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Surgery Flashcards

1
Q

Name a classification system used to determine ease of intubation

A

Mallampati classification

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2
Q

Name a classification system used to calculate morbidity and mortality in general surgical patients

A

POSSUM score

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3
Q

What drugs are stopped before surgery?

A

CHOW:

  • Clopidogrel (7 days)
    • Aspirin/dipyridamole can be continued
  • Hypoglycaemics (day of surgery)
  • OCP/HRT (4 weeks) due to DVT risk
  • Warfarin (5 days) due to bleeding risk
    • Check INR day before surgery
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4
Q

What drugs should be altered before surgery?

A
  • SC insulin - switched to IV variable rate infusion
  • Long term steroids (continued due to Addisonian crisis risk)
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5
Q

What drugs should be started before surgery?

A
  • LMWH (dalteparin) 5000 units if general surgery
    • 28 days post-op
  • Antibiotics prophylaxis if appropriate
  • TED stockings (not vascular surgery)
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6
Q

How is diabetes handled before surgery?

A
  • Commence sliding scale night before
  • Stop metformin morning of surgery
  • First on list to allow best management of blood glucose while NBM
  • 5% dextrose 125 ml/hr while NBM
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7
Q

How is an AAA defined?

A

Irreversible dilatation of the abdominal Aorta >3cm

  • Infrarenal 95%

True = contains all 3 layers of artery wall

False = Only lined by surrounding connective tissue/adventitia

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8
Q

Name some risk factors for developing AAA

A
  • Smoking
  • Hypertension
  • Hyperlipidaemia
  • Family history
  • Male
  • Age > 65
  • Connective tissue disease
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9
Q

What are the clinical features of AAA?

A

Mainly asymptomatic

  • Abdominal / back / loin pain
  • Distal embolisation - limb ischaemia
  • Pulsatile mass in abdomen (above umbilicus)
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10
Q

What is the screening programme for AAA?

A

NAAASP = abdominal US for all men aged 65

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11
Q

How is AAA managed?

A
  • AAA < 5.5cm monitored via duplex US
    • 3.0-4.4cm = yearly
    • 5.0-5.4 = 3 monthly
  • Reduce CVS risk factors (smoking, BP/DM control, weight loss, statin, aspirin)
  • Surgery if > 5.5cm, explanding >1cm/year or symptomatic
    • Open repair = inlay synthetic graft
    • Endovascular repair (EVAR) = stent via femoral arteries
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12
Q

Name some complications of AAA

A
  • Rupture
  • Retroperitoneal leak
  • Embolisation
  • Aortoduodenal fistula
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13
Q

What are the clinical features of a ruptured AAA?

A
  • Severe/sudden epigastric/back/loin pain
  • Transient hypotension
    • Sudden collapse/syncope
  • Vomiting
  • Pulsatile abdominal mass
  • Haemodynamic instability
  • Sweating
  • Grey-Turner’s sign
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14
Q

How is ruptured AAA managed?

A
  • 2 large bore cannulae - fluids/O neg
    • Keep BP < 90 mmHg (permissive hypotension)
    • Activate major haemorrhage protocol
  • High flow O2
  • Bloods - FBC, U&E, clotting, crossmatch 6 units
  • Analgesia (morphine 5-10mg)
  • Contact vascular surgeon
  • If stable - CT with contrast
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15
Q

What is an Aortic dissection?

A

Tear to intimal layer creates false lumen between layers of the wall

  • Acute < 14 days
  • Chronic > 14 days
  • Anterograde towards iliacs
  • Retrograde towards Aortic valve
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16
Q

Name a classification of thoracic Aortic dissection

A

DeBakey classification:

  • I = originates in ascending Aorta and propagates to at least Aortic arch
  • II = ascending Aorta only
  • III = originates distally to left subclavian artery
    • IIIa = extends to diaphragm
    • IIIb = extends beyond diaphragm
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17
Q

Name some risk factors for Aortic dissection

A
  • Hypertension
  • Male
  • Atherosclerosis
  • Caucasian
  • CTD
  • Bicuspid Aortic valve
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18
Q

What are the clinical features of Aortic dissection?

A
  • Tearing / stabbing chest pain
    • Radiates to back
  • Tachycardia
  • Hypotension
  • New Aortic regurgitation murmur
  • End-organ hypoperfusion
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19
Q

How is Aortic dissection investigated?

A
  • Bloods - FBC, U&E, LFTs, troponin, coagulation, crossmatch 6 units
  • ABG
  • ECG
  • CT angiogram
  • Transoesophageal Echo
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20
Q

How is Aortic dissection managed?

A
  • High flow O2
  • Catheterise and fluid balance
  • 2 large bore cannulae and fluid resuscitation
    • permissive hypotension (100mmHg)
  • DeBakey I+II = surgery (removal of ascending Aorta and replacement with synthetic graft
  • Debakey III = manage hypertension with beta blockers (or CCB)
  • Surgery if visceral/limb ischaemia, refractor pain or uncontrolled hypertension
    • Endovascular with stent graft
  • Lifelong antihypertensives and surveillance
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21
Q

What are the complications of Aortic dissection?

A
  • Rupture
  • Aortic regurgitation
  • Stroke
  • MI
  • Cardiac tamponade
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22
Q

How is carotid artery disease investigated?

A
  • Urgent CT - ischaemic or haemorrhagic
  • Bloods - FBC, U&E, clotting, lipid profile, glucose
  • ECG
  • CXR
  • Colour duplex scan (degree of stenosis)
  • CT angiography
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23
Q

What is the acute management of carotid artery disease?

A
  • High flow oxygen
  • Swallow screen assessment
  • Ischaemic = IV alteplase (tPA) within 4.5 hours of symptom onset
    • 300mg aspirin 14 days
  • Haemorrhagic = clot evacuation
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24
Q

What is the long term management of carotid artery disease?

A
  • CVS risk factor reduction - smoking, BP/DM control
  • Anti-platelet therapy - aspirin, dipyridamole
  • Statin (simvastatin 40mg daily)
  • Carotid endarterectomy if symptomatic > 70% stenosis of ICA or > 50% stenosis with recent TIA
    • Within 2 weeks
    • Removes atheroma and damaged intima with temporary bypass shunt
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25
Q

Name some risks of carotid endarterectomy

A
  • Stroke
  • Hypoglossal nerve damage = weak tongue
  • Glossopharyngeal nerve damage = swallowing dysfunction
  • Vagus nerve damage
  • MI
  • Bleeding
  • Infection
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26
Q

What are varicose veins? What veins do they usually affect/

A

Tortuous, dilated segments of vein associated with valvular incompetence

  • Majority long saphenous vein (ant. medial malleolus to femoral vein)
  • Minority short saphenous vein (post. lateral malleolus to popliteal vein)
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27
Q

Name some risk factors for developing varicose veins

A
  • Prolonged standing
  • Obesity
  • Pregnancy
  • Family history
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28
Q

What are the clinical features of varicose veins?

A
  • Cosmetic - skin discolouration, visible veins
  • Pain
  • Aching
  • Swelling/oedema
  • Thrombophlebitis
  • Ulcers (medial malleolus)
  • Lipodermatosclerosis = tapering of legs above ankle (upside down champagne bottle)
  • Atrophie blanche
  • Saphena varix = dilatation of saphenous vein at sapheno-femoral junction
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29
Q

How are varicose veins investigated?

A
  • Trendelenberg test = patient supine, elevate leg to allow veins to empty, apply tourniquet in high thigh and ask patient to stand
    • Release tourniquet - if rapidly fill up then incompetent valve is SFJ
  • Doppler (exclude arterial pathology)
  • Colour duplex US
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30
Q

How are varicose veins managed?

A
  • Education - avoid prolonged standing, weight loss, exercise
  • Compression stockings if interventional treatment inappropriate
    • CI in arterial ulcers
  • If venous ulcer = four-layer compression bandaging
  • Surgery
    • Vein ligation, stripping and avulsion
    • Foam scleropathy = inject sclerosing agent into vein to close it off
    • Thermal ablation = heating vein from inside to close it off
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31
Q

What are the indications for surgery in varicose veins?

A
  • Symptomatic
  • Skin changes
  • Superficial vein thrombosis
  • Venous ulcer
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32
Q

Name some complications of varicose vein surgery

A
  • Bruising
  • Recurrence (50%)
  • Haemorrhage
  • Wound infection
  • DVT
  • Thrombophlebitis
  • Nerve damage - saphenous/sural
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33
Q

What is intermittent claudication?

A

Muscular pain on exercise associated with early-stage peripheral artery disease

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34
Q

Name some risk factors for intermittent claudication

A
  • Hypertension
  • Hyperlipidaemia
  • Diabetes
  • Smoking
  • Family history
  • Obesity
  • Sedentary lifestyle
  • Diet
  • Male
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35
Q

What are the clinical features of intermittent claudication?

A
  • Pain with exercise
    • Relieved by rest
  • Cyanosis
  • Pallor
  • Weak/absent distal pulses
  • Atrophic changes
    • Dec hair
    • Shiny skin
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36
Q

How is intermittent claudication investigated?

A
  • Buerger’s test = patient supine, elevate legs to 45 degrees for 1-2 mins
    • Pallor = ischaemia (peripheral arterial pressure is inadequate to overcome gravity)
    • Hang legs over bed - blue to red
    • Buerger’s angle
  • ABPI (Ankle-brachial pressure index) systolic in leg / highest systolic in either arm (<1 = abnormal)
  • BP
  • Serum glucose, cholesterol
  • Angiography
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37
Q

How is intermittent claudication managed?

A
  • Risk factor modification - smoking, exercise, statins, BP control, DM control, antiplatelet
  • Pharmacological (improve blood flow/circulation)
    • ACE inhibitor
    • Beta blockers
    • Naftidrofuryl (vasodilator)
    • Pentoxifylline (xanthine)
  • Surgery
    • Angioplasty (Aorto-iliac or superficial femoral)
    • Common femoral endarterectomy
    • Graft (Aortobifemoral)
    • Bypass (popliteal)
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38
Q

What is acute limb ischaemia?

A

Sudden decrease in the limb perfusion that threatens the viability of the limb

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39
Q

Name some causes of acute limb ischaemia

A
  • Thrombosis - artheroma in artery ruptures and a thrombus forms on the fibrous cap
    • Dehydration
    • Hypertension
    • Malignancy
    • Polycythaemia
  • Emboli = thrombus travels distally to occlude the artery
    • AF
    • MI
    • Prosthetic heart valves
    • AAA
  • Trauma (compartment syndrome)
  • Aortic dissection
  • Peripheral aneurysm
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40
Q

What are the clinical features of acute limb ischaemia?

A

6 Ps:

  • Pain
  • Pallor
  • Parasthesia
  • Pulselessness
  • Paralysis
  • Perishingly cold

Irreversible - mottled skin, petechial haemorrhages, hard muscles

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41
Q

How is acute limb ischaemia investigated?

A
  • Bloods - FBC, U&E, troponin, clotting, glucose, G&S, lactate, thrombophilia screen
  • ECG (dysrhythmias)
  • CXR
  • Doppler ultrasound
  • CT angiography
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42
Q

How is acute limb ischaemia managed?

A

Irreversible ischaemia within 6 hours

  • 100% O2
  • Fluids
  • Analgesia (5-10mg morphine IM + anti-emetic)
  • Heparin IV bolus (5000 IU unfractionated) + start infusion
  • If embolic - embolectomy (Fogarty catheter), local intra-arterial thrombolysis, bypass surgery
  • If thrombotic - local intra-arterial thrombolysis, angioplasty, bypass surgery
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43
Q

What are the complications of reperfusing after acute limb ischaemia?

A

Reperfusion injury (release from damaged muscle cells):

  • Hyperkalaemia
  • Acidosis
  • Rhabdomyolosis
    • AKI
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44
Q

What is chronic limb ischaemia?

A

Peripheral arterial disease that results in symptomatic reduced blood supply to the limbs

  • Commonly lower limbs
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45
Q

Name some clinical features of chronic limb ischaemia

A
  • Intermittent claudication
  • Ulcers
  • Weak/absent pulses
  • Gangrene
  • Pallor
  • Cold limbs
  • Skin changes - atrophic, hair loss, thickened nails
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46
Q

Name a chronic limb ischaemia classification system

A

Fontaine classification:

I: asymptomatic

II: intermittent claudication

III: ischaemic rest pain

IV: ulceration and/or gangrene

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47
Q

What is the criteria for critical limb ischaemia?

A
  • Ischaemic rest pain for > 2 weeks
  • Presence of ischaemic lesions or gangrene
  • ABPI < 0.5
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48
Q

What is Leriche Syndrome?

A

Peripheral arterial disease affecting the aortic bifurcation

  • Buttock/thigh pain
  • Erectile dysfunction
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49
Q

How is chronic limb ischaemia investigated?

A
  • ABPI (normal > 0.9, severe < 0.5)
    • Value > 1,2 could represent calcification/hardening due to diabetes
  • Buerger’s test (angle when limb goes pale)
  • Doppler US - assess severity and anatomical location
  • CT/MR angiography
  • CVS risk assessment - BP, BM, cholesterol, ECG
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50
Q

How is chronic limb ischaemia managed?

A
  • CVS risk factors modification - smoking, exercise, diet, statins, antiplatelet, BP/DM control
  • Surgery if risk factor modification has been discussed and supervised exercise has not improved symptoms
    • Angioplasty with stenting
    • Bypass graft (diffuse disease)
    • Amputation (if unsuitable or gangrenous)
51
Q

Name some causes of acute mesenteric ischaemia

A
  • Thrombosis - atherosclerosis
  • Embolism - arrhythmias, MI, prosthetic heart valves
  • Non-occlusive - hypovolaemic/cardiogenic shock
  • Venous occlusion - coagulopathy, malignancy
52
Q

Name some clinical features of acute mesenteric ischaemia

A
  • Generalised abdominal pain (out of proportion)
  • Nausea, vomiting
  • May perforate
  • Potential embolic sources - AF, murmurs, prosthetic valves
  • Otherwise unremarkable exam
53
Q

How is acute mesenteric ischaemia investigated?

A
  • Urgent ABG - acidosis, lactate
  • Bloods - FBC, U&E, clotting, amylase, LFTs, group & save
  • CT angiography
  • If perforated - AXR and eCXR / CT abdo
54
Q

How is acute mesenteric ischaemia managed?

A
  • IV fluids
  • Catheter and fluid balance chart
  • Broad spectrum antibiotics
  • Senior/ITU escalation
  • Surgery
    • Excision of necrotic bowel +/- stoma
    • Revascularisation - remove thrombus/embolus (angioplasty)
55
Q

What is chronic mesenteric ischaemia?

A

Gradual deterioration of blood supply to the bowel due to atherosclerosis in the coeliac trunk, SMA and/or IMA

56
Q

What are the clinical features of chronic mesenteric ischaemia?

A
  • Post-prandial pain/mesenteric angina
    • 10 mins - 4 hrs after eating
    • Fear of eating
  • Weight loss / malnutrition / anorexia
  • Other vascular disease - claudication / renal / coronary
  • Change in bowel habit - loose
  • Nausea / vomiting
  • Abdominal bruits
57
Q

How is chronic limb mesenteric managed?

A
  • CVS risk factor control
  • Surgery if severe disease, progressive or debilitating symptoms
    • Endovascular (radiologically guided stenting)
    • Open (endarterectomy) or bypass
58
Q

Describe Virchow’s triad

A
  • Stasis - immobility, operations, varicose veins
  • Endothelial injury - hypertension, atherosclerosis
  • Hypercoagulability - burns, malignancy, pregnancy, smoking, OCP
59
Q

What are ulcers?

A

Abnormal breaks in the skin or mucous membranes

  • Venous (most common)
  • Arterial
  • Diabetic
  • Pressure
60
Q

Describe venous ulcers including cause and anatomy

A
  • Shallow with granulated base and irregular borders
  • Caused by venous insufficiency (retrograde flow in superficial venous system - dilatation - pooling of blood - impedes oxygen delivery to skin)
  • Paths of short and long saphenous veins
    • Lower leg and malleoli
61
Q

Name some risk factors for developing venous ulcers

A
  • DVT
  • Varicose veins
  • Trauma
  • Pregnancy
62
Q

Name some clinical features of venous ulcer

A
  • Painful
  • Dry/itchy skin
  • Distended veins
  • Oedema
  • Lipodermatosclerosis (inverted champagne bottle)
  • Thrombophlebitis
  • Haemosiderin skin staining (blood leaking out)
63
Q

How is a venous ulcer managed?

A
  • Leg elevation
  • Exercise
  • Emollients
  • Antibiotics (if infected)
  • 4 layered compression bandaging (only if not arterial)
  • Varicose treatment via radiorequency ablation
64
Q

Describe an arterial ulcer including cause and location

A

Small, deep lesions with well-defined borders (punched out appearance) and a necrotic base

  • Caused by a reduction in arterial blood flow - decreased perfusion and poor healing
  • Occurs at sites of trauma and pressure areas (heel, malleoli, shin, toe joints)
65
Q

What are the clinical features of an arterial ulcer?

A
  • Intermittent claudication
  • Critical limb ischaemia (night)
  • Painful
  • Little granulation tissue
  • Cold limbs
  • Necrotic toes
  • Hair loss
  • Reduced pulses
66
Q

How is an arterial ulcer managed?

A
  • Conservative - smoking, weight loss, exercise
  • Medical - statin, anti-platelet, BP/DM control
  • Surgical - angioplasty or bypass graft
67
Q

Describe a neuropathic ulcer including cause and location

A

Painless ulcer on pressure points

  • Caused by peripheral neuropathy - loss of protective sensation - repetitive stress - unnoticed injuries
    • Diabetes
    • B12 deficiency
68
Q

How are neuropathic ulcers managed?

A
  • Diabetes control (HbA1c < 7%)
  • Refer to diabetic foot clinic
  • If infected - antibiotics (flucloxacillin)
  • Surgical debridement of necrotic tissue
69
Q

What is charcots foot?

A

Neuroarthropathy where a loss of joint sensation results in continual unnoticed trauma and deformity occurring, predisposing to neuropathic ulcers

70
Q

Describe how to assess if a patient needs fluids

A
  • Systolic BP < 100
  • Urine output < 0.5 ml/kg/hr
  • Cap refill > 2 secs
  • HR > 90
  • Cold peripheries
  • Resp rate > 20
  • Reduced skin turgor
  • Dry mucous membranes
71
Q

Describe the approach to fluid resuscitation

A
  • Fluid bolus of 500ml crystalloid over 15 mins
  • Reassess using ABCDE
  • Continue fluid boluses
  • If > 2000 ml given seek expert help
72
Q

What is the daily requirements of water, electrolytes and glucose?

A
  • 25-30 ml/kg/day water = 2.5L
  • 1 mmol/kg/day Na+, K+, Cl- = 70 mmol
  • 50-100g/day glucose
73
Q

Name some causes of fluid loss

A
  • Vomiting/diarrhoea
  • Drain loss
  • Haemorrhage
  • NG loss
  • Preoperative fasting
  • Stoma loss
  • Evaporative losses from open abdomen
  • Paralytic ileus
  • Leaking anastamosis
74
Q

Roughly describe the components and concentrations of some crystalloid and colloid fluis and how that compares to ECF and ICF

A
75
Q

How long preop before food, breast milk and clear fluids?

A
  • Food 6 hours
  • Breast milk 4 hours
  • Clear fluids 2 hours
76
Q

What physiological problems can poor pain management cause?

A
  • CVS - inc HR, BP, PVR, myocardial O2 consumption
  • Resp - diaphragmatic splinting/weakened cough - infections
  • GI - delayed emptying, reduced motility
  • Urinary retention
  • Endocrine - release of vasopressin, RAAS, cortisol, glucagon, reduction of insultin/testosterone
    • Reduced wound healing
    • Protein breakdown
    • Na+/H2O retention
77
Q

Describe the WHO analgesic pain ladder

A
  1. Non-opioid (paracetemol/NSAID)
  2. Weak opioid (non-opioid + codeine/tramadol)
  3. Strong opioid (non-opioid + morphine)
78
Q

Why can NSAIDs be contraindicated?

A

GRAB:

  • GI (peptic ulcer)
  • Renal (eGFR < 50)
  • Asthma / allergy
  • Bleeding disorders
79
Q

Name some analgesic drugs

A
  • Paracetemol - via prostaglandin, serotonin, opioid paths
  • NSAID = COX inhibitor dec. synthesis of prostaglandins, prostacyclines and thromboxane A2 from arachidonic acid
    • Dec. platelet aggregation, vasoconstriction, renal blood flow
  • Inhalation (entonox = 50% O2, 50% N2O) - quick acting, short duration, potent
  • Opioids (MOP, KOP, DOP receptor agonists)
80
Q

Name some side effects of opioids

A
  • Respiratory depression
  • Sedation
  • Euphoria
  • Nausea and vomiting
  • Constipation
  • Muscle rigidity
  • Bradycardia
  • Pruritis
81
Q

How can morphine be reversed?

A

Nalaxone (400 micrograms to 800 for up to 2 doses)

82
Q

What is patient-controlled analgesia?

A

Self-administration of IV opioids to help overcome post-op pain

  • Patient titrates plasma opioid concentration to remain in the therapeutic window
  • Delivers boluses up to every 5 mins
    • Morphine 1 mg
    • Tramadol 10mg
  • Better control and faster alleviation of pain, overall less morphine needed
  • May not be appropriate for all patients (poor dexterity, critically ill)
83
Q

Name some complications of epidural analgesia

A
  • Dural puncture
  • Headache
  • Nerve/cord injury
  • Hypotension
  • Urinary retention
  • Pruritis
84
Q

Name some patient, surgical and anaesthetic causes of post-op nausea and vomiting

A
85
Q

Name some causes of PONV

A
  • Infection
  • Ileus
  • Obstruction
  • Metabolic (inc Ca, DKA)
  • Antibiotics
  • Opioids
  • Raised ICP
  • Anxiety
86
Q

How is PONV managed?

A
  • Prophylaxis
    • Reduce opiates and volatile gases
    • Avoid spinal anaesthesia
    • Dexamethasone at induction
  • Conservative
    • Adequate fluids
    • Adequate analgesia
  • Pharmaceutical
    • If impaired gastric emptying - metoclopramide/domperidone
    • If metabolic/biochemical imbalance - metoclopramide
    • If opioid-induced - ondansetron
87
Q

Name some anti-emetics and their mechanism of action

A
  • Ondansetron - Serotonin (5H3) inhibitor
  • Domperidone/metoclopramide - dopamine inhibitor
  • Cyclizine - antihistamine
  • Hyoscine - anticholinergic
88
Q

Name the stages of anaesthesia including pupils, BP, RR, HR

A
  1. Induction
  2. Excitement
  3. Operative
  4. Medullary depression / overdose
89
Q

Name the ‘triad’ of anaesthesic drugs

A
  • Unconscious
    • Propofol (induction)
    • Inhalational agents/sevofluorane (maintenance)
  • Immobile (muscle relaxant)
    • Atracurium
  • Comfortable
    • Morphine
90
Q

How are the effects of neuromuscular blocking agents reversed?

A

Acetylcholinesterase inhibitors: Increases concentration of acetylcholine in neruomuscular junction

  • Neostigmine
91
Q

Name some tools for assessing nutritional status

A
  • Malnutrition Universal Screening Tool (MUST)
  • BMI
  • Grip strength
  • Triceps skin fold thickness
  • Mid arm circumference
92
Q

What is BMI?

A

Weight (kg) / height^2 (m)

93
Q

Name the hierachy of feeding

A
  • Unable to eat sufficient calories = oral nutritional supplement
  • Dysfunctional swallow/unable to take sufficient calories orally = NG tube
  • Oesophagus blocked / dysfunctional = gastrostomy feeding (PEG/RIG)
  • Stomach inaccessible / outflow obstruction = jejunostomy
  • Jejunum inaccessible / intestinal failure = Parental (TPN)
94
Q

Name some advantages of day case surgery

A
  • Shorter inpatient stays
  • Reduced waiting list
  • Lower infection rate
  • Cheaper than overnight
95
Q

What surgery qualified as day case?

A
  • Minimal blood loss
  • < 1 hour operating time
  • No expected complications
  • No specialist aftercare
96
Q

Name some causes of post-op pyrexia

A
  • Infections (4 Ws)
    • Wind (respiratory) day 1-2
    • Water (urinary) day 3-5
    • Walking (DVT) day 4-6
    • Wound/surgical site day 5-7
  • Drugs (days 7+) = antibiotics, anaesthetic agents
  • PE
  • Transfusion reaction
97
Q

How is post-op pyrexia investigated?

A

Septic screen:

  • Bloods - FBC, CRP, U&E
  • Urine dip
  • Cultures - blood/urine/sputum/wound swab
  • CXR
  • CT (if anastamotic leak)
  • Doppler US (if DVT)
98
Q

Name some risk factors for post-op delirium

A
  • Age > 65
  • Co-morbidities
  • Dementia
  • Renal impairment
  • Male
  • Sensory impairment
99
Q

Name some causes of post-op delirium

A
  • Hypoxia
  • Infection (UTI/LRTI)
  • Drugs - benzos, diuretics, opioids, steroids
  • Drug withdrawal
  • Dehydration
  • Pain
  • Constipation/urinary retention
  • Endocrine (Na+/Ca2+)
100
Q

How is post-op delirium investigated?

A
  • Bloods - FBC, U&E, Ca2+, TFT, glucose, B12, folate
  • Blood cultures / wound swabs
  • Urinanalysis
  • CXR
  • CT head
  • Abbreviated Mental Test (AMT)
101
Q

How is post-op delirium managed?

A
  • Conservative - fluids, analgesia, antibiotics
  • Treat cause
  • Haloperidol or olanzapine (< 1 week)
102
Q

Name the different types of post-op haemorrhage

A
  • Primary = within intra-operative period
  • Reactive = within 24 hours of operation
  • Secondary = 7-10 days post-op
103
Q

Describe the different classess of shock/haemorrhage

A

Rules of tennis

104
Q

What is sepsis?

A

Clinical features of organ dysfunction (SIRS) in the presence of a known or suspected infection

  • WCC < 4 or > 12
  • Temp < 36 or > 38.3
  • HR > 90
  • RR < 20
105
Q

How is sepsis managed?

A

SEPSIS 6

IN:

  • 100% O2 (15L non re-breathe mask)
  • IV fluid (500-1000ml bolus)
  • IV antibiotics (start empirical then targeted)

OUT:

  • Blood cultures (before antibiotics)
  • Serum lactate (> 4 = escalate)
  • Urine output (aim for >0.5ml/kg/hr)
106
Q

Name some sources of infection

A

7 Cs:

  • Cut (wound)
  • Central line
  • Catheter (UTI)
  • Cannula
  • Chest
  • Collections (abscess)
  • Calves (DVT)
107
Q

What are the risk factors for anastamotic leak?

A
  • Emergency surgery
  • Longer operating time
  • Oesophageal-gastric or rectal anastamosis
  • Smoking/alcohol excess
  • Diabetes
  • Obesity
  • Drugs - steroids, infliximab, immunosuppressants
108
Q

What are the clinical features of anastamotic leak?

A

5-7 days post-op:

  • Abdo pain
  • Fever
  • Tachycardia
  • Peritonism
  • Faeculant material in wound drain
109
Q

How is anastamotic leak investigated?

A
  • Bloods - FBC, CRP, U&E, LFT (dec albumin). clotting
  • ABG - inc lactate
  • CT abdo-pelvis with contrast
110
Q

How is anastamotic leak managed?

A
  • Broad spectrum antibiotics
  • IV fluids
  • Urinary catheter
  • Minor - bowel rest and observation / percutaneous drainage
  • Major - exploratory laparotomy
111
Q

What are the risk factors for developing post-op ileus?

A

Patient:

  • Old age
  • Electrolyte imbalance
  • Neurological disorders
  • Anti-cholinergic drugs

Surgical:

  • Opioids
  • Pelvis surgery
  • Extensive intestinal handling
  • Resection of bowel
  • Peritoneal contamination
112
Q

What are the clinical features of post-op ileus?

A
  • Failure to pass flatus or faeces (absolute constipation)
  • Bloating/distension
  • Nausea and vomiting / high NG output
  • Absent bowel sounds
113
Q

How is post-op ileus managed?

A
  • Correct electrolyte imbalances
  • Encourage mobilisation
  • Reduce opiate analgesia
  • May need NG tube
114
Q

Describe a brief overview of the approach to AXR

A

ABDO X:

  • Air - pneumoperitoneum (perforation)
  • Bowel
    • Distension
    • Positioning
    • Thickening (thumb print sign of oedema)
  • Dense objects
    • Bones
    • Calcification
  • Organs and soft tissue - liver, kidneys, spleen, inguinal hernia
  • eXternal objects - leads, clips etc
115
Q

Describe this AXR

A

Small bowel obstruction:

  • Gas-filled, distended loops of bowel
  • Central position
  • Valvulae conniventes - across whole circumference
  • > 3cm

May represent a post-op ileus or hernia

116
Q

Describe this AXR

A

Large bowel obstruction:

  • Gas-filled and distended bowel down to sigmoid
    • ‘Cut off’ at site of obstruction (sigmoid)
  • Peripheral position
  • Haustra (not across whole circumference)
  • > 6cm
117
Q

Describe this AXR

A

Sigmoid volvulus = twist at the base of the sigmoid mesentery

  • Fixed in LIF
  • Coffee bean sign
118
Q

Describe this AXR

A

Caecal volvulus = if caecum is retroperitoneal, it can become mobile and susceptible to twisting.

  • Grossly dilated caecum
  • Not in RIF like normal
  • Caecal embryo sign
119
Q

What sign is showed on this AXR?

A

Rigler’s sign = free intra-abdominal gas adjacent to a gas filled loop so both sides of the bowel wall are well defined

  • Usually represents bowel obstruction that has perforated
  • Also look for triangles of gas outside the bowel
120
Q

Describe the AXR

A

Extensive bowel wall thickening throughout the colon

  • Thickening of haustral folds = thumb print sign
  • Indicative of bowel wall inflammation of ulcerative colitis
121
Q

Name some causes of post-op breathlessness

A
  • Basal atelectasis
  • PE
  • Pneumonia
  • Pulmonary oedema
  • Anaphylaxis
  • Hypovolaemia
122
Q

Name the main causes of post-op abdominal pain

A
  • Paralytics ileus
  • Anastamotic leak
  • Surgical site infection
123
Q

How is a DVT managed?

A
  • LMWH or fondaparinux
    • if severe renal disease - UFH
  • Continue for 5 days or until INR is > 2
  • Start warfarin
    • 3 months if provoked DVT/PE
    • >3 months if unprovoked
    • Inferior vena caval filter if anticoagulation not tolerated
  • If unprovoked - investigate cancer
124
Q

Name the surgical procedure needed for cancer in different areas of the colon

A
  • Ascending/proximal transverse = right hemicolectomy with ileo-colic anastamosis
  • Distal transverse/descending = left hemicolectomy with colo-colon anastamosis
  • Sigmoid = high anterior resection with colo-rectal anastamosis
  • Upper rectum = Anterior resection (TME) with colo-rectal anastamosis
  • Low rectum = anterior resection (low TME) with colo-rectal +/- defunctioning stoma OR APER
  • Anal = Abdomino-perineal excision of rectum (APER)
  • Emergency = Hartmanns (sigmoid resection with end colostomy)

IPE (13 decks)

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