Surgery Flashcards by Gina B

List the pre-op considerations

history including SHx and whether patient fit for GA
examine patient
organise investigations
ASA score (1-6)
gain consent - give patient the benefits, risks, alternative options (ensure they are competent)
prophylaxis - VTE and abx

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What is ASA grading?

shorthand to communicate the broad level of systemic function for a patient

grading can help to decide which pre-op investigations are useful

ASA grading between 1-6

1 = healthy patient, 6 = declared brain dead and the organs are being removed for donor purposes

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If you smoke, but are otherwise completely healthy, what is your ASA grade?

smoking automatically puts the ASA grade up by 1 so ASA 2

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What is the 2-level DVT Wells score?

If patient is suspected to have a DVT we use his scoring system to assess

If score >= 2 DVT is likely therefore organise proximal leg US within 4 hours

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What are the clinical features listed in the Wells score?

active cancer
Paralysis, paresis or recent plaster immobilisation of the lower extremities
bedridden for 3 days or major surgery within 12 weeks
entire leg swollen
calf swelling >= 3cm larger than symptomatic side
pitting oedema in symptomatic leg only
collateral superficial veins
previous DVT

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What are the risk factors for DVT?

active cancer/chemotherapy
aged over 60
known blood clotting disorder (e.g. thrombophilia)
BMI over 35
dehydration
one or more significant medical comorbidities (e.g. heart disease; metabolic/endocrine pathologies; respiratory disease; acute infectious disease and inflammatory conditions)
critical care admission
use of hormone replacement therapy (HRT)
use of the combined oral contraceptive pill
varicose veins
pregnant or less than 6 weeks post-partum

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What happens in a VTE risk assessment?

All patients admitted to hospital are assesssed for individual risk factors for VTE development and bleeding risk

Decision can be made whether to start VTE prophylaxis or not - start ASAP

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What are the mechanical VTE prophylaxis types?

compression stockings

- flowtron boots (intermittent pneumatic compression device)

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What are the pharmacological VTE prophylaxis types?

LMWH (enoxaparin) - caution in renal patients
fondaparinux sodium (SC)
patients with CKD are offered unfractionated heparin (rather than LMWH)

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What surgical procedures require VTE prophylaxis for all patients?

hip and knee replacement post surgery

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What is Virchow’s triad (factors that contribute to thrombosis)?

endothelial injury
hypercoaguable state
blood stasis

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How much of the human body is made of fluids?

60%

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When we administer fluids, which compartment are we influencing?

intravascular fluid (plasma) of the extracellular compartment

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How much K+ and Na+ do we need everyday?

K+ 0.5 mmol/kg/day

Na+ 1-2 mmol/kg/day

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What factors affect fluid prescription?

pre-existing = renal failure, BP, congestive CF (pulmonary oedema), liver failure, age and fragility
post-op = NBM, blood loss, V&D, obstruction, ileus
end organ damage = AKI, pulmonary oedema, sepsis

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How can fluid status be assessed?

OBS - pulse, BP, RR, O2 sats, stool chart
daily weights
exam = JVP, cap refill, skin turgor, tongue, mucus membranes
investigations - blood tests (renal function - U&Es)
imaging

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What is the normal urine output?

0.5 ml/kg/hr

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What is a fluid challenge?

bolus of 500ml crystalloid (0.9% saline) over less than 15 minutes

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What are the different types of fluids?

-5% dextrose
-crystalloids - 0.9% NaCl + Hartmann’s solution
(Can add K+ into bags)

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If someone is acutely bleeding what fluids do we give them?

blood products - packed red cells, FFP (clotting factors), platelets, factor concentrates

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On admission, what routine bloods are required?

G&S and clotting screen

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Why is nutrition so important in surgical patients?

these patients are metabolically stressed and have increased energy requirements

malnutrition leads to infections, decreased healing, wound breakdown, death

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What is the difference between enteral and paraenteral feeding?

enteral = refers to delivery of food via the GIT

paraenteral = refers to the delivery of calories and nutrients into a vein (bypasses GIT)/venous system via PIC or central line

What are the different types of enteral nutrition tubes?

nasogastric
nasoduodenal
gastrostomy
jujunostomy
nasojejunal

Describe the WHO pain ladder

Step 1 = mild pain - non-opioids (paracetamol +/- NSAIDs) Step 2 = moderate pain - weak opioids (codeine, tramadol) Step 3 = severe pain - strong opioids (morphine, oxycodone, fentanyl)

What local anaesthetic can be given to patients?

lignocaine or lidocaine (1% = 10mg/ml) safe dose = 3mg/kg (with adrenaline for vascularised areas like scalp) = 7mg/kg

List some post-op complications

Immediate (hrs) - bleeding, pain, ischaemia, infection - aspiration Early (days) - infection - VTE/PE - MI - ileus - pressure sores - electrolyte abnormalities Late (weeks) - scar related - wound dehiscence - MI/HF - nutrition related

Colorectal cancer 2 week referral criteria

- significant change in bowel habit - rectal bleeding - palpable rectal masses - unintentional weight loss

What are the red flag sx for gastro hx?

- unintentional weight loss - Fe deficiency anaemia - haematemesis - malaena - significant change in bowel habit

If someone has suspected colorectal cancer what happens?

- they have a colonoscopy - if any masses, need to take biopsies (6-8-biopsy is sent to the histopathologist - cancer nurse specialist counsels the patient - radiologist stages the cancer by CT thorax, abdomen, pelvis (TNM) - MDT meeting is organised

Who are the core members of the MDT for colorectal cancer?

- suregon - oncologist - cancer nurse specialist - radiologist - histopathologist

How long is the rectum and how many sections is it made up of?

15cm, split into 1/3s

What is a right sided hemicolectomy?

Resection of the bowel if there is a cancer in the caecal, ascending or proximal transverse colon Ileo-colic anastamosis

What is a left sided hemi-colectomy?

Resection of the bowel if there is a cancer in the distal transverse or descending colon Colo-colon anastamosis

What is an anterior resection?

removal of the upper rectum colo-rectal anastomosis

What is an APER (abdomino-perineal excision of rectum)?

if a cancer is present in the anal canal, the whole rectum is removed patient will have a permanent stoma/colostomy

What LFTs do the liver cells reflect?

ALT, AST

What LFTs do the common bile duct cells reflect?

ALP, GGT (if obstruction = increased bilirubin)

What are the 3 types of abdominal pain?

somatic visceral referred

Characteristics of somatic pain?

- due to irritated fibres in parietal peritoneum - easy to localise - intense constant pain - aggravated by activity, relived by rest - occurs late

Characteristics of visceral pain

- dull, achy, cramping pain - patient cannot stay still - occurs early - only pathological organ involved

Characteristics of referred pain

- occurs at site distant from site of stimulation - mechanism unclear - does not cross the midline

what is colorectal cancer?

malignancies that arise from beginning of colon, caecum through to the end of the rectum does not include anus or small bowel

what are the mutations involved in the adenoma-carcinoma sequence?

1st - mutation in APC (tumour suppressor) 2nd - mutation in KRAS (protooncogene) 3rd - mutation in p53 4th - mutation in SMAD4

where does rectal cancer usually spread?

lungs

where do other colorectal cancers usually spread to?

liver

what is the NHS screening test of choice for colorectal cancer?

FIT test (from the age of 56) done every 2 years

what is the gold standard for colorectal cancer diagnosis?

colonoscopy with biopsy

what investigation for diagnosing colorectal cancer is used in those declining endosocopy?

CT pneumocolon - CT scan of colon, non invasive requires bowel prep - laxative inflation of the bowel and then CT scan

tests for suspected clolorectal cancer

``` bloods FBC serum ion, transferrin, TIBC U&Es LFTs clotting CEA ```

what are the 3 stoma types?

colostomy ileostomy urostomy

what are the features of a colostomy ?

LIF solid stool in bag flushed

what are the features of ileostomy?

located in RIF liquid faeces spouted - doesnt touch skin

what are the features of urostomy

RIF - typically after cystectomy urine in the stoma bag

what are the 2 main herediatry syndromes that causes colorectal cancer?

Lynch syndrome FAP both autosomal dominant

what other cancers is lynch syndrome associated with?

``` endometrial ovarian small bowel stomach gallbladder liver brain renal tract ```

what management is required in a child known to have FAP?

screening from the age of 12 (colonoscopies) prophylactic ileostomy (before the age of 25)