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Dan Surgery > Peri-Operative Care > Flashcards

Peri-Operative Care Flashcards

1
Q

What is Malignant Hyperthermia?

A

Autosomal Dominant Disorder

Initial muscle rigidity followed by increased temperature under General Anaesthesia

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2
Q

Why should you check the airways in a Pre-Op Exam?

A

Degree of mouth opening
Teeth (Any loose?)
Palate (Mallampati Classification)
How far can they extend neck

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3
Q

What is the American Society of Anaesthesiologist Grade?

A

Grades a patient from I-VI, with increasing severity of disease
Subsequently gives a prediction of mortality from anaesthesia

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4
Q

What is a Group and Save?

A

Done when blood loss is NOT anticipated
Determines blood group/rhesus status/atypical antibodies
No blood is issued

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5
Q

What is a Cross - Match?

A

Done when blood loss IS anticipated

Mixed with donor blood to see if reaction happens

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6
Q

What should you advise patients regarding eating Pre-Op?

A

Stop Eating 6hrs before
Stop clear fluids 2hrs before
To prevent Aspiration Pneumonitis (gastric contents) or Aspiration Pneumonia (direct inhalation)

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7
Q

Using the mnemonic CHOW, what medications should be stopped Pre - Op?

A

Clopidogrel (7d before)
Hypoglycaemics
Oral Contraceptives/HRT (stopped four weeks before)
Warfarin (5d before)

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8
Q

How are T1DM patients managed Pre-Op? Give three features

A
  • Should be first on the morning list
  • Reduce the insulin dose by a 1/3 the night before
  • Omit morning insulin and set up sliding scale of Actrapid
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9
Q

How are T1DM patients managed Post-Op?

A

After Op give SC Insulin 20 mins before first meal

Stop IV infusion 30-60 mins after first meal

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10
Q

How are T2DM patients managed Pre-Op? Give three features

A
  • Metformin stopped the morning of the Op
  • Others stopped 24hrs before
  • Patients put on sliding scale of Insulin, given 5% Dextrose and managed the same as T1DM
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11
Q

How should Steroids be adapted in an operative scenario?

A
  • Need to be continued due to risk of Addisonian Crisis
  • HPA axis increases its activity in surgery due to ‘stress state’ which may end up supressing steroids
  • Stress dose should be given
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12
Q

All Operative patients are started on LMWH, give an exception

A

Head and Neck Surgery

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13
Q

Give three contraindications to TED Stockings

A

Severe Peripheral Vascular Disease
Recent Skin Graft
Severe Eczema

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14
Q

Give three indications for prophylactic antiobiotics

A

Orthopaedics
Bowel Surgery
Vascular Surgery

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15
Q

What Bowel Procedures require preparation? How would you do so?

A

Left Hemicolectomy/Sigmoidectomy/AP Resection/Anterior Resection - Phosphate Enema the morning of

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16
Q

Give four key considerations for fluid management

A

What is the aim? (Rescucitation/Maintenance/Replacement)
Most recent electrolytes
Comorbidities
Weight and Size

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17
Q

Describe the distribution of fluid in a 70kg man

A

42L Total
28L - Intracellular
14L - Extracellular (11L interstitial, 3L circulating)

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18
Q

Describe the target fluid compartment for different purposes

A

General Hydration - distributed across all fluid compartments
Rescucitation - Intravascular

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19
Q

Explain the fluid consideration in septic patients

A

Tight junctions between capillary endothelium breaks down causing fluid to leak out into tissues (therefore large volumes of IV fluid may be needed)

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20
Q

State four fluid outputs

A

Urine
Sweating
Respiration
Faeces

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21
Q

Give 4 features of fluid depletion OE

A

Reduced Skin Turgor
Decreased Urine Output
Orthostatic Hypotension
Increased Cap Refill Time

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22
Q

Give 2 features of fluid overload OE

A

Raised JVP

Oedema

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23
Q

State the daily requirements of Water, Na+, K+, Glucose

A

Water - 25ml/kg/d
Na+ - 1mmol/kg/d
K+ - 1mmol/kg/d
Glucose - 50g/d

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24
Q

What is a Crystalloid Fluid?

A

Contains mineral salts
Cheaper so used more often
Saline/Dextrose/Hartmanns

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25
Q

What is a Colloid Fluid?

A

Contains larger molecules
Higher Osmotic Pressure
Volplex/Blood

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26
Q

Give 2 examples of pathological fluid loss

A

Bowel Lumen in Bowel Obstruction

Retroperitoneum in Pancreatitis

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27
Q

At what concentration of Haemoglobin is a transfusion recommended?

A

<70g/L

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28
Q

Why is Rhesus D Status an important consideration in blood transfusions

A
  • Not important if not pregnant as patients won’t attack their own RBC
  • In pregnancy if first child is Rh positive to a Rh negative mother, antibodies against Rh will be formed, which will cause HND in second child
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29
Q

State the Universal Donor and the Universal Acceptor

A

Donor - O neg

Acceptor - AB pos

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30
Q

Who should be given CMV negative blood?

A

Pregnant Women, Intrauterine Transfusions, Neonates (<28d)

Can cause sensorineural deafness

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31
Q

Give 3 clinical features of administering blood

A
  • Observations before/15 to 20 mins in/1hr/Completion
  • Given through Grey (16G) or Green (18G) to reduce the risk of haemolysis
  • Given via blood giving set (which includes a filter)
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32
Q

Give 3 clinical features of RBC transfusion

A
  • Contains RBC only
  • Indicated in Acute Blood Loss or Symptomatic Anaemia
  • Given over 2-4 hrs
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33
Q

Give 2 clinical features of Platelets transfusion

A
  • Indicated in Haemorrhagic Shock, Profound Thrombocytopenia, Low Pre-Op Platelet
  • Given over 30mins
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34
Q

Give 3 clinical features of FFP transfusion

A
  • Contains Clotting Factors
  • Indicated in DIC, Haemorrhage Secondary to Liver Disease, All Massive Haemorrhages
  • Given over 30 mins
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35
Q

Give 2 clinical features of Cryoprecipitate transfusion

A
  • Contains Fibrinogen, VWF, Factor VIII, Fibronectin

- Indicated in DIC with low fibrinogen or VWF, or massive haemorrhage

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36
Q

Give 2 scores which can be used to assess nutritional status

A

BMI

MUST Score

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37
Q

State the Hierarchy of Feeding Options

A
  • Oral Nutritional Supplements
  • NG Tube
  • PEG/RIG
  • Jejunostomy
  • Intestinal Failure
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38
Q

Albumin levels were thought to be an indicator of nutritional status, why is this not the case?

A

Patients with Anorexia Nervosa have normal Albumin levels

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39
Q

How should nutrition be managed in an Enterocutaneous Fistula?

A

High - Enteral/Parenteral Nutrition

Low - Low Fibre Diet

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40
Q

Give four medical managements of a High Output Stoma

A

Reduce Hypotonic Fluids
Loperamide
PPI
Low Fibre

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41
Q

What is a High Output Stoma?

A

A high output stoma (HOS) is when the output causes the patient to become water, sodium and magnesium depleted.

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42
Q

Give three advantages of day case surgery

A
  • Cheaper
  • Lower infection rates
  • Reduces waiting list
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43
Q

Give four requirements in order for a procedure to be able to be done as a day case

A

Minimal Blood Loss expected
Short operating time
No expected complications
No requirements for specialist aftercare

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44
Q

State three types of Haemorrhage

A
  • Primary - Occurring within the intra-operative period
  • Reactive - Occurring within the first 24 hours of surgery (due to slipped ligature or missed vessels from intraoperative hypotension and vasoconstriction)
  • Secondary - Occurring 7 to 10d post op, normally infective erosion
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45
Q

Other than visible bleeding, give four clinical features of Haemorrhage

A

Tachycardia
Dizziness
Agitation
Reduced UO

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46
Q

State the classification of Haemorrhage from I-IV

A

I - <15% blood loss
II - 15-30% blood loss
III - 30-40% blood loss
IV - >40% blood loss

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47
Q

How does Haemorrhage post Neck Surgery present?

A

Primary Sign is airway obstruction - because pretracheal fascia only distends so far

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48
Q

What vessel is most at risk during Laproscopic procedures?

A

Inferior Epigastric Artery

Runs from External Iliac up Mid-Clavicular line

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49
Q

Define SIRS

A
  • Systemic Inflammatory Response Syndrome
  • Two or more of the following criteria: tachycardia (heart rate >90 beats/min), tachypnea (respiratory rate >20 breaths/min), fever or hypothermia (temperature >38 or <36 °C), and leukocytosis, leukopenia, or bandemia (white blood cells >1,200/mm3, <4,000/mm3 or bandemia ≥10%)
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50
Q

Define Sepsis

A
  • SIRS + Evidence of Infection

- Life threatening Organ Dysfunction due to dysregulated host response to infection

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51
Q

Define Septic Shock

A
  • Perisistent Hypotension despite fluid rescucitation
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52
Q

Describe the qSOFA score

A

RR>22/min
Altered Mental State
Systolic<100mmHg

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53
Q

Describe the 7C’s of Sepsis source identification on a surgical ward

A 
Chest
Catheter
Cannula
Central Line
Collections
Cut
Calves (DVT)
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54
Q

What 3 situations should pain be assessed in?

A

In bed
Mobilising
Deep Breathing

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55
Q

Using the mnemonic IGRAB, state the side effects of NSAIDs

A 
Interactions with other medications (eg Warfarin)
Gastric Ulcers
Renal Impairment
Asthma Sensitivity
Bleeding Risk (interacts with platelets)
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56
Q

Give an example of a weak and strong Opioid respectively

A

Weak - Codeine

Strong - Fentanyl

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57
Q

How do Opioids work as pain relief?

A

Work by activating the opioid receptors MOP, DOP and KOP in the CNS, modifying pain perception

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58
Q

Give four side effects of Opioids

A

Nausea
Constipation
Sedation
Respiratory Depression

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59
Q

What Opioid should be given in Renal Impairment?

A

Oxycodone or Fentanyl rather than Morphine

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60
Q

Give two points about co-prescribing with Opioids

A
  • Paracetamol should be co-prescribed to reduce the requirements of opiates
  • Do not co-prescribe weak and strong opioids as they competitively inhibit the same receptors
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61
Q

Describe the bioavailability of Morphine

A

Oral is 30%

SC/IV is 80%

62
Q

What is Patient Controlled Analgesia?

A

Use of pumps that give IV bolus when patient presses a button
Analgesia is tailored to patient, and the amount they use it can be converted to a regular dose

63
Q

What is Neuropathic Pain?

A

Irritation/Injury to nerves which present as shooting/stabbing pain

64
Q

Describe the non pharmacological and pharmacological management of Neuropathic Pain

A

Non Pharmacological - CBT, Transcutaneous Nerve Stimulation

Pharmacological - Gabapentin, Amitryptyline, Pregabalin

65
Q

Define Major Haemorrhage

A

Bleeding to the extent that the patient is in shock

66
Q

Define Massive Haemorrhage

A

Loss of whole blood volume within 24 hours

67
Q

How does Tranexamic Acid work?

A

Reduces the conversion of Plasminogen to Plasmin and hence clot break down

68
Q

What is Thromboelastography?

A

Measures: How quickly a clot forms, how ‘strong’ the clot is, and how quickly the clot breaks down

69
Q

What is the Lethal Triad of Death

A

Acidosis
Hypothermia
Coagulopathy

70
Q

What is Cell Salvage?

A

Used in haemorrhages where you give the patient back their own blood
Good for Jehovah’s Witnesses

71
Q

State the order of Cannulas from smallest to largest

A 
Blue - 22G
Pink - 20G
Green - 18G
Grey - 16G
Orange - 14G
72
Q

Give 6 complications of blood transfusions

A 
ARDS
O2 Affinity Abnormalities
Hypothermia
Electrolyte abnormalities
Thrombocytopenia
Acid Base Abnormalities
73
Q

State four consequences of PONV

A

Increased recovery time
Aspiration Pneumonia
Incisional Hernia
Metabolic Alkalosis

74
Q

Name one patient factor, one surgical factor and one anaesthetic factor increasing risk of PONV

A

Patient - Female
Surgical - Intra-abdominal Lapropscopic Surgery
Anaesthetic - Inhalation agents

75
Q

What is the Vomiting Centre?

A

Lateral reticular formation located in Medulla Oblongata responsible for co-ordinating movements involved in vomiting

76
Q

Name four inputs to the Vomiting Centre

A

Chemoreceptor Trigger Zone
Vestibular System
GI tract
Higher Cortical

77
Q

Give an example of neurotransmitters used in : Vomiting Centre, CTZ, GI tract, Vestibular Apparatus

A

Vomiting Centre and Vesitibular Apparatus: Histamine

GI Tract and CTZ: Dopamine

78
Q

What prophylaxis could you give a patient to try and avoid PONV?

A

Reduce use of volatile gases
Anti-Emetics
Dexamethasone at anaesthetic induction

79
Q

The management of PONV post op should be multimodal. Give two examples of medications that could be used

A

Ondansetron

Cyclizine

80
Q

Describe the likely aetiology of a post-op infection depending on the time frame

A

Day 1-2 : Resp Source
Day 3-5: Urinary Tract Source
Day 5-7: Surgical Site/Abscess

81
Q

What is PUO

A

Pyrexia of Unknown Origin
Recurrent Fever>38 persisting for more than 3 weeks without an obvious cause despite more than a weeks worth of inpatient investigations

82
Q

How should you treat a PUO with an unknown infective cause?

A

IV Cefuroxime, Metronidazole and Gentamicin

83
Q

What is Atelectasis?

A

Partial collapse of the small airways

84
Q

What causes Atelectasis

A

Thought to be a combination of airway compression, intraoperative alveolar gas resorption, and impaired surfactant production

85
Q

Give four risk factors for Atelectasis

A

Age
Smoking
Prolonged Bed Rest
Pre-existing lung disease

86
Q

How would Atelectasis present clinically?

A

Varying degrees of compromise but normally increased resp rate and decreased O2 sats

87
Q

How is Atelectasis managed?

A

Deep breathing exercises
Chest Physio
If persisting - Bronchoscopy

88
Q

State four O2 giving devices WITHOUT ventilatory support

A

Nasal Cannulae
Simple Hudson Face Mask
Venturi Face Mask
Non Rebreath Mask

89
Q

Why is a Venturi Mask used for Controlled Oxygen Therapy?

A

Can measure the exact oxygen given

90
Q

What is a physiological shunt (in terms of ventilation)?

A

Alveoli that are perfused but not ventilated

91
Q

What is physiological dead space (in terms of ventilation)?

A

Alveoli that are ventilated but not perfused

92
Q

What is PEEP?

A

Positive End Expiratory Pressure

Splints open small airways so that they don’t collapse after expiration (hence reducing physiological shunt)

93
Q

What is CPAP?

A

Focuses on maximising PEEP by giving a continuous amount of pressure

94
Q

What is BiPAP?

A

Respiratory support AND ventilatory support
Two different levels of CPAP (one higher during insp and one lower during exp)
Used in Type 2 Resp Failure

95
Q

Name two possible harmful outcomes of artifical ventilation

A

Volutrauma

Barotrauma

96
Q

Give three reasons why post- op patients are pre-disposed to Pneumonia

A

Reduced chest ventilation (stasis of fluids)
Change of Commensals (Hospital)
Intubation

97
Q

What is ARDS?

A

Acute Respiratory Distress Syndrome

Acute lung injury characterised by severe hypoxaemia in the absence of a cardiogenic cause

98
Q

Describe the four diagnostic features of ARDS

A
  • Acute onset within 7 days
  • PaO2:FiO2 is less than 300
  • Bilateral infiltrates on CXR
  • Alveolar Oedema not explained by cardiogenic causes or fluid overload
99
Q

Give two direct and two indirect causes of ARDS

A

Direct - Pneumonia, Smoke Inhalation

Indirect - Sepsis, Polytrauma

100
Q

Describe the pathophysiology of ARDS

A
  • Direct injury or activation of inflammatory cascade results in breakdown of alveolar capillary barrier
  • Permeability increases leading to alveolar oedema
  • Reduces gas exchange and damages type II alveolar cells
101
Q

How would you manage ARDS?

A 
Resp Support (likely requiring intubation and ITU)
Treat underlying cause
102
Q

Describe the components of Virchow’s Triad

A
  • Abnormal Blood Flow
  • Abnormal Blood Contents
  • Abnormal Vessel Wall
103
Q

Give four clinical features of a DVT

A

Unilateral leg pain and swelling
Low grade pyrexia
Pitting Oedema
Prominent Superficial veins

104
Q

How is the Wells Score used to determine further investigations in DVT?

A

If Wells Score<1 then a DVT is unlikely and D-Dimers should be used
If Wells Score>1 then DVT is likely and should be confirmed using USS or Contrast Venography

105
Q

Describe D-Dimers in terms of Sensitivity and Specificity

A 
High Sensitivity
Low Specificity (also raised in Heart Failure, Cancer etc)
106
Q

How would you manage a haemodynamically stable DVT/PE?

A

DOACs (Unless Renal Impairment - Warfarin)

Direct Factor Xa Inhibitor - Apixiban, Rivaroxiban
Direct Thrombin Inhibitor - Dabigatran (5 days of LMWH first)

107
Q

How is the Wells Score used to determine further investigations in PE?

A

If Wells Score<4 then a PE is unlikely and D-Dimers should be used
If Wells Score>4 then PE is likely and should be confirmed using CTPA

108
Q

Describe 3 ways a PE could present on an ECG

A

RBBB
RV Strain (inverted T waves in V1-V4)
S1Q3T3 - Deep S, Pathological Q, Inverted T

109
Q

What is a Massive PE?

A

PE causing haemodynamic compromise

Requires thrombolysis

110
Q

Give two examples of mechanical thromboprophylaxis

A

Antiembolic Stockings

Intermittent Pneumatic Compression (in theatre)

111
Q

What is an Anastamotic Leak?

A

Leak of luminal contents from a surgical join

112
Q

Name four risk factors for Anastamotic Leaks

A

Steroid Use
Obesity
Emergency Surgery
Longer Intraoperative Time

113
Q

Give 3 clinical presentations of Anastamotic Leaks

A

Abdominal Pain and Fever (usually 5-7 days post-op)
Delirium
Prolonged Ileus

114
Q

What technique of imaging should be used for Anastamotic Leaks?

A

CT with contrast

115
Q

Describe three managements of Anastamotic Leaks

A

NBM
Broad Spectrum Abx
Percutaneous Drainage/Explorative Laparatomy

116
Q

What is Post-Op Ileus?

A
  • Deceleration/Arrest in intestinal motility following surgery
  • Very common but may be a sign of a more serious pathology such as anastamotic leaks
117
Q

Give four risk factors for Post-Op Ileus

A

Electrolyte Imbalances
Anticholinergics
Opioids
Extensive Intra-Operative bowel handling

118
Q

Give three clinical features of Post-Op Ileus

A
  • Failure to pass flatus/faeces
  • Nausea/Vomiting
  • Bloating
119
Q

Describe the bowel sounds of Post-Op Ileus compared to Mechanical Obstruction

A

Post - Op Ileus = Absent

Mechanical Obstruction = Tinkling

120
Q

Describe the management of Post-Op Ileus

A

Conservative
Daily Bloods
Encouraging mobilisation
Could drain with NG tube

Warn patients they may have watery diarrhoea for the first few days after

121
Q

What are Bowel Adhesions?

A

Fibrous bands of scar tissue secondary to previous surgery or intra-abdominal inflammation
Most common cause of small bowel obstruction

122
Q

How would you manage uncomplicated Bowel Obstruction?

A

Tube decompression
NBM
Analgesia
IV Fluids

123
Q

How would you manage complicated (ie ischaemia, perforation) Bowel Obstruction?

A

Adhesiolysis (normally laproscopically)

124
Q

What is an Incisional Hernia? Give 3 risk factors

A

Protrusion of contents of a cavity through the previously made incision in the bowel wall

Midline Incision, Pre-Op Chemo, BMI>25

125
Q

Give four different aetiologies of Constipation

A

Physiological (eg low fibre diet)
Iatrogenic (eg Opioids)
Pathological (eg BO)
Functional (eg previously painful defaecation)

126
Q

Give an example of an Osmotic, Stimulant, Bulk Forming and Rectal Laxative respectively

A

Osmotic - Movicol
Stimulant - Sodium Picosulfate
Bulk Forming - Ispaghula Husk
Rectal - Glycerin Suppository

127
Q

Give four causes of Post-op Hypogylcaemia

A
  • Hypoglycaemics/Insulin Overdose
  • Late Gastric Dumping
  • Decompensated Liver Disease
  • Adrenal Insufficiency
128
Q

State four clinical features of Hypoglycaemia

A

Sweating
Tingling Lips
Slurred Speech
Tachycardia (Beta Blockers may distort this)

129
Q

How should you manage conscious patients with Hypoglycaemia?

A

Oral Glucose and Complex Carbohydrates

130
Q

How should you manage unconscious patients with Hypoglycaemia?

A

O2 and IV Glucose
IV Glucose Fluid Therapy
Any delay - IM Glucagon

131
Q

How is Hypoglycaemia managed intra-operatively?

A

BM measurements taken every 30 mins
<4mmol/l causes insulin infusion to be stopped
<2mmol/l is a hypoglycaemic emergency

132
Q

Give 3 causes of post op Hyperkalaemia

A

Post Op AKI
Repeated Blood Transfusions
Diuretics

133
Q

What other electrolyte abnormality might you have to correct along with HYPOkalaemia?

A

HYPOmagnesaemia

134
Q

Why is Post-Op HYPOnatraemia a problem?

A

Most common post-op electrolyte abnormality

Can cause cellular oedema and swelling which impairs tissue healing

135
Q

Why is Post-Op Hyponatraemia common?

A

They are likely given a lot of Dextrose Fluid intra-op

Fluid retention is part of the stress response to surgery (via increased cortisol and ADH)

136
Q

Give 3 Pre-Op prophylactic measures to prevent wound infections

A

Prophylactic Antibiotics
Dont routinely remove hair
Maximise Diabetic control

137
Q

What is Wound Dehiscence?

A

The wound fails to heal, reopening a few days after surgery

Most common with Abdominal Wounds

138
Q

Describe the two types of Wound Dehiscence

A

Superficial - Skin wound alone fails, rectus sheath remains intact (often secondary to infection/DM)

Full Thickness - Rectus sheath fails to heal and bursts causing potential protrusion of abdo organs

139
Q

How would you manage Superficial Wound Dehiscence?

A

Wash out with saline
Simple wound care
Advise patient the wound now needs to heal by secondary intention

140
Q

How would you manage Full Thickness Wound Dehiscence?

A

Analgesia
Broad Spectrum Abx
Cover with saline gauze
Return to surgery

141
Q

What are Keloid Scars?

A

Abnormal proliferations of scar tissue occurring at the site of injury (due to excess fibroblast activity)
Rising above the skin level
Projects beyond margins
Does not regress

142
Q

Give four risk factors for Keloid Scars

A

Ethnicity (Black and Asian)
Age (between 20 and 30)
Cause of injury (Burns)
Anatomical Site (Ear Lobes, Shoulder, Sternum)

143
Q

What is the difference between Keloid Scars and Hypertrophic Scars?

A

Keloid Scars proliferate outside of the wound margins whereas Hypertrophic scars remain within

144
Q

Describe the management of Keloid Scars

A

Rarely operated on (due to recurrence)
Intralesional Steroids
Silicone Gel
Radiation Therapy

145
Q

How would you classify cardiac risk pre-op?

A

High: >5%
Intermediate: 1-5%
Low: <1%

Increased if you are going into a body cavity

146
Q

Describe the ASA from I to VI

A 
I - Normal Healthy
II - Smoker/Obese/Pregnant
III - Severe systemic disease
IV - Severe systemic disease with constant threat to life
V - Will die without op
VI - Brain dead
147
Q

What is SORT?

A

Surgical Outcome Risk Tool

Used to stratify the risk of mortality one month after surgery etc
If more than 5% consider post-op ITU

148
Q

Describe the time scale of Surgical Procedures

A

Urgent
Emergency
Expedited
Elective

149
Q

Name a classification system for cellulitis

A

Enron Classification

150
Q

Name two early and two late adverse transfusion reactions

A

Early - Anaphylaxis, Acute Haemolytic

Late - Infections, Iron Overload

151
Q

How should you manage Heart Failure patients requiring transfusion?

A

Absolutely essential if Hb<50g/l
Transfuse with caution if Hb 60-80g/l

Give blood alongside furosemide

Dan Surgery (9 decks)

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