p e r i o p

Question 1

before going to theatre what things need to be addressed

Answer 1

Pre-operative assessment (pre-op)
Consent
Bloods (including groups and save / crossmatch)
Fasting
Medication changes
Venous thromboembolism assessment

Question 2

what is pre op assessment and what does it involve

Answer 2

assess if pt fit to undergo the specific operation.

involves exploring their co-morbidities, risk from anaesthesia, their frailty status and their cardiorespiratory fitness.

Question 3

pre operative assessment involves asking about

Answer 3

Past medical problems
Previous surgery
Previous adverse responses to anaesthesia
Medications
Allergies
Smoking 
Alcohol use

Question 4

what must be considered in females undergoing surgery

Answer 4

pregnancy

Question 5

what other factors need to be assessed pre operatively

Answer 5

asking about a family history of sickle cell disease.

general examination is performed to look for cardiovascular and respiratory disease.

Patients who may be malnourished (e.g., BMI under 18.5 or significant unintentional weight loss) may need input from a dietician and additional nutritional support before surgery and during admission.

Question 6

what is an ASA Grade

Answer 6

classifies the physical status of the patient for anaesthesia.

patients are given a grade to describe their current fitness prior to undergoing anaesthesia/surgery

Question 7

what are the grades for asa

Answer 7

ASA I – normal healthy patient
ASA II – mild systemic disease
ASA III – severe systemic disease
ASA IV – severe systemic disease that constantly threatens life
ASA V – “moribund” and expected to die without the operation
ASA VI – declared brain-dead and undergoing an organ donation operation
E – this is used for emergency operations

Question 8

what pre operative investigations are required pts

Answer 8

ECG - Known or possibly cv disease

Echocardiogram if there are heart murmurs, cardiac symptoms or heart failure

Lung function tests may be required if there is known or possible respiratory disease

Arterial blood gas testing may be required if there is known or possible respiratory disease

HbA1C (within the last 3 months) for people with known diabetes

U&Es for patients at risk of developing an acute kidney injury or electrolyte abnormalities (e.g., taking diuretics)

FBC may be required if there is possible anaemia, cardiovascular or kidney disease

Clotting testing may be required if there is known or possible liver disease

Question 9

group and save vs cross matching

Answer 9

group and save = send off to establish blood group and match them. used when there is lower probability they weill require blood products

cross macthing involving taking a unit or more of blood and assigning it to pt

Question 10

why do pt fast before surgery

Answer 10

ensure they have an empty stomach for the duration of their operation.

The aim is to reduce the risk of reflux of food around the time of surgery (particularly during intubation and extubation), which subsequently can result in the patient aspirating their stomach contents into their lungs.

Question 11

fasting for an operation involves

Answer 11

6 hours of no food or feeds before operation

2 hours no clear fluids (fully “nil by mouth”)

Question 12

what specific meds may need changing before a major surgery

Answer 12

anticoagulants
oestrogen containing contraception
long term corticosteroids

Question 13

describe how anti coagulants are stopped before surgery

Answer 13

ing can be mounted in to to ensure normal before operation

warfarin can be rapidly reversed with vitamin k

treatment dose LMWH OR unfractionated heparin infusion can be used to bridge the gap between stopping warfarin and surgery in higher risk pt (mechanical heart valve) ), and stopped shortly before surgery depending on the risk of bleeding and thrombosis

Question 14

when are docs stopped before surgery

Answer 14

24-72hrs before surgery

depending on half life, produce and renal function

Question 15

OCP or HRT needs to be stopped how many weeks before surgery

Answer 15

4 weeks = reduce risk of vte

Question 16

pt with long term corticosteroids before surgery need management because

Answer 16

in pts on long-term steroids, there is adrenal suppression that prevents them from creating the extra steroids required to deal with this stress

Question 17

management of patients on long term steroids 5mg oral pred or more

Answer 17

Management involves:

Additional IV hydrocortisone at induction and for the immediate postoperative period (e.g., first 24 hours)
Doubling of their normal dose once they are eating and drinking for 24 – 72 hours depending on the operation

Question 18

which oral anti diabetics meds need to be adjusted or omitted around surgery

Answer 18

Sulfonylureas (e.g., gliclazide) can cause hypoglycaemia and are omitted until the patient is eating and drinking

Metformin is associated with lactic acidosis, particularly in patients with renal impairment

SGLT2 inhibitors (e.g., dapagliflozin) can cause diabetic ketoacidosis in dehydrated or acutely unwell patients

Question 19

patients on insulin going for surgery require

Answer 19

continue a lower dose of their long actin insulin

stop short acting insulin whilst fasting or not eating until E+D again

NEED sliding scale/ variable rate insulin infusion alongside glucose, sodium chloride and potassium

Question 20

what measures are taken in VTE prophylaxis

Answer 20

Low molecular weight heparin (LMWH) such as enoxaparin

DOACs (e.g., apixaban or rivaroxaban) may be used as an alternative to LMWH

Intermittent pneumatic compression (inflating cuffs around the legs)

Anti-embolic compression stockings

Question 21

what are the four criteria of capacity

Answer 21

Understand the decision

Retain the information long

enough to make the decision

Weigh up the pros and cons

Communicate their decision

Question 22

what is enhanced recovery

Answer 22

aims to get patent back to their pre operative condition as quickly as possible = early mobility and appropriate diet

Question 23

what are the principles of enhanced recovery

Answer 23

Good preparation for surgery (e.g., healthy diet and exercise)
Minimally invasive surgery (keyhole or local anaesthetic where possible)
Adequate analgesia
Good nutritional support around surgery
Early return to oral diet and fluid intake
Early mobilisation
Avoiding drains and NG tubes where possible, early catheter removal
Early discharge

Question 24

post operative analgesia is important because

Answer 24

allows pt to mobilise

ventilate lungs fully + reducing

risk of chest infections and atelectasis

have adequate oral intake

Question 25

NSAIDS may be cl in pts with

Answer 25

Asthma
Renal impairment
Heart disease
Stomach ulcers

Question 26

what is pca

Answer 26

patient controlled analgesia - iv infusion of strong opiate e.g morphine attached to patient controlled pump

the button will stop responding for a set time after administering a bolus to prevent over-use. Only the patient should press the button (not a nurse or doctor).

Question 27

pca requires

Answer 27

requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur

Question 28

what additional things are required in pt with pca

Answer 28

access to naloxone for respiratory depression,

antiemetics for nausea

atropine for bradycardia.

The anaesthetist may prescribe background opiates (e.g., patches) in addition to a PCA, but avoid other “as required” opiates whilst a PCA is in use. The machine is locked to prevent tampering.

Question 29

what are the rx factors of post operative vomiting

Answer 29

Female
History of motion sickness or previous PONV
Non-smoker
Use of postoperative opiates
Younger age
Use of volatile anaesthetics

Question 30

which prophylactic antiemetics are given at the end of a procedure in surgery

Answer 30

Ondansetron (5HT3 receptor antagonist) – avoided in patients at risk of prolonged QT interval

Dexamethasone (corticosteroid) – used with caution in diabetic or immunocompromised patients

Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patient

Question 31

when are tubes removed after surgery

Answer 31

1. Drains are usually removed once they are draining minimal or no blood or fluid
2. Nasogastric tubes are removed when they are no longer required for intake or drainage of gas or fluid
3. Catheters are removed when the patient can mobilise to the toilet/ TWOC due to risk of urinary retention

Question 32

why is good nutrition important post surgery

Answer 32

important for healthy wound healing and overall recovery from surgery.

Question 33

what is enteral feeding and what are the options

Answer 33

1. nutrition via gi tract

Mouth
NG tube
Percutaneous endoscopic gastrostomy (PEG) – a tube from the surface of the abdomen to the stomach

Question 34

what is tpn

Answer 34

involves meeting the full ongoing nutritional requirements of the patient using an intravenous infusion of a solution of carbohydrates, fats, proteins, vitamins and minerals

when gi tract cannot be used

normally given via central line as peripheral veins are sensitive to tpn - thrombophlebitis risk

Question 35

what are some post operative complications

Answer 35

1. Anaemia
2. Atelectasis is where a portion of the lung collapses due to under-ventilation
3. Infections (e.g., chest, urinary tract or wound site)
4. Wound dehiscence is where there is separation of the surgical wound, particularly after abdominal surgery
5. Ileus is where peristalsis in the bowel is reduced (typically after abdominal surgery)
6. Haemorrhage with bleeding into a drain, inside the body creating a haematoma or from the wound
7. Deep vein thrombosis and pulmonary embolism
8. Shock due to hypovolaemia (blood loss), sepsis or heart failure
9. Arrhythmias (e.g., atrial fibrillation)
10. Acute coronary syndrome (myocardial infarction) and cerebrovascular accident (stroke)
11. Acute kidney injury
    Urinary retention requiring catheterisation
12. Delirium refers to fluctuating confusion and is more common in elderly and frail patients

Question 36

describe treatment of anaemia following surgery

Answer 36

Hb under 100 g/l – start oral iron (e.g., ferrous sulphate 200mg three times daily for three months)

Hb under 70-80 g/l – blood transfusion in addition to oral iron

Question 37

what are the two main categories of anaesthesia

Answer 37

general anaesthesia – making the patient unconscious

Regional anaesthesia – blocking feeling to an isolated area of the body (e.g., a limb)

Question 38

why is pre oxgyentation required

Answer 38

gives them a reserve of oxygen for the period between when they lose consciousness and are successfully intubated and ventilated

• several minutes of breathing 100 percent oxygen

Question 39

what medications can be given before general anaesthetic

Answer 39

1. Benzodiazepines (e.g., midazolam) to relax the muscles and reduce anxiety (also causes amnesia)
2. Opiates (e.g., fentanyl or alfentanyl) to reduce pain and reduce the hypertensive response to the laryngoscope
3. Alpha-2-adrenergic agonists (e.g., clonidine), which can help with sedation and pain

Question 40

what is the triad of general anaesthesia

Answer 40

1. hypnosis
2. muscle relaxation
3. analgesia

Question 41

what are hypnotic agents and how are they given

Answer 41

make pt unconscious

inhaled or iv

e.g ketamine, propofol

Question 42

how do muscle relaxations work and what are examples

Answer 42

block nmj from working

Acetylcholine (the neurotransmitter) is released by the axon but is blocked from stimulating a response from the muscle. Muscle relaxants are given to relax and paralyse the muscles. This makes intubation and surgery easier.

Question 43

give examples of analgesia given in general anasthesia

Answer 43

fentanyl
morphine

with antiemetics

Question 44

what is emergence and how are pt woken up

Answer 44

pt given nerve stimulator to see of muscle relaxant has worn pff

Once the muscle relaxant has worn off, the inhaled anaesthetic is stopped. The concentration of the anaesthetic in the body will fall, and the patient will regain consciousness. They are extubated at the point where they are breathing for themselves.