Operative Care Flashcards
(70 cards)
What are the broad aims of the pre-operative assessment?
Communication Education - ERAS Establish rapport Optimize patient - weight loss, glucose control Plan Assess risk Consent
Involves:
- history (medical, family)
- Examination (Mallampati)
- Investigations (ECG, Exercise tolerance, Spirometry)
- Protocols (with holding certain drugs etc)
Done by:
- GP
- Surgical team
- Anaesthetist
- Nurse
<p>Surgical Safety checklist, what are the components?</p>
<p>Before induction of anaesthesia: Sign in
Before Incision: Time out / surgical pause
Before Patient leaves operating theatre: Sign out</p>
<p>Before the induction of anaesthesia, what check list must be completed?</p>
<p>Pt confirmed, and is aware of procedure.
Site is marked
Anaesthesia safety check is done
Pulse oximeter is on pt and is working
Check allergies of pt again
Is there a difficult in airway
Is there a risk of >500ml loss of blood</p>
<p>Which patients are at increased risk of developing VTE?</p>
<p>Medical:
- reduction in mobility for >3 days
~~~
Surgical:
- Hip surgery
- knee surgery
- GA >90mins time
- surgical admission of inflammatory or intra abdominal causes
-
~~~
General risk factors:
- >60 years
- BMI >35
- Known clotting disorders
- active cancer
- Oral contraception
- HRT
- >1 serious core morbidity
- ICU admission
- Pregnancy or 6 weeks postpartum
- varicose veins
- dehydration</p>
<p>What types of VTE are available for patients?</p>
<p>TED Stockings
LMWH - enoxaparin
- 20mg prophylactic, 40mg treatment
- given prior to surgery
Fondaparinux
- 2.5mg
- given 6 hours post surgery
Unfractionated heparin</p>
<p>Where should you not cannulate on a diabetic patient with neuropathy?</p>
<p>Foot</p>
<p>What must you use to clean a post surgical wound with?</p>
<p>Sterile Saline up to 48 hours post surgery.
after 48 hours patient may use normal water, shower etc.
if there has been an opening or infection following 48 hours, then sterile water should be used.</p>
<p>Following surgery, if a patient develops DIC, what should be done?</p>
<p>Clotting studies
Platelet counts
Advice of haematology
FFP may be given - up to 4 units in meantime
cryoprecipitate may also be given</p>
<p>List some of the causes of pyrexia post operatively:</p>
<p>0-5 days:
- Blood transfusion
- cellulitis
- atelectasis
- SIRS
>7 days
- P.E
- pneumonia
- Wound infection
- Anastomotic leak</p>
<p>Following surgery the patient is extubated but fails to make any respiratory effort. They are re-intubated and sent to ITU. 24 hours extubation is attempted again and they make succeed making a full recovery. what has likely happened?</p>
<p>Suxamethonium apnea
| - congenitally lack amounts of acetylcholinesterase which break Suxamthonium</p>
<p>What procedure is less likely to cause adhesions?</p>
<p>laparoscopy</p>
<p>If a female is on the oral contraceptive pill, when should she stop before surgery?</p>
<p>4 weeks</p>
<p>What system can be used to assess an individual's fitness levels for anaesthesia?</p>
<p>The American Society of Anesthesiology physical status system
ASA
ASA I - Normal healthy
ASA II - well controlled comorbidities
ASA III - Poorly controlled comorbidities, BMI >40, previous MI/ stroke, pacemakers, End stage Renal failure
ASA IV - Constant ongoing threat to life comorbidity, recent M.I/ Stoke <3 months, DIC
ASA V - Without surgery patient will likely die
ASA VI - declared brain dead</p>
<p>List some points which can be done to help avoid surgical complications:</p>
<p>WHO checklists
Prophylactic antibiotics (if needed)
Assess DVT risk
Mark site of surgery
Be aware of coupling injuries when using diathermy
Inferior epigastric artery is often injured during ports for laparoscopic surgery</p>
<p>What is a serious reaction that can occur with anaesthesia which is passed on in families? what is the gene and how is it inherited?</p>
<p>Malignant hyperthermia
RYR1 gene
Autosomal Dominant fashion</p>
<p>How is a oropharyngeal airway measured to fit and list some advantages of it:</p>
<p>From incisors to angle of the jaw.
- no paralysis required
- Easy to put in
- used as a bridge for definitive airway
- can be used for short procedures</p>
<p>What are the two most worrying causes of a fever postoperatively that one wants to rule out?</p>
<p>Thrombosis
Infection
*these usually occur a few days later</p>
<p>What is the best investigation for an anastomotic leak?</p>
<p>CT contrast of abdomen</p>
<p>If an anastomotic leak occurs what must you immediately do?</p>
<p>Phone consultant
| - patient needs to go back to surgery</p>
<p>What are the fasting guidelines to induction of GA?</p>
<p>6 hours prior no food
2 hours prior no fluids</p>
<p>What are the symptoms of malignant hyperthermia?</p>
<p>Increasing high fever
Muscle rigidity</p>
<p>When should diabetics be operated on during the allocated slots and why?</p>
<p>First thing, to prevent poor BM control</p>
<p>What is a contraindication to use of LMAs?</p>
<p>Not being fasted
| - they offer little protection against reflux</p>
<p>If a patient is on prednisolone and is going for surgery, what medication should they be prescribed?</p>
<p>Hydrocortisone</p>
If a patient on warfarin is going for elective surgery, then what should be done regarding the warfarin?
~5 days prior to surgery stop warfarin and start on LMWH
What tests should be conducted for an elective case?
Pre admission clinic - for medical issues Blood tests - FBC, U&Es, LFTs, Group and Save Urinary analysis Pregnancy test Sickle cell test ECG/ Chest xray
If a patient has malignant hyperthermia family history what drug should be especially avoided?
Suxamethonium
What are some complications of TPN?
Sepsis Vessel irritation Hyperosmolarity Cholestasis - leading to LFT derangements Fluid overload Lack of vitamins Re-feeding syndromes - cut has atrophied
How is an insulin dependant diabetic managed the day of the operation?
Minor surgery: Omit Preoperative insulin - monitor blood glucose every 4 hours. - restart once normal oral diet has started Marjory surgery: Commence IV insulin sliding scale pre-operatively. - continue until diet is re-established. - check sugars every 4 hours - restart normal routine at half dose when diet resumes
How should oral - controlled diabetic patients be managed before surgery?
Omit medication preoperatively
When should aspirin be continued preoperatively?
When there is a high risk of thrombosis
Which medicines need to be withheld 24 hours prior to surgery?
K+ sparing diuretics ACE inhibitors Angiotensin II blockers
What drug should be increased prior to surgery?
Steroids | - during surgery the stress response will increase and cortisol will be more in demand
