Surgery 2

Question 1

Pain management - drug misusers

Answer 1

• Pain management is a basic human right.
• Regular doses of methadone/buprenorphine does not provide an effective analgesic profile.
• Additional pain medication is required.

Question 2

Consequences of inappropriate pain management - drug misusers

Answer 2

• Relapse to addiction.
• Potentially fatal toxicity due to misjudged tolerance or drug interactions.
• Compromised medical care.

Question 3

Monitoring - drug misusers

Answer 3

• Pain score
• Respiratory depression

Question 4

Current guidlines - drug misuers

Answer 4

• Opioids are not contraindicated.
• Long-acting opioids are preferred.
• Wean as soon as possible.
• Buprenorphine can generally be continued

Question 5

Use of opioids

Answer 5

• Former addicts = small risk of triggering relapse.
• Discuss with patient - they may prefer non-opioid analgesia.
• Support during and after discharge.

Question 6

Buprenorphine OST

Answer 6

• Patients on buprenorphine OST may require alternative treatments to manage pain (non-opioid).
• Doses >12 mg may cause total blockage of µ-opioid receptor.

Question 7

Alternative non-opioid approaches

Answer 7

• Paracetamol
• NSAIDs
• Adjuvant medications (tricyclic antidepressants)

Question 8

Buprenorphine OST - incomplete blockage

Answer 8

• 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.

Question 9

Venous Thromboembolism (VTE)

Answer 9

• Blood clot forms in vein.
• Commonly occurs in the deep veins of the legs (DVT).

Question 10

VTE - Clinical presentation

Answer 10

• Varies
• Often asymptomatic.
• Pain and swelling in the leg.

Question 11

Complications of VTE

Answer 11

• Pulmonary embolism (PE)
• Chronic venous insufficiency
• Venous ulceration
• Post-thrombotic limb

Question 12

Pulmonary embolism (PE)

Answer 12

• Thrombus dislodges from site of origin and travels in the blood, leading to more serious pulmonary embolisms (PE).
• Part or all of the thrombus
• Travel to the lungs = potentially fatal pulmonary embolism.

Question 13

Post-thrombotic limb

Answer 13

• Chronic pain
• Swelling
• Skin changes

Question 14

VTE - Pharmacological treatment

Answer 14

• LMWH
• Heparin
• Dabigatran
• Rivaroxaban

Question 15

VTE - non pharmacological treatment

Answer 15

• TEDs
• Foot pumps
• Flowtron intermittent pneumatic compression (IPC)

Question 16

VTE - NICE Guidelines

Answer 16

1. Asses pt on admission for risk of VTE.
   
   • Bleeding risk vs. thrombotic risk
2. If needed, started pharmacological VTE prophylaxis ASAP.

Question 17

Surgical patients - risk of VTE

Answer 17

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.

Question 18

Risk factors for VTE

Answer 18

• Cancer
• 60+
• Dehydration
• Obese
• One or more medical comorbidities
• History/family history of VTE
• HRT
• Pregnancy (or <6 weeks postpartum)

Question 19

PONV - at risk groups

Answer 19

• Young, Female
• Non smoker
• History of PONV or motion sickness.
• Use of pre/post-op opioids.

Question 20

PONV - risk factors

Answer 20

• Age
• Anxiety level
• Non-compliance with pre-op fasting recommendations
• Duration and type of surgery
• Anaesthetic factors
• Use of opioids
  -Pre-op drug treatment

Question 21

PONV - consequences

Answer 21

• 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.

Question 22

PONV - drugs

Answer 22

• Cyclizine
• Ondansetron/Granisetron
• Dexamethasone
• Metoclopramide/Domperidone
• Hyoscine
• Prochlorperazine
• Droperidol
• Aprepitant

Question 23

Cyclizine

Answer 23

• Antihistamine
• Antimuscarin properties

Question 24

Ondansetron/Granisetron

Answer 24

• 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).

Question 25

Dexamethasone

Answer 25

• Generally not used unless there is significantly untreated nausea

Question 26

Metoclopramide

Answer 26

• Dopamine antagonist
• Gastro patient s
• Max 5 days
• Risk of neurological SE

Question 27

Domperidone

Answer 27

• Dopamine antagonist
• Max 7 days
• Risk of cardiac SE

Question 28

Droperidol

Answer 28

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

Question 29

Aprepitant

Answer 29

• 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.

Question 30

PONV - post op management

Answer 30

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

Question 31

Prochlorperazine - buccal

Answer 31

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

Question 32

Non-pharmacological

Answer 32

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