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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Monitoring - drug misusers

A
  • Pain score
  • Respiratory depression
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Alternative non-opioid approaches

A
  • Paracetamol
  • NSAIDs
  • Adjuvant medications (tricyclic antidepressants)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Venous Thromboembolism (VTE)

A
  • Blood clot forms in vein.
  • Commonly occurs in the deep veins of the legs (DVT).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

VTE - Clinical presentation

A
  • Varies
  • Often asymptomatic.
  • Pain and swelling in the leg.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Complications of VTE

A
  • Pulmonary embolism (PE)
  • Chronic venous insufficiency
  • Venous ulceration
  • Post-thrombotic limb
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Pulmonary embolism (PE)

A
  1. Part or all of thrombus dislodged from site of origin
  2. Travels in the blood to the lungs
  3. Potentially fatal PE
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Post-thrombotic limb

A
  • Chronic pain
  • Swelling
  • Skin changes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

VTE - Pharmacological treatment

A
  • LMWH
  • Heparin
  • Dabigatran
  • Rivaroxaban
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

VTE - non pharmacological treatment

A
  • TEDs
  • Foot pumps
  • Flowtron intermittent pneumatic compression (IPC)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

VTE - NICE Guidelines

A
  1. Asses pt on admission for risk of VTE.
    • Bleeding risk vs. thrombotic risk
  2. 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
Q

Dexamethasone

A
  • Generally not used unless there is significantly untreated nausea
26
Q

Metoclopramide

A
  • dopamine antagonist
  • Gastro patient s
  • Max 5 days
  • Risk of neurological SE
27
Q

Domperidone

A
  • Dopamine antagonist
  • Max 7 days
  • Risk of cardiac SE
28
Q

Droperidol

A
  • Butyrophenone
  • Structurally related to haloperidol
  • Blocks dopamine receptors in the chemoreceptor trigger zone.
29
Q

Aprepitant

A
  • 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
Q

PONV - post op management

A
  • Actively vomiting = avoid PO.
  • Cyclizine (IV or IM)
  • Metoclopramide (IV)
  • Ondansetron (IV)
  • Hyoscine (transdermal)
  • Prochlorperazine (buccal)
31
Q

Prochlorperazine - buccal

A
  • Absorbed through the lining of mouth
  • Direct absorption into the systemic circulation, avoids first-pass metabolism.
  • Higher plasma conc.
32
Q

Non-pharmacological

A
  • Adequate hydration and pain management.
  • Minimise use of GA
  • Minimise opioid use
  • Acupuncture
  • Ginger/ Mint
  • Wristbands