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surgery Flashcards

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1
Q

what are the key responsibilities of a surgical pharmacist in the pre-assessment clinic?

A

take medication history, reconcile meds, assess suitability, optimise therapy (e.g. diabetes, anticoagulants), and provide lifestyle advice

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2
Q

what does a surgical pharmacist do during admission?

A

review charts, ensure continuation of essential meds, monitor labs and vitals

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3
Q

how does a pharmacist contribute in the post-op phase?

A

restart meds, manage pain, monitor fluids/nutrition, prevent complications (e.g. VTE, post-operative n+v [PONV]), review discharge meds/letter

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4
Q

what is the role of a surgical pharmacist?

A

pre assessment clinic
drug therapy during peri operative period
VTE prophylaxis
Abx prophylaxis
PONV
post-op pain relief
laxative therapy and bowel prep
fluid + electrolyte management
nutritional support (TPN)
wound management

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5
Q

what is the pharmacist’s role at discharge?

A

reconcile meds, counsel patient, summarise changes for GP, and provide follow-up advice

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6
Q

what does the suffix “-ectomy” mean?

A

removal of an organ (e.g., appendectomy = appendix removal)

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7
Q

what does “-ostomy” mean?

A

creating an opening to the skin surface (e.g., ileostomy)

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8
Q

what does “-otomy” refer to?

A

surgical incision or opening (e.g., laparotomy)

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9
Q

what does “-oscopy” mean?

A

visual examination using a scope (e.g., colonoscopy)

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10
Q

what is a splenectomy and what do we offer patients if they had this?

A

removal of spleen
spleen produces WBCs for immunity to fight off infections, stores and removes RBCs
offer vaccinations and prophylactic Abx (could be for life for high risk)

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11
Q

what is a pancreatectomy and what do we offer patients if the had this?

A

removal of pancreas
exocrine: enzymes to breakdown food
endocrine: insulin via beta cells (islets of langerhaans), alpha cells make glucagon (islets of langerhaans)
offer creon (= digestive enzymes) to take w meals to aid digestion and offer insulin!

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12
Q

what is the surgical stress response?

A

hormone-driven changes to maintain homeostasis and promote healing after surgery
can even be anticipation stress or physical stress of surgery

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13
Q

what are key physiological effects of the stress response?

A

↑ blood glucose, ↑ coagulability, ↓ BP, ↓ perfusion, ↑ infection risk

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14
Q

when is the stress response at its peak?

A

during and immediately after surgery

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15
Q

how does a decrease in blood volume affect the surgical stress response?

A

reduced blood volume may be due to blood loss or dehydration so body releases ADH in response (inc vasopressin = inc BP)

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16
Q

how does a decrease in calorie intake affect the surgical stress response?

A

not eating may be due to NMB period - this triggers increased glucagon and cortisol levels

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17
Q

what is ACTH?

A

adrenocorticotropic hormone
moves into adrenal cortex to raise cortisol - increased in stress!

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18
Q

how does an increase in hypercoagulability affect the surgical stress response?

A

increased hypercoagulability = protective response to prevent bleeding
also dehydration increases risk of clotting, longer surgery = more prone to clot

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19
Q

what are key pre op considerations?

A

ensuring Pt is haemostatically stable
manage existing conditions esp: DM, long term steroid use (as reduces steroid response in surgery - if Pt needs steroids, cannot produce cortisol on their own), anticoagulant, other meds, keeping Pt NBM, Abx prophylaxis

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20
Q

which medications should NOT be stopped peri-operatively?

A

antiepileptics (antiseizure), DM meds (insulin), antibiotics, Parkinson’s meds (missed dose can = dysphagia = dehydration = AKI), antiretrovirals, key cardiac meds
still able to take meds 2 hrs pre surgery (leave 2 hr gap to prevent risk of aspiration)

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21
Q

what’s the goal of antibiotic prophylaxis?

A

to prevent surgical site infections (SSIs) with a single pre-op dose to produce effective tissue levels
watch for markers of infection post op: WBC, neutrophils, CRP (inflammation marker), fever

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22
Q

what are common meds used post-op?

A

analgesics, laxatives, PPI, insulin, anticoagulants, antiemetics

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23
Q

what factors should be considered before restarting meds post-op?

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A

eating/drinking status, bowel function, infection risk, vital signs
is there a need to change formulation? i.e., DM - patch for those who cannot take oral
changing route? –> NEWT guidelines, consider bioequivalence
are the Hb levels ok to restart warfarin again (if needed)
does drug have long 1/2 life? i.e., amiodarone has long 1/2 life

24
Q

what does NBM mean and how long does it last pre-op?

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A

nil-by-mouth; no solids for 6h pre op, clear fluids until 2h pre-op
consider stress ulcer prophylaxis as acid production increased due to stress (increased cortisol = increased acid)

25
why do we keep patients NBM?
when under anaesthetic, laryngeal reflexes stop if Pt has full stomach then risk of regurgitation of contents and pulmonary aspiration = cannot breathe
26
why is stress ulcer prophylaxis used?
to prevent GI damage due to ↑ cortisol; IV PPI (e.g., pantoprazole) is used
27
when should warfarin be stopped pre-op?
usually several days before surgery to get INR < 1.5
28
why should we not restart warfarin immediately post-op?
high bleeding risk - restart when haemostasis is confirmed
29
what needs to be considered for DM?
pre op - surgical stress = hyperglycaemia need to maintain normoglycaemia to prevent complications such as infection and DKA during surgery: first on list (shorter NBM period), VRIII, monitor K+ (insulin drives K+ into cells), co-administer fluids, usually continue LA insulin (stop SA as Pt is not having meals) post op: stop VRIII when eating and drinking (give SA before stopping and first meal) if metformin Pt - are they dehydrated from surgery? AKI? can we restart? check renal function
30
what is VRIII and when is it used?
variable rate insulin infusion - used in diabetics peri-operatively (fast acting insulin given at continuous rate depending on Pt blood glucose and insulin needs) (during surgery)
31
what’s the role of long-acting insulin during surgery?
continue it while stopping short-acting insulin pre-op
32
what are key post op considerations?
continuing/restarting regular meds VTE prophylaxis, analgesia, anti-emetics, laxatives, fluids and electrolytes, post op infection
33
what do we start w post op infections?
1st treat w broad spectrum antibiotics like vancomycin then narrow down Tx after sensitivity results come back
34
what should be considered when restarting meds?
is Pt eating and drinking? lab results - check Pt on long term steroids - increase dose initially anticoagulants - restart at right time (Hb levels, haemostatically stable?) UKCPA peri operative guidance
35
when restarting long term steroids, why do we start them on higher dose initially?
risk of adrenal crisis as Pt may be unable to product cortisol due to long term steroid use - higher dose mimics natural stress response
36
what Pt are at higher risk of VTE?
previous VTE/medical conditions FHx of VTW elderly > 60 yrs certain meds, i.e., HRT, contraceptives obesity dehydrated co-morbidities prolonged immobility malignancy type of surgery
37
what options are there for VTE prophylaxis?
mechanical and chemical thromboprophylaxis mechanical: TED stockings, increase venous return/reduce stasis avoid in PAD (low blood flow = increased risk of ischaemia) chemical: LMWH - prevent formation + development of thrombi DOACs - apixaban, rivaroxaban for TKR, THR how long does it need to be continued for? take into account considerations! i.e., if Pt was on HRT, would need to stop this (check BNF)
38
when would we offer bridging therapy in Pt who are restarting/continuing anticoagulant meds? what meds are offered as bridging therapy and why?
would offer for those restarted on warfarin bc warfarin takes a few days to work so a LMWH will provide immediate anticoagulation till warfarin takes effect would NOT offer to Pt who are restarted on DOACs such as apixaban bc these work within a few hrs
39
why is post op pain management important?
if not managed: -ve 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
40
what needs to be considered w post op analgesia?
WHO pain ladder!! 1st rung: non opioids +/- adjuvant 2nd: weak opioids + non opioid +/- adjuvant 3rd: strong opioid + non opioid +/- adjuvant post-op, we do 3 --> 2 ---> 1 (step DOWN) pain score?? opioid: resp depression risk, CI in children (ultra rapid metabolisers) NSAID: consider GI protection in elderly or at risk
41
what does PCA stand for?
patient-controlled analgesia – allows patients to self-administer IV boluses for immediate pain relief (opioids within specific dose and lockout time)
42
name one benefit and one risk of PCA
benefit – faster pain relief; risk – patient may wake in pain if no background dose
43
outline the adv of PCA
reduces adverse effects and excess use if analgesia not required quicker initial control of pain = faster recovery reduces nursing time - removes need for repeated IM/SC injections avoids peak and trough opioid levels patient empowerment improved individualisation of drug dosing
44
outline the disadv of PCA
analgesia not achieved during sleep (unless background analgesia given overnight) patient may wake in pain lack of education = lack of understanding of PCA fears about opioid addiction/toxicity (better to have appropriate initial control for better long term outcomes) cost and maintenance of PCA equipment
45
what is an epidural?
injection into spinal cord of anaesthesia + opioid (synergistic effects) adv: allows for lower doses of both drugs, allows for earlier assisted movement
46
what increases risk of PONV?
female gender, history of motion sickness, use of opioids or anaesthetics, age, weight, type of surgery
47
name 3 antiemetics used for PONV
ondansetron, cyclizine, prochlorperazine domperidone: CI in children and certain conditions metoclopramide: restricted duration of use/dose
48
what causes post-op constipation?
opioids, NBM status, reduced mobility
49
name 2 laxatives used post-op
movicol (osmotic - need water), senna (stimulant) senna - NOT in intestinal obstruction as can = perforation
50
what should be advised for Pt w constipation?
adequate fluid intake exercise/mobilisation
51
why are fluids important in surgery?
to maintain blood volume, organ perfusion, and prevent dehydration can be depleted for variety of reasons such as surgical stress [sweat. pyrexia], NBM, hypotension due to hypovolaemia)
52
name two types of IV fluids
crystalloids (e.g. 0.9% NaCl), colloids (e.g. albumin - stay in plasma to maintain circulatory volume)
53
what can increase fluid loss post-op?
drains, vomiting, diarrhoea, sweating, GI output
54
what should be included in discharge medication counselling?
drug changes, when to restart held meds, opioid weaning, VTE duration
55
what is the pharmacist’s role in surgical discharge?
reconcile meds, communicate w GP, provide follow-up and safety-netting

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