Preoperative management Flashcards

Question

How should patients with low thromboembolic risk be managed surgically?

Answer 1

 Stop warfarin 5d pre-op: need INR <1.5 |  Restart next day

Answer 2

```  Need bridging c¯ LMWH  Stop warfarin 5d pre-op and start LMWH  Stop LMWH 12-18h pre-op  Restart LMWH 6h post-op  Restart warfarin next day  Stop LMWH when INR >2 ```

Answer 3

 Discontinue warfarin  Vit K .5mg slow IV  Request FFP or PCC to cover surgery

Answer 4

 Basal atelectasis  Aspiration  Chest infection

Answer 5

 CXR  PFTs  Physio for breathing exercises  Quit smoking (at least 4wks prior to surgery)

Answer 6

hypnosis, analgesia, muscle relaxation

Answer 7

local infection, clotting abnormality

Answer 8

cardio respiratory depression

Answer 9

 Oro-pharyngeal injury c¯ laryngoscope |  Oesophageal intubation

Answer 10

 Urinary retention  Pressure necrosis  Nerve palsies

Answer 11

 Corneal abrasion |  No cough → atelectasis + pneumonia

Answer 12

 Rare complication ppted by halothane or suxamethonium  AD inheritance  Rapid rise in temperature + masseter spasm  Rx: dantrolene + cooling

Answer 13

 Pain → autonomic activation → arteriolar constriction → ↓ wound perfusion → impaired wound healing  Pain → ↓ mobilisation → ↑ VTE and ↓ function  Pain → ↓ respiratory excursion and ↓ cough → atelectasis and pneumonia  Humanitarian considerations

Answer 14

Epidural anaesthesia: e.g. c¯ bupivacaine

Answer 15

 Infiltrate wound edge c¯ LA |  Infiltrate major regional nerves c¯ LA

Answer 16

``` 1. Non-opioid ± adjuvants  Paracetamol  NSAIDs  Ibuprofen: 400mg/6h PO max  Diclofenac: 50mg PO / 75mg IM ``` 2. Weak opioid + non-opioid ± adjuvants  Codeine  Dihydrocodeine  Tramadol 3. Strong opioid + non-opioid ± adjuvants  Morphine: 5-10mg/2h max  Oxycodone  Fentanyl

Answer 17

 Optimise pre-op preparation for surgery  Avoid iatrogenic problems (e.g. ileus)  Minimise adverse physiological / immunological responses to surgery  ↑ cortisol and ↓ insulin (absolute or relative)  Hypercoagulability  Immunosuppression  ↑ speeded of recovery and return to function  Recognise abnormal recovery and allow early intervention

Answer 18

 Aggressive physiological optimisation  Hydration  BP (↑ / ↓)  Anaemia  DM  Co-morbidities  Smoking cessation: ≥4wks before surgery  Admission on day of surgery, avoidance of prolonged fast  Carb loading prior to surgery: e.g. carb drinks  Fully informed pt., encouraged to participate in recovery

Answer 19

 Short-acting anaesthetic agents  Epidural use  Minimally invasive techniques  Avoid drains and NGTs where possible

Answer 20

 Aggressive Rx of pain and nausea  Early mobilisation and physiotherapy  Early resumption of oral intake (inc. carb drinks)  Early discontinuation of IV fluids  Remove drains and urinary catheters ASAP

Answer 21

 Intubation → oropharyngeal trauma  Surgical trauma to local structures  Primary or reactive haemorrhage

Answer 22

```  Secondary haemorrhage  VTE  Urinary retention  Atelectasis and pneumonia  Wound infection and dehiscence  Antibiotic association colitis (AAC) ```

Answer 23

 Scarring  Neuropathy  Failure or recurrence

Answer 24

 Primary: continuous bleeding starting during surgery  Reactive  Bleeding at the end of surgery or early post-op  2O to ↑ CO and BP  Secondary  Bleeding >24h post-op  Usually due to infection

Answer 25

Drugs: opioids, epidural/spinal, anti-AChM  Pain: sympathetic activation → sphincter contraction  Psychogenic: hospital environment

Answer 26

```  Male  ↑ age  Neuropathy: e.g. DM, EtOH  BPH  Surgery type: hernia and anorectal ```

Answer 27

```  Conservative  Privacy  Ambulation  Void to running taps or in hot bath  Analgesia  Catheterise ± gent 2.5mg/kg IV stat  TWOC = Trial w/o Catheter  If failed, may be sent home c¯ silicone catheter and urology outpt. f/up. ```

Answer 28

 Occurs after every nearly every GA |  Mucus plugging + absorption of distal air → collapse

Answer 29

 Pre-op smoking  Anaesthetics ↑ mucus production ↓ mucociliary clearance  Pain inhibits respiratory excursion and cough

Answer 30

 w/i first 48hrs  Mild pyrexia  Dyspnoea  Dull bases c¯ ↓AE

Answer 31

 Good analgesia to aid coughing |  Chest physiotherapy

Answer 32

 Clean: incise uninfected skin w/o opening viscus  Clean/Cont: intra-op breach of viscus (not colon)  Contaminated: breach of viscus + spillage or opening of colon  Dirty: site already contaminated – faeces, pus, trauma

Answer 33

```  Pre-operative  ↑ Age  Comorbidities: e.g. DM  Pre-existing infection: e.g. appendix perforation  Pt. colonisation: e.g. nasal MRSA  Operative  Op classification and wound infection risk  Duration  Technical: pre-op Abx, asepsis  Post-operative  Contamination of wound from staff ```

Answer 34

 Regular wound dressing  Abx  Abscess drainage

Answer 35

 Occurs ~10d post-op |  Preceded by serosanguinous discharge from wound

Answer 36

```  Pre-Operative Factors  ↑ age  Smoking  Obesity, malnutrition, cachexia  Comorbs: e.g. BM, uraemia, chronic cough, Ca  Drugs: steroids, chemo, radio  Operative Factors  Length and orientation of incision  Closure technique: follow Jenkin’s Rule  Suture material  Post-operative Factors  ↑ IAP: e.g. prolonged ileus → distension  Infection  Haematoma / seroma formation ```

Answer 37

```  Replace abdo contents and cover c¯ sterile soaked gauze  IV Abx: cef+met  Opioid analgesia  Call senior and arrange theatre  Repair in theatre  Wash bowel  Debride wound edges  Close c¯ deep non-absorbable sutures (e.g. nylon)  May require VAC dressing or grafting ```

Answer 38

```  Conversion to open: 5%  CBD injury: 0.3%  Bile leak  Retained stones (needing ERCP)  Fat intolerance / loose stools ```

Answer 39

``` Early  Haematoma / seroma formation: 10%  Intra-abdominal injury (lap)  Infection: 1%  Urinary retention  Late  Recurrence (<2%)  Ischaemic orchitis: 0l5%  Chronic groin pain / paraesthesia: 5% ```

Answer 40

 Abscess formation  Fallopian tube trauma  Right hemicolectomy (e.g. for carcinoid, caecal necrosis)

Answer 41

```  Early  Ileus  AAC  Anastomotic leak  Enterocutaneous fistulae  Abdominal or pelvic abscess  Late  Adhesions → obstruction  Incisional hernia ```

Answer 42

 Bowel handling  Anaesthesia  Electrolyte imbalance

Answer 43

 Distension  Constipation ± vomiting  Absent bowel sounds

Answer 44

 IV fluids + NGT |  TPN if prolonged

Answer 45

 Anal incontinence  Stenosis  Anal fissure

Answer 46

 Short gut syndrome (≤250cm)

Answer 47

 Gastric dilatation (2O gastric ileus)  Prevent c¯ NGT  Thrombocytosis → VTE  Infection: encapsulated organisms

Answer 48

 Thrombosis and embolization  Anastomotic leak  Graft infection

Answer 49

```  Gut ischaemia  Renal failure  Aorto-enteric fistula  Anterior spinal syndrome (paraplegia)  Emboli → distal ischaemia (trash foot) ```

Answer 50

 Arm lymphoedema  Skin necrosis  Seroma

Answer 51

 Urinary incontinence  Erectile dysfunction  Retrograde ejaculation  Prostatitis

Answer 52

```  Wound haematoma → tracheal obstruction  Recurrent laryngeal N. trauma → hoarse voice  Transient in 1.5%  Permanent in 0.5%  R commonest (more medial)  Hypoparathyroidism → hypocalcaemia  Thyroid storm  Hypothyroidism ```

Answer 53

 Stenosis  Mediastinitis  Surgical emphysema

Answer 54

 Mal-/non-union  Osteomyelitis  AVN  Compartment syndrome

Answer 55

```  Deep infection  VTE  Dislocation  Nerve injury: sciatic, SGN  Leg length discrepancy ```

Answer 56

 Pneumo-/haemo-thorax |  Infection: mediastinitis, empyema

Answer 57

``` Early: 0-5d post-op  Blood transfusion  Physiological: SIRS from trauma: 0-1d  Pulmonary atelectasis:24-48hr  Infection: UTI, superficial thrombophlebitis, cellulitis  Drug reaction ``` ``` Delayed: >5d post-op  Pneumonia  VTE: 5-10d  Wound infection: 5-7d  Anastomotic leak: 7d  Collection: 5-20d ```

Answer 58

```  Observation chart, notes and drug chart  Wound  Abdo + DRE  Legs  Chest  Lines  Urine  Stool ```

Answer 59

 Urine: dip + MCS  Blood: FBC, CRP, cultures ± LFTs  Cultures: wound swabs, CVP tip for culture  CXR

Answer 60

 Anaesthesia → atelectasis  Pain → ↓ cough  Surgery → immunosuppression

Answer 61

 Chest physio: encouraging coughing  Good analgesia  Abx

Answer 62

 Malaise  Swinging fever, rigors  Localised peritonitis  Shoulder tip pain (if subphrenic)

Answer 63

```  Pelvic: present @ 4-10d post-op  Subphrenic: present @ 7-21d post-op  Paracolic gutters  Lesser sac  Hepatorenal recess (Morrison’s space)  Small bowel (interloop spaces) ```

Answer 64

 FBC, CRP, cultures  US, CT  Diagnostic lap

Answer 65

abx | drainage/washout

Answer 66

Acute infection of the subcutaneous connective tissue

Answer 67

β-haemolytic Streps + staph. aureus

Answer 68

 Pain, swelling, erythema and warmth  Systemic upset  ± lymphadenopathy

Answer 69

Virchows Triad ``` Blood Contents  Surgery → ↑ plats and ↑ fibrinogen  Dehydration  Malignancy  Age: ↑ ``` Blood Flow  Surgery  Immobility  Obesity Vessel Wall  Damage to veins: esp. pelvic veins  Previous VTE

Answer 70

 Peak incidence @ 5-10d post-op  65% of below knee DVTs are asymptomatic  Calf warmth, tenderness, erythema, swelling  Mild pyrexia  Pitting oedema

Answer 71

```  D-Dimers: sensitive but not specific  Compression US (clot will be incompressible)  Thrombophilia screen if:  No precipitating factors  Recurrent DVT  Family Hx ```

Answer 72

1. Assess probability using Wells’ Score 2. Low-probability → perform D-dimers  Negative → excludes DVT  Positive → Compression US 3. Med / High probability → Compression US

Answer 73

``` Anticoagulate  Therapeutic LMWH: enoxaparin 1.5mg/kg/24h SC  Start warfarin using Tait model: 5mg OD for first 4d  Stop LMWH when INR 2.5  Duration  Below knee: 6-12wks  Above knee: 3-6mo  On-going cause: indefinite ``` Graduated Compression Stockings  Consider for prevention of post-phlebitic syndrome

Answer 74

``` Pre-Op  Pre-op VTE risk assessment  TED stockings  Aggressive optimisation: esp. hydration  Stop OCP 4wks pre-op ``` Intra-Op  Minimise length of surgery  Use minimal access surgery where possible  Intermittent pneumatic compression boots ``` Post-Op  LMWH  Early mobilisation  Good analgesia  Physio  Adequate hydration ```

Answer 75

```  Previous lung disease  Atelectasis, aspiration, pneumonia  LVF  PE  Pneumothorax (e.g. due to CVP line insertion)  Pain → hypoventilation ```

Answer 76

 FBC, ABG  CXR  ECG

Answer 77

```  Post-renal  Commonest cause  Blocked / malsited catheter  Acute urinary retention  Pre-renal: hypovolaemia  Renal: NSAIDs, gentamicin  Anuria usually = blocked or malsited catheter  Oliguria usually = inadequate fluid replacement ```

Answer 78

Post Renal  Commonest cause  Blocked / malsited catheter  Acute urinary retention Pre-renal: hypovolaemia  Renal: NSAIDs, gentamicin  Anuria usually = blocked or malsited catheter  Oliguria usually = inadequate fluid replacement

Answer 79

Information  Op Hx  Obs chart: UO  Drug chart: nephrotoxins Examination  Assess fluid status  Examine for palpable bladder  Inspect drips, drains, stomas, CVP Action  Flush c¯ 50ml NS and aspirate back  Fluid challenge

Answer 80

Obstruction  Ileus  Emetic drugs: e.g. opioids

Answer 81

 S(I)ADH: pain, nausea, opioids, stress |  Over administration of IV fluids

Answer 82

 Acute: 1mM/h |  Chronic:15mM/d

Answer 83

 Tilt bed head down, give O2 |  Assess fluid status

Answer 84

CHOD Cardiogenic  MI  Fluid overload Hypovolaemia  Inadequate replacement of fluid losses  Haemorrhage Obstructive  PE Distributive  Sepsis  Neurogenic shock

Answer 85

```  Hypovolaemia → fluid challenge  250-500ml colloid over 15-30min  Haemorrhage → return to theatre  Sepsis → fluid challenge, start Abx  Overload → frusemide  Neurogenic → NA infusion ```

Answer 86

 Pain  Urinary retention  Previous HTN

Answer 87

 Rx cause |  May use labetalol 50mg IV every 5min (200mg max)

Answer 88

DELIRIUM ```  Drugs: opiates, sedatives, L-DOPA  Eyes, ears and other sensory deficits  Low O2 states: MI, stroke, PE  Infection  Retention: stool or urine  Ictal  Under- hydration / -nutrition  Metabolic: Na, AKI, glucose, EtOH withdrawal ```

Answer 89

 May need sedation: midazolam / haldol  Nurse in well-lit environment  Rx cause

Preoperative management Flashcards

(113 cards)