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Surgery > Post-Op _1 > Flashcards

Post-Op _1 Flashcards

1
Q

What’s the minimum monitoring immediately post-operatively?

A
  • obs (BP, HR, sats, RR)
  • ECG

*sometimes GCS

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2
Q

What should all patients receive post-op and how long for?

A

All pt should receive post-op oxygen for at least 4 hours

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3
Q

(3) important factors to review regularly post -op

A
  • vital signs -> is patient shocked?
  • pain relief/management -> is there more bleeding than expected?
  • wounds/drains
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4
Q

What’s staff to patient ratio on:

  • surgical ward
  • HDU
  • ITU
A

Surgical ward 4:1

HDU 2:1

ITU 1:1

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5
Q

What are the components of an analgesic pain ladder?

A
  1. Non-opiates (start with) e.g. paracetamol/ NSAIDs
  2. Weak opiate (e.g *Co-codmol*) +/-non-opiate**
  3. Strong opiates (Morphine) +/- non - opiate
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6
Q

NSAIDs

  • what are they good for?
  • contraindications
A

NSAIDs

Good for: orthopaedic pain -> given either orally, IM or as a suppository

Containdications: asthma, renal impairment, peptic ulcers

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7
Q

Examples of specific weak-opiates

A

Paracetamol + codeine phosphate -> Co-codamol

Dihydrocodeine -> Co-dydramol

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8
Q
  • When do we think of use of weak opiates (such as Co-codamol, Co-dydramol)?
  • What are their side effects?
A
  • We think of starting weak opiates when Paracetamol on its own is ineffective
  • Side effect: constipation
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9
Q

Morphine

  • class
  • main use
  • forms that can be administrated
  • site effects
A

Morphine

Class: strong opiates

Forms: oral, enteral, IM, SC, IV, continous infusion (patient-controlled analgesia)

Side effects: respiratory depression (careful in trauma and elderly patients), hypotension, nausea and constipation

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10
Q

Whare epidural analgesia is injected into?

A

The injection is usually made in the lumbar region at the L2/3 or L3/4 space

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11
Q

What’s epidural analgesia?

A

Epidural analgesia is an injection of local anaesthetic alone, or more commonly in combination with pain.

  • may be used for pain relief intraoperatively (instead of using general anaesthetic for that purpose)
  • often used in combination with GA -> to provide intra and post operative pain relief
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12
Q

What is the drug often used in epidural analgesia?

What is it usually combined with?

A

Bupivacine - a local anaesthetic

It is commonly used with diamorphine

*this combination is to enhance analgesia

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13
Q

Contraindication for epidural

A

Contraindications for an epidural:

  • clotting disorders

- warfarin, heparin use and INR >1.5

*these are risk fo epidural haematoma -> paraplegia

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14
Q

What are possible risks (complications) for use of epidural haematoma?

A
  • epidural haematoma leading to paraplegia -> if clotting disorders, warfarin/heparin use
  • hypotension
  • urinary retention
  • small risk of infection -> epidural abscess
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15
Q

In what cases can we consider epidural in patient on Warfarin?

A

If the benefits outweigh risks, e.g. in patients with major abdominal or thoracic surgery -> epidural will reduce pain so the patient would be able to mobilise early and cough effectively -> reduced risks of pneumonia

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16
Q

What to do if e decide to give epidural to a patient on warfarin?

A

Heparin infusion (as warfarin would have been stopped earlier) would be switched on 4 hours pre op and INR rechecked

If INR <1.5 we can go ahead with epidural

17
Q

How does patient-controlled analgesia work?

A

The patient presses the bottom that delivers a bolus of morphine IV -> normally every 5 min 1 mg

  • maximum 12 mg / hr can be delivered -> so no risk of overdose
18
Q

(1) advantage of patient-controlled analgesia
(1) disadvantage of patient controlled analgesia

A

Advantage: patient feels in control of their pain relief

Disadvantage: the patient must have physical ability to press the bottom -> may not be suitable for patient with severe RA or dementia

19
Q

Why do we provide post-op pain care? (3)

A
  • part of compassionate care
  • to reduce complications e.g. pneumonia - if the patient would not be able to breathe deeply (e.g. due to pain) -> predisposed to pneumonia
  • to mobilise early -> reduce risk of DVT
20
Q

Differential diagnosis for post-op pain

A
  • true post-op pain -> pain related to the disease process for which the procedure was undertaken OR/AND tissue damage sustained by the operation itself
  • post- op complication -> additional attention is required
  • pain arises from completly separate pathology from the one that the procedure was carried out for (least likely but still possible0
21
Q

What’s the most important distinguishing sign between SIRS and pain in terms of vital signs? (2)

A

BP

  • in SIRS/ sepsis -> it may be low
  • in pain -> may be high

Cap refill

  • expected to be normal in pain
  • would be increased in SIRS/sepsis

*other vital signs may be similar in both

22
Q

What to prescribe together with opioids? (2)

A
  • Anti-emetic PRN
  • Laxative PRN
23
Q

Examples of intraoperative complications

A
  • haemorrhage -> hypovolemic shock
  • dehydration and decreased organ perfusion
  • MI
  • faecal contamination -> becomes apparent 1-4 days post-op
24
Q

Early (<24) post-op

A
  • haemorrhage
  • respiratory: pneumothorax, adult respiratory distress syndrome
  • poor urine output
  • dehydration
25
Q

Post-op complications seen in days 1-4

A
  • urinary retention (also can occur in first 24 hours)
  • pneumonia
  • DVT, PE
  • paralytic ileus
  • operative sepsis (e.g. faecal contamination) shows up
  • sepsis due to different causes (e.g. resp infection via ventilation, UTI via catheter)
26
Q

Wound complications (post-op) that may occur before discharge

A
  • anastomotic breakdown
  • faecal fistula
  • wound dehiscence -> may result in an incisional hernia
27
Q

Post-op complications that may show up weeks later (2)

A
  • incisional hernia
  • obstruction due to adhesions
28
Q

What organisms usually cause cellulitis (3)

A
  • Clostridium perfringens
  • staphylococci
  • Beta- haemolytic streptococci
29
Q

Types of gangrene (3)

A
  • wet
  • dry
  • gas
30
Q

Describe dry gangrene

A

Dry gangrene

Cause: a gradual reduction in blood supply e.g. atherosclerosis

Appearance: tissue becomes dry, wrinkled and black (from the disintegration of haemoglobin)

31
Q

Wet gangrene description

A

Wet gangrene

Cause: death and decay of the tissue due to bacterial infection

Appearance: moist and infected areas

32
Q

Gas gangrene description

  • cause
  • pathological process
  • risk factors
  • prognosis
  • management
A

Gas gangrene

Cause: infections of the deep wounds or abdominal cavity (e.g. bowel) with Clostridium Performans or other gas-forming organisms (e.g. anaerobes)

Pathology: involves tissue enzymes (proteases, collagenase, hyaluronidase) and alpha toxin

Risk factors: DM, immunosuppression, malignancy, AKI

Prognosis: poor

Management: aggressive Rx with Penicillin and repeated debridement

33
Q

What’s Fournier’s gangrene?

A

Fournier’s gangrene

Spreading cellulitis of perineum and scrotum (may involve tights and abdominal wall) -> can result in necrotising fascitis

*may be fatal if systemic spread

Management: broad-spectrum antibiotics and debridement

34
Q
A

Surgery (18 decks)

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