Surgery 1 Flashcards
What is pre-medication
- Medication given before surgery
- May be sedatives, antiemetics etc
What is elective surgery
- Surgeries that are planned in advance i.e. not emergency, life-threatening surgeries
- May be for serious conditions however, such as cancer
What is the pre-operative assessment
- Ask the patient questions about their health, PMHx and home circumstances to see if any arrangements need to be made prior to the surgery
What is the peri-operative assessment
- Comprehensive review of the patient to determine their stability for surgery and how to optimise existing medical conditions
What is anastomosis
- Artificial connection made between two ends of the same organ during surgery
- Often between tubular structures e.g. blood vessels, loops of intestine
What is wound dehiscence
- Breaking open of a wound/incision site
What are adhesions
- Fibrous bands that form between tissues and organs as a result of injury during surgery
- It is scar tissue that attaches to organs
Angio-
Relates to blood vessels
Arthr-
Related to joints
Colono- or col-
Related to large intestine
Cysto-
think cystitis
Related to bladder
Gastr-
Related to stomach
Lapar-
Related to adbominal cavity
Mammo and masto-
think ma to remember
Related to breasts
Nephro-
Related to kidney
-ectomy
To remove e.g. colectomy is removal of the whole colon
-otomy
To open up
-ostomy or -stomy
Artificial opening or hole
-oscopic
- Use a scope - keyhole surgery, minimally invasive
-plasty
think plastering
To modify or reshape
8 Common surgical complications
- n+v
- infection
- pain
- wound dehiscence
- VTE
- haemorrhage
- fluid overload or dehydration
- paralytic ileus
Why is VTE a risk after surgery
- VTE = blood clot forms in vein
- Immobility post op
- Use of plaster casts
- Disrupted vascular bed-thrombogenic surface
8 patient related risks of VTE
- High BMI
- OCP (pill)
- HRT
- Diabetes
- Malignancy
- History of thrombosis
- Thrombophilia
- Pregnancy
Haemorrhage
- Acute loss of blood from a damaged blood vessel
- Caused by:
- Blood clotting disorders
- Complications from surgery
- Damage to internal organs
Why is fluid overload or dehydration a common surgical complication
- Under and over hydration
- Fluid and blood loss during procedure
What is paralytic ileus
- Intestinal blockage in the absence of an actual physical obsturction
- Caused by malfunction in the muscles and nerves of the intestine that impairs digestive movement
Pre-op assessment in elective surgeries - what does it involve
- Inform patient of procedure + if they need to do anything e.g. food/drinks
- Conduct relevant blood tests, X-rays etc
- Determine anaesthetic risk/bleeding risk
- Consider if any meds should be stopped
- Provide alternatives if necessary
- Plan and predict for any post-op complications
- Highlight if patient will be at risk of malnutrition post op (e.g. likely prolonged NBM periods, refer to dieticians)
read over don’t memorise
Roles of pre-op pharmacists (10)
- Taking DHx
- Writing inpatient medication chart
- Administration of medicines during pero-operative period
- Counselling
- Prescribing regular meds
- Advising on appropriate medicaiton management during peri-operative period
- Forsee post-op complications and recommend appropriate treatment
- Smoking cessation
- Producing guidelines for pre-op team
- Preparing for discharge
Anaesthesia clasification: ASA
6 classes ASA1-6
- Healthy patients
- Mild-moderate systemic disease
- Severe systemic disease which limits activity but not incapacitating
- Severe disease process that is a constant threat to life
- Moribund (at death) patient not expected to surivive 24h w/o op
- Declared brain-dead patient, organs being removed for donor purposes
You see Mr Jones in a pre-op assessment clinic 2 weeks before his elective total knee replacement. He is 76 years old and has hypertension as well as RA and osteoporosis.
Why is he at higher risk of post-op complications? What considerations do you need to make?
- Impaired wound healing - RA patients often on immunosuppressants e.g. steroids, MABs, MTX
- Elderly - anaesthetic risk, sedation, drug clearance, respiratory impact, risk of VTE as elderly and non-mobilising surgery
You see Mr Jones in a pre-op assessment clinic 2 weeks before his elective total knee replacement. He is 76 years old and has hypertension as well as RA and osteoporosis. Which class of anaesthesia risk is he likely to be in?
ASA 3: severe disease process which limits activity but is not incapacitating
7 areas for pharmaceutical intervention in surgical pharmacy
- Pain
- Post operative nausea and vomiting (PONV)
- Nil by mouth (NBM) period
- VTE prophylaxis
- Fluid management
- Anticoagulation in the perioperative period
- Abx prophylaxis
What is the WHO analgesic ladder
What is the MHRA advice on NSAID selection
○ Assess CV risk vs gastro risk
○ Ibuprofen 2.4g is lowest
○ Diclofenac has high cardio risk
○ Naproxen has higher GI risk
5 methods of pain management in surgery
- WHO pain ladder
- Patient controlled analgesia (PCA)
- Spinal
- Regional/peripheral nerve LA blocks
- Epidural
What is patient controlled analgesia (PCA)
- Strong opioid based
- Gives pt control of pain so they aren’t waiting potentially long times for the nurse for PRN doses of analgesia
- Pt must be alert to use and have some understanding of process and how to use
- Some pt can become very drowsy with morphine PCA - counter productive, as they will not be able to operate PCA effectively
What is spinal pain management
- Diamorphine administered spinally during surgery
What is regional/peripheral nerve LA blocks
- Nerve blocks are good for fracture
- Hip fracture (neck of femur NOF) - insert LA to nerve = good results for pain relief
What is an epidural
- Form of anaesthetic injected into epidural space
- Numbs limb post-op
- Alleviates pain
- Consists of LA + opioid, synergic action of drugs acting on different sites
- LA acts on nerve blocks
- Opioids act on opioid receptors near spinal cord
- Less n+v with epidural and less risk of DVT due to mobility
Advantages of PCA
- Patient in control of analgesia
- Lockout period protects against OD
- Number of requests for drug can be monitored
- Fast acting
- Rduced patient anxiety on pain
- Improved patient experience
- Suitable if patient NBM
- Useful for incident pain e.g. physio, dressing changes
- Patient’s don’t need multiple injections
Disadvantages of PCA
- not suitable for all patients
- renal impairment - accumulation of morphine metbaolites
- SE: n+v, pruritis, constipation, sedation
- not to be used with any other opoids
- if patients sleeps without PCA, may wake up in pain
