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Finals > Perioperative Care > Flashcards

Perioperative Care Flashcards

1
Q

What medications are used during induction of anaesthesia? What are their roles?

A 
Fentanyl - analgesia
Propofol - hypnotic agent (may use volatile instead)
Muscle relaxant (if intubation required, or if surgery requires a still pt)
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2
Q

Give an example of a depolarising muscle relaxant used in induction of anaesthesia

A

Suxamethonium

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3
Q

Give an example of a non-depolarising muscle relaxant used in induction of anaesthesia

A

Rocuronium

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4
Q

What medications are used during the maintenance of anaesthesia? What are their roles?

A

Sevo-, iso-, or desflurane - hypnotic agents
Analgesia may be given
If hypotension occurs - ephedrine (inc HR) or metaraminol
Fluids - usually Hartmann’s
Antibiotics (depending on surgery)

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5
Q

What medications are given just before emergence from anaesthesia?

A

Analgesia - e.g. paracetamol, fentanyl
Anti-emetics - e.g. ondansteron, cyclizine
Non-depol NM block reversal - neostigmine (+ glycopyrronium)

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6
Q

What are the common side effects of propofol?

A

Headache
Hypotension
Tachycardia

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7
Q

What are the common side effects of fentanyl?

A

Bradycardia or tachycardia
Confusion
Constipation and urinary retention
Dizziness

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8
Q

What are the common side effects of the volatile induction agents?

A

Arrhythmias
Cardioresp. depression
Hypotension

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9
Q

What are spider naevi?

A

Dilated capillaries (central arteriole with radiating small vessels)
Benign and painless
>5 is strongly indicative of liver disease

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10
Q

What is the most likely cause of an ulcer with sloping edges? What else might you see?

A

Venous ulcer - no raised edges, granulation tissue seen

Might also see varicose veins, haemosiderin deposits.

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11
Q

Give the 2 causes of a punched out ulcer. How can you differentiate them?

A

Arterial - intensely painful, grey or yellow base. Pulses will be absent
Neuropathic - major complication of DM + likely cause of diabetic foot

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12
Q

What is the most likely cause of an ulcer with undermined edges?

A

Pressure sore - compression of blood vessels between surface and bone -> tissue breakdown

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13
Q

What is the most likely cause of an ulcer with rolled edges?

A

Basal cell carcinoma - less aggressive, but may present late

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14
Q

What is the most likely cause of an ulcer with everted edges?

A

Squamous cell carcinoma - more aggressive, looks clearly ulcerated and offensive

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15
Q

Define ‘hernia’

A

A hernia is the protrusion of a viscus through the wall of its containing cavity

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16
Q

What are the 3 common features of herniae?

A
  • occur at a weak spot
  • reduce on lying down +/- direct pressure
  • expansile cough will exacerbate them
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17
Q

Cause of a hernia that begins lateral to the epigastric artery

A

Indirect inguinal hernia

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18
Q

Cause of a hernia medial to the epigastric artery

A

Direct inguinal hernia

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19
Q

Describe the course of an indirect inguinal hernia

A

Passes through int ring, down ing canal, and through superficial ring.

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20
Q

Describe the course of a direct inguinal hernia

A

Pass through Hesselbach’s triangle in the transversalis fascia. May then pass through the superficial ing ring.

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21
Q

How would you distinguish between a scrotal swelling (e.g. hydrocoele) and a hernia?

A

Can you get above it? (are the contents contained within the scrotum, or is there thickening above - indirect)
Hydrocoeles are transluminate
Hydrocoeles won’t reduce

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22
Q

How would you distinguish between a direct inguinal, an indirect inguinal and a femoral hernia?

A

Femoral = appears below and lat to pubic tubercle
Indirect ing = appear above and med to pubic tubercle. The swelling begins higher and is contained within the spermatic cord.
Direct ing = appears above and med to pubic tubercle. There is no higher swelling

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23
Q

Give some causes of visceral pain

A

Ischaemia
Distension/stretching
Tension

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24
Q

Where is visceral pain felt, and give some organs that may be effected

A

Epigastric - stomach, duodenum, liver/biliary tree, pancreas, spleen
Periumbilical - duodenum, jejunum, ileum, appendix, ascending and part of transverse colon
Suprapubic - distal transverse colon to anal verge

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25
Q

Give some conditions that may cause generalised peritonitis

A

Perforated viscus
1’ infective peritonitis
Cyst rupture

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26
Q

Give some conditions that may cause localised peritonitis

A 
Appendicitis
Cholecystitis
Pancreatitis
Diverticulitis
Abscesses
Salpingitis/ruptured ectopic
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27
Q

Give some intra-abdo causes of abdo pain

A 
Generalised peritonitis
Localised peritonitis
Motility disorders (obstruction, spasm)
Ischaemia
Other - ruptured AAA
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28
Q

Give some extra-abdo causes of abdo pain

A

Thoracic - lung disease, IHD, oesophageal disease
Neuro - herpes zoster, spinal arthritis, radiculopathy, tabes dorsalis, abdo epilepsy
Metabolic - DM, CKD, acute adrenal insufficiency
Toxins - bites, lead poisoning, peptic ulcer, inflammatory diseases

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29
Q

What are your differentials if a pt describes a sudden onset pain?

A

Perforation or rupture (DU, AAA)

Non-abdo - MI, angina, mesenteric occlusion

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30
Q

What are your differentials if a pt describes a rapidly accelerating pain?

A

Colic syndromes - renal, biliary, SB obstruction

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31
Q

What are your differentials if a pt describes a gradual onset pain?

A

Inflammatory conditions, obstructive processes, other mechanical process

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32
Q

When taking a Hx of an acute abdo, what associated features should you ask about?

A

N+V, haemotemesis
Appetite, W/L
Diarrhoea/constipation, malaena
Distension

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33
Q

What features in a Hx and exam would make you think malignancy?

A 
Intermittent pain >48hr duration
Altered bowel habit
Abdo distension
Mass
W/L
Systemic upset
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34
Q

What features in a Hx would make you think intestinal obstruction?

A 
Colicky, severe pain
No aggravating factors
Vomiting + constipation (obstipation later) (depending on level)
Prev. surgery
Abdo distension
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35
Q

What features in a Hx and exam would make you think of a perforated viscus?

A 
Sudden onset
Constant, severe pain
Pain aggravated by movement or coughing
Diffuse tenderness
Silent, rigid abdo
ALWAYS CHECK AMYLASE
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36
Q

What features in a Hx and exam would make you think of a ruptured AAA?

A

Sudden onset, central abdo pain
May be collapsed
Hypotensive

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37
Q

What investigations would you do for an acute abdo?

A

Bedside: cap gluc, pregnancy test, urinalysis, ECG, normal obs
Lab: FBC (anaemia, inc WCC), U+E (AKI, CKD), amylase, LFTs (esp if jaundiced), ABG (acidotic?), clotting
Imaging: CXR (free air under dia), AXR, USS (if DDx gynae, renal or hepatic), CT.
Exploratory laparotomy/laparoscopy may be needed

38
Q

What is the general management of an acute abdoment

A 
NBM
IV fluids
Regular obs
Catheter +/- NG tube
Analgesia +/- antiemetic
ABx + theatre may be required
39
Q

What ABx would you prescribe in suspected spontaneous bacterial peritonitis?

A

Ceftriaxone (or another 3rd gen cephalosporin)

40
Q

How can you differentiate between SB and LB obstruction on an XR?

A 
SB = >3cm, central, valvulae conniventes (across lumen)
LB = >6cm (caecum >9cm), haustra visible, peripheral
41
Q

What are the most common causes of intestinal obstruction?

A

Adhesion
Hernias
Tumours
Others - congenital malrotation, intussusception, foreign bodies etc

42
Q

What features on an exam would make you think of obstruction?

A 
Tachy + hypotension
Fever = strangulation is likely
Distension
Surgical scars
Early - hyperactive sounds, Late - silent
DRE - intraluminal masses, blood
Hernial orifices
43
Q

What monitoring is required when a patient is on Dalteparin?

A

None required, but can be monitored via Anti-Factor Xa

44
Q

What monitoring is required when a patient is on UFH?

A

APTT

45
Q

Give 2 side effects of gentamicin

A

Nephrotoxicity

Ototoxicity

46
Q

Normal ABPI measurements

A

0.9-1.2

47
Q

ABPI <0.9 cause

A

Arterial disease

48
Q

ABPI >1.3 cause

A

Arterial disease secondary to arterial calcification (e.g. diabetes)

49
Q

Management of venous ulcers

A 
Compression bandaging
Oral pentoxifylline (peripheral vasodilator)
50
Q

Causes of lower abdo pain 3d post-op (not related to surgery itself)

A

Urinary retention

51
Q

Risk factors for urinary retention

A

TWOC
Constipation
Immobility
Opiates

52
Q

Management of unruptured sigmoid volvulus

A

Decompression via rigid sig and flatus tube insertion

53
Q

Name of the surgical sign seen in appendicitis when palpation of the LIF causes pain in the RIF

A

Rosvings sign

54
Q

When should LMWH be initiated for surgical prophylaxis of VTE?

A

6-12hrs post-op

55
Q

For elective procedures, when should clopidogrel be stopped?

A

7d pre-op

56
Q

When would you stop the COCP before surgery?

A

4wks

57
Q

Causes of a midline neck lump

A

Goitre

Thyroglossal cyst

58
Q

Causes of a neck lump in the anterior triangle

A

Branchial cyst
Carotid body tumour
Lymph node

59
Q

Causes of a neck lump in the posterior triangle

A

Cystic hygroma

Lymph node

60
Q

Risk of direct hernia strangulation over 1yr if not treated

A

<5%

61
Q

Diagnostic investigation in spontaneous bacterial peritonitis

A

Aspiration of the peritoneal cavity

62
Q

Describe Leriche syndrome in a male patient

A
  1. Claudication of the buttocks and thighs
  2. Atrophy of the musculature of the legs
  3. Impotence (due to paralysis of the L1 nerve)
63
Q

What is the cause of Leriche syndrome?

A

atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries

64
Q

Peri-umbilical bruising in acute pancreatitis

A

Cullen’s sign

65
Q

Hyperaesthesia beneath right scapula in acute cholecystitis

A

Boas sign

66
Q

Pain management in acute pancreatitis

A

IV morphine in 1-2mg boluses until comfortable

67
Q

Differentials for a LIF mass

A 
Renal transplant
Loaded colon
Diverticular mass
Colorectal carcinoma
Ovarian
68
Q

Differentials for a RIF mass

A 
Renal transplant
Appendix mass
Crohn's disease (inflamed, matted small intestine)
Caecal carcinoma
Ovarian
69
Q

Findings on colonoscopy in Peutz-Jeghers syndrome

A

Hamartomas

70
Q

What is atelectasis?

A

Common post-op complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions

71
Q

Haemorrhoids vs fissure in ano

A

Haemorrhoids are usually painless unless thrombosed

Fissures are intensely painful

72
Q

Single most important factor that indicates need for liver transplant

A

Arterial pH 7.25

73
Q

Initial therapy for a large fissure in ano

A

Topical diltiazem - relax sphincter and facilitate healing

74
Q

Most common viral infection associated with solid organ transplants

A

CMV

75
Q

What is Boerhaaves syndrome?

A

Rupture of the oesophageal wall (full thickness)

76
Q

Treatment of acute cholecystitis

A

IV ABx and lap chole within 1wk

77
Q

Management of congenital inguinal hernias

A

Repair ASAP

78
Q

Management of congenital umbilical hernias

A

Manage conservatively (most resolve by age 4/5yrs)

79
Q

Cause of delayed weaning from ventilation post-op

A

Suxamethonium apnoea - auto dom deficiency of specific AChE

80
Q

Management of post-op ileus

A

NBM

Insert NG tube

81
Q

Briefly outline rapid sequence induction

A 
NG tube and IV access
Pre-oxygenate
IV induction
Fast muscle relaxant
Cricoid pressure
ET intubation
82
Q

Medication to avoid in bowel obstruction. Why?

A

Metoclopramide - it’s a pro-kinetic anti-emetic that may result in perforation

83
Q

Supplementation required in ileal-ceacal resection

A

B12

84
Q

Cramping in LIF relieved by defecating and associated with passage of wind

A

Diverticular disease

85
Q

Steatorrhoea, abdo pain (acute on chronic) and chronic weight loss

A

Chronic pancreatitis

86
Q

What ASA would the following pt be?
Mild disease w/o functional limitations (e.g. smoker, pregnancy, obesity (but BMI <40),well controlled diabetes/HTN, mild lung disease

A

ASA II

87
Q

What ASA would the following pt be?
Substantive functional limitations, one or more mod-sev disease (e.g. poorly controlled DM/HTN, COPD, BMI>40, ESRD, MI >3m ago)

A

ASA III

88
Q

What ASA would the following pt be?

Recent MI <3m ago, ongoing cardiac ischaemia, severe valve dysfunction, sepsis, DIC, ESRD w/o dialysis

A

ASA IV

89
Q

What ASA would the following pt be?

Ruptured AAA, massive trauma, IC bleed, multiple organ/system dysfunction

A

ASA V

90
Q

What ASA would the following pt be?

Declared brain-dead pt whose organs are being removed for donor purposes

A

ASA VI

Finals (25 decks)

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