid-sequence induction

A

Sodium thiopentone

57
Q

What is the agent of choice for induction of anaesthesia in those who are haemodynamically unstable and why

A
  • Ketamine

- Produces little myocardial depression

58
Q

What is the agent of choice for induction of anaesthesia in daycase surgery

A

Propofol

59
Q

Which induction agents have antiemetic properties

A

Propofol

60
Q

Which induction agent is associated with adrenal suppression

A

Etomidate

61
Q

Why can thiopentate not be used with laryngeal airways

A

Sensitises the pharynx

62
Q

What are the common depolarising neuromuscular blockers

A

Suxamethonium

63
Q

What is the mechanism of action of Suxamethonium

A

Inhibits the action of acetylcholine at the neuromuscular junction

64
Q

What is the fastest onset muscle relaxant

A

Suxamethonium

65
Q

What are the adverse affects of suxamethonium use

A
  • Hyperkalaemia
  • Malignant hyperthermia
  • Delayed recovery
66
Q

Which anaesthetic agent is associated with dissociative anaesthesia

A

Ketamine

67
Q

What anaesthetic agent is safe to use for sedation in the less monitored environment and why

A

Ketamine - maintains airway protection

68
Q

What is suxamethonium metabolised by

A

Plasma cholinesterase

69
Q

List the non-depolarising muscle relaxants

A
  • Altracurium
  • Vecuronium
  • Pancuronium
70
Q

Why does altracurium cause facial flushing, tachycardia, and hypotension

A

Causes generalised histamine release on administration

71
Q

What is the reversal agent for altracurium, vecuronium, and pancuronium

A

Neostigmine

72
Q

What is the incidence of malignant hyperthermia

A

1 in 15000

73
Q

What is the inheritance pattern and gene defect associated with malignant hyperthermia

A
  • Autosomal dominant

- Defect in gene on chromosome 19 encoding the ryanodine receptor

74
Q

What are the clinical features of malignant hyperthermia

A
  • Hyperpyrexia

- Muscle rigidity

75
Q

What is the treatment of malignant hyperthermia

A

Dantrolene - prevents calcium release from the sarcoplasmic reticulum

76
Q

What percentage of total volume does plasma make up

A

5% (3L)

77
Q

In what physiological state should Hartmann’s solution be used cautiously and why

A

Alkalosis - as lactate is metabolised to bicarbonate

78
Q

Where is a tracheostomy inserted

A

2cm below the cricoid cartilage

79
Q

What is the background radiation rate

A

2.2msv per year

80
Q

What is the CT scan attributable risk of cancer

A

1 in 2000

81
Q

What is used to maintain anaesthesia

A

Inhalational anaesthetics

82
Q

What are the side effects of Halothane

A
  • Causes respiratory depression and CO2 retention
  • Negative inotrope
  • Mild muscle relaxant
83
Q

Which inhalational anaesthetic should be avoided in epileptics

A

Enflurane

84
Q

What condition is associated with isoflurane use

A

Coronary steal syndrome

85
Q

What substance can be used to potentiate the effect of inhalational anaesthetics

A

Nitrous oxide

86
Q

What are the risks of prolonged exposure to nitrous oxide

A

Suppresses methionine synthase which leads to myelosuppression and megaloblastic anaemia

87
Q

What are the absolute contraindication to halothane

A
  • History of pyrexia after admission

- Jaundice

88
Q

What agents are associated with malignant hyperthermia

A
  • Halothane
  • Suxamethonium
  • Antipsychotics
89
Q

What is the treatment of Torsades de Pointes

A

IV Magnesium sulphate

90
Q

What should be given to patients 2-3hrs before elective surgery

A

Carbohydrate-rich drinks

91
Q

In whom do benzodiazepines reduce the incidence of post-operative delirium

A

Those already taking benzodiazepines

92
Q

What is the postoperative concern in those with aortic stenosis

A

Cannot increase CO

93
Q

What is the risk of using verapamil in VT

A

Can cause VF

94
Q

What are the characteristics of stored blood

A
  • High K+
  • Low pH
  • Decreased 2,3-DPG
  • Less factor V and 8
95
Q

Why does hypotension occur under spinal anaesthetic

A

Splanchnic vasodilatation

Perioperative Care (6 decks)

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