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POST-OP CARE Flashcards

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1
Q

What is the ERAS pathway?

A

Enhanced Recovery After SUrgery Pathway
This is an evidence-based MDT Pt-centred strategy developed for each surgical speciality to achieve early recovery and reduce post-op complications

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2
Q

What are the goals of ERAS/

A

• Pre-operative optimisation and preparation for surgery
• Reducing the stress response to surgery
• Early recovery and return to normal daily function
• Reducing post-operative complications, mortality and morbidity
• Decreased length of hospital stay

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3
Q

What are the body’s responses to surgery?

A

• HPA axis is activated leading to release of cortisol -> hyperglycaemia and peripheral insulin resistance. It also has roles in suppressing the inflammatory and immune responses of the body
• Sympathetic nervous system is activated resulting in release of catecholamines which increase HR, BP and RR to redirect blood flow to vital organs
• Can lead to alterations in metabolism e.g increasing energy expenditure, protein breakdown and gluconeogenesis -> hyperglycaemia which is a major factors in poor wound healing, prolonged hospital stays and increased risk of nosocomial infections
• Fluid and electrolyte imbalances due to SNS activating RAAS which causes sodium and water retention

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4
Q

ERAS; pre-op

A

• patient education on surgery and stopping regular meds if necessary
• Fasting and bowel prep
• VTE prophylaxis
• Smoking cessation

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5
Q

ERAS: Intra-op

A

• minimally invasive surgical techniques where possible e.g. If open technique is necessary then transverse incisions should be used as these have been shown to reduce post-op pain, avoid NG tubes where possible and give antibiotic prophylaxis before skin incision
• A multimodal analgesic approach should be encouraged to reduced high dose opioid use. Give antiemetics if scoring moderate risk on Apfel scoring system
• Intraoperative fliuod administration if needed. Fluid maintenance is sufficient for low risk pts

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6
Q

ERAS: post-op

A

• early enteral feeding to reduce need for IV fluids and postop ileus. Adequate nutrition will help with wound healing, improve muscle strength for mobilisation and reduce infection risk
• Mobilise early to improve respiratory function, reduce skeletal muscle loss and increase oxygen delivery to tissues
• Recommended that pts should sit out of bed for 2 hours on day or surgery and 6 hours of the day until discharge
• Multimodal analgesia should be continued and avoid excessive use of opioids
• Remove drains and urinary catheters as early as possible

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7
Q

Complications of a GA?

A

• injury to tongue, gums, teeth etc in airway management
• Sore throat
• Bronchospasm/laryngospasm - more common in pts with hyper-responsive airways e.g. asthma.
• Aspiration of gastric contents
• Subcutaneous emphysema or pneumothorax from air instrumentation
• Pulmonary oedema following laryngoscopasm or airway obstruction as inspiratory effort against the closed glottis lead to excesssive negative pressure within the alveoli resulting in pulmonary oedema
• Pharyngeal obstruction due to sedation - worsened by OSA
• Hypoxia
• PE
• Hypotension from haemorrhage or reduced vascular tone
• Arrhythmias
• Hypertension
• AKI
• Urinary retention - higher risk with spinal anaesthetic
• Post op nausea and vomiting
• Post-op ileus - particuarly where bowel handling has occurred in surger
• Post-op cognitive dysfunction - more common in elderly and may present with delirium or just some difficulty comprehending
• Peripheral nerve injury’s from position in surgery
• Hypothermia

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8
Q

Complications of regional anaesthesia?

A

• post-dural puncture headache from intracranial hypotension - usually occurs 72 hours after the dural puncture
• Cord damage, ischaemia, compression, abscess, meningitis
• Peripheral nerve injuries which may manifest as sensory or motor deficits

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9
Q

What is laryngospasm?

A

Laryngospasm is the sustained closure of the vocal cords resulting in the partial or complete loss of the patient’s airway.
Causes strider and abnormal see-saw movements of abdomen and chest wall

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10
Q

Management of laryngospasm?

A

remove stimulus, call for senior anaesthetic help, 100% FiO2, application of PEEP, deepening of anaesthesia with propofol. If this doesnt work then pt will require suxamethonium to relax the vocal cords and ETT

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11
Q

What is malignant hyperthermia? Cause? Characterised by?

A

A rare but potentially lethal complication of anaesthesia where there is a hypermetabolic response.
Characterised by a rapid rise in temperature, increased muscle rigidity, massater spasm, tachycardia, increasing end-tidal CO2, hyperkalaemia, rhabdomyolysis leadin to acute renal fialure and acidosis.
Most commonly caused by volatile anaesthetics and in some cases suxamethonium so these should be avoided if pt is considered high risk
There are genetic mutations that increase this risk and these are inherited in an AD pattern. The genetic mutation causes raised intracellular Ca2+ leading to prolonged muscle contraction

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12
Q

Management of malignant hyperthermia?

A

call for senior anaesthetic help, disconnect pt from anaesthetic machine, supply 100% FiO2, maintain anaesthesia with TIVA propofol, dantrolene, active cooling, monitor urine output and treat any hyperkalaemia

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13
Q

How does dantrolene work to treat malignant hyperthermia?

A

Interferes with the movement of Ca2+ in the skeletal muscle which interrupts muscle rigidity and hypermetabolism

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14
Q

Complications of malignant hyperthermia?

A

Hyperkalaemia
AKI
Arrhythmias

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15
Q

What are common triggers of anaphylaxis in anaesthetics?

A

Antibiotics
Muscle relaxants
Latex

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16
Q

What are the 3 types of post-op haemorrhage?

A

Primary bleeding
Reactive bleeding
Spontaneous bleeding

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17
Q

What is primary bleeding?

A

bleeding that occurs within the intra-operative period and should be resolved during the operation

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18
Q

What is secondary bleeding?

A

bleeding that occurs 7-10 days post-op. Often due to erosion of a vessel from a spreading infection

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19
Q

What is reactive bleeding?

A

bleeding that occurs within 24 hours of operation. Often from a ligature that slips or a missed vessel

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20
Q

Which surgeries require a high threshold for suspicion of any post-op bleeding?

A

Neck surgery - risk of airway obstruction
Laparoscopic surgery or pfannenstiel incision - risk of inferior epigastric artery damage
Angiography surgery - risk of external iliac artery damage causing retroperitoneal bleeding

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21
Q

What does post-op pyrexia within 24 hours of surgery usually indicate?

A

Physiological systemic inflammatory reaction

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22
Q

What does post-op pyrexia within 5 days of surgery usually indicate?

A

Blood transfusion reactions
Cellulitis
UTI
Pulmonary atelactasis

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23
Q

What does post-op pyrexia after 5 days from surgery usually indicate?

A

VTE
Pneumonia
Wound infection
Anastamotic leak

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24
Q

What is pyrexia of unknown origin?

A

a recurrent fever persisting for >3 weeks without an obvious cause despite >1 week of inpatient investigation
Causes include infection of unknown source, malignancy e.g. lymphoma, CTD, vasculitis and drug reactions

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25
What is the PACU discharge criteria?
• pts observations within acceptable limits • Is pt comfortable • Wound site not bleeding excessively • Drains have no excessive drainage • Pts who receive post-op analgesia e.g. morphine have remained in PACU for 20 mins to monitor for SE • IV lines are flushed after giving IV drugs
26
What are the benefits of prone positioning?
Reduces compression on the lungs by organs Improves blood flow to lungs Improves the clearance of secretions Improves overall oxygenation
27
Oxygen flow rate and FiO2 through a nasal cannula?
1-4L 24-44%
28
Oxygen flow rate and FiO2 through a simple facemask?
5-8L 40-60%
29
Oxygen flow rate and FiO2 through a non-rebreathe mask?
8-10L 80-95%
30
Flow rates of Venturi mask and indication?
2-15L Usually for COPD for pt at risk of retaining CO2 if FiO2 is too high
31
What is the end-expiratory pressure?
The pressure remaining in the airways at the end of exhalation which stops the airways from collapsing
32
How can you achieve positive end-expiratory pressures?
High-flow nasal cannula NIV Mechanical ventilation
33
What is a high-flow nasal cannula?
A nasal cannula with humidified and warmed oxygen Allows for up to 60L Increases the concentration of oxygen inhaled with each breath, washes out the dead space and adds PEEP
34
What is CPAP?
This is when there is a constant pressure added to the lungs to keep the airways expanded It’s used to maintain pts airway in conditions such as OSA Does not involve ventilation
35
What is NIV?
Involves using a full face mask and hood, or a tight-fitting nasal mask to forcefully blow air into the lungs and ventilate them BiPAP is thr machine that provides this It involves cycles of high and low pressures that correspond to the pt’s inspiration and expiration
36
When is mechanical ventilation used? What is it?
Mechanical ventilation is used when other respiratory support forms are inadequate. A ventilator machine is used to move air into and out of the lungs. Pts generally require sedation. An ETT or tracheostomy is required to connect the ventilator to the lungs.
37
What is ECMO? When is it used?
ECMO is the most extreme form of respiratory support and is very rarely used. It’s only used when respiratory failure is not adequately managed by intubation and ventilation. Blood is removed from the body, passed through a machine where oxygen is added and carbon dioxide is removed, then pumped back into the body. The process is similar to haemodialysis but for respiratory support rather than renal support. ECMO is only used short-term, where there is a potentially reversible cause of respiratory failure. It is not a long-term treatment. It is only provided in specialist ECMO centres and is not available in most intensive care units. Patients need to be transferred to a specialist centre for ECMO.
38
Why should we treat pain?
• It’s the human thing to do - less suffering and greater dignity • Fewer physical problems - better sleep, appetite, earlier mobilisation, fewer medical complications • Fewer psychological problems - depression and anxiety • Allows pt to function as part of family and provide • Reduces health costs for society as pt are discharged earlier and less likely to be readmitted • Pts are able to work and contribute to the commmunity
39
What is nociceptive pain?
sharp or dull, well localised, has a protective function for the body, there’s obvious tissue injury and illness, responds well to conventional analgesics
40
What is neuropathic pain?
caused by lesions/disease of nervous system, tissue injury may not be obvious, burning/shooting/numbness, poorly localised, does not respond well to conventional analgesics This has no beneficial function1
41
What can affect pain threshold levels?
Beliefs Psychological factors Cultural issues Other illnesses Personality Social factors e.g. family
42
Whats the difference between A delta and C fibres?
A delta fibres are myelinated with a low threshold for firing and a fast conduction speed. They are responsible for transmitting the first pain felt. C fibres are unmyelinated and have a slow conduction speed so they are respsible for the dull, deep secondary pain that is poorly localised.
43
What approach should be used for pain?
RAT Recognise Assess Treat
44
How can pain be measured?
Verbal rating scales Numerical rating scales Children - smiley face scale
45
What can be used to assess the characteristics of pain and the likelihood of neuropathic pain?
DN4 questionnaire
46
What is allodynia?
When pain is experienced from sensory inputs that do not normally cause pain e.g. light touch in trigeminal neuralgia
47
Outline the DN4 questionnaire?
Does the pain have 1 or more of the following characteristics: burning, painful cold, electric shots? Is the pain associated with tingling, pins & needles, numbness or itching? Is the pain located in an area where physical examination reveals hypoesthesia to touch or to pinprick? In the painful area can the pain be caused/increased by brushing? Each gets 1 point and a score of 4 or more indicates likely neuropathic pain
48
How many neuropathic pain meds can be used at once?
Only 1!
49
What is first line treatment for trigeminal neuralgia?
Carbamazepine
50
What are examples of adjuvants for pain maabgement?
amitryptiline, gapapentin, duloxetine, pregabalin, capsaicin cream
51
Outline the WHO analgesic ladder for pain
◦ Step 1: paracetamol and NSAIDs +/- PPI ◦ Step 2: mild opioids e.g. codeine or Tramadol - continue simple analgesics ◦ Step 3: strong opioids e.g. morphine - continue simple analgesics
52
How is chronic pain usually managed?
Supervised exercise programmes Acceptance and commitment therapy CBT Acupuncture Antidepressants
53
Outline the World Federation of Societies of Anaesthesiologists analgesic ladder?
Initial pain is severe so may need controlling with strong analgesics in combination with local anaesthetic blocks and peripherally acting drugs The second rung on the postop ladder is restoration of the use of the oral route to deliver analgesia - strong opioids may no longer bee needed and adequate analgesia can be obtained by using a combination of peripherally acting agents and weak opioids The final step is when pain can be controlled by peripherally acting agents alone
54
What is Patient Controlled Analgesia?
patients administer their own IV analgesia and titrate the dose to their own end-point of pain relief using a small microprocessor-controlled pump. Morphine is most commonly used. Only pt can administer it!!
55
How common is post-op nausea and vomiting?
Occurs in 20-30% of patients within the first 48 hours
56
Which surgeries carry a higher risk of PONV?
ntra-abdominal laparoscopic surgery, intracranial or middle ear surgery, squint surgery or gynaecological surgery.
57
What are the 5Rs of fluid therapy?
Resuscitation Replacement Routine maintenance Redistribution Reassessment
58
How to assess volume status in a pt post-op?
History: Thirst, decrease intake, dizziness, abnormal losses, bowel prep Examination: SBP <100, HR >90, CRT >2, dry mucous membranes
59
Resuscitation fluids?
500mls crystalloids over 15 minutes If no improvement after 2000ml call for help (If haemorrhage then replace losses with blood products!!)
60
In which pts must you be cautious about giving a 500ml bolus for resuscitation fluids?
Cardiac failure Renal failure Elderly
61
Daily requirements for Na+?
1mmol/kg/day
62
Daily requirements for K+?
1mmol/kg/day
63
Daily requirements for fluid?
25-30ml/kg/day
64
Daily requirements for glucose?
50-100g a day
65
Which fluids should be used for rescitation fluids and why
0.9% sodium chloride or hartmanns As they are isotonic so will remain in the intravascular space for longer
66
What is the maximum rate of infusion for K+ peripherally?
10ml/hour
67
What are the options for routine maintenance regimes?
4% dextrose and 0.18% NaCl 0.9% NaCl and then 5% dextrose in a 1:2 ratio Hartmanns can be prescribed perioperatively for 24-48 hours
68
Why should you never use 0.9% NaCl for routine maintenance alone?
As you will get hyperchloraemic metabolic acidosis
69
What are inotropes?
Medications that alter the contractility of the heart Positive inotropes increase contractility which increases CO and MAP
70
Examples of positive inotropes?
Adrenalin Dobutamine Isoprenaline
71
What are examples of negative inotropes?
BB CCB Flecainide
72
What are vasopressors?
Meds that cause vasoconstriction which increases systemic vascular resistance and therefore MAP
73
Examples of vasopressors drugs?
Noradrenaline Adrenaline Vasopressin Metaraminol Ephedrine Phenylephrine
74
What is an intraortic balloon pump?when may it be used?
A temporary measure. May be used in carcinogenic shock, ACS and immediately following heart surgery A catheter is inserted into the arterial system via the femoral artery up to the descending thoracic aorta. At the tip of the catheter is an inflatable balloon which is intermittently inf;aged ad deflated synchronised to heart contractions e.g. during systole when heart is contacting the balloon deflates creating a vacuum effect which reduces the afterload and increases CO

ACUTE (18 decks)

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