Ward Visit After Major Surgery Flashcards
Which patients should be visited by the anaesthetist in the ward?
- ASA 3,4,5
- Epidural or PCA
- CVL
- Complicated intra-operative course
Name the surgical regions with pain scores > 2 and duration of opioid use (days) ≥ 2
Thoracotomy
Laparotomy
Describe assessment and management of PCA in ward
Clinical: Pain/sedated
Demands: few/many
Successful attempts: few/many
Usual initial settings: Morphine 1mg bolus with lock out time of 5 minutes, no background
Side effects: NV, pruritis, sedation
If high successful attempts and pain still severe –> increase bolus
If high successful attempts and sedated –> increase lock out time
If low demand and low successful attempts and in pain –> re-educate
If the sensory block is inadequate with a functioning epidural, what actions can be taken
Bolus 3 - 5 ml and increase infusion rate
What action should be taken if block is unilateral
Withdraw catheter 1 - 2 cm and give bolus dose
If the sensory block is adequate in an epidural and analgaesia is inadequate, what action should be taken?
Consider other causes of pain (i.e. non-Standard surgical pain) - Compartment syndrome - Haemorrhage - Infection Obtain surgical review
What anaesthetic related factors cause pruritis and what is the treatment
Epidural or spinal opioids
Mild - reassure
Severe: Chlorphenamine 4mg PO or 10 - 20 mg IV
What actions should be taken if the epidural becomes disconnected
Any disconnected catheter should be considered contaminated. This contamination risk increases with increasing time to discovery.
Therefore, all catheters should be removed unless the epidural is essential and reinsertion would be problematic or impossible.
If the catheter is left in place, clean it with iodine, alcohol and sterile water and reattach a new filter. Consider a dose of antibiotic. Follow up the patient closely and remove the epidural at earliest opportunity.
What are the initial considerations in a patient with an epidural that develops hypotension
Check the fluid status
Check the block height
Consider fluids and decreasing epidural infusion rate
Exclude surgical cause - e.g bleeding
What should be done if increasing or complete motor block occurs?
Stop infusion
Watch for signs of block wearing off
If block wears off restart infusion at a reduced rate and consider decreasing the infusion concentration.
If motor block persists ≥ 2 hours or becomes progressive –> consider CNS damage –> MRI to exclude epidural hematoma/abscess
What is the classic triad of symptoms for a spinal epidural abscess
Fever
Backache
Neurological deficit
Other
- Pus at skin entry site
- erythema > 1cm in diameter
- Local tenderness
What actions should be taken in the case of a suspected spinal epidural abscess?
- CRP, WCC, Blood cultures
- Swab skin entry point
- Send epidural catheter tip for culture
- Start broad spectrum A/B
- MRI
- Neurosurgical opinion
How long does a peripheral nerve block usually provide pain relief
2 - 18 hours depending on the site and drugs used
Describe and classify the incidence of persistent peripheral nerve blockade
> 1 week (occur in 1 - 5% of blocks)
Of these 95% recover after 1 month
And 99% recover within a year
What is the incidence of permanent nerve damage subsequent to peripheral nerve blocks
1:5000 to 1:30 000
How can nerve damage occur during peripheral nerve blockade
- Direct nerve injury by needle
- Stretching or compression of the nerve
- Hematoma
- Inadequate blood supply
- Infection
Exacerbated by pre-existing medical conditions: Diabetes/Atherosclerosis
What actions should be taken in the instance of persistent neuropathy subsequent to peripheral nerve blockade
Refer to neurologist for nerve conduction studies/MRI
Why is the Early Warning System effective
It allows early detection of a problem as it collaborates multiple small changes for early recognition rather than one marked change in one such as a drop in BP which can be a pre-terminal event
What is the most sensitive indicator of a patient’s well being
Respiratory Rate
What is the incidence of PONV after GA
25 - 30%
Give a step wise approach to a patient with PONV
- Exclude hypovolaemia, hypotension, hypoxia, dehydration, tachycardia other illness related causes of N and V
- Ensure opioid sparing agents are used (Paracetamol & NSAIDS)
- Ensure minimum dose of opioid to achieve pain control
- ? Surgical cause - ? distended abdomen + aspirate NG tube
- ? Prophylactic antiemetic prescribed
- Prescribe antiemetic from a class different to the prophylactic drug used
What is the most common cause for hypoxia after surgery and what is the treatment
Atelectasis
- Rx: Humidified O2 + Nebulized BD + physiotherapy + ensure adequate analgaesia
Describe the presentation of Atelectasis
Tachypnoea, dyspnoea, tachycardia, pyrexia, hypoxaemia
Describe a typical presentation of aspiration.
Summarize the treatment
Usually a history in keeping
Hypoxia
Wheeze
Rx:
- Increase FIO2
- HDU/ICU: CPAP/IPPV
- Send sputum and blood for culture
- Give antibiotics if indicated
Describe risk factors for pneumothorax
- Bullous lung disease
- CVL insertion
- Brachial plexus block
Describe the classical presentation of PE
Sudden SOB with:
- Pleuritic chest pain
- Cyanosis
- Hypotension
- Haemoptysis
- Raised JVP
Describe the presentation of small PE
Tachycardia, SOB and a low grade pyrexia.
What is ARDS
ARDS is a non-specific inflammatory lung condition with many underlying causes. It is frequently associated with organ failure elsewhere. Hypoxia may be severe.
You should give oxygen and seek help from ICU.
Define oliguria and classify the causes.
Oliguria is defined as urine output less than 0.5 ml/kg/h and is a sign that normally indicates an underlying disorder. It is important to firstly diagnose the cause correctly, in order to manage the oliguria successfully.
The cause may be:
Prerenal
Renal
Postrenal
Describe three common causes of pre-renal oliguria
Hypovolaemia
Heart failure
Renal hypoperfusion (NSAIDS)
What causes intrinsic renal disease
Prolonged pre-renal failure
Nephrotoxic drugs
What are the most common causes of postrenal oliguria in a postoperative patient
Obstructed urinary catheter
BPH
Which maintenance fluid should be avoided in children and why
4% glucose with 0.18% NaCl
- Hypotonic and high risk of life threatening hyponatraemia in kids is significant
An 80-year-old man is on the ward. He is day 1 post laparotomy for small bowel obstruction and has an epidural in situ.
He is alert with a heart rate of 110 bpm. He has a respiratory rate of 14 breaths/min, blood pressure of 85/50 mmHg and urine output of 35 ml/h. He has a temperature of 38.0°C.
Is his EWS high (>4), medium (3-4) or low (1-2), and what is the relevant management?
Select one answer from the options, then select Submit.
Possible answers:
A. Low EWS, he needs further observation in 1 hour
B. Medium EWS, he needs review by a doctor
C. Medium EWS, he needs further observation in
1 hour
D. High EWS, he needs immediate intensive care
A. Incorrect.
B. Correct.
C. Incorrect.
D. Incorrect.
His EWS is 3 and he needs review by a doctor.
The level of his epidural should be assessed. He is probably hypovolaemic and requires a fluid bolus. He should then be reassessed after the fluid bolus.
