General pre-op and risks

Question 1

Aims of Anaesthesia (4)

Answer 1

1. No conscious awareness of
pain
2. Still surgical field
3. Anxiolysis, sedation or
complete hypnosis
4. Cardiorespiratory stability

Question 2

7 A’s of Anaesthesia

Answer 2

1. Allergy
2. Aspirations
3. Apnea
4. Access
5. Activity levels/function
6. Aortic stenosis
7. Airway assessment

Question 3

Items to discuss with anethetist

Answer 3

1. Previous anaesthesia
2. Family history->malignant hyperthermia, bleeding, reactions to anaesthesia
3. Medications->considerations to cease/withhold
4. CVD risk: comorbidities, risk factors
5. CNS: stroke, TIA, seizures
6. Respiratory: smoke, asthma, triggers, bronchitis
7. LFTs, OSA, ABG
8. Airway examination
9. Endocrine, thyroid, obesity
10. Fluid status
11. Strategy for blood replacement
12. GIT aspiration risk
13. Arthritis

Question 4

Pre-aneathetic exam

Answer 4

1. Open mouth
2. Presence of teeth
3. Size of tongue
4. Subluxation of TMJ
5. Relative position of larynx
6. CV and respiratory
7. Assess recent blood
8. Signs and symptoms of reason for operation

Question 5

Management of acute post-operative pain

Answer 5

1. NSAIDS
2. Paracetamol
3. Opioids
   a. PCA 1mg morphine bolus with 5-8 minute lockout
   b. Consider tramadol if no PCA
4. Epidural

Question 6

Preoperative checklist

Answer 6

1. Bloods and investigations
FBC, UEC, LFTs, crossmatch GH, INR, glucose (some will depend on patient)
2. IV cannula
3. ECR + CXR
4. Drug chart: Regular medications, Analgesia, Antiemetic, Antibiotics, Heparin, compression stockings
5. Consent
6. Mark side/site
7. Inform anaesthetics
8. Inform theatre
9 Infections risk
10. NBM >2 hr preop clear fluids, >6-8 h for solids
11. Catheter if required
12. Post-op physioT

Question 7

Specific complications of surgery: laparoscopic, biliary, thyroid, breast

Answer 7

1. Laparoscopic: conversion to open procedure
2. Biliary: damage to common bile duct, anastomic leak, retained stone with another surgery, post hepatic jaundice, stricture, pancreatitis
3. Thyroid: bleeding->airway compromised, hypocalcemia, hypothyroid, recurrent and superficial laryngeal nerve palsy, voice different for few days (intubation and swelling)
4. Breast: lymphedema, seroma, hematoma, brachial plexus injury

Question 8

Specific complications of surgery: arterial, colonic, SB surgery, splenectomy

Answer 8

1. Arterial: graft infection, AV fistula, graft failure
2. Colonic: damage to other structures, leakage, ileus, adhesions
3. SB: damage to surrounds, leak, ileus, short gut, adhesions
4. Splenectomy: damage to surrounds, acute gastric dilitation, sepsis/future infections->will need vaccinations

Question 9

Specific complications of surgery: GU, hemorrhoidectomy, prostate, gastrectomy

Answer 9

1. GU: Damage, ureters, subfertility
2. Hemorrhoidectomy: stenosis
3. Prostate: blood in urine/ejaculate initially, urethral stricture, retrograde ejaculation, incontinence and impotence
4. Gastrectomy: dumping syndrome, weight loss, malabsorption, ulceration of stomach, tumor, blind loop syndrome, abdominal fullness/early satiety

Question 10

General surgical risks

Answer 10

1. Anaesthetic
Toxic->brady, asystole, dizzy, NV, CNS depression
Failure
MI, stroke
Allergy
Death
2. Surgical
Hemorrhage
Infection of wound, other
Impaired healing
Surgical injury
Atelectasis, pneumonia, ARDS
VTE
Sepsis
Urinary retention
UTI
Electrolyte disturbances
Antibiotic colitis
Pressure sores

Question 11

ASA system

Answer 11

1. Healthy person.
2. Mild systemic disease-
   X interfere normal activity
3. Severe systemic disease-
   limits normal
4. Severe systemic disease-
   that is a constant threat to life.
5. A moribund person who is not
   expected to survive without the operation-
   wont live >24 hours
6. A declared brain-dead person whose
   organs are being removed for donor purposes.
   E- signifies emergency

Question 12

What are the two types of skin prep/antiseptics commonly used in surgery and their mechanism of action?

Answer 12

1. Benidine (Iodine-based) - destroys wide range including staph by iodisation of microbial proteins
2. Chlorhexidine gluconate - disinfect mucous membrane, bactericidal via binding phospholipids and disrupting cell wall integrity.

Question 13

What is the ASA classification? (5)

Answer 13

Determines patient status

1. Fit for age
2. Patient has systemic disease that does not interfere with normal activity
3. Systemic disease that limits normal activity
4. Systemic disease that is constant threat to life
5. Patient not expected to survive 24 hours

Question 14

Common types of sutures and their use

Answer 14

Polytetrafluoroethylene = for arteries, Syn, Mono, Non
Plain catgut = nat, multi, Ab
Silk & linen = Nat, multi, Non

Question 15

Monofilament vs multifilament

Answer 15

Monofilament pass through skin easily, less reactive, more difficult to handle and secure.
Multifilament are braided or twisted thread, easier to handle and . knot, but more likely to harbour micro-organisms.

Question 16

What is the purpose of a surgical drain?

Answer 16

1. remove blood or serous fluid which would otherwise accumulate in operative area
2. Provide track or line of minimal resistance so that potentially harmful fluids can drain away from p particular site (e.g. drain placed into an intra-abdominal abscess cavity)

Question 17

Post-splenectomy management

Answer 17

Vaccinations: S. pneumonia, meningococcal, H. Influenza (encapsulated bacteria)

Antibiotics - amoxycillin script given at first sign of infection

Question 18

What are the types of nasogastric tubes?

Answer 18

1. Levin: single lumen - administration of medications or nutrition
2. Salem sump: double lumen (one for suction and drainage and other for ventilation to reduce pressure and prevent gastric mucosa from being drawn into catheter)
3. Moss: (surgery): radiopaque tip & three lumens. First, positioned & inflated in cardia, serves as a balloon inflation port. 2nd is oesophageal aspiration port, 3rd duodenal feeding port.

Question 19

Complications of NG tube insertion?

Answer 19

Aspiration
Tissue damage
Induce gagging/vomiting

Question 20

How to prevent adhesions?

Answer 20

Laparoscopy (rather than laparotomy)
Minimize/avoid contomination
Avoid non-absorbable sutures and ligatures except for abdo wall closure
Avoid powered gloves

Question 21

What does valid consent involve?

Answer 21

patient must be competent (<18, able to understand and communicate information and its consequences)
Informed all information disclosed and discussed
Free from coercion
Understanding of benefits and risks checked

Question 22

What do you need to outline to the patient

Answer 22

BRA BAD
Benefits of surgery
Risks
Alternative options
Before - pre-operative assessment & management
After - immediate post-operative care (analgesia, diet, expectations, returning to normal activity), give (info, scripts, work cert, discharge), follow up
During - anaesthesia and procedure

Question 23

What drugs do you need to stop prior to surgery?

Answer 23

CHOW 
Clopidogrel and anti-platelets 
Hypoglycaemias (metformin etc)
OCP (4 weeks prior) 
Warfarin & NOACs (bridged with heparin)

Question 24

What drugs do you need to start prior/just after surgery?

Answer 24

TED stockings
LMWH or UFH (prophylactic dose for DVT)
Antibiotics (indications - GI, urological or cardiovascular)

Question 25

How to optimise diabetics for major surgery?

Answer 25

Morning surgery to minimise fasting Measure BGL hourly for hypoglycaemia) Withhold metformin morning of (other hypoglycaemics 24 hours prior) If hyperglycaemic (>10mmol/L commence supplemental insulin subcut T1DM: cut basal insulin by 1/3 to avoid hypos and omit morning insulin and continuous insulin infusion pump with glucose-insulin infusion for 24h post-op.