Care Of The Surgical Patient Flashcards
(52 cards)
1
Q
What is suspended in human plasma?
A
Human plasma (55%)
- RBCs (45%)
- Buffy coat (1%)
- WBCs
- Platelets
2
Q
Four blood transfusion components?
A
Whole blood donation
- RBCs
- Severe anaemia from trauma or surgery
- 42 days in fridge
- 10 years in freezer
- Fresh frozen plasma
- Coagulation deficiency correction
- Plasma loss from burns or bleeding
- 1 year in freezer
- Concentrate of platelets
- Low platelet levels or functional problems
- 5 days at room temperature
- Cryoprecipitate
- Fibrinogen deficiency
- 1 year in freezer
3
Q
Red cell transfusion
- Indication
- Dose
A
RBCs
- Increase O2
Replace blood loss - One unit for a 10g/L Hb increase in a 70kg patient
4
Q
Platelet Transfusion
- Indication
- Dose
A
Platelets
- Prophylaxis in thrombocytopenia
- One therapeutic dose can increase count by 20x10^9/L
5
Q
- FFP
- Indication and dose
- Cryoprecipitate
- Indication and dose
A
- Fresh Frozen Plasma (10-15ml/kg)
- Clotting factors
- Coagulation factor deficiencies
- DIC and massive haemorrhage
- Cryoprecipitate (10 units/ 2 pools for adult)
- Clinically significant bleeding
- Fibrinogen below 1.5g/l
- Fibrinogen and factor VIII
6
Q
Which blood types contain A and/or B antibodies?
A
A antibodies - B blood or O Blood
B antibodies - A blood or O blood
No antibodies - AB blood
7
Q
Pathophysiology of ABO never events
A
- Anti-A binds to A antigens or Anti-B to B antigens
- Agglutination
- Complement activation
- Cytokines, Haemolysis
- Shock, renal failure, DIC
8
Q
How many Rhesus Antigens?
A
- There are 5 Rh antigens (C,c,D,E,e)
- Rhesus D is most important.
- If antigen present, D positive.
9
Q
Alloantibodies significance
A
- Antibodies (not ABO) produced when exposed to different blood through transfusion or pregnancy
- Problem in multiple transfusions
- Amount/frequency dependant
- Immune response dependant
- Immunogenicity (of antigens) dependant
10
Q
Prevention of HDFN?
A
To prevent Haemolytic Disease of the Foetus and Newborn (HDFN)
- D negative or Kell negative girls and women should not be transfused with D or K positive red cells
11
Q
Examples of Alloantibodies
A
Alloantibodies
- Duffy
- Kell
- Kidd
- Lewis
- Lutharen
- MNS
- P
12
Q
Two ways of requesting blood
A
- Group and screen (checked including for antibodies)
2. Cross-match (can be electronic)
13
Q
What blood can be given in emergency, and what are the risks?
A
- O negative
2. May have unknown alloantibodies
14
Q
Points in transfusion process
A
- Decision to transfuse
- Request/prescreption
- Sampling
- Lab testing
- Collection from storage
- Administration
15
Q
Blood sampling for transfusion
- Good Practice (5 points)
A
- 1 historic blood group in the computer for the lab to issue components
- ID positively
- 3 points of ID
- Label at patient’s side (never pre-label)
- 15-30 minutes monitoring after transfusion
16
Q
Acute Haemolytic Transfusion Reaction
- Symptoms
A
Acute haemolytic transfusion reaction
- Fever
- Dyspnoea
- Pain
- Chest, abdo, flank, bck - Hyptension
- Mucous membrane bleeding
17
Q
Definition of consent?
A
Consent is:
A Precondition
1. Autonomous decision-making
2 Lawful medical treatment
18
Q
Touching a patient without consent
- Commits:
A
Touching a patient without consent
- Commits:
- Tort
- Wrongful act or civil wrong
- Resulting in suffering/loss/harm
- Crime
- Subject to criminal law
19
Q
Treatment without consent
- What action can result?
A
Treatment without consent
- Action for battery or negligence (Tort)
- Action for battery or crime of assault
20
Q
Consent
- Three legal requirements
A
Three legal requirements of consent:
- Given voluntarily (not coerced, overt or covert)
- Capacity to consent
- Understand the nature of the treatment
21
Q
Montgomery
- What changed?
- When
A
Montgomery
- What changed?
- Patients must be aware of material risks
- Must be aware of reasonable alternatives
- When
- 2015 (Lord Kerr and Lord Reed)
22
Q
Pre-op
- Drug management
- CHOW
- Anti-caogs
- AED
- Beta-blockers
A
Pre-op drug management
C. Clopidogrel
- Stop 7 days before surgery
H. Hypoglycaemics
- Metformin and pioglitazone as normal
- SU, DPPIV, GLP-1: omit on day of surgery
- Start VRIII insulin if missed two meals
- Continue long acting insulin
- Stop short acting insulin on morning of surgery
O. OCP/HRT
- Stop 4 weeks before
- Start 2/52 later if mobile
W. Warfarin
- Stop
- Bridge LMWH 5 days till day before
- Bridge LMWH after for 1 day
- Anti-coags
- Balance risk of haemorrhage
- Avoid epidural, spinal, regional - Beta block as usual
- AED
- Give as usual
- IV or NG post-op
23
Q
Bowel prep
- Indication
- Drugs
A
Bowel prep
Indications
- Left sided ops
- Not usually in rigt sided
- Controversial
- Dehydration & electrolytes
- Liquid contents and leak
Drugs
- Picolax
- Picosulfate and Mg Citrate - Klean-Prep
- Macrogol
24
Q
Prophylactic Abx
- Operative indications
A
Prophylactic Abx
- GI surgery
- Joint replacement
25
Prophylactic ABx
| - Operative Regimens
Prophylactic ABx regimens
- 15-60 minutes before surgery
GI (eg. broad spec.)
1. Biliary
- IV Cef + Met
2. CR or Appendicectomy
- Cef + Met TDS
3. Vascular (eg. Strep)
- IV Co-amox TDS
4. MRSA
- Vanc
26
ASA Grades
ASA
1. Normally healthy
2. Mild systemic disease
3. Severe and limits activity
4. Systemic, threatening life
5. Moribund (24h)
27
Pre-op assessment
| - Insulin
Pre-op insulin
1. Long acting
- Stop night before
2. AM insulin
- stop if morning surgery
28
Insulin
| - Sliding scale
VRIII
0. Aim for 7-11mM
- Hourly CPG
1. 5% dex, 20mmol KCL
2. 50units Actrapid
29
Insulin
| - Post-op
Post-op insulin
1. Stop when tolerating food
2. SC regimen around meals
30
Non-ID-DM
| - Pre-op Insulin
Non-ID-DM
1. If CBG>10mM treat as ID-DM
- Omit morning drugs
2. Resume oral drugs with meals post-op
31
Pre-op assessment
| - Steroid dependent
Steroids and surgery
1. Increase steroid for stress
2. Major surgery
- IV Hydrocortisone 3/7
3. Minor surgery
- Hydrocortisone for 24 hrs
32
Pre-op assessment
| - Jaundice
Pre-op jaundice
1. ERCP
2. Risk renal failure
3. Risk cholangitis
4. Avoid morphine pre-med
5. Clotting
- Check
- Consider vit K
6. Cef+Met
33
Pre-op
| - Antithrombotic drugs
Pre-op antithrombotics
1. Continue aspirin/clopidogrel
- Stop 7 days if high risk
2. Stop warfarin and check INR
34
Pre-op Warfarin
| - High VTE Risk
Pre-op warfarin VTE risk
1. Stop warfarin 5d pre-op
2. Bridging LMWH
3. Stop LMWH 12-18 pre-op
4. Restart LMWH 6h post op
5. Restart warfarin D2
6. Stop LMWH
- When INR >2
35
Emergency surgery
| - Warfarin
Emergency surgery warfarin
1. Stop warfarin
2. Vit K
- Slow IV
3. FFP or PCC cover
36
Post-op pyrexia
| - Classifications
Post-op pyrexia
1. Early
- 0-5 days
2. Delayed
- 5+ days
37
Post-op pyrexia
| - Early causes
Early post-op pyrexia
1. Transfusion/drug reaction
2. SIRS to trauma
3. Atelectasis
4. Infections
- UTI
- Thrombophlebitis
- Cellulitis
38
Post-op pyrexia
| - Delayed causes
Delayed post-op pyrexia
1. Pneumonia
2. VTE
3. Wound infection
4. Leak
5. Collection
39
Post-op pneumonia
| - Mx
Post-op pneumonia mx
1. Analgesia
2. Physio + Cough
3. ABx
40
Post-op collection
| - Mx
Post-op collection mx
1. ABx
2. Drainage
3. Washout
41
Post-op collection
| - Locations
Post-op collections
1. Pelvic
2. Paracolic
3. Small bowel
- Interloop spaces
4. Subphrenic
5. Lesser sac
6. Hepatorenal recess
- Morrison's space
42
Post-op cellulitis
| - Mx
Post-op cellulitis mx
1. IV Benpen
- Strep
2. PO Pen V + Fluclox
- Staph
43
DVT
| - Mx
DVT mx
1. DOAC
- Three months
OR
2. Warfarin
- Five day LMWH bridge
AND
3. Stockings
44
Post-op assessment
| - Urinary retention
Post-op retention
1. Fluid status
2. Palpable bladder
3. Drips/drains/stomas/CVP
4. 50mo NS and aspiration
5. Fluid challenge
45
Post-op Hypotension
| - CHOD causes
Post op HTN CHOD
C ardiogenic
- MI
- Overload
H ypovolaemia
- Inadequate fluids
- Haemorrhage
O bstructive
- PE
D istributive
- Sepsis
- Neurogenic
46
Delirium Causes
| - Delirium
Delirium
```
D rugs
E yes, ears, sensory
L ow O2
I nfection
R etention
I ctal
U nder-hydration
M etabolic
```
47
Fluid balance
| - Average insensible
Fluid balance
| - 700-800 insensibles
48
TPN
| - Macro requirements (1,2,3,4)
TPN /kg/24h
```
1g Protein
2g Carbs
3g Fat
40 Kcal (20+)
0.4g Nitrogen (0.2+)
```
49
TPN
| - Delivery
TPN Deliver
ST
1. CV catheter
LT
2 . Hickman
3. PICC
50
Refeeding
| - Electrolyte derangements
Refeeding syndrome change
1. Potassium low
2. Magnesium low
3. Phosphate low
51
Refeeding syndrome
| - Mx
Refeeding syndrome mx
PO4 supplements
1. Parenteral
2. PO
52
C-Spine
| - NEXUS
C-Spine Nexus
1. No neck pain
2. No head injury
3. No distracting injury
4. No abnormal neurology
5. Alert and oriented
6. No drugs or alcohol
