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Peri-operative care Flashcards

Peri-operative care Anaesthetics Principles of surgery

1
Q

List the early (<5 days) causes post-op pyrexia

A
  • Blood transfusion
  • Physiological SIRS from trauma (<24hr)
  • Pulmonary atelectasis (24-48hr)
  • Infection: UTI, superficial thrombophlebitis, cellulitis
  • Drug reaction
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2
Q

List the delayed (>5 days) causes of post-op pyrexia

A
  • Pneumonia
  • VTE (5-10 days)
  • Wound infection (5-7) days
  • Anastomotic leak (7 days)
  • Collection (5-20 days)
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3
Q

A 75-year-old man attends the surgical assessment unit prior to an elective Hartmann’s procedure in 7 days due to bowel cancer. He has a past medical history of atrial fibrillation, hypertension and previous cerebrovascular accident. Your registrar asks you to review him prior to his procedure next week. You notice that he is currently taking warfarin and his INR today is 2.6. His remaining blood tests are normal. What is the most appropriate management for his anticoagulation peri-operatively?

A

High VTE risk (valves, Hx): need bridging LMWH

Stop warfarin 5 days before

Stop LMWH 12-18 hr before

Restart LMWH 6 hr post op

Restart warfarin next day

Stop LMWH when INR> 2

Low VTE risk (AF): stop warfarin 5 days before op (INR <1.5) and restart next day

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4
Q

Which blood products should be requested for the following operations?

A. Lap Cholecystectomy
B. Oopherectomy
C. Total hip replacement

A

A. Group and save
B. Cross match 4-6 units
C. Cross match 2 units

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5
Q

Specific pre-operative assessment in Rheumatoid Arthritis and Ankylosing Spondylitis

A

Lateral C-spine flexion and extension XR

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6
Q

When are pre-operative prophylactic antibiotics indicated

A

GI surgery and joint surgery
15-60 mins before surgery
Broad spectrum

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7
Q

What are the guidelines for medium risk DVT prophylaxis?

A

A. Medium risk: early mobilisation + TEDS + 20mg enoxaparin

Low: early mobilisation
High: early mobilisation + TEDS + 40mg enoxaparin + intermittent compression boots

Started at 1800 post op, may continue medical prophylaxis at home for one month

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8
Q

A patient smokes 20 cigarettes per day and has hypertension, which ASA grade are they?

A

A. 2

1 = healthy, non-smoker, minimal alcohol use

2 = mild disease, current smoker, social drinker, pregnant or obese

3 = severe systemic disease

4 = systemic disease which is a constant threat to life e.g. recent MI, CVA, current sepsis

5 = moribund patient not expected to survive without the operation

6 = declared brain dead

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9
Q

A patient with GCA on long-term steroids is due to have a THR after a fractured NOF, how should they be managed?

A

A. Major surgery: 100mg hydrocortisone before induction and 50mg every 8 hours for 24 hours, then half dose every 24 hours until maintenance dose reached

Moderate: same regimen, but half dose

Mild: no supplementation needed

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10
Q

What is the risk of operating in patients with jaundice?

A

A. Post-op renal failure. Also coagulopathy and infection causing cholangitis

Pre-op: avoid morphine, check clotting and give vitamin K, 1L NS, catheter and Abx

Intra-op: hourly UO, titrating NS to output

Post-op: intensive monitoring of fluid status and consider CVP + frusemide if poor

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11
Q

How long before surgery do you need to stop warfarin in low risk patients?

A

A. 5 days (INR <1.5) and restart next day

High risk: need bridging LMWH (stop 12-18hr before, restart 6 hours post-op), restart warfarin next day, stop LMWH when INR>2

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12
Q

Name a non-depolarising muscle relaxer

A

A. Vecuronium

Depolarising: suxamethonium

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13
Q

Which anaesthetic is used for rapid sequence induction?

A

A. Sodium thiopentone

Suxamethonium is rapid acting so is used for muscle relaxation in RSI

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14
Q

Which anaesthetic is good for haemodynamically unstable patients?

A

A. Ketamine

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15
Q

What is malignant hyperpyrexia?

A

A. Rare complication of halothane or suxamethonium with AD inheritance.
Rapid rise in temperature with masseter spasm.
Mx: dantrolene + cooling

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16
Q

Describe the three principles of Enhanced Recovery After Surgery (ERAS)

A
  1. Optimisation pre-op
    - aggressive physiological optimisation e.g. BP
    - smokin cessation 4 weeks before
    - admission on day of surgery
    - carb loading
  2. Intra-operative reduction of stressors
    - short anaesthesia
    - minimally invasive
    - avoid drains and NGT
  3. Post-op early mobilisation
    - aggressive mx of pain and nausea
    - early PT
    - early oral intake and cessation of IV fluids
    - removal of drains and catheters
17
Q

List immediate, early and late complications of surgery

A

Immediate (<24h)

  • intubation and surgical trauma
  • primary or reactive haemorrhage

Early (<1 month)

  • Secondary haemorrhage
  • VTE
  • Urinary retention
  • Atelectasis (<48hr)
  • Wound infection and dehiscence (5-10 days)

Late (>1 month)

  • Scarring
  • Neuropathy
  • Failure or recurrence
18
Q

Complications of Cholecystectomy

A
  • Conversion to open 5%
  • CBD injury 0.3%
  • Bile leak
  • Retained stones needing ERCP
  • Fat intolerance/ loose stools
19
Q

Complications of Inguinal hernia repair

A 
•	Early 
o	Haematoma/ seroma formation 10% 
o	Intra-abdominal injury 
o	Infection 1% 
o	Urinary retention 
•	Late 
o	Recurrence 2% 
o	Ischaemic orchitis 
o	Chronic groin pain/ paraethesia 5%
20
Q

Complications of Appendicectomy

A
  • Abscess formation
  • Fallopian tube trauma
  • Right hemicolectomy e.g. for carcinoid, caecal necrosis
21
Q

Complications of Colonic surgery

A 
•	Early 
o	Ileus 
o	Anastomotic leak 
o	Enterocutaneous fistulae 
o	Abdominal or pelvic abscess 
•	Late 
o	Adhesions leading to obstruction 
o	Incisional hernia
22
Q

Complications of Prostatectomy

A
  • Urinary incontinence
  • Erectile dysfunction
  • Retrograde ejaculation
  • Prostatitis
23
Q

Complications of fracture repair

A
  • Mal/non-union
  • Osteomyelitis
  • AVN
  • Compartment syndrome
24
Q

Complications of hip replacement

A
  • Deep infection
  • VTE
  • Dislocation
  • Nerve injury: sciatic, superior gluteal nerve
  • Leg length discrepancy
25
Q

A patient presents a week post-operatively with malaise, swinging fever, rigors and localised peritonitis.

A

A. Collection

Locations: 
•	Pelvic: present 4-10 days post-op 
•	Subphrenic: present 7-21 days post-op 
•	Paracolic gutters 
•	Lesser sac 
•	Hepatorenal recess (Morrison’s space) 
•	Small bowel (interloop spaces)
26
Q

Nutritional requirements per kilogram bodyweight per day

A
  • Calories 20-40 Kcal
  • Carb 2g
  • Fat 3g
  • Protein 0.5-1
  • Nitrogen 0.2-0.4g
27
Q

Complications of parenteral feeding

A 
•	Line-related 
o	Pneumothorax/ haemothorax 
o	Cardiac arrhythmia 
o	Line sepsis 
o	Central venous thrombosis  PE or SVCO 
•	Feed-related 
o	Villous atrophy of GIT 
o	Electrolyte disturbances 
	Refeeding syndrome 
	Hypercapnoea from excessive CO2 production 
o	Hyperglycaemia and reactive hypoglycaemia 
o	Line sepsis increased risk with TPN 
o	Vitamin and mineral deficiencies
28
Q

What is Refeeding Syndrome and how is it managed?

A

A. • Life threatening metabolic complication of refeeding via any route after a prolonged period of starvation

Features
o	Hypophosphataemia 
o	Rhabdomyolysis 
o	Respiratory insufficiency 
o	Arrhythmias 
o	Shock 
o	Seizures

Mx
• Parenteral and oral phosphate supplementation
• Treat complications

29
Q

What are the stages of wound healing?

A

Haemostasis (mins-hrs)

Inflammation (

30
Q

4 stages of anaesthesia (Guedel classification)

A

o 1. Induction
o 2. Excitement – complete LOC, may be uncontrolled movement
o 3. Surgical anaesthesia – skeletal muscle relaxation and eye movement stops
o 4. Overdose – overmedication, severe brain stem or medullary depression

31
Q

TURP syndrome

A

o Follows absorption of excess irrigation fluid (mostly glycine)

o Features: increased intravascular volume, dilutional hyponatraemia, intracellular oedema and metabolism of glycine to ammonia

o Signs: bradycardia or arrhythmias, hypertension followed by hypotension, dyspnoea, visual disturbance and mental irritation leading to reduced consciousness

o Mx
 ABCDE
 Slow correction of hyponatraemia with diuretics
 Close monitoring for coagulopathy, electrolyte disturbance, hypothermia and arrhythmias
 Liaise with ITU and surgical team

32
Q

Bohr effect

A

o Shift of the oxygen dissociation curve to the right as a result of the reduction in oxygen affinity of haemoglobin
o Greater tendency of haemoglobin to offload oxygen into tissues
o Causes: increase in temperature, acidity, 2,3-BPG (organophosphate produced as a product of glycolysis in RBCs) and PCO2

33
Q

Signs of cardiac tamponade

A 
o	Hypotension (obstructive shock) 
o	Increased JVP 
o	Muffled heart sounds 
o	Kussmaul’s sign: paradoxical rise in JVP on inspiration 
o	Electromechanical dissociation arrest
34
Q

Features of ARDS

A

o CXR or CT confirms bilateral pulmonary infiltrates
o Acute onset within 1 week of a known clinical insult
o Refractory hypoxaemia: PaO2: FiO2 <200

35
Q

Features of hypocalcaemia (SPASMODIC)

A 
Spasms (carpopedal = Trousseau's) 
Perioral paraesthesia
Anxious 
Seizures 
Muscle tone increased 
Orientation impaired 
Dermatitis 
Impetigo herpetiformis 
Chovstek's, Cardiomyopathy

Finals (13 decks)

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