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Year 3 Surgery > Surgical Basics + Anaesthetics > Flashcards

Surgical Basics + Anaesthetics Flashcards

1
Q

List 6 methods of preventing Post-op DVT

A

Pre op mobilisation

Post op mobilisation

Graduated compression/ Anti-embolism stockings

Intra-operative intermittent calf compression

Maintain hydration

Stop pro-thrombotic drugs

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2
Q

Compare effectiveness of;

  • LMWH started within 12hrs of finishing surgery
  • LMWH started before surgery

Suggest 2 reasons why this may be? (Need to check if these are true)

A

Just as effective

  • Reduced renal blood flow in 3day post-op phase, so in both cases les heparin is being excreted
  • Half life of 2hrs, so steady state reached at 10-12hrs after starting LMWH. Heparin is stopped before surgery anyway. (24hrs, 12 if prophylactic)
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3
Q

Why must 4hrs have passed since epidural insertion, before administering LMWH?

(Some sources say 2hrs after removal)

A

Risk of Epidural or Spinal Haematoma
Bleeding into spinal canal can cause Spinal Cord Ischaemia, Parapelgia

(Risk also present with removal of epidural catheter)

(Insertion of epidural catheter should be delayed until anticoagulant effect of medication is minimal: Usually 8–12 hrs after a SC dose of heparin or a BDS prophylactic dose of LMWH, or at least 18 hrs after an ODS prophylactic dose of LMWH)

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4
Q

Who is eligible to give blood

A

Fit and healthy

Between 50 and 158kg

Between 17 and 66 (70 if given blood before)

Over 70, if given full blood donation in last 2 yrs

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5
Q

How often can blood be given

A

Men- every 6wks

Women- every 12wks

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6
Q

Who can’t give blood

A

Possible HIV, HTLV or Hepatitis

Previously had Syphilis, even if treated

Ever injected/ been injected with drugs (may be able to if prescribed)

Taking Pre-Exposure or Post-Exposure Prophylaxis (PrEP or PEP)

People who have had a transfusion

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7
Q

What is blood regularly checked for before being sent to blood bank?

Other than blood type

A

Syphilis, HIV, Hep B, Hep C, Hep E

HTLV (Human T-lymphotropic Virus)

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8
Q

List some additional tests that may be done on blood being given for donation

A

Malaria, T-Cruzi (Can cause Chagas disease)
WNV, West Nile Virus, CMV
Non-specific reactivity (doesn’t affect donor’s health)

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9
Q

How long does a full cross match of blood take?

A

45mins

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10
Q

How long can you wait after eating and drinking for anaesthetic administration

A

6-8hrs food, 2 hrs clear fluid

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11
Q

Outline Rapid Sequence Induction, RSI

Used if an emergency surgery needed on someone who isn’t starved

A

Anaesthetic agent as uscle relaxant

ODP presses on Cricoid cartilage to prevent reflux

Anaesthetist puts in ET tube and blows up balloon so that refluxed food doesn’t go beyond pharynx

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12
Q

Which vasopressor is commonly used to manage sepsis

A

Noradrenaline

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13
Q

Define septic shock

A

Lactate >4mM
Systolic = 90mmHg, not responsive to IV fluids

OR

MAP <70mmHg, not responsive to IV fluids

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14
Q

How long can RBCs be stored in refrigerator and freezer

A

42 days fridge, 10yrs freezer

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15
Q

What is Fresh Frozen Plasma (FFP) used for?

(Can be used to prepare Cryoprecipitate, contains Clotting Factors)

How long can it be stored in freezer

A

To provide coagulation factors or treat shock due to plasma loss (Burns or bleeding)

1yr in the freezer

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16
Q

What is Concentrate of platelets

How long can it be stored at room temp (Only stored this way)

A

To treat/ prevent bleeding due to low platelet levels

5 days at room temperature

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17
Q

What is Cryoprecipitate used for?

How long can it be stored in freezer

(Contains Fibrinogen and Factor VIII)

A

To treat fibrinogen deficiency (Given with Frozen Plasma, to absorb Coag factors)

1yr in freezer

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18
Q

When does the ABO blood group develop in a new-born

A

After 3mths of life, due to lack of immune system and antigenic exposure

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19
Q

How long should a blood transfusion take?

A

A couple hours, maximum 4 hrs

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20
Q

Define a massive blood transfusion

A

Replacement by transfusion of 10 units of RBCs in 24hrs

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21
Q

List 5 Acute Transfusion Reactions

A

Acute Haemolytic Transfusion reaction (Fever, Chills, HypoT, TachyC, Flank pain, Haemoglobinuria)

  • Anaphylaxis
  • Urticarial reaction (Only urticaria)
  • Febrile non-haemolytic transfusion reactions (Idiopathic >1 degree temp. rise)

TRALI (Dyspnea, Hypoxia, non-Cardiogenic pulmonary oedema)

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22
Q

What can TRALI be confused for?

A

TACO- Transfusion associated circulatory overload

Biggest cause of death

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23
Q

How can pts’ Hb be optimised before surgery

A
  • Oral iron
  • EPO
  • Consider stopping antiplatelets/ coagulants
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24
Q

List some blood alternatives

A

Iron (Supplements, Diet, IV iron)

EPO/ ESAs (Erythropoiesis Stimulating Agents)

PAD (Preoperative Autologous Blood Donation)

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25
If normal renal function, Hhow long should pt not take DOACs prior to; - Surgery with low bleeding risk - Surgery with high bleeding risk
Low risk: 24hrs High risk: 48hrs
26
Compare Colloids to Crystalloids
Crystalloids: Smaller molecules, Immediate fluid resuscitation, may cause Oedema Colloids: Increase Oncotic Pressure, More costly, Can cause Anaphylaxis, AKI, Clotting disorders
27
Outline the 4 stages of blood loss
1: Upto 750ml 2: Upto 1.5L 3: Upto 2L 4: >2L
28
List 3 general transfusion complications
Clotting abnormalities (Dilution effect as packed RBCs don’t have clotting factors) Electrolyte abnormalities (Low Ca or High K) Hypothermia (Monitor core body temp)
29
How can clotting abnormalities be prevented after transfusion?
Fresh Frozen Plasma and Platelets should be given, usually if >4 units of RBCs
30
List 3 Delayed Complications of Transfusion | Delayed transfusion is becoming more common
Infection (Hep B/C, HIV, Syphilis, Maria, vCJD) Graft vs Host Disease, GvHD (HLA Mismatch) Fe Overload (Repeated transfusions)
31
Outline Transfusion Associated Circulatory Overload (Presentation, Diagnosis, Management) Prophylaxis: 20mg Furosemide during transfusion
Dyspnea + Fluid Overload features Agitation, Confusion CXR O2 + Diuretic
32
Outline an Acute Haemolytic Reaction (ABO incompatibility) (Presentation, Diagnosis, Management) (Tell blood bank if happened, as may have happened to other pts)
Urticaria, HypoT, Fever. May have Haemoglobinuria Reduced Hb, High LDH + Bilirubin +ve Direct Antiglobulin test (DAT) to confirm Stop transfusion, Give O2 and Fluids
33
How is Wound Dehiscence managed
Cover wound with Wet sterile gauze (Dry gauze may stick to wound contents) Suture in theatre
34
List 4 ways emergence can be carried out (other stages: Induction, Maintenance) (Some people use Respiratory Stimulants)
Allow drug to wear off (Suxamethonium, Mivacurium) Withdraw (TIVA, Volatiles) Reverse Antagonise (Opiates, Benzodiazepines)
35
List 3 types of Regional Anaesthesia
Local infiltration Nerve/ plexus blocks Central neuraxial blocks
36
What is Monitored Anaesthesia Care
Conscious sedation
37
List the 2 components of pre-anaesthetic care
Pre-op Assessment and Optimisation
38
Compare Spinal and Epidural anaesthetics
Epidural: Injected/ catheterised into Epidural space - Between Dura Mater and Vertebral Wall Spinal: Injected into Subarachnoid space, so immediate relief - Between Pia and Arachnoid Mater
39
Why is Pre-oxygenation done?
To increase O2 reserves to prevent Hypoxaemia during Apnoea
40
When is the Pre-op Assessment done for pts schedueld for elective procedures List components of the Assessment
2-4wks before surgery History Examination Routine investigations
41
List components of the Pre-op History | Similar to usualy history taking, but with some added Anaesthetic+Surgical topics
PC Hx: Presentation, Operation scheduled PMHx: - CVD, Resp disease (Can lie flat, Chronic cough) - Renal Function, Endocrine (DM, Thyroid) - Pregnancy, Sickle Cell Past Surgical Hx, Past Anaesthetic Hx: Had before? Any problems? Drug + Family Hx: Allergies, Problems with Anaesthesia run in the family Social Hx: Smoking, Alcohol, Recreational drugs
42
List the 2 components of the Pre-op Examination
General Exam: Underlying pathology. Look for CV, Resp, Abdo signs Airway Exam: - Predict difficuilty of airway management - Mallampati score involved
43
A pt’s ASA Grade correlates with their risk of Post-op Complications and Absolute Mortality Outline the grading system
Grade I: Normal + healthy (No Alcohol or smoking) Grade II: Mild Systemic disease Grade III: Severe Systemic disease Grade IV: Severe Systemic disease, that is a constant threat to life Grade V: Moribund, not expecetd to survive w/o operation Grade VI: Brain-dead pt, whose organs are being used for donation
44
List examples of Grade II ASA | Without substantiative functional limitations
Smoking, Social drinking, Obesity Pregnancy Well controlled DM/HTN, Mild lung disease
45
List examples of Grade III ASA | Substantiative functional limitations
1/+ moderate-severe diseases - Morbid obesity (40 or more) - Poorly controlled DM/ HTN - COPD, Alcohol dependence - >3mth Hx of MI, TIA, CVA, CAD/ stents - ESRD undergoing regular dialysis
46
List examples of Grade IV ASA
- <3mth Hx of MI, CVA, TIA or CAD/ Stents - Severe EF Reduction - Sepsis, DIC, ARD - ESRD not undergoing regular Dialysis
47
List some potential Pre-op Investigations | Exact ones depend on Age, Comorbidities, Procedure
Bloods: - FBC: Assess for Anaemia or Thrombocytopenia - G+S, Crossmatch, Clotting screen, U&Es, LFTs - ECG, Spirometry, CXR - Urinalysis, MRSA Swab, CPET
48
Ehanced Recovery After Surgery, ERAS is used to help people recover faster post-op Outline it, in its 3 stages
Pre-op: Pt education about surgery. Fasting. Optimisation (Weight, Exercise) Intra-op: Analgesia, PONV prophylaxis, Minimally invasive surgery Post-op: Analgesia, Early oral intake
49
Outline which drugs are to be Stopped as part of Pre-op Management (D-CHOW)
DOACs stopped 2 days before C: - Clopidogrel stopped 7days (5 days) before - Aspirin + Anti-platelets can be continued H: Hypoglycaemics O: Contraceptive Pill/ HRT stopped 4wks before W: Warfarin - Stopped 5days before, can reverse with Vit K - Surgery often only goes ahead if INR<1.5
50
What drugs must be Altered before surgery
SC Insulin -> IV Variable rate infusion Long term Oral steroids-> Must be continued IV, higher dose as steroid demand increases after acute stress (Hydrocortisone 50-100mg)
51
Outline which drugs are to be Started as part of Pre-op Management
- LMWH (if GI surgery for cancer, discharge with TEDs and 28 days of LMWH) - Below knee TED Stockings (Contra-Is: Severe PVD, Peripheral Neuropathy/ Eczema, Recent skin graft) - Abx Prophylaxis (Ortho/Vascular/General op)
52
Outline Specific Pre-op Management for Type I DM pts | All should be 1st on morning list
Insulin: - Night before op, reduce SC Basal insulin dose by 1/3 - Omit Morning Insulin - Start IV Variable Insulin Infusion Glucose: - While NBM, 5% Dextrose 125ml/hr - Nurse should check BM/ Capillary Glucose every 2hrs Once able to eat + drink; - Overlap SC and Variable rate Insulin - Give Rapid-acting SC Insulin 20mins before meal - Stop IV Insulin 30-60mins after meal
53
Outline Specific Pre-op Management for Type II DM patients | If diet controlled, no action needed
Metformin: Stop on Morning of Surgery if taking TDS, otherwise continue Other Hypoglycaemic agents: - Stop 24hrs before operation - Put on VR Insulin and 5% Dextrose
54
Pts having Colorectal surgery may need Bowel Preparation Outline this (Can prolong pt Recovery+ Stay length)
Phosphate Enema on Morning of Surgery: - Left hemi-colectomy - Sigmoid colectomy - AP Resection 2 sachets of Picolax day before OR Phosphate Enema on Morning of Surgery: - Anterior resection None required for: - Upper GI, HPB or SI Surgery - Right (extended) Hemi-colectomy
55
Compare Lidocaine and Bupivacaine
Lidocaine works faster Bupivacaine lasts longer
56
Why is adrenaline used peri-operatively
Increases the effect of Anaesthetic agents used Vasoconstricts vessels, reducing bleeding around incision site
57
Who are Transfusion assoicated complications reported to
SHOT
58
List reasons a Spinal Anaesthetic may be better than a General Anaesthetic
- Lower cost - Better Post-op Pain - Allergy to GA - Contra-I to GA (e.g COPD)
59
When starting a DM pt on VRII for their surgery, which fluid should be prescribed to run alongside
5% Dextrose in 0.45% NaCl w/ 0.15-0.3% KCl
60
List reasons why DM is considered to carry a high peri-op risk
- Risks of GA - Obesity associated w/ higher mortality - Predisposition to Peripheral Vascular Disease - Renal problems - Cardiac arrest due to Autonomic neuropathy - IHD carries a greater risk of Peri-op MI
61
List RFs for PONV
- Female, Age, Non Smoker, PONV FHx, Hx of motion sickness - Poor pain control, Long Op, Intracranial op, Intra-abdominal Laparoscopic surgery - Opioid/ Spinal analgesia, Inhalation agents, Dehydration
62
Suggest 3 anti-emetics for PONV
Ondansetron Cyclizine- Good in Functional bowel obstruction Metoclopromide- Avoid in Bowel obstruction
63
How would you manage Post op Ileus (Physiological= ≤3 days post-op Paralytic= ≥3 days Mechanical obstruction= Fibrous adhesions, take ≥1wk to form Functional obstruction= Absent bowel sounds)
- NBM, IV Fluids, Daily bloods - Encourage mobilisation, Reduce Opioid analgesia - Fluid balance chart
64
Explain the benefit of RSI
Minimises insufflation of air into pt’s stomach, reducing risk of regurgitation This reduces aspiration risk and risk of unexpected contents entering lungs (No ventilation)
65
Name drugs used in RSI
Modern: Propofol, Ketamine, Etomidate Traditionally: Suxamethonium, Na Thiopentone
66
What is the mutation in Malignant Hyperthermia
Autosomal dominant mutation in Ryanodine Receptor 1 Increased Ca levels In sarcoplasmic reticulum and increased metabolic rate
67
How does Malignant Hyperthermia present
- Hyperthermia, TachyC - Muscle rigidity and/or Spasms - Metabolic acidosis - Increased exhaled CO2
68
How is Malignant Hyperthermia managed
- Stop causative agent - IV Dantrolene, O2 - Restore Normothermia (Cooling Blankets/ Cooled Fluids/ Ice Packs)
69
List advantages of using Regional Blocks over GA
- Better pain control post-op - Reduced risk of cardiac complications post-op - Allergy to GA - Contra-I to GA
70
List post-op complications that can cause TachyC
Sepsis, AFib, PE, Haemorrhage, Uncontrolled Pain

Year 3 Surgery (7 decks)

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