Surgery

Question 1

What are the risks associated with poor glycemic control?

Answer 1

significant impact on the risk of postoperative

infection

Question 2

Give contraindications to use of antiembolism stockings?

Answer 2

Peripheral vascular disease and neuropathy.

Question 3

Diabetic patients should be well controlled before surgery, what HbA1c value are we aiming for?

Answer 3

<69 mmol/l

Question 4

T or F - all medication which reduces gastric acid should be given on the day of surgery?

Answer 4

True

Question 5

T or F - all asthma drugs and inhalers should be given before surgery?

Answer 5

True

Question 6

How many days before an operation should clopidogrel be stopped?

Answer 6

7 days

Question 7

If a patient is taking dual antiplatelet therapy and requires surgery, what should we try and do and why?

Answer 7

Try and delay the surgery until it is safe to stop one of the antiplatlets

Question 8

Should lithium be taken before surgery?

Answer 8

NO- omit 24 hours pre-op unless minor surgery

Question 9

How long before surgery should the COC be stopped?

Answer 9

4 weeks

Question 10

What general monitoring is required during and after surgery?

Answer 10

Fluids
Blood pressure
Renal function
Pain control

Question 11

What non pharmacological advice is very important for patients with Ulcerative colitis?

Answer 11

Stopping smoking!

Question 12

Should mesalazine be taken the day of surgery?

Answer 12

No should discontinue the day before surgery

Question 13

How do we ensure patients who are taking long term steroids have adequate glucocorticoid levels to cope with the stress of surgery?

Answer 13

Give IV hydrocortisone 25mg-50mg at induction and afterwards (how long afterwards will depend on surgery)
Dose depends on patients normal daily dose

Question 14

How can we manage pain in a patient with UC following a colectomy?

Answer 14

Paracetamol

Dihydrocodeine or morphine

Question 15

Why is codeine not a suitable analgesic in patients with UC?

Answer 15

Risk of toxic megacolon

Question 16

Why is dihydrocodeine preferred to codeine as a post-op analgesic?

Answer 16

Approx. 20% of patients are unable to metabolise codeine and obtain its analgesic effects

Question 17

What analgesic should never been given to patients with UC?

Answer 17

NSAIDS

Question 18

T or F - smoking is protective against PONV?

Answer 18

True - non smokers are more likely to experience PONV

Question 19

Are men or women more likely to experience PONV?

Answer 19

Female

Question 20

Which antiemetic is not useful for PONV?

Answer 20

Metoclopramide

Question 21

When should antiemetics be given to prevent PONV?

Answer 21

30 mins before the end of surgery

Question 22

Outline the management of patients taking warfarin who have a planned surgery

Answer 22

Need to assess the reason patient is taking warfarin and this will determine there risk of VTE.
Last dose of warfarin needs to be taken 6 days before surgery.
Whether we bridge or not with LMWH or UFH depends on VTE risk

Question 23

What INR are we aiming for before surgery?

Answer 23

<1.5

Question 24

If a patient taking warfarin is at low risk of VTE how should we manage this pre-operatively?

Answer 24

No LMWH is required
Stop warfarin, take the last dose 6 days before
Use non-pharmacological methods

Question 25

If a patient taking warfarin is at moderate risk of VTE how should this be managed pre-operatively?

Answer 25

Stop warfarin 5 days before Start therapeutic-dose LMWH at 8 am 2 days after stopping warfarin Take last LMWH dose 24 hours before surgery is planned (i.e. at 8 am the day before surgery)

Question 26

If a patient taking warfarin is at high risk of VTE how should this be managed pre-operatively?

Answer 26

Stop warfarin 5 days before Start therapeutic dose of LMWH at 8 am 2 days after stopping warfarin Take last dose LMWH 24 hours before surgery Start patient on UFH and this should be stopped 6 days before surgery

Question 27

Should aspirin for secondary prevention of CVD be omitted before surgery?

Answer 27

Should continue unless very high bleeding risk

Question 28

What dose of exogenous steroids and within what time period might mean patients require additional glucocorticoids during surgery?

Answer 28

Patients on >10mg/day of prednisolone within 3 months of surgeyr

Question 29

If patients stop taking COC before surgery what are the risks associated with this?

Answer 29

Pregnancy - also has a vte risk

Question 30

Should tamoxifen be stopped before surgery?

Answer 30

Patients taking tamoxifen are at increased risk of VTE, but need to discuss with oncologists whether safe to stop. if we can stop then try and stop 3 weeks before.

Question 31

What are the two main issues associated with MAOIs and surgery?

Answer 31

Potentially fatal drug interactions and with anaesthesia | and risk of hypertensive crisis

Question 32

What is very important that we ensure in patients taking lithium during surgery where we havent been able to stop the lithium 24 hours before?

Answer 32

Need to ensure hydrated - Li is renally excreted and want to avoid accumulation. Should monitor fluid balance and Li levels

Question 33

In terms of VTE prophylaxis post-op how do we classify patients in terms of risk and how does their managemnet vary accordingly?

Answer 33

Either classified as low or high risk. One risk factor puts patient in the high risk category If low risk - use non pharmacological methods if high risk - use LMWH or NOACs

Question 34

Extended VTE prophylaxis is required following surgery on a fractured neck of femur, how long should VTE prophylaxis be continued?

Answer 34

4 weeks

Question 35

Extended VTE prophylaxis is required following abdominal/pelvic cancer surgery, how long should VTE prophylaxis be continued?

Answer 35

4 weeks

Question 36

How do we managed pain post-op?

Answer 36

Use the WHO pain ladder in reverse

Question 37

Outline the Apfel scoring system

Answer 37

Female- 1 History of PONV or motion sickness - 1 Post op use of opioids - 1 Non-smoker - 1

Question 38

What is meant by a clean surgical procedure? Are antibiotics required prophylatically?

Answer 38

Clean: No break in sterile technique, site not inflamed or infected e.g. breast surgery Generally no prophylaxis is needed

Question 39

What is meant by a clean-contaminated procedure? Are antibiotics required prophylatically?

Answer 39

Clean – Contaminated – at induction and up to 24 hours post op Used at induction and up to 24 hours post op

Question 40

What is meant by contaminated surgery?

Answer 40

Contaminated: Major break in sterile technique, spillage from GI tract or acute inflammation encountered

Question 41

What is the preferred route for antibiotic prophylaxis?

Answer 41

IV

Question 42

What time should antibiotic prophylaxis be given and why?

Answer 42

Dose / infusion completed just before incision if iv – to be effective we want the concentration of antibiotic to be highest at the time of incision.

Question 43

should atorvastain be taken the morning of surgery?

Answer 43

Yes