Surgery Flashcards
(103 cards)
1
Q
What is the pharmacist role in pre-op assessment
A
- Drug histroy
- Medication changes up to surgery?
2
Q
What does the pharmacist do upon admission for surgery
A
- Another and more updated Drug history and Medicines reconciliation
- Any medication changes and documentation
3
Q
What pharmacist role in post-op care
A
- Optimising pain relief.
- Reinstating blood thinning medication or VTE
- When or should we restart pre-operative meds previously held or do they still need them
4
Q
What pharmacist role in discharge
A
- Screen TTA
- Counselling and safety netting
- Write discharge letter(specifically medications part)
5
Q
What is HDU, CCU, ITU AND ICU
A
HDU – high dependency unit
CCU – coronary care unit or critical care
ITU/ICU – intensive care unit (here patients are less clinically stable and pt. receive 1-1 care from a nurse)
6
Q
What are the 4 surgical terminologys
A
Ectomy - removal of
Otomy - opening of
Oscopy - Looking into
Ostomy- bringing to skin surface
7
Q
What is peri-operative period
A
Time from and including pre-op admission to hospital for surgery and post-op discharge back to community
8
Q
What is pre-medication
A
One off medication give to patients (I.e single dose benzo for pre-op anxiety)
9
Q
What are the grades of elective surgery
A
Minor (Removal of skin lesion)
Intermediate (Removal of varicose vein)
Major (hysterectomy, thyroidectomy)
Complex/Major+ (Joint replacement, neuro/cardio surgery)
10
Q
What ASA grades
A
a scale used to assess a patient’s fitness for surgery and anesthesia
11
Q
explain ASA grades
A
ASA 1 -Normal healthy patient
ASA 2 - Mild systemic disease
ASA 3 - Severe systemic disease
ASA 4 - Severe systemic disease with constant threat to life
12
Q
What is splenectomy
A
Removal of the spleen
13
Q
What is the spleen
A
Largest organ of the lymphatic system.
14
Q
What are the main functions of the Spleen
A
important role in immunity as part of the lymphatic system, it is also the storage organ of RBC and contains some WBC
15
Q
What are the main functions of the pancreas
A
endocrine function- control of blood glucose
exocrine functioning - production of pancreatic digestive enzymes – proteases, lipases and amylases
16
Q
What medications might we start in patients who have a total splenectomy
A
- Life long prophylactic antibiotics(only if high risk)
- keeping up with vaccines(pneumococcal menC/b FLU)
17
Q
What medications might we start in patients who have a total pancreatectomy?
A
Creon/pancreatin pancreatic enzymes(given with meals or snacks)
Insulin(adjusted to requirements)
18
Q
What about post-thyroidectomy?
A
Levothyroxine
19
Q
What would a patient who has a stoma bag require
A
Codeine or high doses of loperamide to reduce stoma output.
Notes does for loperamide can be way higher than max 16mg in stoma patients and are QDS
20
Q
What are the 4 pharmacuetical considerations for medicatiosn administered NG,NJ PEG
A
- Where are drugs absorbed?
- Need for enzymatic activation in stomach? (prodrugs activated in stomach?)
- Interactions with feeds (i.e phenytoin 2 hour gap)
- How can we get the medicine through a feeding tube (dilution/ alternative routes/forms)
21
Q
What are 5 surgical stressors that stimulate the surgical stress response
A
- ↓ calorie intake (NBM period)
- ↓ blood volume (↓ BP) due to dehydration from NBM or blood loss
- ↓ tissue perfusion (Caused be low BP)
- ↑ hypercoagulability
- ↑ invasive infection(open wound)
22
Q
Why are surgical patients hypercoagulable
A
Higher risk of clot, as if it is prolonged surgery lying still for a while.
Dehydrated less blood volume and more likely to clot.
23
Q
What is the surgical stress response
A
Is the hormone mediated response effort by the body to maintain homeostasis and to aid wound healing.
This can also occur pre-surgery in anticipation of surgery.
24
Q
What is the surgical stress response to Low BP
A
ADH release from posterior pituitary, which causes less diuresis and increases blood volume
25
What is the surgical response effect to low blood glucose
pancreas
- increases glucagon release
- decreases insulin secretion
Think about diabetics
26
What is the surgical stress effort on cortisol
Cortisol increases(stress hormone) causes many effects
- Increases BP
- Increased water retention
- Downregulates non essential bodily functions(Immunosuppression)
27
What are the considerations for surgical patients who take steriods
Patients who take long-term steroids may have adrenal insufficiency. During surgery they need cortisol to maintains homeostasis thus are often give IV stat doses during surgery or double doses for a few days after surgery to prevent this risk of adrenal crisis.
28
What are pre-op pharmacist considerations
- Ensure patient haemodynamically stable
- drug management of existing long term conditions
- Keep patients NBM
- antibiotic prophylaxis
29
2 Goals of peri-op pharmaceutical care
* Preventing surgical complications
* Respond to patient requirements
Aim: enhance recovery for improved post-op outcomes
30
what is Nil by Mouth (NBM)
No solids up to 6h pre-op (usually from midnight)
Can have clear fluids until 2h pre-op
31
Why are patients NBM prior to surgery
Supine position (on back) during op - Laryngeal reflexes are stopped due to anaesthesia - risk of regurgitation of stomach contents, pulmonary aspiration.
GI or gut rest may be needed post-op. (for a few hours or days
32
What is the effect on stomach acid
↑ cortisol leads to ↑ acid production
33
What medications do you still give if the patient is NBM
Critical medicines
34
What do you give to prevent stress ulcers from Cortisol
prophylaxis – IV pantoprazole
35
What are 6 critical medicines that must not be stopped
Anti-seizure meds
Diabetes meds
Antiretrovirals – HIV
Antibiotics
Parkinson’s meds
Certain cardiovascular meds
36
What happens if a parkinsons medication is not given
must be taken on time to maintain control (missed dose- dysphagia --> dehydration -->AKI--> decline)
37
What medication should not be restarted for specific period post op
i.e. warfarin
38
Should stop antibiotics
What is the clinical need and urgency of the medicine?
Is the antibiotic prophylactic or needed for a course?
39
What type of medications may need to be temporarily changed to an alternative regimen
Sliding scale on insulin may be given.
Change to patches for Parkinson’s medications
40
When stopping a drug what pharmacokinetic parameter should you think about
Half life
- Amiodarone has a half life of 50 days so missing one dose is not so bad
41
Should you stop warfarin before surgery
1. Depends on the bleeding risk of the surgery i.e minor surgeries skin tag removal is low
42
How should you stop warfarin in preparation for surgery
Advise them to stop taking for 4-5 days before surgery as warfarin takes 2-3 days to wear off.
before surgery INR to be below 1.5 for them to have surgery and not be worried about bleeding.
43
What INR is safe for surgery to be commenced
1.5
44
How should you restart warfarin
Warfarin has a slow onset of action; so restart on evening of operation.
Bridge them with a LWMH
45
What should you give a patient for emergency surgery who is on warfarin
Vitamin K (phytomenadione)for quick reversal
46
What is the goal of antibiotic prophylaxis
Reduce post-procedural wound infections and infectious complications (e.g. sepsis)
47
How is antibiotic prophylaxis given for surgery
A single large dose of antibiotic is typically given pre-incision to produce effective tissue levels.
48
Why do we stop the antibiotics after the large dose
As continuing them on increases risk of C.diff
49
How do we choose antibiotic for surgery prophylaxis
1. Likely pathogens to be introduced into blood stream – depending on where surgery is
2. Type of surgery/ surgical wound classification (clean, contaminated, dirty)
3. Local guidelines
50
What are the four classifications of surgical wounds
1. Clean
2. Clean Contaminated
3. Contaminated
4. Dirty
51
If the surgery is of a higher contamination risk, do you still give further antibiotics
if higher contamination risk then continued course may be used
52
how to check for post-op infection?
* Temperature spiking?
* IV line infection
* Was there a risk of Aspiration pneumonia.
* UTI?
* Wound infection?
* MC&S from sample?
o When results come back empirical treatment can stop and we can choose an susceptible antibiotic
* CRP, WCC, Nuetrophils
53
How do manage diabetics in pre-surgery
1. What Anti-diabetic medication are they taking and their requirements
2. what type of diabetes - Type 1 (IDDM) vs Type 2 (NIDDM)
3. Pre-op NBM period, surgical stress → hyperglycaemia.
4. Monitor and maintain normoglycaemia to prevent complications (e.g. infections, DKA)
54
How do you manage insulin dependant diabetics during surgery
1. Diabetic patients are usually first on list to reduce how long they are NBM
2. Variable continuous IV insulin infusion (VRIII)- sliding scale.
55
What is Variable rate IV insulin infusion
It is an IV infusion of Soluble **human insulin** which acts quickly (short duration).
It is given during and post operatively to keep BMs within range.
it is adjusted according to blood glucose levels
56
What must you monitor patients on VRIII
- Blood glucose
- Potassium levels(insulin drives potassium into cells)
57
Should you continue the patients long-acting insulin on whilst they are on a VRIII
Yes
but hold their short acting insulin
58
When do you stop VRIII and what must you give before stopping
when pt E+D again BUT give short-acting insulin before stopping sliding scale)
59
When restarting oral anti-diabetic agents what must you check
Renal function in case they were dehydrated(look on bnf page)
60
How do you stop and start a DOAC before surgery
DOACs do not need to be held for days before surgery, just one day before as they work rapidly and they do not need to be bridged
61
What are the Pharmacuetical considerations post-op
* Ensure to reconcile medications - Continuing/ restarting regular medications.
* VTE Thromboprophylaxis
* Analgesia
* Anti-emetics
* Laxatives and bowel prep
* Fluids and electrolytes
62
What things should you consider when restarting medications post-operatively
1. Patient E+D/ is bowel functioning/ Gut Rest
2. Clinicals Ob/results - are they okay
3. is there still an indication for medicine post op?
4. long term steroids - increase dose initially
5. Anticoagulant restarting?
63
What is gut rest
Can't otherwise it will affect healing process post GI surgeries
Must give TPN
64
What is VTE prophylaxis
Reduces the risk of hospital acquired DVT or PE
65
Why is surgery a risk factor for VTE
Patient is immobile during and after surgery
66
VTE triad
Explain 3 things that increase the risk of clotting.
1. Endothelial injury - release clotting factors --> increased risk
2. Circulatory stasis – blood flowed slowed and more likely to pool and stick together to form a clot
3. Hypercoagulable state – dehydrated, cancer or recently had a blood clot
67
What is mechanical thromboprophylaxis
Anti-embolism TED stockings
This pressure helps to squeeze the veins and push blood back towards the heart, preventing blood from pooling and potentially clotting.
68
When should you not give TED stockings
Avoid in Peripheral Arteriole Disease- already have reduced blood flow so risk of ischaemia(in bnf)
69
What two drug classes are used chemical thromboprophylaxis
LMWH and DOACs
70
When are DOACs used for VTE
are used for Total Knee Replacement or Total Hip Replacement
71
How long is VTE prophylaxis needed for after surgery
Duration of recovery period for surgery until mobile again.
If in a cast for 6 weeks, if it says on pt notes non-weight bearing(NWV) 6 weeks so on thromboprophylaxis for 6 weeks.
72
How is post operative pain managed
Who pain ladder - step down approach
73
What 5 things can failure to achieve pain control for acute post-op pain can lead to
* Negative effects on mobility and function
* Slowed recovery (potentially leading to chronic pain)
* Increased time in hospital
* Poor well-being and QoL
* Pulmonary or thromboembolic complications
74
What is step 1 of the WHO pain ladder
1. Non-opioid +/- adjuvants (paracetamol, NSAID)
75
What is step 2 of the WHO pain ladder
Weak opioids +/- adjuvants(codeine, tramadol)
76
What is step 3 of the WHO pain ladder
3Strong opioids+/- adjuvants (Morphine
77
How is pain managed in surgical patients
Start strong and reduce
Post-op 3→2→1
If we step down too quickly and patient in pain then step UP treatment
78
How can you monitor pain
continued reviews of pain control
Use pain scores
79
What is the major side effect of opioids and benzodiazepines
Respiratory depression
Addiction
79
What are the 6 signs and symptoms of respiratory depression
SOB
shallow breathing
Cyanosis
Fatigue
Loss of consciousness
Low RR
80
What is PCA
Patient-controlled analgesia
Patients can administer small boluses IV via a PCA pump to achieve rapid pain relief as needed
81
What is the lockout period for PCA
to prevent pt pressing too many times
Often 1mg/5mins so cannot go over 1mg in 5 minutes.
82
What are 6 advantages of PCA
1. ↓ adverse effects and excess use if not required.
2. Quicker initial control of pain → faster recovery
3. Negate need for repeated IM/SC injections which ↓ nursing time
4. Avoidance of peak and trough opioid levels
5. Patient empowerment
6. Improved individualisation of drug dosing
83
What are 5 disadvantages of PCA
1. Analgesia not achieved during sleep (unless background)
2. Patient may wake in pain as haven’t been pressing the button
3. Lack of education → lack of understanding of PCA
4. Fear about opioid addiction/ overdose – reassure patient its only short term and will help them recover which reduces overall time needing pain relief and we get them off opioids as soon as we can. We use the lowest effective dose for the shortest period of time
5. Cost and maintenance of PCA equipment
84
What two drugs are in epidurals
*Combination of local anaesthesia + opioids(i.e fentanyl buvicane)
85
Why are two medicine given in epidurals
Two medicines working in different ways so Synergistic action which enables lower doses of both reduced SE
86
What are benfits of epidurals
1. reduced SE
2. Allows patient to deep breath - ↓ likelihood of chest infections
3. early ambulation ↓ likelihood of DVT, pressure sores
4. Aids faster recovery
87
How to you manage opioid toxicity
naloxone
NPSA alert- take care with doses for naloxone (between opioid naïve and opioid tolerant)
88
When are NSAIDS cautioned
elderly, asthma, renal impairment
89
What is the risk of NSAIDS
Risk of thrombotic events (e.g. MI, stroke)
Risk of GI events (e.g. ulcer, bleed) – see BNF
Selective COX-2 inhibitors associated with lower risk of serious UGI side effects
Consider gastroprotection in elderly or higher risk patients
90
What are 6 risk factors for post-op nausea and vomiting (PONV)
* younger age
* Female
* Weight
* History of N/V, motion sickness
* Use of drugs which cause N/V – opioids, anaesthesia.
* Type and length of surgery
91
What are 4 anti-emetics used for PONV
ondansetron
cyclizine
prochlorperazine
dexamethasone(sometimes)
92
What is the MRHA advice for domperidone
Lack of efficacy in children
Not indicated in children < 12 or <35kg
Contraindicated in cardiac disease, GI obstruction, or haemorrhage.
Restricted to max 10mg TDS for 1 week
93
What is the MRHA advice for metoclopramide
Risk of neurological adverse effects (EPSE/tardive dsykinesias)
1. Restrict dose to 10mg TDS for 5 days in adults
2. induces acute dsytonic reactions in young patients(especially females)
3. Contraindicated 3-4 days post surgery
4. Do not use in Parkinsons
94
why might patients get constipated post-op
May be due to NBM period (dehydration) or use of opioids.
95
What laxative therapy is given for post-op constipation
Movicol (osmotic laxative)- need water intake
Senna (stimulant laxative)- not in intestinal obstruction (causes perforation)
96
What additional advice for post op constipation
Adequate fluid intake
Exercise/ mobilisation
97
Why are Fluids important in surgery?
to maintain circulating volume to prevent decreased organ perfusion.
to replenish substantial deficits or continuing losses post-operatively
98
What are two types of fluids
colloids or crystalloids.
99
What are suitable colloids and what do they do
proteins/ high molecular weight substances
Stay in plasma to maintain circulatory volume.
100
what are crystalloids
0.9% NaCl, 5% dextrose,
101
Why are fluids low in surgical patients
Increased output due to drains from surgical site
Increased GI output (ileostomy, diarrhoea due to abx/ feed, PONV)
Hyperventilation (stress) and pyrexia/ sweating
Patients in continued NBM state or limited eating and drinking (dehydration)
Hypotension – due to hypovolaemia or epidural
102
What is also given alongside the VRII
Fluids containing glucose to prevent hypoglycaemia
