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PHAY0085 > Surgery [COMPLETED] > Flashcards

Surgery [COMPLETED] Flashcards

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1
Q

Outline the patient journey for elective surgery.

A

GP referral
Surgical outpatient clinic
Pre-op assessment
Admission
Theatre and recovery
Post-op care
Discharge

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2
Q

What are some roles of the surgical pharmacist?

A

Pre-assessment clinic - perioperative drug therapy, NBM alterations, short term pre-op and post-op treatment
VTE prophylaxis and treatment
Antibacterial prophylaxis and treatment
PONV
Pain relief
Laxative therapy and bowel prep
Fluid and electrolytes
Nutritional support especially if on gut rest
Wound management - dressings, maggots, leeches
HDU, CCU, ITU/ICU management

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3
Q

What are the different types of surgery?

A

-ectomy (removal)
-otomy (opening of)
-oscopy (looking in)
-ostomy (bring to the skin surface)

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4
Q

What is pre-medication for surgery?

A

A one off/stat dose of medication given to patients such as a benzodiazepine to relieve pre-op anxiety

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5
Q

What are the grades of elective surgery?

A

1 Minor - removal of skin lesion
2 Intermediate - removal of varicose vein, tonsillectomy
3 Major - full hysterectomy, thyroidectomy
4 Complex/major+ - total joint replacement, neuro or cardiac surgery

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6
Q

ASA grades for physical status of a surgical patient.

A

ASA 1 - normal health
ASA 2 - mild systemic disease
ASA 3 - severe systemic disease
ASA 4 - severe systemic disease that is a constant threat to life , more difficult surgical and recovery period is likely

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7
Q

What are some considerations when carrying out laparoscopic surgery as opposed to open surgery?

A
  • Smaller incision
  • Smooth recovery
  • Need to consider patient and complexity of surgery : not every surgery can be done laparascopically
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8
Q

What are some examples of GI surgery?

A

Cholecystectomy - removal of gallbladder (can be open or lap)
Pancreaticoduodenectomy - removal of head of pancreas, duodenum and gall bladder (remaining pancreas and bile duct attached to small intestine)
Right/left hemicolectomy (removal of right or left [descending] colon)
Sigmoid colectomy - removal of sigmoid colon : the part that attaches the left (desceding) colon to the rectum
transverse hemicolectomy - removal of transverse colon

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9
Q

What is anastamosis?

A

a surgical joining of two different parts - e.g. after a hemicolectomy

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10
Q

How can damage be avoided after anastamosis in the colon?

A

Hugging pillow when coughing
Avoid sudden movement
Gut rest

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11
Q

What is a spleenectomy?

A

Partial or total removal of the spleen if ruptured, infected or enlarged - spleen is the largest organ of the lymphatic system

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12
Q

What is the function of the spleen?

A

Part of lymphatic system
Infection control and immunity
Stores RBCs and may also contains WBCs

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13
Q

What is the function of the pancreas?

A

Endocrine function: hormone secretion of glucagon from alpha cells and insulin from beta cells to control blood glucose

Exocrine function: digestive enzymes amylase, protease and lipase

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14
Q

What medications would we expect to start in a patient following a total spleenectomy?

A

Antibiotics - prophylactic and may be lifelong if high risk (under 16 or over 50, history of infections, immunocompromised, HIV)
Antivirals
Vaccines

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15
Q

What medications would we expect to start in a patient following a total pancreatectomy?

A

Creon (enzymes) - given with meals and snacks
Insulin

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16
Q

What medications would we expect to start in a patient following a thyroidectomy?

A

Levothyroxine

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17
Q

Stoma following ileostomy

A
  • Small intestine brought to surface of skin
    STOMA PLACED IN RIGHT LOWER QUADRANT
  • 500-1300ml/day output
  • Liquid/mushy stool
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18
Q

Stoma following colostomy

A

Large intestine brought to surface of the skin
STOMA PLACED IN LEFT LOWER QUADRANT
- 200-700ml/day output
- Semi-formed stool

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19
Q

What medications may stoma patient require?

A

To reduce stoma output: Codeine or high dose loperamide (BNF max. dose is 16mg a day but stoma patients may be on much higher doses outside product license)

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20
Q

What are the types of enteral feeding tubes?

A

Nasogastric
Nasoduodenal
Gastrotomy (PEG)
Jejunostomy
Nasojejunal

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21
Q

What are some pharmaceutical considerations when using enteral feeding tubes? (3)

A
  • Drug pharmacokinetics :
    Bypassing site of absorption meds wont be effective
    Does drug undergo enzymatic activation in the stomach
  • Interactions with feeds
    Phenytoin needs 2 hours feed breaks before and after dosing
  • How can we get meds through tubes ?
  • Formulations: liquids need to consider viscosity, dilutions, flushing tube
  • Other routes
  • Advise on instructions
  • Licensed or off-label use? crushing tablets, opening capsules
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22
Q

What are some physiological changes that occur in the surgical patient (5)

A

Reduced caloric intake (NBM)
Reduced blood vol –> reduced BP (blood loss, dehydration as NBM)
Reduced tissue perfusion - BP not high enough to push blood where it needs to go
Increased hypercoagulability - higher VTE risk due to immobility, dehydration and reduced blood vol
Increased chance of invasive infection - infection can enter bloodstream thorough open wound if skin is already infected or aseptic technique not used

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23
Q

What is the surgical stress reponse?

A

The body counteracting surgical stress
Maintaining homeostasis and managing wound healing
Can be anticipatory
Moderated by HPA axis - body goes into fight or flight

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24
Q

What are some pre-op considerations for the surgical patient?

A
  • Haemostatically stable
  • Drug management of existing medical issues - diabetes, steroids
    Anticoagulants (consider bleed and VTE risk)
    Other medications
    NBM
    Antibiotic prophylaxis
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25
What can long term steroid use do in surgery?
Reduce steroid response
26
NBM.
No solids for 6 hours and clear fluids to be stopped 2 hours before operation Supine position (on back) during surgery Risk of regurgitation/pulmonary aspiration if general anaesthesia is used in patients with a full stomach as laryngeal reflexes are held Gut rest may be needed Stress ulcer prophylaxis (IV pantoprazole) - more cortisol = more stomach acid
27
When can IV pantoprazole be stopped in patients who are nbm?
after surgery
28
What is a critical medication?
A medication that is important for the patient to not miss doses. Can be taken up to two hours before surgery with wate
29
What are some examples of critical medications?
Anti-seizure Diabetes Antiretrovirals (HIV) Antibiotics Parkinson's Certain cardiovascular meds
30
What considerations need to be made if a surgical patient is on critical meds?
- Risk of stopping: clinical need and urgency - Effect on observations (BP, glucose etc) - Restarting as soon as pt can eat and drink - Temporary change to alternative regimen (VRIII, rotigotine patch) - Meds that should not be started for a specific period post op - Route and bioequivalence - Half-life - Bleed risk (warfarin)
31
How should a surgical patient taking warfarin be managed?
Elective surgery: Warfarin takes 2-4 days to work so hold for 4-5 days before to make sure its not having an effect Emergency surgery: give vitamin K to reverse absorption When restarting bridge with LMWH as warfarin takes a few days to work
32
What is the target INR during surgery?
< 1.5
33
What are some resources that can be used when holding medications in surgical patients?
UKPCA peri-op guidelines local guidance for holding and restarting anticoagulants pre and post-op
34
What is the goal of antibiotic prophylaxis in surgical patients?
reduce post-procedural wound infections and infectious complications such as sepsis
35
How is antibiotic prophylaxis administered in surgical patients?
Single large dose given before the incision to produce effective tissue levels (doses may be given after as well) Choice of antibiotic based on allergies and likely pathogen Type of surgery (clean, contaminated, dirty) Timing and dose Local guidelines
36
What are the four types of surgical wound?
Clean Clean-contaminated Contaminated Dirty
37
Describe clean surgery
No inflammation or infection No breach of aseptic technique Resp/GI/Urinary tract not entered E.g. Elective surgery WITHOUT implants , thyroidectomy
38
Describe clean contaminated surgery
Incision through intact skin Resp/GI/Urinary tract entered but no significant leakage E.g. biliary tract operations, abdominal hysterectomy
39
Describe contaminated surgery
Acute but non-purulent acute inflammation Visible contamination Aseptic technique broken E.g. Major colonic procedures
40
Describe dirty surgery
Open injuries (e.g. car accident) Existing clinical infection Presence of pus or wet gangrene E.g. removing a burst appendix More likely to need antibiotics AFTER surgery
41
Types of post op infection
IV/catheter line infection Aspiration pneumonia UTI Wound infection
42
How would we check for post-op infection?
Temperature spike Infection markers - CRP, neuts, WBC Microculture and sensitivity testing - giving empirical antibiotics before organism is narrowed down
43
Diabetes and surgery general
Patient is NBM pre-op Surgical stress --> more glucagon less insulin --> hyperglycaemia Need to monitor and maintain normoglycaemia to prevent complications such as infections and DKA
44
Diabetes management DURING surgery
- Try to schedule earliest in the day so there is less NBM time so lower risk of complication - Variable rate intravenous insulin infusion - fast acting, soluble human insulin given continuously on a sliding scale depending on blood glucose - Monitor potassium levels - insulin drives potassium to cells - if pt is hypokalaemia administer KCl and fluids incl. glucose so insulin has a substrate - Fluids - Continue long acting insulin BUT HOLD SHORT ACTING
45
Diabetes management after surgery.
Stop VRIII when eating and drinking but give short acting insulin BEFORE stopping VRIII so patient is still covered by VRIII in the time it takes for short acting insulin to work Consider factors that would affect the reintroduction of oral therapy - e.g. metformin need to consider renal function/AKI
46
What are some post-op considerations for the surgical patient
Continuing/restarting regular medication VTE prophylaxis Analgesia Antiemetics Laxatives and bowel prep Fluid and electrolyets
47
What factors should be considered when restarting/continuing regular meds in the surgical patients?
Risk vs benefits by considering PRESENT state of patient Eating and drinking? bowel function? gut rest - would pt require TPN? Clinical obs and lab results Indication for med post-op UKCPA peri-op guidelines Monitoring - side effects and toxicity
48
Post-op consideration for patients on long term steroids?
- dose increased initially usually double dose : if dose is doubled for over a week would taper down but if not then can go straight back to pre-op dose
49
Post-op consideration for patients on anticoagulants?
Look at hameoglobin - blood loss Local guidelines based on type of surgery Warfarin can take 2-4 days to work so need to bridge with LMWH DOACs (rivaroxaban, edoxaban) only need to be held for a day and work quicker so do not have to bridge
50
VTE Thromboprophylaxis - Risk factors for hospital acquired DVT or PE
Previous VTE Family history of VTE Age over 60 Prolonged immobility - major surgery, c-section, hip and knee replacement, major ankle surgery Malignancy Obesity (BMI over 30) Dehydration Medical co-morbidities Use of HRT
51
Why are surgical patients are risk of VTE?
CIRCULATORY STASIS : reduced blood flow especially in long procedures or if patient is immobile - blood pools in one area = higher risk of clot ENDOTHELIAL INJURY : operation damages endothelial wall - factors release and there is platelet activation - higher risk of blood clots HYPERCOAGULABLE STATE : dehydration, cancer or recent clot - higher risk of clot
52
Two types of thromboprophylaxis
Mechanical Chemical
53
Describe mechanical thromboprophylaxis.
Anti-embolism TED stockings (compression stockings) Increase venous return to prevent stasis Need to fit properly Avoid in PERIPHERAL ARTERIAL DISEASE - Patient already has low blood flow so there is risk of ischaemia
54
Describe chemical thromboprophylaxis.
LMHW - prevents the formation and development of thrombi Can cause thrombocytopaenia !!!!!! SC injection - need to rotate sites DOACs - apixaban and rivaroxaban - used in ~TKR and ~THR - 28-35 days How long will patient be immobile Was patient already on anticoagulants
55
What are some consequences of uncontrolled post-op pain?
Negative effects on mobility and function Slowed recovery (could lead to chronic pain) Increased time in hospital - increased risk of infection Poor wellbeing and QoL Pulmonary and thromboembolic complications (as in hospital for longer)
56
What is the goal when controlling post-op pain?
Optimise analgesia during critical post-op recovery period
57
How do we move up and down the WHO pain ladder post-op?
Start on STEP 3 - strong opioid + non opioid (paracetamol/ibuprofen) +/- adjuvant AND STEP DOWN AS APPROPRIATE
58
How else is post-op pain managed?
Holistic recovery faster recovery if patient starts physiotherapy ASAP but if they are in too much pain they can't attend physio
59
What are some side effects of analgesia?
N/V Constipation Itching
60
Who is codeine contraindicated in?
Ultra-rapid metabolisers
61
What is PCA?
Patient controlled analgesia used for strong opioids such as morphine, oxycodone and fentanyl Patinent can administer a smll bolus dose to achieve rapid pain relief with specified dose and lockout itme Can calculate 24h use to find a starting point so surgical team can adjust to lowest effective dose Used for 1-2 days
62
Advantages of PCA (6)
Less adverse effects/excess use if not required Quicker initial control of pain - faster recovery Negate the need for repeated IM/SC injections - frees up nurses time Avoiding peak + trough opioid levels Patient empowerment Improved individualisation of drug dosing
63
Disadvantages of PCA (5)
Analgesia not achieved during sleep (unless background long acting formulations used) Patient may wake up in pain Lack of education - lack of understanding Fears about opioid addiction/overdose Cost and maintenance of equipement
64
Epidurals contianing opioids?
Contain local anaesthetic + strong opioid E.g. labour epidural is bupivacaine and fentanyl Work synergistically Lower doses of each medication can be used which reduces side effects Allow patient to deep breathe and early moving around (ambulation) - reduced risk of DVT, chest infection and pressure sores
65
Step down approach to analgesia when using PCA.
IV PCA --> oral then wean down then dtep down to weak opioids before discharge if possible
66
NSAIDs for post operative pain
May be useful chronic disease but less common if no complications Consider patient factors - age, asthma, renal impairment Risk of thrombotic events or GI events (selective COX-2 lower risk of GI events) Gastroprotection (PPI)
67
PONV risk factors?
Female Non-smoker History of motion sickness Weight Use of drugs which cause nausea and vomitng - opioids , anaesthesia Type of surgery
68
Antiemetics used for PONV
Usually used PRN but can be regular Ondansetron - 5HT3 antagonist Cyclizine - antihistamine Prochlorperazine - first gen antipsychotic Dexamethasone in some patients
69
MHRA advice on domperidone for N/V
not indicated in children under 12 or under 35kg Restrict to max 10mg TDS for up to ONE week Contraindicated in cardiac disease, GI obstruction or haemmorhage
70
MHRA advice on metoclopramide for N/V
Restricted to 10mg TDS for 5 days in adults Risk of extrapyramidal side effects/tardive dyskinesias Can induce acute dystonic reactions in young patient especially females CONTRAINDICATED 3-4 DAYS after GI surgery DO NOT USE IN PARKINSONS DISEASE AS ITS A DOPAMINE ANTAGONIST
71
Post op constipation causes
NBM - dehydrated Opoid use
72
Postop constipation treatment
Movicol (osmotic laxative) - need water intake Senna (stimulant laxative) - do NOT use in intestinal obstruction as can cause perforation Adequate fluid intake, mobilisation
73
When may bowel cleansing preparations be used in surgical patients?
Pre-operatively e.g. in emergency surgery cannot be nbm beforehand so need to clear bowel
74
Why is the administration of fluids important in surgical patients?
Need to maintain circulating vol. to prevent decrease organ perfusion PERIOPERATIVELY
75
Colloids and crystalloids
Colloids - proteins/ high MW - stay in plasma to maintain volume Crystalloids (MOST COMMON) - 0.9% NaCl, 5% dextrose
76
Why may there be losses in volume post-operatively?
Increased output due to drains from surgical site Increased GI output - ileostomy, diarrhoea, PONV Hyperventilation and pyrexia - sweating NBM state/ limited eating and drinking (dehydrated) Hypotension (hypovolaemia, epidural)
77
How could we monitor if a patient is dehydrated?
Measure blood urea - INCREASE Urine output/colour

PHAY0085 (15 decks)

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