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Surgery > Peri-operative care > Flashcards

Peri-operative care Flashcards

1
Q

What does the pre-op assessment allow for?

A

Identify co-morbidities that may cause complications during anaesthetic, surgical or post-op period (generally 2-4 weeks before surgery)

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2
Q

What is asked specifically in the pre-op history?

A

PMH: CVD (risk of acute cardiac event during anaesthesia), respiratory disease, renal disease, endocrine disease (specifically DM and thyroid disease)

Risk of pregnancy? or risk of undiagnosed sickle cell disease (if african / afro-caribbean)

Previous operations

Past anaesthetic history (specifically post op N&V)

Drug history (may need changing before surgery)

Family history (malignant hyperpyrexia)

Social history (smoking, alcohol, exercise tolerance)

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3
Q

What is malignant hyperpyrexia?

A

Autosomal dominant condition which result in muscle rigidity (despite neuromusclar blockade) followed by a rise in temperature caused by certain anaesthetics

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4
Q

What forms the pre-operative examination?

A

General examination (for undiagnosed pathology)

Airway examination (predict difficulty of intubation)

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5
Q

What is an ASA grade (given after a pre-operative assessment)?

A

Correlates with risk of post-op complications and absolute mortality (grade V - not expected to survive without operation)

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6
Q

Which pre-op blood tests might be needed? Why?

A

FBC (for anaemia / thrombocytopaenia)

U&E (baseline renal function - inform IV fluid management)

LFTs (for metabolism and synthesising function)

Clotting screen (for indications of deranged coagulation e.g. iatrogenic cause - warfarin OR inherited coagulopathies - haemophilia A)

Group and save (G&S) + / - cross matching

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7
Q

What is the difference between group and save and cross match?

A

Group and save = patients blood group (ABO and RhD) and screens blood for atypical antibodies (takes 40 mins)

Cross match = physically mixing the patients blood with donors bloos and seeing if immune reaction (done if blood loss anticipated)

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8
Q

What imaging may be done pre-operatively?

A

CXR (if resp illness and no CXR in 12 months, new cardiorespiratory symptoms, recent travel from area endemic with TB, significant smoking history)

Spirometry (if chronic lung condition for baseline)

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9
Q

Which ‘other tests’ may be required pre-operatively?

A

Pregnancy testing = ensure consent

Sickle cell test = if FH of SCC or african / afro-caribbean descent

Urinalysis = evidence / suspicion of ongoing glycosuria or UTI

MRSA swab = from nostil and perineum and or other site

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10
Q

What should be look at on the pre-op air way assessment?

A

Receding mandible (retrognathia)

Degree of mouth opening (favourable if inter-incisor distance > 3cm)

Teeth (and dentition - any loose)

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11
Q

What is the advice on food pre-operatively?

A

Stop eating - 6 hours before

Stop dairy products (including tea and coffee) - 6 hous before

Stop clear fluids - 2 hours before

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12
Q

Why do patients need to fast before surgery?

A

To prevent pulmonary aspiration causing aspiration pneumonitis (inflammation due to acidic gastric contents) and aspiration pneumonia (due to secondary infection following pneumonitis)

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13
Q

Which drugs should be stopped before surgery and when?

A

CHOW

Clopidogrel - 7 days (due to bleeding risk, aspirin and other anti-platelets can be continued)

Hypoglycaemics

Oral contraceptive pill or HRT - 4 weeks before surgery due to DVT risk

Warfarin - 5 days prior (due to bleeding risk - swapped to LMWH)

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14
Q

In reference to warfarin what INR is required for surgery to go ahead?

A

INR <1.5 - may have to reverse warfarinisation with PO vitamin K

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15
Q

Which drugs to alter prior to surgery?

A

Subcutaneous insulin - switched to IV variable rate insulin

Long term steroids - Orally to IV (conversion 5mg PO prednisolone = 20mg IV hydrocortisone)

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16
Q

Why is steroid prescribing important in surgery?

A

The stress response will normally activate HPA axis however this has been suppressed in patients on steroid therapy (confirmed through short synacthen testing)

Thus stress dose corticosteroid therapy must be given

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17
Q

Which drugs should be started prior to operations?

A

LMWH - after VTE risk assessment and appropriate prescription (exception in neck / endocrine surgery)

TED stockings - exception of vascular surgery patients (contraindicated in peripheral vascular disease, peripheral neuropathy, recent skin graft, severe eczema

Antibiotic prophylaxis - in orthopaedic, vascular, GI surgery

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18
Q

What is the pre-op management of patients with T1DM?

A

First on the morning list

Night before = reduce subcut basal insulin dose by 1/3

Morning of = omit insulin, start IV variable rate insulin infusion pump (usually actrapid)

Whilst nil-by mouth = infusion 5% dextrose (usually at 125mL/hr - check capillary glucose every 2 hours and alter insulin accordingly)

After operation = continue until patient eating and drinking - then overlap IV variable rate insulin infucion and normal SC insulin

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19
Q

What is the peri-op care of patients with T2DM?

A

If diet controlled = no action

Oral hypoglycaemics = metformin stopped on morning of surgery (all others stopped 24 hours before operation)

Started on IV variable rate insulin infusion along with 5% dextrose as in T1DM - post-op management same as T1DM

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20
Q

When is bowel prep needed in surgery?

A

Upper GI, HPB, small bowel = none needed

Right hemi-colectomy or extended right hemi-colectomy = none

Left hemi-colectomy, sigmoid colectomy or abdominal-perineal resection = phosphate enema on morning of surgery

Anterior resection = 2 sachets of picolax the say before / phosphate enema on the morning of

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21
Q

What amount of total body weight is water?

A

2/3rd (2/3rd is intracellular and 1/3rd is extracellular)

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22
Q

If the aim of fluids is resuscitation where is it important that the fluids stay?

A

Intravascular space

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23
Q

What are losses of fluid from non-urine sources?

A

Insensible loss

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24
Q

What to look for on assessment for dehydration?

A
  • Dry mucous membranes and reduced skin turgor
  • Decreasing urine output (target > 0.5ml/kg/hr)
  • Orthostatic hypotension
  • Increased cap refill
  • Tachycardia
  • Low blood pressure
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25
Q

What to look for on assessment of fluid overload?

A

Raised JVP

Peripheral / sacral oedema

Pulmonary oedema

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26
Q

How to monitor fluid status?

A

Fluid input-output chart

Daily weight chart

U&Es (for evidence of dehydration, renak hypoperfusion or electrolyte abnormalities)

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27
Q

What are the daily requirements of water, sodium, potassium and glucose?

A

Water: 25 mL/kg/day

Na+: 1.0 mmol/kg/day

K+: 1.0 mmol/kg/day

Glucose: 50g/day

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28
Q

What are the two types of IV fluids?

A

Crystalloids e.g. 0.9% saline, 5% dextrose, Hartmann’s solution (cheaper than colloids)

Colloids e.g. gelatin

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29
Q

How to correct a fluid deficit?

A

If reduced urine output (<0.5ml/kg/hr) managed with a fluid challenge (either 250ml or 500ml over 15-30mins)

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30
Q

What are the two important blood groups?

A

ABO blood system

Group D of rhesus system

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31
Q

What percent of the population has rhesus D surface antigens?

A

85%

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32
Q

What is the ABO group?

A

Presence of A and / or B antigens on the surface of RBCs

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33
Q

Which blood is the universal donor?

A

O-ve (no AB or rhesus antigens on donor RBC surface(

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34
Q

Which blood is the unversal acceptor?

A

AB +ve (no A, B or Rhesus antibodies in circulation)

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35
Q

When should CMV-negative blood products be given?

A

Can cause congenital infection so should be given:

  • During pregnancy
  • Intra-uterine transfusions
  • Neonates (up to 28 days)
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36
Q

Why are irradiated blood products given?

A

Reduce risk of graft-versus-host-disease

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37
Q

Who should receive irradiated blood?

A
  • If blood from first or second degree family members
  • Patients with Hodgkin’s Lymphoma
  • Recent haematopoietic stem cell transplants
  • After anti-thymocyte globulin (ATG) or Alemtuzumab therapy
  • Those receiving purine analogues (e.g. fludarabine) as chemo
  • Inter-uterine transfusions
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38
Q

What are the obsevation timings of blood transfusions?

A

Before

12-20 mins after started

1 hour

At completion

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39
Q

Why should blood products be given through a green (18g) or grey (16g) cannula?

A

Cells haemolyse due to sheering forces in narrow tube

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40
Q

How is a blood giving set different from a normal fluid giving set?

A

Contains a filter in the chamber

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41
Q

What are the different types of blood products?

A

Packed red cells (RBCs)

Platelets

Fresh frozen plasma (clotting factors)

Cryoprecipitate (fibrinogen, vWF, Factor VIII, fibronectin)

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42
Q

When are packed red cells given? Over how long?

A

Acute blood loss, chronic anaemia (Hb <70g/L or <100 in CVD), symptomatic anaemia

Must be completed within 4 hours

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43
Q

How much should 1 unit of blood increase a patient’s Hb by?

A

10g/L

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44
Q

Why do you need a new G&S for future transfusions?

A

May produce autoantibodies to donor surface antigens (new if longer than 3 days of most recent transfusion)

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45
Q

When are platelets given and over how long?

A

Haemorrhagic shock in a trauma patient

Profound thrombocytopaenia (normal range 150-400)

30 minutes

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46
Q

When is fresh frozen plasma (FFP) given?

A

Disseminated intravascular coagulation (DIC)

Haemorrhage secondary to liver disease

Over 30 minutes

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47
Q

When is cryoprecipitate given? Over how long?

A

DIC with fibrinogen

von Willebrands disease

Massive haemorrhage

Stat

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48
Q

What are malnourished patients at increased risk of?

A

Reduced wound healing

Increased infection rates

Skin breakdown

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49
Q

What screening tool can be used for malnutrition?

A

Malnutrition universal screening tool

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50
Q

Which features suggest disease-related cachexia?

A

Muscle wasting

Loose skin

Patient’s clothes no longer fitting

Aphthous ulcers

Angular cheilitis

Pressure sores

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51
Q

What is the hierarchy of feeding?

A

Oral nutritional supplements (ONS)

Nasogastric tube feeding (NGT)

Gastrostomy feeding (PEG/RIG)

Jejunal feeding (jejunostomy)

Parenteral nutrition

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52
Q

What does a low serum albumin indicate?

A

Chronic inflammation, proteinuria, hepatic dysfunction (not malnutrition)

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53
Q

What are the aspects of enhanced recovery after surgery?

A

Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)

Pre-op carb loading

Minimally invasive surgery

Minimising the use of drains and NG tubes

Reintroduction of feeding post-operatively

Early mobilisation

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54
Q

When can GI surgery patients have an enteral diet?

A

Within 24 hours of uncomplicated GI surgery

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55
Q

How should feeding be managed where there is an entero-cutaneous fistula?

A

High fistula (jejunal) = support with enteral or parenteral nutrition

Low fistulae (ileum / colon) = low fibre diet

Proportion of ECF that will heal spontaneously with PN is relatively small (presence of faeculaent material emanating from ECF = not an indication for parenteral nutrition)

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56
Q

How can a reduction in stoma output be achieved?

A
  • Reduction in hypotonic fluids to 500ml / day
  • Reduction in gut motility with lopermide / codeine phosphate
  • Reduction in secretions with high dose PPI (twice a day dose)
  • Low fibre diet to reduce intraluminal retention of water
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57
Q

What are the three aspects of the ERAS protocol?

A

Pre-op

Intra-op

Post-op

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58
Q

What is in the pre-op ERAS protocol?

A

Patient education on surgery and post-op course

Exercise and weightloss before the surgery

Optimise medical management - smoking and alcohol cessation

Pre op fasting (along with 12.5% carb beverage within 2 hours of surgery)

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59
Q

What forms part of the intra-operative ERAS protocol?

A

Multimodal and opioid sparing alagesia (including regional anaesthesia - avoid benzos in enderly)

Multimodal post-op N&V prophylaxis

Minimally invasive surgery

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60
Q

What forms the post-op care in ERAS?

A

Adequate pain control to allow for early ambulation

Early oral intake

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61
Q

What are the advantages of day case surgery?

A

Shorter inpatient stays

Lower infection rates

Reduced waiting lists

Cheaper than overnight stay

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62
Q

How to prepare for a day case?

A

Not to eat / drink for 6 hours prior to surgery

Most medications can continue until day of operation with care over anti-coagulants / anti-platelets in operations where bleeding is a risk

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63
Q

What is the criteria for day case surgery?

A

Minimal blood loss expected

Short operating time (<1 hour)

No expected complications

No specialist aftercare needed

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64
Q

Give some examples of day case surgeries?

A

Inguinal hernias

Varicose veins

Cataract

Extraction of wisdom tooth

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65
Q

What are the different classifications of haemorrhage in the surgical patient?

A

Primary bleeding - during intra-operative period, resolved during operation, recorded in op notes

Reactive bleeding - within 24 hours of operation, usually from ligature that slips / missed vessel (due to hypotension)

Secondary bleeding - 7-10 days post-op (erosion of a vessel from a spreading infection)

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66
Q

What are the clinical features of haemorrhagic shock?

A

Raised RR

Tachycardia

Dizziness

Agitation

Visible bleeding

Decreased urine output

Hypotension (often late sign)

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67
Q

What is the management of post-operative bleeding?

A

A to E approach

Adequate IV access (18G cannula) and rapid resuscitation

Read op notes (location of wounds, drains)

Direct pressure to bleeding site

Urgent senior surgical review

Urgent blood transfusion (moderate to severe post-op haemorrhage)

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68
Q

Why is bleeding post thyroidectomy or parathyroidectomy so dangerous?

A

Causes airway obstruction as the pretracheal fascia of neck will only distend so far

Compression on venous return = venous congestion = laryngeal oedema = asphyxiation

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69
Q

Which vessel is vulnerable from laparoscopic ports?

A

Inferior epigastric artery (arising from external iliac artery) runs up abdominal wall, vertically in mid clavicular line

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70
Q

Which vessel is vulnerable in angio-graphy?

A

External iliac artery (goes into retroperitoneum)

Apply pressure to site (resus patient)

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71
Q

Which criteria are needed for a diagnosis of sepsis?

A

Presence of a known / suspected infection

Features of organ dysfunction

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72
Q

What is the qSOFA score?

A

Shortened version of SOFA critera - allowing for rapid assessment of potential sepsis based purely on clinical signs

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73
Q

What forms part of the qSOFA criteria?

A

Resp rate > 22 / min

Altered mental state

Systolic blood pressure <100

(if >= 2 then treat as sepsis)

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74
Q

What is the sepsis 6?

A

Oxygen (15L O2 via non-rebreath mask, target sats of 94-98% or 88-92% in chronic retainers) titrate once appropriately saturated

IV fluid therapy (500-1000ml inital fluid bolus)

Blood cultures (prior to administering abx)

IV abx (empirical - based on local guidelines)

Routine bloods inc lactate (FBC, U&Es, LFTs, clitting, CRP, glucose, lactate from blood gas)

Monitor urine output (aim for >0.5mL/kg/hour)

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75
Q

What further management is there for septic patients?

A

Hourly observations from nursing staff

Assessment by intensive care teams

Vasopressor agents (e.g. noradrenaline)

Renal replacement therapy

Ventilator support

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76
Q

What investigations for source identification in sepsis?

A

Urine dip +/- culture

CXR

Swabs (e.g. surgical wounds)

Operative site assessment (via CT or US)

CSF sample (via LP)

Stool culture

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77
Q

When should clinical outreach teams be involved in the care of a septic patient?

A

Evidence of septic shock

Lactate > 4.0mmol

Failure to improve from initial management

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78
Q

What are the 7 sources of pyrexia in a surgical patient?

A

Chest (infection)

Cut (infection)

Catheter (UTI)

Collections (abdo, pelvic etc)

Calves (DVT)

Cannula (infection)

Central line (infection)

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79
Q

What is septic shock?

A

Sepsis with hypotension despite adequate fluid resuscitation

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80
Q

What is the management of septic shock?

A

Aggressive fluid resus and abx therapy

Inotropes used to maintain organ perfusion

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81
Q

How to objectively assess pain?

A

Tachycardia

Tachypnoea

Hypertension

Sweating

Flushing

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82
Q

What are the consequences of poor pain control?

A

Slower recovery dur to:

  • Reluctance to mobilise
  • Not breathing as deeply (causing atelectasis)
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83
Q

What are the steps of the WHO pain ladder?

A

Simple analgesics (paracetamol or NSAIDs)

Weak opiates (codeine or tramadol)

Stronger opiates (morphine, oxycodone, fentanyl)

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84
Q

How do NSAIDs work?

A

Inhibit synthesis of prostaglandins (inhibit inflammatory response causing the pain)

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85
Q

What re the side effects of NSAIDs?

A

I-GRAB

Interactions with other medications e.g. warfarin

Gastric ulceration (consider adding PPI when prescribing NSAIDs long term)

Renal impairment (use NSAIDs sparingly here)

Asthma sensitivity (triggers 10% of thos with asthma)

Bleeding risk (due to effect on platelets)

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86
Q

How do opioids work?

What are their side effects?

A

Activate opioid receptors (in CNS)

Constipation

Nausea

Laxitives and anti-emetics often prescribed concurrently

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87
Q

What are the other side effects of opioids?

A

Sedation

Confusion

Respiratory depression

Pruritus

Tolerance

Dependence

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88
Q

What are some prescribing tips for opioids?

A

Concurrent regular paracetamol

Avoid weak and stron opiates in combination (competitively inhibit same receptor to varying degrees)

If renally impaired then consider oxycodone / fentanyl rather than morphine

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89
Q

What are the advantages of patient controlled analgesia?

A

Analgesia tailored to requirements

Safe - risk of overdose is negligible

Accurately record how much administered - converted to regular dose

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90
Q

What are the disadvantages of PCA?

A

Cumbersome / prevent mobilisation

Not appropriate for poor manual dexterity / LDs

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91
Q

What are the various treatments for neuropathic pain?

A

Non-pharmacological = CBT, transcutaneous electric nerve stimulation

Pharmacological = gabapentin, amitriptyline, or pregabalin

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92
Q

What are the patient risk factors for PONV?

A

Female

Younger age

Previous PONV / motion sickness

Use of opioid analgesics

Non-smoker

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93
Q

What are the surgical risk factors for PONV?

A

Intra-abdo laparoscopic surgery

Intracranial / middle ear surgery

Squint surgery

Gynae surgery (especially ovarian)

Prolonged op times

Poor pain control post op

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94
Q

What are the anaesthetic risk factors for PONV?

A

Opiate analgesia / spinal anaesthesia

Inhalational agents (e.g. isoflurane / nitrous oxide)

Prolonged anaesthetic time

Intra op dehydration

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95
Q

What are the two areas of the brain which play a role in control of vomiting?

A

Vomiting centre - in the lateral reticular formation of medulla oblongata (controle and coordinates movements in vomiting)

Chemoreceptor trigger zone - inferoposterior aspect of 4th ventricle - outside BBB, thus responds to stimuli in circulation

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96
Q

Where does the vomiting centre receive input from?

A

CTZ

GI tract

Vestibular system

Higher cortical structures (sight, smell, pain)

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97
Q

Which neurotransmitters act at:

  • CTZ
  • Vestibular apparatus
  • GI tract
  • Vomiting centre
A
  • CTZ: dopamine and 5HT3 receptors
  • Vestibular apparatus: acetylcholine and histamine
  • GI tract: dopamine receptors
  • Vomiting centre: histamine and 5HT3 receptors
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98
Q

What are some other causes of PONV?

A

Infection

GI causes (post op ileus, bowel obstruction)

Metabolic causes (hypercalcaemia, uraemia, DKA)

Medications (abx, opioids)

CNS causes (raised ICP)

Psychiatrica causes (anxiety)

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99
Q

What are some prophylactic measures against PONV?

A

Anaesthetic measures - reduce opiates, reduce volatile gases, avoid spinal anaesthetics

Prophylactic antiemetic therapy

Dexamethasone at induction of anaesthesia (esp. follwing small and large bowel surgery)

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100
Q

What are some conservative measures againsts PONV?

A

Adequate fluid hydration

Adequate analgesia

Ensure no obstructive cause

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101
Q

What should patients with impaired gastric emptying be given?

A

Prokinetic agent: metoclopramide, domperidone (dopamine antagonists)

Anti-muscarinic: Hyoscine - reduces recretions and N&V

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102
Q

What should patients with metabolic / biochemical imbalance causing PONV be given?

A

Metoclopramide (for uraemia, electrolyte imbalance or cytotoxic agents)

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103
Q

What should patients with opioid induced N&V be given?

A

Ondansetron (5-HT3 receptor antagonist)

Cyclizine (H1 Histamine receptor antagonist)

104
Q

What is pyrexia?

A

Raised body temperature (greater than 37.5)

105
Q

What may be an infective cause of pyrexia on the following days after surgery:

Day 1-2

Day 3-5

Day 5-7

Any day

A

Day 1-2: respiratory

Day 3-5: UTI

Day 5-7: surgical site infection

Any day: infected IV lines or central lines

106
Q

What are some other causes of pyrexia following surgery?

A

Iatrogenic: drug induced reaction (e.g. abx or anaesthetic agents) from a transfusion reaction

VTE (can cause low grade fever)

Secondary to prosthetic implantation - e.g. after AAA repair

Pyrexia of unknown origin

107
Q

What is pyrexia of unknown origin?

A

Recurrent fever (>38) persisting for 3 weeks or more without obvious cause despite 1 week inpatient investigations

108
Q

What are some causes of PUO?

A

Infection of unknown source

Malignancy (B-symptoms from lymphoma)

Connective tissue disease

Vasculitis

Drug reactions

109
Q

What to ask for in the history of pyrexia post surgery?

A

Ask about systems symptoms:

  • Urinary frequency, urgency, dysuria
  • Productive cough, dyspnoea, haemoptysis
  • Chest / calf pain
  • Wound / IV line tenderness / discharge
110
Q

What to look for on examination of patient with post-op pyrexia?

A

Pulmonary infection

IV line infection

Wound infection

Calf tenderness

Signs of peritonism (e.g. for anastomotic leak)

111
Q

What investigations to do for post-op pyrexia?

A

Blood tests - FBC, CRP, U&Es

Urine dipstick

Cultures - blood, urine, sputum, wound swab

Imaging - CXR

CT for anastomotic leak

Doppler US for DVT

112
Q

What is the management of a patient with post-op pyrexia?

A

A to E if unwell and needs resuscitation

If infection identified then start empirical abx

If no infection identified then don’t start abx - first look for non-infectious causes

113
Q

What are some example empirical abx for the following infections:

LRTI

Lower urinary tract infection

Upper urinary tract infection

Surgical site / cellulitis

IV line

Intra-abdominal

Septic arthritis

Unknown

A

LRTI = Co-amoxiclav

Lower urinary tract infection = Trimethoprim

Upper urinary tract infection = Co-amoxiclav

Surgical site / cellulitis = flucloxacillin

IV line = flucloxacillin (vancomycin but levels need close monitoring)

Intra-abdominal = cefuroxime

Septic arthritis = flucloxacillin

Unknown = Cefuroxime + metronidazole + gentamycin

Unknown

114
Q

What is delerium?

A

Acute confusional state = disturbed consciousness and reduced cognitive function

115
Q

What are the three main types of delerium?

A

Hypoactive = lethargy and reduced motor activity

Hyperactive = agitation and increased motor activity

Mixed agitation = fluctuations throughout the day

116
Q

How is delerium differentiated from dementia?

A

Delerium has acute onset (as opposed to insidious) it fluctuates (not constant) attention is poor (not good) delusions are common, simple and fleeting (as opposed to stable)

117
Q

What are the risk factors for delirium?

A

Age > 65 years old

Multiple co-morbidities

Underlying dementia

Renal impairment

Male gender

Sensory impairment (hearing / visual)

118
Q

What are the common causes for delerium?

A

Hypoxia (post operatively)

Infection (UTI / LRTI)

Drug induced (benzos, diuretics, opioids, steroids)

Drug withdrawal (alcohol / BZN)

Dehydration / pain

Constipation / urinary retention

Electrolyte imbalance (e.g. hyponatraemia, hypernatraemia or hypercalcaemia)

119
Q

What to ask in the history of a patient with delerium?

A

Onset and course of confusion

Symptoms of underlying cause

Co-morbidies and previous baseline cognition

Previous episodes

Drug history (including alcohol intake)

120
Q

What questionnaires can be used to assess current cognitive function?

A

AMT

MMSE

Confusional assessment methods - CAM - further quantifies delerium

121
Q

What to look for on examination of a patient with delerium?

A

Review observations

Drug chart

Look for signs of infection / pain

Check for signs of constipation or urinary retention

122
Q

What examination to rule out stroke / subdural haematoma in post op delerium?

A

Neurological examination

123
Q

Give some example questions from the AMT?

A

Age

Time (to nearest hour)

Address (recall at end)

Year

Name of home addres

Current monarch

124
Q

Which investigations form part of the confusion screen?

A

Bloods - FBC, U&Es, Ca2+, TFTs and glucose

B12 and folate can be additionally requested

Blood cultures and / or wound stabs

Urinalysis and / or CXR

CT head (only if relevant)

125
Q

What is the management of post-op delerium?

A

Treat underlying cause (e.g. abx for infection, oxygen if hypoxic, laxatives for constipation)

Nursed in quiet area, regular routines, clocks

Encourage oral fluid intake and analgesia as necessary

126
Q

Which sedatives can be used for patients with delerium?

A

Haloperidol (used sparingly)

Lorazepam may be needed, especially in elderly

127
Q

What is atelectasis?

A

Partial collape of the small airways (majority of post-op patients develop)

128
Q

Why does atelectasis occur?

A

Combination of airway compression, alevolar gas resporption, decreased production of surfactant

129
Q

When does atectasis usually occur post operatively?

A

Within 24 hours

130
Q

What are the risk factors for atelctasis?

A

Age

Smoking

Use of general anaesthesia

Duration of surgery

Preexisting lung / neurological disease

Prolonged bed rest (limited position changes)

Poor post op pain control (shallow breathing)

131
Q

What are the clinical features of atelectasis?

A

Increased resp rate

Reduced oxygen sats

Fine cfackles over pulmonary tissue

Low grade fever

132
Q

How is atelectasis diagonsed?

A

Clinically

CXR can show small airway collapse

133
Q

What is the management of atelectasis?

A

Deep breathing exercises

Chest physio (to help with coughing)

Adequate pain control to help with deep breathing

If physio not adequate then bronchoscopy (to suction out pulmonary secretions)

134
Q

What is pneumonia?

A

LRTI with consolidation visible on CXR

135
Q

What are the four main types of pneumonia?

A

Community acquired pneumonia (CAP)

Hospital acquired pneumonia (HAP)

Aspiration penumonia

Immunocompromised pneumonia

136
Q

Which is the most common post op pneumonia?

A

Hospital acquired

137
Q

What is HAP?

A

Pneumonia with onset >48 hours since admission and not present on admission

138
Q

Why are surgical patients at a greater risk of pneumonia?

A

Reduced chest ventilation (reduced mobility = not able to fully ventilate causing secretions which become infected)

Change in commensals (microflora in invironment)

Debilitation (sick after surgery = compromised immune systems)

Intubation

139
Q

Which bacteria commonly causes HAP?

A

E. Coli

S. aureus (including MRSA)

S. pneumoniae

Pseudomonas

140
Q

Who is most at risk of ventilator associated pneumonia?

A

Endotracheal tube in-situ

141
Q

What are the risk factors for developing hospital acquired pneumonia?

A

Age

Smoking (current / previous)

Known respiratory disease or recent viral illness

Poor mobility (baseline / post op)

Mechanical ventilation

Immunosuppression

Co-morbidities e.g. diabetes or cardiac disease

142
Q

How do patients with HAP present?

A

Cough (productive / non)

Dyspnoea

Chest pain

(May not be obvious - only malaise, pyrexia or impaired cognition may present)

143
Q

How do patients with pneumonia present?

A

Bronchial breath sounds (localised or diffuse)

Inspiratory crackles (on auscultation)

Dull percussion note

144
Q

What are some differentials as opposed to post-op HAP?

A

Acute heart failure

Acute coronary syndrome

PE

Asthma

COPD exacerbation

PE

Empyema

145
Q

Which lab tests are ordered for suspected post-op HAP?

A

Routine bloods (FBC, CRP, U&Es for inflammation raised WCC and CRP)

Arterial blood gas (showing type 1/2 resp failure)

Sputum sample for culture

If signs of severe infection then blood cultures

146
Q

Which imaging for CAP?

A

CXR (for consolidation)

Bronchoalveolar lavage (if sputum sample unobtainable / non-responsive infections)

147
Q

How can the severity of community-acquired pneumonia be assessed?

A

CURB-65 score (0-1 = mild, 2 = moderate, 3= severe)

148
Q

What are each given a point in CURB-65?

A

Confusion

Urea >7.0mmol

RR >30

Systolic bp < 90 or diastolic <60

Age > 65

149
Q

What is the management of HAP?

A

O2 therapy as indicated

Empirical antibiotics if confirmed pneumonia

150
Q

Which empirical abx could be used to treat mild-moderate or severe HAP?

A

Mild/moderate = Co-amoxiclav

Severe = Tazocin

151
Q

How best to prevent post-op HAP?

A

Chest physio post op

152
Q

What are the complications of pneumonia?

A

Pleural effusion

Empyema

Resp failure

Sepsis

153
Q

Which areas of the lungs will aspirated contents affect?

A

Right middle OR lower lobes

154
Q

What are the main risk factors for aspiration in surgical patients?

A

Reduced GCS (secondary to anaesthesia)

Iatrogenic intervention (e.g. misplaced NG tube)

Prolonged vomiting without NG tube indertion

Underlying neurological disease

Oesophageal strictures or fistulas

Post abdo-surgery

155
Q

How is aspiration pneumonia prevented?

A

NG tube if at risk

156
Q

What is the management of pneumonitis vs aspiration pneumonia?

A

Pneumonitis = supportive

Aspiration = antibiotic therapy (similar to HAP - suction is rarely performed)

157
Q

What does the term VTE refer to?

A

Deep vein thrombosis (DVT)

Pulmonary embolism (PE)

158
Q

When should surgical patients be assessed for VTE?

A

Admission

After 24 hours

159
Q

When may a thrombus form?

A

If Virchow’s triad is present

160
Q

What is Virchow’s triad?

A

Abnormal blood flow (immobility e.g. bed-bound)

Abnormal contents (smoking, sepsis, malignancy, inherited blood disorders e.g. Factor V Leiden)

Abnormal vessel wall (atheroma or direct trauma)

161
Q

What are the risk factors for a VTE?

A

Increasing age

Previous VTE

Smoking

Pregnancy (or recently post partum)

Recent surgery (abdo, pelvic, hip / knee)

Prolonged immobility (>3 days)

HRT / COCP

Active malignancy

Obesity

Thrombophilia disorder (e.g. antiphospholipis syndrome / Factor V Leidin)

162
Q

What is a DVT?

A

Blood clot in deep veins of a limb

163
Q

What are the features of a DVT?

A

Unilateral leg pain

Swelling

Low-grade pyrexia

Pitting oedema

Tenderness

Prominent superficial veins

65% asymptomatic

164
Q

What well’s score indicates a DVT?

A

0/1 = unlikely, D-dimer to exclude

> 1 = Likely, confirmed with USS (common) or contrast venography

165
Q

Is a d-dimer test sensitive / specific?

A

Sensitive but not specific

166
Q

What may cause a raised D-dimer test?

A

Recent surgery

Ongoing infection

Liver disease

Pregnancy

167
Q

What is first line treatment for DVT? Give some examples

A

DOACs (direct oral anticoagulants) e.g. apixaban, rivaroxaban, edoxaban (direct factor Xa inhibitors)

168
Q

Which DOACs require initial treatment with LMWH before commencement?

A

Dabigatran

Edoxaban

(Rivaroxaban and apixaban do not)

169
Q

What is used to treat cancer-associated VTE?

A

LMWH alone

170
Q

How long should anticoagulation be continued for after DVT?

A

3 months (provoked DVT)

Lifelong (persistent risk factor / high risk of recurrence)

171
Q

What are the causes of a DVT?

A

DVT

Right sided mural thrombus (e.g. post MI)

Atrial fibrillation

Neoplastic cells

From fat cells (e.g. following tibial fracture)

172
Q

What are the features of pulmonary embolism?

A

Sudden onset dyspnoea

Pleuritic chest pain

Cough

Haemoptysis (rarely)

173
Q

What may be found on examination of a patient with a PE?

A

Tachycardia

Tachypnoea

Pyrexia

Raised JVP (rare)

Pleural rub

Pleural effusion

Signs of DVT

174
Q

What wells score excludes a DVT (what to order to confirm)?

A

Less than or equal to 4 order d-dimer to confirm

175
Q

What if a well’s score is greater than 4?

A

Confirm diagnosis with CT pulmonary angiogram

176
Q

Is a D-dimer test sensitive / specific?

When else can d-dimers be raised?

A

Sensitive but not specific

Ongoing infection / inflammation

Concurrent liver disease

Pregnancy

177
Q

How may a pulmonary embolism appear on an ECG?

A

Right bundle branch block, right ventricular strain

Inverted T waves in V1-V4 strain or rareS1Q3T3 (deep S wave in Lead I, pathological Q wave in lead III, and inverted T wave in lead III)

178
Q

What is the management of:

Haemodynamically stable PEs

PEs causing haemodynamic compromise

Recurrent PEs

A

Haemodynamically stable PEs = same as DVTs

PEs causing haemodynamic compromise = thrombolysis

Recurrent PEs (secondary to DVTs) = IVC filter

179
Q

What options are there for mechanical thromboprophylaxis?

A

Antiembolic stockings (AES)

Intermittent pneumatic compression (IPC)

180
Q

When should mechanical prophylaxis not be offered?

A

Peripheral aterial disease

Peripheral oedema

Local skin conditions

181
Q

What is used for pharmacological thromboprophylaxis?

A

LMWH (unless poor renal function eGFR < 30 then UFH)

182
Q

What is acute respiratory distress syndrome?

A

Acute lung injury - severe hypoxaemia in absence of cardiogenic cause

183
Q

How does ARDS occur?

A

Inflammatory damage to the alveoli causing pulmonary oedema, respiratory compromise and acute respiratory failure

184
Q

What are the 4 points of acute respiratory distress syndrome?

A

Acute onset (within 4 day)

Bilateral infiltrates on CXR

Alveolar oedema not explained by fluid overload or cardiogenic cause

185
Q

What are the direct and indirect causes of ARDS?

A

Direct = pneumonia, smoke inhalation, aspiration, fat embolus

Indirect = sepsis, acute pancreatitis, polytrauma, major burns

186
Q

What are the three phases of ARDS?

A

Exudative = initial injury causes cytokines and inflammatory mediators causing direct alveolar and endothelial injury

Proliferative = restoration of alveolar-capillary membrane integrity by fibroblasts and type-2 pneumocytes, new surfactant is also produced

Fibrotic = extensive fibrin deposition across lungs causing scarring and long term morbidity

187
Q

What are the clinical features of ARDS?

A

Worsening dyspnoea (presence of related risk factor)

Hypoxia

Tachypnoea

Inspiratory crackles

Acute onset (< 7 days)

188
Q

What are the differentials to ARDS?

A

Congestive heart failure

Interstitial lung disease

Diffuse alveolar haemorrhage

Drug induced lung injury

189
Q

What are the investigations for suspected ARDS?

A

ABG (for hypoxia)

Routine bloods (FBC, U&Es, amylast, CRP)

CXR (diffuse bilateral infiltrates)

Echo (exclude cardiogenic causes)

190
Q

What imaging is alternative to CXR for ARDS?

A

CT thorax scan

191
Q

What is the management of ARDS?

A

Supportive with ventilation

Focused treatment of underlying cause (early intubation and ITU admission for respiratory and circulatory support)

192
Q

What are the aims of ventilation in ARDS?

A

Maintaining minimum intravascular volume to ensure tissue perfusion (limiting excess oedema)

Lower tidal volumes (reducing shear forces from over-distension)

Positive end-expiratory pressure

193
Q

Is pharma treatment useful in ARDS?

A

Previously used artificial surfactant and corticosteroids less used now (surfactant still used in neonatal ARDS) corticosteroids may reduce ventilation days when used 7-14 days after onset

194
Q

What are the key prognostic factors for ARDS?

A

Increasing age

Co-morbidities

Active malignancy

Liver disease

195
Q

What is an anastomotic leak?

A

Leak of luminal contents from a surgical joint

196
Q

What are the patient and surgical factors which increase the risk of an anastomotic leak?

A

Patient = corticosteroids, smoking, alcohol excess, diabetes, obesity

Surgery = emergency surgery, longer intra-op time, oesophageal-gastric or rectal anastomosis

197
Q

What are the clinical features of an anastomotic leak?

A

Abdo pain

Fever (5-7 days post op)

Delerium

Prolonged ileus

198
Q

Examination findings for anastomotic leak?

A

Pyrexia

Tachycardia

Signs of peritonism

199
Q

What are the investigations of an anastomotic leak?

A

CT scan with contrast of abdo-pelvis (definitive investigation)

FBC

CRP

U&Es

LFTs

Clotting screen

Venous blood gas (to assess tissue perfusion)

G&S for possible surgery

200
Q

What is the inital and definitive management of an anastomotic leak?

A

Initial = nil by mouth, broad spectrum abx, IV fluid therapy, insert urinary catheter (monitoring fluid balance)

Definitive

Minor leak (collection < 5cm) = IV abx

Large = drained percutaneously / surgical intervention

Septic = exploratory laparotomy (wash outs, drain insertion)

201
Q

What type of bowel obstruction is post-op ileus?

A

Functional

202
Q

What are the patient and surgical risk factors for post-op ileus?

A

Patient = increased age, electrolyte derangement (Na, K Ca), neurological disorder, anti-cholinergic medication

Surgical = opioid medication, pelvic surgery, extensive intra-operative intestinal handling, peritoneal contamination, intestinal resection

203
Q

What are the features of post-op ileus?

A

Failure to pass flatus / faeces

Bloating and distension

N&V

Absent bowel sounds (if mechanical then ‘tinkling’ heard)

204
Q

What are the investigations for post-op ileus?

A

Initial routine bloods (FBC, CRP, U&Es - fluid shifts in adynamic bowel causing AKI)

Electrolytes (calcium, potassium, magnesium)

CT abdo pelvis (with contrast) to confirm diagnosis

205
Q

What is the management of post-op ileus?

A

Once anastomotic leak excluded then conservative management:

  • NBM
  • IV fluids
  • Daily bloods (correct abnormalities and monitor for AKI)
  • Encourage mobilisation
  • Reduce opiate analgesia

Once it does settle = watery stool for first 2-3 bowel movements

206
Q

What are the preventative steps for post-op ileus?

A

Minimise intra-op intestinal handling

Avoid fluid overload

Minimise opiate use

Encourage early mobilisation

207
Q

What are adhesions, and when can they occur?

A

Fibrous bands of scar tissue

Secondary to previous surgery or intra-abdominal inflammation (pelvic) also congenital

208
Q

How do adhesions present?

A

Infertility

Chronic pelvic pain

209
Q

How should bowel adhesions be investigated and managed?

A

Bowel obstruction = tube decompression, NBM, IV fluids, analgesia

Surgical management (for features of ischaemia, perforation or failed conservative management) = adhesiolysis (only for adhesions causing mechanical obstruction / strangulation) laparoscopically or opwn

210
Q

How can adhesions be prevented?

A

Correct surgical technique

Reducing intraperitoneal organ handling

211
Q

What are the risk factors for incisional hernias?

A

Emergency surgery

BMI > 25

Midline incision

Wound infection

Pre-op chemo

Pregnancy

Advancing age

212
Q

What complications can occur with hernias?

A

Incarceration (irreducible)

Strangulation (blood supply compromised)

Bowel obstruction

213
Q

What are the features of an incisional hernia?

A

Non-pulsatile

Reducible

Soft

Non-tender swelling

214
Q

How may an incarcerated hernia present? And with obstruction

A

Painful

Tender

Erythematous

Obstruction = distension, vomiting, constipation

215
Q

What else may cause an abdo lump?

A

Lipoma

216
Q

What investigation for incisonal hernia?

A

Clinical diagnosis

US / CT = diagnosis unclear

217
Q

What is the management of an incisional hernia?

A

Surgery for painful hernias (suture repair, laparoscopic mesh repair, open mesh repair)

218
Q

What are the complications of incisional hernia repair?

A

Pain

Bowel injury

Seroma formation

219
Q

What is the prognosis of incisional hernias?

A

If no surgery then asymptomatic / incarcerate / strangulate

If surgery then possible chronic pain

220
Q

What is post-op constipation defined as?

A

Infrequent bowel movements (<3 per week) with hard, dry stools

221
Q

What are the main causes of constipation on surgical wards?

A

Physiological - low fibre diet, poor fluid intake, low physical activity

Iatrogenic - opioid analgesia, anticonvulsants, iron supplements or antihistamines

Pathological - bowel obstruction, hypercalcaemia, hypothyroidism, neuromuscular disease

Functional - painful defecation (e.g. anal fissures)

222
Q

What are the features of constipation?

A

Lower abdo pain

Abdo distension

N&V

Decreased appetite

223
Q

What examination for constipation?

A

DRE

224
Q

What bloods may be requested for constipation?

A

TFTs

Serum calcium

225
Q

Is imaging required for constipation?

A

Generally no, unless obstruction suspected (Abdo XR, CT scan, endoscopy)

226
Q

What is the management of post-op constipation?

A

Conservative = hydration, sufficient dietary fibre, early mobilisation

Pharma = osmotic laxative (increase fluid in bowel e.g. lactulose, movicol), stimulant laxative (e.g. senna, picosulphate), bulk forming (help stool retain watere.g. ispaghula husk), rectal medication (e.g. glycerin suppository OR phosphate enema both stimulants)

227
Q

What to give:

Patient with hard stool / chronic constipation =

Post-op ileus =

Resistant constipation =

A

Patient with hard stool / chronic constipation = movicol / lactulose (glycerine suppository to help initally)

Post-op ileus / opioid induced = senna / picosulphate

Resistant constipation = manual evacuation or enema

228
Q
A
229
Q

How can AKI be defined?

A

>50% rise in serum creatinine from baseline in last 7 days

Urine output <0.5mls/kg/hr for > 6 hours

230
Q

How can severity of AKI be decided?

A

Stage 1 = 1.5-1.9 times the baseline

Stage 2 = 2-2.9

Stage 3 = > 3 times baseline

231
Q

What are some pre-renal causes of AKI?

A

Sepsis

Dehydration (including pre-op NBM or bowel prep)

Haemorrhage

Intra-op (accidental graft occlusion, proximal aortic clamp for too long)

232
Q

What are some intra-renal causes of AKI?

A

Nepohrotoxins e.g. NSAIDs, ACEi, aminoglycosides, chemo

GN, rhabdomyolysis, HUS, multiple myeloma

233
Q

What are some post-renal causes of AKI?

A

Ureteric = bilateral renal stones, tumours

Bladder = acute urinary retention, blocked catheter

Urethral = prostatic enlargement (BPH or malignancy), renal stones

234
Q

What are the investigstions for AKI?

A

Examine patient

Bladder scan (retention)

Review drug chart (nephrotoxins)

Urine dip (specific gravity and osmolality will be higher in pre-renal causes but Na excretion will be lower, GN show blood and protein)

Bloods (U&Es, FBC, CRP, LFTs and Ca2+)

US scan - KUB (obstruction)

235
Q

What is the management of AKI?

A

Resus if critically unwell (especially if pre-renal)

Assess hydration status (look for signs of dehydration - dry mucous membranes, increased cap refil, reduced skin turgor, tachycardia)

Start fluid balance chart (consider catheterisation to accurately assess)

Regular blood tests to monitor serum creatinine

236
Q

Which drugs should be stopped or altered in AKI?

A

Stopped = NSAIDs, ACEi, ARB, aminoglycoside abx, potassium-sparing diuretics (due to increased risk of hyperkalaemia)

Altered / reduced = metformin (lactic acidosis), diuretics (intravascular-fluid depletion), LMWH

237
Q

What are the features of post-op urinary retention?

A

Little / no passed urine

Senation of needing to void without being able to micturate

Suprapubic mass - dull to percuss

238
Q

What are some common causes for post-op urinary retention?

A

Uncontrolled pain

Constipation

Infection

Anaesthetic agents

239
Q

What are some risk factors for post op-urinary retention?

A

Age > 50 y/o

Male gender

Previous retention

Pelvic / urological surgery

Neuro co-morbidities

Medications (e.g. anti-muscarinics, alpha agonists, opiates

240
Q

How to assess post op urinary retention?

A

Ultrasonic bladder scan (assesses post-void residual volume - should be negligible)

U&Es

Check for reversible causes (pain managed?)

241
Q

What is the management of post-op urinary retention?

A

Catheterisation

TWOC (if fail then reinserted and retried in 1-2 weeks)

242
Q

Which organisms commonly cause UTI?

A

E. Coli

Klebsiella sp.

Enterobacteur sp.

Proteus sp.

Pseudomonas sp.

Staphylococcus sp.

243
Q

What are the risk factors for post-op UTI?

A

Age > 60

Female

Co-morbidities e.g. renal failure, diabetes

Catheterisation

Pregnancy

Urinary retention

244
Q

What are the clinical features of UTI?

A

Urinary frequency

Urgency

Dysuria

Suprapubic pain

Pyrexial

(delerium, septic, pyelonephritis - loin pain)

245
Q

What are the investigations for post-op UTI?

A

Urine dip (might show sterile pyuria - isolated raised WCC due to STI, renal stones, half treated UTI)

Send mid-stream sample for MC&S (if nitrites / blood)

Bloods (FBC, CRP, U&Es, blood cultures, VBG) depending on clinical picture

Bladder scan if retention

If pyelonephritis suspected then US

246
Q

What is the management of post-op UTI?

A

Ensure well hydrated (PO / IV)

Abx (start empirical and change if poor response, replace catheter before starting if applicable)

247
Q

What are the risk factors for hypoglycaemia?

A

Diabetes mellitus

Post-gastrectomy

Alcohol excess

BBs (inhibit liver gluconeogenesis)

248
Q

What are the features of hypoglycaemia?

A

Sweating

Tingling lips

Tremor

Dizziness

Slurred speech

249
Q

What are the clinical signs of hypoglycaemia?

A

Pallor

Confusion

Tachycardia

Tachypnoea

Focal neurology

250
Q

What is gastric dumping syndrome?

How can it be managed?

A

Following gastric bypass surgery

10-30 mins post-prandial = sudden hypertonic gastric content in small intestine results in intraluminal fluid shift and intestinal distension (N&V, diarrhoea, hypovolaemia causing tachycardia and diaphoresis)

1-3 hours after = surge in insulin causes hypo

Managed with small volume and more frequent meals (avoiding simple carbs

251
Q

What are the investigations of hypoglycaemia?

A

BM measurement (serum blood glucose)

(have they been starved pre-op? do they have liver disease?)

252
Q

What is the management of hypoglycaemic patients?

A

A-E

If conscious = oral glucose (lucozade) and complex carbs (bread) and monitor BM every 1-2 hrs (if no improvement start IV 10% dextrose)

If unconscious = protect airway and give high flow O2, give IV glucose or IM glucagon

253
Q

What is the glucose monitoring intra-operatively for diabetic patients?

A

BM taken regularly every 30 mins (if <4 mmol at any point then IV glucose increased and insulin infusion stopped, recheck after 30 mins, if <2mmol then treat as hypoglycaemic emergency)

If major surgery then consider variable rate insulin infusion device (should be continued until pt is eating and drinking normally, if T1DM then continue for 30 min after normal SC insulin injections are given)

254
Q

What is hyperkalaemia?

A

Serum potassium > 5.5 mmol/L

255
Q

What are the causes of hyperkalaemia?

A

Post-op AKI

Repeated blood transfusions

Drugs (spironolactone, ACEi)

Excessive potassium treatment

256
Q

What are the investigations for hyperkalaemia?

A

Bloods (including U&Es, Ca2+ and PO42- and Mg2+)

VBG (for immediate result of patients potassium levels)

ECG

Catheterisation for fluid balance monitoring

257
Q

What are the ECG findings in hyperkalaemia?

A

Tall tented T waves

Small indiscernible P waves

Prolonged QRS (eventually merges with T wave)

Surgery (2 decks)

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