Perioperative / Pre op

Question 1

consent discussion 4 things

Answer 1

informed consent
explain risks vs benefits
optimise patient fitness and preparedness
check anaesthesia type and WHO doing

Question 2

pre op checks to perform

Answer 2

Operative fitness (cardioresp comorbidities)
Pills taking
Consent
History (prev complications and surgery / significant PMH)
Ease of intubations (neck arthiritis, dentures)
Clexane (prophylaxis)
Site - marked + checked

OP CHECS

Question 3

operation and anticoag

Answer 3

balance risk

avoid epidural, spinal and reigonal

Question 4

antiepiletpics and operation

Answer 4

continue, ensure IV or NGT arranged if can’t do oral intake post op

Question 5

OCP and HRT and operation

Answer 5

stop 4 weeks before major or leg surgery

restart 2 weeks after if mobile

Question 6

beta blockers and surgery

Answer 6

give

Question 7

typical pre op investigation bloods panel

Answer 7

routine = FBC, UE, G+S, clotting, glucose
do FTs if relevant
electrophoresis if at risk group

MRSA swabs

Question 8

which ops need extra cross match

Answer 8

gastrectomy 4 units

AAA repair 6 units

Question 9

special investigations pre op for certain conditions

Answer 9

any cardioresp comorbidities:
CXR, echo, ECG

any RA or anksond - lateral C spine

Question 10

typical pre op prep

Answer 10

NBM 2 hours+ for clear fluids, 6 hours for solids

Question 11

bowel prep for left sided bowel ops

Answer 11

macrogol or picolax

up to surgeon, follow advice

Question 12

when is prophylactic antibiotic used?

Answer 12

GI surgery and joint replacement, give 15 mins pre op

biliary cef met
appendix cef met
vascular coamox
MRSA vanc

Question 13

DVT prophylaxis by risk level

Answer 13

low early mobilise
medium TEDS + 20mg enoxaparin
high risk TEDS + 40mg enoxaparin with compression boots post op

Question 14

ASA grade descriptors

Answer 14

1. healthy
2. mild systemic
3. severe systemic
4. severe systemic with constant threat to life
5. <24 hours to live

Question 15

diabetes op risk

Answer 15

more risk of infection and vascular disease
need change to insulin dose proabably due ot cortisol rise

do dipstick for proteinuria, venous glucose, check UEs and K+ pre op

Question 16

insulin and operations type 1

Answer 16

stop long acting the night before
omit AM insulin if morning surgery
start sliding scale and check glucose hourly

Question 17

post op diabetic type 1

Answer 17

continue sliding scale until tolerating food, switch to subcut around first meal

Question 18

describe sliding scale insulin regime

Answer 18

actrapid infusion pump 50 units
check cap gluc hourly and adjust rate
5% dextrose + 20mmol KCl mixed in, rate of 125ml/hr

if in doubt, speak tot the diabetes specialist nurse!!!

Question 19

type 2 diabetes and operation

Answer 19

manage as type 1 if fasting >10mM glucose

omit oral hypoglycaemics on AM of surgery

resume with first meal

if not eating after op do sliding scale and refer to specialists

Question 20

on steroids and operation

Answer 20

poor healing, infection, risk of adrenal crisis

Question 21

managing someone on steroids with op

Answer 21

up steroid

major surgery - hydrocortisone 50-100mg IV pre med then 8 hrly for 3 days

only for one day if minor surgery

Question 22

jaundiced patient and op

Answer 22

avoid, only ERCP investigatio

Question 23

increased op risk of obstructive jaundice

Answer 23

higher risk of post op renal failure and coagulopathy and infection

Question 24

changes to pre op for jaundice and ERCP

Answer 24

avoid morphine, check clotting carefully and consider vit K
1 litre normal saline pre op unless heart failure
urinary catheter
abx prophylaxis

close urine moiniotirng in op and titrate fluids closely

furosemide, CVP if struggling with urine output after

Question 25

anticoagulated patients and operations

Answer 25

balance risk don't need to stop warfarin if INR <3.5 and minor procedure avoid epidural and blocks continue aspirin, clopidrogrel unless high bleeding risk - then stop one week pre op

Question 26

major op and warfarin low clot risk

Answer 26

low clot risk stop 5 days pre and get INR <1.5 restart warf next day

Question 27

major op and warfarin high clot risk

Answer 27

stop warfarin 5 days prior and replace with LMWH stop LMWH 12 hours pre op restart LMWH 6 hrs post op then warfarin next day, continue enox until INR>2

Question 28

emergency surgery and warfarin

Answer 28

stop taking vit K 0.5mg slow IV request FFP for surgery

Question 29

COPD surgery risks

Answer 29

atelectasis aspiration chest infection

Question 30

COPD pre op

Answer 30

CXR, pulmonary function tests, physio, stop smoking 4 weeks prior to op

Question 31

anaestheisa start/maintenance/end

Answer 31

induction with propofol muscle relaxation depolarising: suxamethonium non depol: atracurium airway: endotracheal tube or laryngeal mask airway (iGel) maintaining anaesthesia: gas- halothane, enflurane ending anaesthesia switch gas to 100% oxygen reversal: neostigmine + atropine to prevent muscarinic side effects

Question 32

typical pre-med for an operation

Answer 32

``` temazepam opioids, paracetamol, NSAIDs antiemetics lansoprazole glycopyrolate anti secretions Abx ```

Question 33

complications of anaesthesia

Answer 33

``` cardioresp depression airway trauma retention palsies atelectasis/pneumonia risk malignant hyperpyrexia anaphylaxis ```

Question 34

malignant hyperpyrexia

Answer 34

rare auto dominant reaction to halothane or suxamethonium v high temp, masseter spasm give danatrolene and cool

Question 35

pain relief principles with surgery

Answer 35

oral is always best if poss regular / PCA follow stepwise approach to increasing if difficult ask acute pain service for advice should have local in wound and regional nerves at end of surgery too

Question 36

stepwise pain relief

Answer 36

non opioids paracetamol max 500mg every 6 hrs ibuprofen max 400mg every 6 hrs diclofenac max 50mg every 8 hours weak opioids codeine dihydrocodeine tramadol opioids morphine 10mg 4 hourly (max?) oxycodone fentanyl

Question 37

risks x2 of spinal or epidural anaesthesia

Answer 37

resp depression | neurogenic shock, low BP

Question 38

ERAS protocol

Answer 38

enhanced recovery after surgery evidence based approach used for colorectal/ortho surgery mainly about optimising pt condition

Question 39

pre op, peri op, post op means of promoting fast recovery

Answer 39

``` Pre-op: optimise BP, hydration, ensure not anaemic stop smoking 4 weeks prior admit on day if poss carb-loading pre op patient centred ``` ``` peri-op: use shortest acting agents limit op time limit invasiveness minimise drains ``` ``` Post-op: mobilise early!! good pain and nausea control physio off IV to oral ASAP urinary cath + drains for minimum time possible ```

Question 40

immediate early late surgical complications

Answer 40

Immediate (<24h) - tubing trauma - trauma to surrounding structures in surgery - bleeding Early (1-30 days) - secondary bleed - clots - retention - atelectasis and pneumonia - wound infection / breakdown - abx complications (colitis) Late (>1month) - scarring - neuropathy - op failure or recurrence of problem

Question 41

classify operative bleeding

Answer 41

primary - in op reactive - immediately post op secondary - 1 day + post op, usually infection

Question 42

urinary retention and surgery risk factors

Answer 42

``` various drugs BPH male hernial/anorectal op neuropathies ```

Question 43

categorising risk factors for surgical complications same approach for preventing complications categorising

Answer 43

split into pre op operative and post op

Question 44

causes of early and late post op pyrexia

Answer 44

``` within 5 days atelectasis sepsis transfusion reaction drug reaction sepsis not resolved by op ``` ``` later pneumonia VTE infection of wound leaking anastomosis collection formed ```

Question 45

approach to post op patient with a fever

Answer 45

obs, notes, drug chart examine ``` wound abdo DRE legs chest lines urine stool ``` urine dip and culture FBC, CRP, cultures, LFTs wound swabs / line swabs CXR

Question 46

presentation post op collections

Answer 46

swinging fevers localised peritonitis shoulder tip referred pain

Question 47

DVT

Answer 47

peaks 5 days post op warmth, erythema, swelling, pain in calf

Question 48

post op SOB

Answer 48

``` atelectasis pain not controlled pneumothorax PE pneumonia ```

Question 49

post op low UO

Answer 49

blocked or misplaced catheter | hypovolaemia

Question 50

vomiting post op

Answer 50

emetic drugs ileus obstruction consdier NGT antiemetiics

Question 51

hypotensive post op

Answer 51

tilt head back assess fluid status ``` hypovol bleeding sepsis overload neurogenic shock ```

Question 52

hypertension post op

Answer 52

may be drug omission or urinary retention pain

Question 53

acute confusion post op

Answer 53

``` sedating drugs sensory deficit low oxygen states infection retention of stool or urine hydration issues electrolytes glucose withdrawal ```