Surgery - Perioperative care Flashcards
What are the pre-operative checks which should be carried out for surgery patients?
O - operative fitness (cardio/resp comorbidities?)
P - pills (med review)
C - consent
H - PMHx
E - ease of intubation (Mallampati score, dental)
C - clexane (throboprophylaxis)
S - site marked
What are the 5 features which determine if someone has capacity?
RACUM
- make a reasoned decision
- to act
- to communicate their decision
- to understand their decision
- to retain memory of their decision
What is consent and who can give it
Consent is the authoritisation for medical intervention which is given by a patient with capacity
- over 16yrs in Scotland consent is assumed
- no one can give proxy consent (i.e. consent on behalf of someone) for an adult with capacity
What is the Adult with Incapacity Act 2000
(Equivalent in Eng/Wales is the ‘Mental Capacity Act’
- this means that if an adult lacks capacity then the doctor can give a certificate of incapacity and then a welfare guardian can be appointed to make decisions on their behalf
What happens in a genuine emergency if an adult lacks capacity (e.g. unconscious) and they do not have a welfare guardian?
It is lawful to provide life-saving treatment
With exceptions of:
- DNA CPR
- if court authority has been obtained e.g. for adults in a vegetative state
What is the ‘Age of Legal Capacity Act 1991’
Means that adults may have capacity to consent under 16yrs
What is the surgical pause?
• This is a brief, less than one minute pause in operating-room activity immediately before incision, at which time all members of the operating team—surgeons, anaesthetists, nurses and anyone else involved—verbally confirm the identity of the patient, the operative site and the procedure to be performed.
It is a means of ensuring clear communication among team members and avoiding ‘wrong-site’ or ‘wrong-patient’ errors.
What is the WHO checklist used for and describe the steps involved in it:
A checklist with 4 areas of focus:
1) Before commencing the list:
- all staff members present
- check machinery working
- check patient details and what procedures are to be performed that day
2) Before induction of anaesthesia
- Check patient identity and consent valid.
- Check site and side marked, if appropriate.
- Check anaesthetic requirements are correct and functioning (machine,
medication, monitoring).
- Check allergies, anticipated blood loss.
3) Before skin incision
- Surgical pause!
- Check all team members present and known.
- Check the procedure to be performed.
- Confirm any surgical/anaesthetic/nursing concerns.
- Confirm vital imaging/equipment available.
4) Before pt leaves the theatre
- Check the correct name for the procedure actually performed is known and recorded.
- Check the swab and instrument count correct.
- Confirm any surgical specimens collected, ‘potted’, and labelled correctly.
- Confirm any specific instructions, either surgical or anaesthetic, which apply to the patient in recovery or on transfer to the ward.
What is included in the triad of anaesthesia?
Paralysis
Analgesia
Hypnosis
What are the 6 stages/steps of the anaesthetist during an op
1. Pre-op assessment clinic • Systematic, nurse led • To identify any issues pre-op • Systematic enquiry • The patient is asked when they last ate/drank: ○ Fasted food >6hrs ○ Fasted clear liquid >2hrs • Mallampati score • Stop necessary drugs
- Induction
• Keep the patient calm
• Secure the airway
• Maintain physiological normality
• Ensure pre-oxygenation
○ Normally 79% of inhaled air is nitrogen
○ By giving patients oxygen to inhale pre-anaesthetic this fills their FRC (functional residual capacity) with oxygen
• Sedate the patient
○ With the aim that the patient should still be arousable and can maintain their own airway
• Induction can be IV/with gas
○ In children, gas is used and then a cannula inserted once under sedation
• Equipment:
○ Mask
○ LMA (laryngeal mask airway)
○ ETT (endotracheal tube) -> the only true way to maintain the airway as the cuff (balloon) goes into the trachea below the level of the vocal cords and stops aspiration
3. Maintanence • Continuous monitoring • Physiology • Analgesia • Anti-emesis • Intra-operatively, the patient is given paracetamol and strong opiates
- Emergence
• A dangerous time
• Reverse what has been done to the patient
○ Reverse hypnosis
○ Reverse paralysis with neostigmine
§ Used to treat myaesthenia gravis
§ Interferes with the breakdown of aceytlcholine
§ To cause paralysis in the first place, paralysis agents are competitive inhibitors of the ACh receptor and stop the binding of ACh on the post-synaptic membrane = no muscle contraction
§ By giving neostigmine, it slows the breakdown of acetylcholine (ACh)
§ This means that there is more ACh present in the synaptic junction, the synaptic concentration of ACh increases and more binds to the post-synaptic membrane
○ Do NOT reverse analgesia!
• Remove ETT
○ Be careful if laryngospasm occurs - Post-op visit
6. On-ward check • Anaesthetist will visit and check: ○ Anti-emesis ○ Analgesia ○ Physiology
Describe drugs which should be stopped pre-surgery
- Anticoagulants (warfarin, DOAC’s, antiplatelets…)
- Diabetic medications (stop all short acting insulin and oral hypoglycaemics)
• Keep the patient on an insulin sliding scale, and their long-acting insulin - ACE inhibitors/ARB’s (but no other antihypertensives need to be stopped!)
Describe the ASA grading system
- Assesses and communicates a patient’s pre-anaesthesia medical co-morbidities.
- Is used with other factors (e.g., type of surgery, frailty, level of deconditioning), it can be helpful in predicting perioperative risks
Describe all the lung volumes: • TV • VC • IRV • ERV • FCR • RV
TV = volume of gas exchanged at rest
VC = maximum amount of air someone can exhale from their lungs after maximal inhalation
IRV = additional amount of air that can be inhaled after TV
ERV = the amount of air which can be forcefully exhaled on top of TV
FCR = the volume of air present in the lungs at the end of passive respiration
RV = volume of air that remains in the lungs after forceful expiration
What is the normal fluid maintenance regimen?
salty and 2 sweet
○ 1 x NaCl 2 x 5% glucose (add K+ as required)
At what opportunities in a patients life can antibodies against Rhesus factor be made?
Transfusion
Pregnancy
Organ transplant
