Surgery 2 Flashcards
1
Q
Pain management - drug misusers
A
- Pain management is a basic human right.
- Regular doses of methadone/buprenorphine does not provide an effective analgesic profile.
- Additional pain medication is required.
2
Q
Consequences of inappropriate pain management - drug misusers
A
- Relapse to addiction.
- Potentially fatal toxicity due to misjudged tolerance or drug interactions.
- Compromised medical care.
3
Q
Monitoring - drug misusers
A
- Pain score
- Respiratory depression
4
Q
Current guidlines - drug misuers
A
- Opioids are not contraindicated.
- Long-acting opioids are preferred.
- Wean as soon as possible.
- Buprenorphine can generally be continued
5
Q
Use of opioids
A
- Former addicts = small risk of exposure triggering relapse.
- Discuss with patient - they may prefer non-opioid analgesia.
- Support during and after discharge.
6
Q
Buprenorphine OST alternative treatment need
A
- Patients on buprenorphine OST may require alternative treatments to manage pain (non-opioid).
- Doses >12 mg may cause total blockage of µ-opioid receptor.
7
Q
Alternative non-opioid approaches
A
- Paracetamol
- NSAIDs
- Adjuvant medications (tricyclic antidepressants)
8
Q
Buprenorphine OST - incomplete blockage
A
- Opioids can be used, but higher doses required.
- If the patient wants to remain on buprenorphine = 6-8 hourly dosing regime to improve the pain management response.
9
Q
Venous Thromboembolism (VTE)
A
- Blood clot forms in vein.
- Commonly occurs in the deep veins of the legs (DVT).
10
Q
VTE - Clinical presentation
A
- Varies
- Often asymptomatic.
- Pain and swelling in the leg.
11
Q
Complications of VTE
A
- Pulmonary embolism (PE)
- Chronic venous insufficiency
- Venous ulceration
- Post-thrombotic limb
12
Q
Pulmonary embolism (PE)
A
- Part or all of thrombus dislodged from site of origin
- Travels in the blood to the lungs
- Potentially fatal PE
13
Q
Post-thrombotic limb
A
- Chronic pain
- Swelling
- Skin changes
14
Q
VTE - Pharmacological treatment
A
- LMWH
- Heparin
- Dabigatran
- Rivaroxaban
15
Q
VTE - non pharmacological treatment
A
- TEDs
- Foot pumps
- Flowtron intermittent pneumatic compression (IPC)
16
Q
VTE - NICE Guidelines
A
- Asses pt on admission for risk of VTE.
- Bleeding risk vs. thrombotic risk
- If needed, started pharmacological VTE prophylaxis ASAP.
17
Q
When is a surgical patient at risk of VTE
A
Surgical patients at risk if:
- Surgical procedure of more than 90 mins or 60 mins involving pelvis or lower limb.
- Acute surgical admission with inflammatory or intra-abdominal condition.
- Expected significant reduction in mobility.
- One or more VTE risk factors.
18
Q
Risk factors for VTE
A
- Cancer
- 60+
- Dehydration
- Obese
- One or more medical comorbidities
- History/family history of VTE
- HRT
- Pregnancy (or <6 weeks postpartum)
19
Q
PONV - at risk groups
A
20
Q
PONV - risk factors
A
- Age
- Young, Female
- non- smoker
- History of PONV or motion sickness.
- Anxiety level
- Obesity
- Non-compliance with pre-op fasting recommendations
- Duration and type of surgery
- Anaesthetic factors
- Use of pre/post-op opioids
21
Q
PONV - consequences
A
- Delayed administration of opioid analgesia.
- Wound disruption after abdominal/max fac surgery.
- Bleeding
- Dehydration and electrolyte imbalance.
- Interference with nutrition.
- Delay in mobilisation, recovery & discharge.
- Patient discomfort and distress.
22
Q
PONV - drugs
A
- Cyclizine
- Ondansetron/Granisetron
- Dexamethasone
- Metoclopramide/Domperidone
- Hyoscine
- Prochlorperazine
- Droperidol
- Aprepitant
23
Q
Cyclizine
A
- 1st line
- Antihistamine
- Antimuscarin properties
24
Q
Ondansetron/Granisetron
A
- 5-HT3 antagonists.
- Licensed for treatment and prophylaxis.
- Short treatment for post surgery
- Usually recommended 2nd line after cyclizine.
- Post-op- CV risk (QT interval prolongation).
25
Dexamethasone
- Generally not used unless there is significantly untreated nausea
26
Metoclopramide
- dopamine antagonist
- Gastro patient s
- Max 5 days
- Risk of neurological SE
27
Domperidone
- Dopamine antagonist
- Max 7 days
- Risk of cardiac SE
28
Droperidol
- Butyrophenone
- Structurally related to haloperidol
- Blocks dopamine receptors in the chemoreceptor trigger zone.
29
Aprepitant
- NK1 antagonist
- NK1 is a G protein-coupled receptor in CNS and PNS.
- This receptor has a dominant ligand known as Substance P (SP).
- SP, when activated sends impulses to vomiting centre of the brain.
30
PONV - post op management
- Actively vomiting = avoid PO.
- Cyclizine (IV or IM)
- Metoclopramide (IV)
- Ondansetron (IV)
- Hyoscine (transdermal)
- Prochlorperazine (buccal)
31
Prochlorperazine - buccal
- Absorbed through the lining of mouth
- Direct absorption into the systemic circulation, avoids first-pass metabolism.
- Higher plasma conc.
32
Non-pharmacological
- Adequate hydration and pain management.
- Minimise use of GA
- Minimise opioid use
- Acupuncture
- Ginger/ Mint
- Wristbands
