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Preoperative management Flashcards

1
Q

What are the aims of pre operative assessment?

A

 Informed consent
 Assess risk vs. benefits
 Optimise fitness of patient
 Check anaesthesia / analgesia type c¯ anaesthetist

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2
Q

What pre operative checks are carried out?

A

OP CHECS

 Operative fitness: cardiorespiratory comorbidities
 Pills
 Consent
 History
 MI, asthma, HTN, jaundice
 Complications of anaesthesia: DVT, anaphylaxis
 Ease of intubation: neck arthritis, dentures, loose teeth
 Clexane: DVT prophylaxis
 Site: correct and marked

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3
Q

What are pre operative considerations for anti-coagulants?

A

 Balance risk of haemorrhage c¯ risk of thrombosis

 Avoid epidural, spinal and regional blocks

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4
Q

What are pre operative considerations for anti epileptic drugs?

A

 Give as usual

 Post-op give IV or via NGT if unable to tolerate orally

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5
Q

What are pre operative considerations for OCP or HRT?

A

 Stop 4wks before major / leg surgery

 Restart 2wks post-op if mobile

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6
Q

How many units of blood should be cross matched for a gastrectomy?

A

4

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7
Q

How any units of blood should be cross matched for AAA?

A

6

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8
Q

When should a chest x ray be carried out as a pre op investigation?

A

cardiorespiratory disease/symptoms, >65yrs

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9
Q

When should an ECG be carried out as a pre op investigation?

A

HTN, Hx of cardiac disease, >55yrs

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10
Q

How long should a patient be NBM prior to surgery?

A

≥2h for clear fluids, ≥6h for solids

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11
Q

What are the risks of bowel prep pre surgery?

A

 Liquid bowel contents spilled during surgery
 Electrolyte disturbance
 Dehydration
 ↑ rate of post-op anastomotic leak

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12
Q

What are the options for bowel prep pre surgery?

A

 Picolax: picosulfate and Mg citrate

 Klean-Prep: macrogol

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13
Q

In what surgeries are prophylactic abx used?

A

 GI surgery (20% post-op infection if elective)

 Joint replacement

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14
Q

How is DVT risk managed for low, medium and high risk?

A

 Low risk: early mobilisation
 Med: early mobilisation + TEDS + 20mg enoxaparin
 High: early mobilisation + TEDS + 40mg enoxaparin +
intermittent compression boots perioperatively.

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15
Q

What are the ASA grades?

A
  1. Normally healthy
  2. Mild systemic disease
  3. Severe systemic disease that limits activity
  4. Systemic disease which is a constant threat to life
  5. Moribund: not expected to survive 24h even c¯ op
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16
Q

How should insulin dependent DM patients be managed surgically?

A

 Put pt. first on list and inform surgeon and anaesthetist
 Some centres prefer to use GKI infusions
 Sliding scale may not be necessary for minor ops

 Put pt. first on list and inform surgeon and anaesthetist
 Some centres prefer to use GKI infusions
 Sliding scale may not be necessary for minor ops

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17
Q

How should NIDDM patients be managed surgically?

A

 If glucose control poor (fasting >10mM): treat as IDDM
 Omit oral hypoglycaemics on the AM of surgery
 Eating post-op: resume oral hypoglycaemics c¯ meal
 No eating post-op
 Check fasting glucose on AM of surgery
 Start insulin sliding scale
 Consult specialist team ore. restarting PO Rx
Diet Controlled
 Usually no problem
 Pt. may be briefly insulin-dependent post-op
 Monitor CPG

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18
Q

What are the risks of steroids in a surgical patient?

A

 Poor wound healing
 Infection
 Adrenal crisis

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19
Q

How should patients taking steroids be managed surgically?

A

 Need to ↑ steroid to cope c¯ stress
 Consider cover if high-dose steroids w/i last yr
 Major surgery: hydrocortisone 50-100mg IV c¯ pre-med
then 6-8hrly for 3d.
 Minor: as for major but hydrocortisone only for 24h

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20
Q

What are the risks of surgery in a jaundiced patient?

A

 Pts. c¯ obstructive jaundice have ↑ risk of post-op renal
failure  need to maintain good UO.
 Coagulopathy
 ↑ infection risk: may → cholangitis

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21
Q

How should jaundiced patients be managed pre operatively?

A

 Avoid morphine in pre-med
 Check clotting and consider pre-op vitamin K
 Give 1L NS pre-op (unless CCF) → moderate diuresis
 Urinary catheter to monitor UPO
 Abx prophylaxis: e.g. cef+met

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22
Q

How should jaundiced patients be managed intraop.?

A

 Hrly UO monitoring

 NS titrated to output

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23
Q

How should jaundiced patients be managed post op?

A

 Intensive monitoring of fluid status

 Consider CVP + frusemide if poor output despite NS

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24
Q

What should be considered in anti-coag patients?

A

 Very minor surgery may be undertaken w/o stopping
warfarin if INR <3.5.
 Avoid epidural, spinal and regional blocks if
anticoagulated,
 In general, continue aspirin/clopidogrel unless risk of
bleeding is high – then stop 7d before surgery

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25
Q

How should patients with low thromboembolic risk be managed surgically?

A

 Stop warfarin 5d pre-op: need INR <1.5

 Restart next day

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26
Q

How should patients with high thromboembolic risk be managed surgically?

A 
 Need bridging c¯ LMWH
 Stop warfarin 5d pre-op and start LMWH
 Stop LMWH 12-18h pre-op
 Restart LMWH 6h post-op
 Restart warfarin next day
 Stop LMWH when INR >2
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27
Q

How should emergancy surgery in pts anticoagulated be managed?

A

 Discontinue warfarin
 Vit K .5mg slow IV
 Request FFP or PCC to cover surgery

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28
Q

What are the risks of COPD to surgery?

A

 Basal atelectasis
 Aspiration
 Chest infection

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29
Q

What should be done pre op for pts with COPD?

A

 CXR
 PFTs
 Physio for breathing exercises
 Quit smoking (at least 4wks prior to surgery)

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30
Q

What are the aims of anaesthesia?

A

hypnosis, analgesia, muscle relaxation

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31
Q

What are the contraindications to regional anaesthesia?

A

local infection, clotting abnormality

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32
Q

Complication of propofol induction

A

cardio respiratory depression

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33
Q

complication of intubation

A

 Oro-pharyngeal injury c¯ laryngoscope

 Oesophageal intubation

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34
Q

Complication of loss of pain sensation

A

 Urinary retention
 Pressure necrosis
 Nerve palsies

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35
Q

Complication of loss of muscle power?

A

 Corneal abrasion

 No cough → atelectasis + pneumonia

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36
Q

What is malignant hyperpyrexia?

A

 Rare complication ppted by halothane or suxamethonium
 AD inheritance
 Rapid rise in temperature + masseter spasm
 Rx: dantrolene + cooling

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37
Q

Why is analgesia necessary post op?

A

 Pain → autonomic activation → arteriolar constriction →
↓ wound perfusion → impaired wound healing
 Pain → ↓ mobilisation → ↑ VTE and ↓ function
 Pain → ↓ respiratory excursion and ↓ cough →
atelectasis and pneumonia
 Humanitarian considerations

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38
Q

What are the pre op options for analgesia?

A

Epidural anaesthesia: e.g. c¯ bupivacaine

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39
Q

What are the end op options for analgesia?

A

 Infiltrate wound edge c¯ LA

 Infiltrate major regional nerves c¯ LA

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40
Q

What are the post op options for pain relief?

A 
1. Non-opioid ± adjuvants
 Paracetamol
 NSAIDs
 Ibuprofen: 400mg/6h PO max
 Diclofenac: 50mg PO / 75mg IM
  1. Weak opioid + non-opioid ± adjuvants
     Codeine
     Dihydrocodeine
     Tramadol
  2. Strong opioid + non-opioid ± adjuvants
     Morphine: 5-10mg/2h max
     Oxycodone
     Fentanyl
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41
Q

What are the aims of enhanced recovery after surgery?

A

 Optimise pre-op preparation for surgery
 Avoid iatrogenic problems (e.g. ileus)
 Minimise adverse physiological / immunological responses
to surgery
 ↑ cortisol and ↓ insulin (absolute or relative)
 Hypercoagulability
 Immunosuppression
 ↑ speeded of recovery and return to function
 Recognise abnormal recovery and allow early intervention

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42
Q

How can a patient be optimised pre surgery under the enhanced recovery programme?

A

 Aggressive physiological optimisation
 Hydration
 BP (↑ / ↓)
 Anaemia
 DM
 Co-morbidities
 Smoking cessation: ≥4wks before surgery
 Admission on day of surgery, avoidance of prolonged fast
 Carb loading prior to surgery: e.g. carb drinks
 Fully informed pt., encouraged to participate in recovery

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43
Q

How are patients on enhanced recovery programmes managed intra op?

A

 Short-acting anaesthetic agents
 Epidural use
 Minimally invasive techniques
 Avoid drains and NGTs where possible

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44
Q

How are patients on enhanced recovery programmes managed post op?

A

 Aggressive Rx of pain and nausea
 Early mobilisation and physiotherapy
 Early resumption of oral intake (inc. carb drinks)
 Early discontinuation of IV fluids
 Remove drains and urinary catheters ASAP

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45
Q

What are the immediate complications of surgery?

A

 Intubation → oropharyngeal trauma
 Surgical trauma to local structures
 Primary or reactive haemorrhage

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46
Q

What are the early complications of surgery?

A 
 Secondary haemorrhage
 VTE
 Urinary retention
 Atelectasis and pneumonia
 Wound infection and dehiscence
 Antibiotic association colitis (AAC)
47
Q

What are the late complications of surgery

A

 Scarring
 Neuropathy
 Failure or recurrence

48
Q

How is surgical hemorrhage classified

A

 Primary: continuous bleeding starting during surgery
 Reactive
 Bleeding at the end of surgery or early post-op
 2O to ↑ CO and BP
 Secondary
 Bleeding >24h post-op
 Usually due to infection

49
Q

What are the causes of post op urinary retention?

A

Drugs: opioids, epidural/spinal, anti-AChM
 Pain: sympathetic activation → sphincter contraction
 Psychogenic: hospital environment

50
Q

What are the risk factors for post op urinary retention?

A 
 Male
 ↑ age
 Neuropathy: e.g. DM, EtOH
 BPH
 Surgery type: hernia and anorectal
51
Q

How is post op urinary retention managed?

A 
 Conservative
 Privacy
 Ambulation
 Void to running taps or in hot bath
 Analgesia
 Catheterise ± gent 2.5mg/kg IV stat
 TWOC = Trial w/o Catheter
 If failed, may be sent home c¯ silicone catheter
and urology outpt. f/up.
52
Q

What is pulmonary atelectasis?

A

 Occurs after every nearly every GA

 Mucus plugging + absorption of distal air → collapse

53
Q

What are the causes of pulmonary atelectasis?

A

 Pre-op smoking
 Anaesthetics ↑ mucus production ↓ mucociliary
clearance
 Pain inhibits respiratory excursion and cough

54
Q

How does pulmonary atelectasis present?

A

 w/i first 48hrs
 Mild pyrexia
 Dyspnoea
 Dull bases c¯ ↓AE

55
Q

How is pulmonary atelectasis managed?

A

 Good analgesia to aid coughing

 Chest physiotherapy

56
Q

How are operative wound infections managed?

A

 Clean: incise uninfected skin w/o opening viscus
 Clean/Cont: intra-op breach of viscus (not colon)
 Contaminated: breach of viscus + spillage or opening of
colon
 Dirty: site already contaminated – faeces, pus, trauma

57
Q

What are the risk factors for wound infection?

A 
 Pre-operative
 ↑ Age
 Comorbidities: e.g. DM
 Pre-existing infection: e.g. appendix perforation
 Pt. colonisation: e.g. nasal MRSA
 Operative
 Op classification and wound infection risk
 Duration
 Technical: pre-op Abx, asepsis
 Post-operative
 Contamination of wound from staff
58
Q

How are wound infections managed?

A

 Regular wound dressing
 Abx
 Abscess drainage

59
Q

How does wound dehiscence present?

A

 Occurs ~10d post-op

 Preceded by serosanguinous discharge from wound

60
Q

What are the risk factors for wound dehiscence?

A 
 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
61
Q

How is wound dehiscence managed?

A 
 Replace abdo contents and cover c¯ sterile soaked gauze
 IV Abx: cef+met
 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
62
Q

What are the complications of cholecystectomy?

A 
 Conversion to open: 5%
 CBD injury: 0.3%
 Bile leak
 Retained stones (needing ERCP)
 Fat intolerance / loose stools
63
Q

What are the complications of inguinal hernia repair?

A 
Early
 Haematoma / seroma formation: 10%
 Intra-abdominal injury (lap)
 Infection: 1%
 Urinary retention
 Late
 Recurrence (<2%)
 Ischaemic orchitis: 0l5%
 Chronic groin pain / paraesthesia: 5%
64
Q

What are the complications of appendectomy?

A

 Abscess formation
 Fallopian tube trauma
 Right hemicolectomy (e.g. for carcinoid, caecal
necrosis)

65
Q

What are the complications of colonic surgery?

A 
 Early
 Ileus
 AAC
 Anastomotic leak
 Enterocutaneous fistulae
 Abdominal or pelvic abscess
 Late
 Adhesions → obstruction
 Incisional hernia
66
Q

What causes post op ileus?

A

 Bowel handling
 Anaesthesia
 Electrolyte imbalance

67
Q

How does post op ileus present?

A

 Distension
 Constipation ± vomiting
 Absent bowel sounds

68
Q

How is post op ileus managed?

A

 IV fluids + NGT

 TPN if prolonged

69
Q

What are the complications of anorectal surgery

A

 Anal incontinence
 Stenosis
 Anal fissure

70
Q

What are the complications of small bowel surgery?

A

 Short gut syndrome (≤250cm)

71
Q

What are the complications of splenectomy?

A

 Gastric dilatation (2O gastric ileus)
 Prevent c¯ NGT
 Thrombocytosis → VTE
 Infection: encapsulated organisms

72
Q

What are the complications of arterial surgery?

A

 Thrombosis and embolization
 Anastomotic leak
 Graft infection

73
Q

What are the complications of aortic surgery?

A 
 Gut ischaemia
 Renal failure
 Aorto-enteric fistula
 Anterior spinal syndrome (paraplegia)
 Emboli → distal ischaemia (trash foot)
74
Q

What are the complications of breast surgery?

A

 Arm lymphoedema
 Skin necrosis
 Seroma

75
Q

What are the complications of prostatectomy?

A

 Urinary incontinence
 Erectile dysfunction
 Retrograde ejaculation
 Prostatitis

76
Q

What are the complications of thyroidectomy?

A 
 Wound haematoma → tracheal obstruction
 Recurrent laryngeal N. trauma → hoarse voice
 Transient in 1.5%
 Permanent in 0.5%
 R commonest (more medial)
 Hypoparathyroidism → hypocalcaemia
 Thyroid storm
 Hypothyroidism
77
Q

What are the complications of tracheostomy?

A

 Stenosis
 Mediastinitis
 Surgical emphysema

78
Q

What are the complications of fracture repair?

A

 Mal-/non-union
 Osteomyelitis
 AVN
 Compartment syndrome

79
Q

What are the complications of hip replacement?

A 
 Deep infection
 VTE
 Dislocation
 Nerve injury: sciatic, SGN
 Leg length discrepancy
80
Q

What are the complications of cardio thoracic surgery?

A

 Pneumo-/haemo-thorax

 Infection: mediastinitis, empyema

81
Q

What are the causes of post op pyrexia?

A 
Early: 0-5d post-op
 Blood transfusion
 Physiological: SIRS from trauma: 0-1d
 Pulmonary atelectasis:24-48hr
 Infection: UTI, superficial thrombophlebitis, cellulitis
 Drug reaction
Delayed: >5d post-op
 Pneumonia
 VTE: 5-10d
 Wound infection: 5-7d
 Anastomotic leak: 7d
 Collection: 5-20d
82
Q

What should be examined in a post op febrile patient?

A 
 Observation chart, notes and drug chart
 Wound
 Abdo + DRE
 Legs
 Chest
 Lines
 Urine
 Stool
83
Q

What investigations should be carried out in a febrile post op patient?

A

 Urine: dip + MCS
 Blood: FBC, CRP, cultures ± LFTs
 Cultures: wound swabs, CVP tip for culture
 CXR

84
Q

What are the causes of post op pneumonia

A

 Anaesthesia → atelectasis
 Pain → ↓ cough
 Surgery → immunosuppression

85
Q

What is the management of post op pneumonia?

A

 Chest physio: encouraging coughing
 Good analgesia
 Abx

86
Q

How does a collection present?

A

 Malaise
 Swinging fever, rigors
 Localised peritonitis
 Shoulder tip pain (if subphrenic)

87
Q

What are the common locations for collections?

A 
 Pelvic: present @ 4-10d post-op
 Subphrenic: present @ 7-21d post-op
 Paracolic gutters
 Lesser sac
 Hepatorenal recess (Morrison’s space)
 Small bowel (interloop spaces)
88
Q

What are the investigations carried out for collections?

A

 FBC, CRP, cultures
 US, CT
 Diagnostic lap

89
Q

What is the management for collections?

A

abx

drainage/washout

90
Q

What is cellulitis?

A

Acute infection of the subcutaneous connective tissue

91
Q

What are the typical causes of cellulitis?

A

β-haemolytic Streps + staph. aureus

92
Q

how does cellulitis present

A

 Pain, swelling, erythema and warmth
 Systemic upset
 ± lymphadenopathy

93
Q

What are the risk factors for DVT?

A

Virchows Triad

Blood Contents
 Surgery → ↑ plats and ↑ fibrinogen
 Dehydration
 Malignancy
 Age: ↑

Blood Flow
 Surgery
 Immobility
 Obesity

Vessel Wall
 Damage to veins: esp. pelvic veins
 Previous VTE

94
Q

What are the signs of DVT?

A

 Peak incidence @ 5-10d post-op
 65% of below knee DVTs are asymptomatic
 Calf warmth, tenderness, erythema, swelling
 Mild pyrexia
 Pitting oedema

95
Q

What investigations should be done in DVT

A 
 D-Dimers: sensitive but not specific
 Compression US (clot will be incompressible)
 Thrombophilia screen if:
 No precipitating factors
 Recurrent DVT
 Family Hx
96
Q

how are dvts diagnosd?

A
  1. Assess probability using Wells’ Score
  2. Low-probability → perform D-dimers
     Negative → excludes DVT
     Positive → Compression US
  3. Med / High probability → Compression US
97
Q

How are DVTs managed?

A 
Anticoagulate
 Therapeutic LMWH: enoxaparin 1.5mg/kg/24h SC
 Start warfarin using Tait model: 5mg OD for first 4d
 Stop LMWH when INR 2.5
 Duration
 Below knee: 6-12wks
 Above knee: 3-6mo
 On-going cause: indefinite

Graduated Compression Stockings
 Consider for prevention of post-phlebitic syndrome

98
Q

How are DVTs prevented?

A 
Pre-Op
 Pre-op VTE risk assessment
 TED stockings
 Aggressive optimisation: esp. hydration
 Stop OCP 4wks pre-op

Intra-Op
 Minimise length of surgery
 Use minimal access surgery where possible
 Intermittent pneumatic compression boots

Post-Op
 LMWH
 Early mobilisation
 Good analgesia
 Physio
 Adequate hydration
99
Q

What are the causes of post op hypoxia?

A 
 Previous lung disease
 Atelectasis, aspiration, pneumonia
 LVF
 PE
 Pneumothorax (e.g. due to CVP line insertion)
 Pain → hypoventilation
100
Q

What investigations should be done in a post op hypoxic patient

A

 FBC, ABG
 CXR
 ECG

101
Q

What are the causes of post op reduced UO?

A 
 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 replacement
102
Q

What is the management of post op reduced UO

A

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 replacement

103
Q

How is post op reduced UO managed?

A

Information
 Op Hx
 Obs chart: UO
 Drug chart: nephrotoxins

Examination
 Assess fluid status
 Examine for palpable bladder
 Inspect drips, drains, stomas, CVP

Action
 Flush c¯ 50ml NS and aspirate back
 Fluid challenge

104
Q

What are the causes of post op N and V?

A

Obstruction
 Ileus
 Emetic drugs: e.g. opioids

105
Q

What are the causes of post op decreased sodium?

A

 S(I)ADH: pain, nausea, opioids, stress

 Over administration of IV fluids

106
Q

How should post op decreased sodium be managed?

A

 Acute: 1mM/h

 Chronic:15mM/d

107
Q

What is the immediate management for post op hypotension

A

 Tilt bed head down, give O2

 Assess fluid status

108
Q

What are the causes of post op hypotension?

A

CHOD

Cardiogenic
 MI
 Fluid overload

Hypovolaemia
 Inadequate replacement of fluid losses
 Haemorrhage

Obstructive
 PE

Distributive
 Sepsis
 Neurogenic shock

109
Q

How is post op hypotension managed?

A 
 Hypovolaemia → fluid challenge
 250-500ml colloid over 15-30min
 Haemorrhage → return to theatre
 Sepsis → fluid challenge, start Abx
 Overload → frusemide
 Neurogenic → NA infusion
110
Q

What are the causes of post op hypertension?

A

 Pain
 Urinary retention
 Previous HTN

111
Q

How is post op hypertension managed?

A

 Rx cause

 May use labetalol 50mg IV every 5min (200mg max)

112
Q

What are the common causes of acute confusional state?

A

DELIRIUM

 Drugs: opiates, sedatives, L-DOPA
 Eyes, ears and other sensory deficits
 Low O2 states: MI, stroke, PE
 Infection
 Retention: stool or urine
 Ictal
 Under- hydration / -nutrition
 Metabolic: Na, AKI, glucose, EtOH withdrawal
113
Q

What is the management of acute confusional state?

A

 May need sedation: midazolam / haldol
 Nurse in well-lit environment
 Rx cause

CSP (5 decks)

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