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- FINALS > Surgery > Flashcards

Surgery Flashcards

1
Q

Routine investigations for all surgeries?

A 
FBC
U+E
LFT
Clotting
G+S/X-match
TFTs (if on thyroxine)
Sickle cell screen (Afro-caribbean)

CXR/ECG
Spirometry/CPX (if lung disease)

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2
Q

When to stop warfarin?

A

Warfarin - 5 days (bridge with LMWH)

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3
Q

When to stop Aspirin/clopi/dipyrid?

A

7 days (unless high risk indication)

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4
Q

When to stop insulin?

A

avoid morning dose and prescribe slidng scale from midnight

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5
Q

When to stop oral hypoglycaemics?

A

avoid on day of operation and prescribe sliidng scale if not well controlled

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6
Q

When to stop diuretics/ACEi?

A

avoid on day of op

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7
Q

When to stop OCP/HRT?

A

4 weeks before

Restart 2 weeks post op if mobile

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8
Q

AEDs in surgery?

A

Give as usual - post-op give IV or NG if unable to tolerate orally

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9
Q

Beta blockers in surgery?

A

Continue as normal

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10
Q

How long NBM?

A

> 2h for clear fluids
6h for solids

“Clear fluids from midnight, NBM from 6am”

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11
Q

Bowel prep?

A

Needed in left sided ops (not usually in right sided procedures

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12
Q

When do you need prophylactic abx?

A

GI surgery
Joint replacement

15-60 mins before surgery

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13
Q

What proohylactic abx to give?

A

SEE LOCAL GUIDLINES

Biliary - Cef 1.5g + Met 500mg IV

Colorectal or appendicetomy - Cef+Met TDS

Vascular - co-amoxiclav 1.2g IV TDS

  • MRSA+ve: vancomycin
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14
Q

DVT prophylaxis in surgery?

A

Stratify according to patient risk and type of surgery

LOW - early mobilisation
MED - early mobilisation + TEDS + 20mg enox
HIGH - early mobilisation + TEDS + 40mg enox + intermittent compression boots pre-op

Prophylaxis started at 1800 post-op

May need medical prophylaxis at home (up to 1 month)

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15
Q

ASA Grades?

A
  1. Normally healthy
  2. Mild systemic disease
  3. Severe systemic disease that limits activity
  4. Systemic disease which is a constant threat to life
  5. Moribund: not expected to survive 24h post-op
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16
Q

Insulin-controlled diabetes in surgery?

A

Patient needs to be first on the list - sliding scale may not be necessary in minor ops (liaise with diabetes specialist nurse)

Stop short acting insulin night before, omit AM insulin if surgery is in morning.

SLIDING SCALE

Continue post-op until tolerating food, switch to SC when eating and drinking normally.

17
Q

Non-insulin controlled diabetes in srugery?

A

If control poor, treat as insulin-dependent.

Omit oral hypoglycaemics on AM of surgery

If eating post-op continue oral hypoglycaemics

If not, check fasting glucose on AM of surgery and start sliding scale and contact specialist team about restarting oral drugs

18
Q

Anticoagulated patients in surgery?

A

Avoid epidural, spinal and regional blocks if anticoagulated

Aspirin/clopi stop 7days before

19
Q

Low risk anticoagulated patients in surgery? (e.g. AF)

A

Stop warfarin 5 days pre-op (INR needs to be <1.5)

Restart next day

20
Q

High risk anticoagulated patients in surgery? (e.g. valves, recurrent VTE)

A

NEED BRIDGING LMWH

Stop warfarin 5d pre-op and start LMWH
Stop LMWH 12-18h pre-op
Restart LMWH 6h post-op
Restart warfarin next day
Stop LMWH when INR >2
21
Q

Anticoagulcated patients in emergency surgery?

A

Discontinue warfarin

Vit K .5mg slow IV

Request FFP or PCC to cover surgery

22
Q

Pre-op considerations for smokers/COPD?

A

CXR

PFTs

Physio for breathing exercises

Quit smoking (at least 4wks prior to surgery)

23
Q

Steroids in surgery?

A

Need to ↑ steroid to cope c¯ stress

Consider cover if high-dose steroids w/i last yr

Major surgery: hydrocortisone 50-100mg IV c¯ pre-med then 6-8hrly for 3d.

Minor: as for major but hydrocortisone only for 24h

24
Q

Wound infection Rs?

A 
PRE-OPERATIVE
↑ Age
Comorbidities: e.g. DM
Pre-existing infection: e.g. appendix perforation
Pt. colonisation: e.g. nasal MRSA

OPERATIVE
Op classification and wound infection risk
Duration
Technical: pre-op Abx, asepsis

POST-OPERATIVE
Contamination of wound from staff

25
Q

Causes of post-op urinary retention?

A

Drugs: opioids, epidural/spinal, anti-AChM

Pain: sympathetic activation → sphincter contraction

Psychogenic: hospital environment

26
Q

Management of post-op urinary retention?

A 
CONSERVATIVE
Privacy
Ambulation
Void to running taps or in hot bath
Analgesia

Catheterise ± gent 2.5mg/kg IV stat

TWOC = Trial w/o Catheter

If failed, may be sent home with silicone catheter
and urology outpt. f/up.

27
Q

What is pulmonary atelectasis?

A

Occurs after every nearly every GA

Mucus plugging + absorption of distal air → collapse

28
Q

Presentation of atelectasis?

A

w/i first 48hrs

Mild pyrexia
Dyspnoea
Dull bases with ↓AE

29
Q

Management of atelectasis?

A

Good analgesia to aid coughing

Chest physiotherapy

30
Q

Presentation of wound dehiscence?

A

Occurs ~10d post-op

Preceded by serosanguinous (pink serous fluid) discharge from wound

31
Q

RFs for wound dehiscence?

A 
PRE-OPERATIVE FACTORS
↑ age
Smoking
Obesity, malnutrition, cachexia
Comorbs: e.g. BM, uraemia, chronic cough, Ca
Drugs: steroids, chemo, radio

OPERATIVE FACTORS
Length and orientation of incision
Closure technique: follow Jenkin’s Rule
Suture material

POST-OPERATIVE FACTORS
↑ IAP: e.g. prolonged ileus → distension
Infection
Haematoma / seroma formation

32
Q

Management of wound dehiscence?

A

Replace abdo contents and cover with sterile soaked gauze

IV Abx: cef+met (or cover skin, fluclox)

Opioid analgesia

Call senior and arrange theatre

Repair in theatre
 Wash bowel
 Debride wound edges
 Close with deep non-absorbable sutures (e.g. nylon)

May require VAC dressing or grafting

33
Q

Management of anastamotic leak? (need to act quickly, high mortality)

A

Bloods – FBC, CRP, WCC, clotting, cultures, lactate

A-E –> fluids/blood

Abx

?return to theatre

34
Q

Management of paralytic ileus?

A

Anti-emetics IV

NG tube + NBM – drip and suck – bowel rest

Fluid balance is key

Self-resolving – may take a few days

35
Q

Type of retention that doesn’t fix with a normal catheter?

A

Clot retention (increased risk in urology patients)

Need a 3 way catheter and bladder washout (aim for urine to drain Rosé –> clear)

36
Q

When to transfuse if bleeding

A

<70/symptomatic

- FINALS (24 decks)

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