Surgical Preparation

Question 1

What are the 4 signs of peritonism on examination?

Answer 1

1. Rebound tenderness
2. Percussion tenderness
3. Cough tenderness
4. Freely moving

Question 2

What are the 4 broad categories of patient management?

Answer 2

1. Active management
2. Supportive management
3. Ongoing investigations
4. Safety netting

Question 3

What 3 things should you consider prior to surgery?

Answer 3

1. Medications - all should continue except for anticoagulants, immunosuppressants, and diabetic medications
2. Food and fluid - NBM - 6hrs prior, clear fluid 2hrs prior
3. Are antibiotics required prior to surgery?

Question 4

What is the general fluid maintenance rate?

Answer 4

40ml + weight (kg) per hour

*this does not account for losses, just maintenance!

Question 5

How much K+ is required per day?

Answer 5

1mmol/kg/day

For a 70kg person, they need 70mmol per day

Question 6

Signs of fluid depletion

Answer 6

1. Dry mucous membranes
2. Reduced skin turgor (over sternum)
3. Urine output low (<0.5ml/kg/hr)
4. Complaining of thirst
5. In worsening stages - CRT prolonged, tachycardia, hypotension

Question 7

Signs of fluid overload

Answer 7

1. Raised JVP
2. Peripheral oedema
3. Pulmonary oedema
4. In worsening stages - tachycardia, tachypnoea +/- hypoxia

Question 8

Crystalloids

Answer 8

• Most commonly used
• Cheap
• Used for acute settings, theatre and fluid maintenance
• Types: 0.9% saline (N/S), Hartmann’s, dextrose

Question 9

Colloids

Answer 9

• Have high colloid osmotic pressure - were thought to raise intravascular pressure faster (no strong evidence of this)
• Used in resuscitation
• Disadvantages - anaphylactic reactions, coagulopathy, high cost

Question 10

Difference between 0.9% saline, dextrose and Hartmann’s solution?

Answer 10

0.9% saline - Na (154), Cl (154)
Dextrose - glucose (50)
Hartmann’s - Na (131), Cl (111), K (5), Ca (2)

Question 11

Consenting for surgery

- General risks and followup required

Answer 11

General risks
Common
- Infection - requiring abx and further treatment
- Bleeding - may require return to the operating room
- Small areas of the lungs collapse -> increases risk of chest infection -> may need abx, chest physio

Uncommon

• Heart attack or stroke
• Blood clot in leg -> lungs
• Death

Question 12

ABCDEF of surgical patient preparation

Answer 12

A - call anaesthetist
B - book patient theatre
C - consent/capacity
D - disposition - where will the patient go post surgery?
E - equipment - is there extra equipment that needs to be organised?
F - NFR - know what the patient’s wishes are

Question 13

SIRS - systemic inflammatory response syndrome

Answer 13

4 criteria:

• Temperature >38
• HR >100
• RR >24
• WCC > 12

Must meet 2 criteria

Question 14

Group and Hold

Answer 14

• Determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies.
• The process takes around 40 minutes and no blood is issued.
• Recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected.

Question 15

Cross Match

Answer 15

• Involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places.
• If it does not, the donor blood is issued and can be transfused in to the patient. This process also takes ~40 minutes, in addition to the 40 minutes required to G&H the blood (which must be done first).
• A cross-match is done if blood loss is anticipated

Question 16

Post surgical nausea and vomiting - risk factors

Answer 16

Factors which increase the likelihood of developing postoperative nausea and vomiting in adults include:

female sex
<50 years old
non–smoker
history of motion sickness
prior history of postoperative nausea and vomiting
type of anaesthetic medicines used (opioids, volatile anaesthetics and nitrous oxide)
dehydration
longer duration of surgery and type of surgery.

Question 17

Patient with Post-operative nausea and pain - what questions should you ask?

Answer 17

• Pain severity - determines type of analgesia required
• Site of pain - is the pain in the region of the surgery, or somewhere else (chest pain)
• What medications has the patient already received?
• Has the patient opened their bowels or passed flatus - absence of BO/flatus -> increases suspicion for postoperative ileus
• Is nausea associated with vomiting?
• Other postoperative symptoms
• Regular medications/allergies
• Current medical conditions

Question 18

Increased pain following surgery - what conditions should be suspected?

Answer 18

• Compartment syndrome
• Bleeding
• Infection

Question 19

Sedation Score

Answer 19

Respiratory depression is the most dangerous adverse effect of opioid analgesics.
It is almost always preceded by excessive sedation. Monitoring your patient’s sedation score is more effective at detecting early respiratory depression than monitoring the respiratory rate.
Aim for a sedation score of < 2.
A score of 2 indicates early respiratory depression and that intervention is required.

0 – wide awake
1 – easy to rouse
2 – easy to rouse, but cannot stay awake
3 – difficult to rouse

Question 20

What things should be monitored while a patient is using pharmacological VTE prophylaxis?

Answer 20

1. Platelets
2. Hb
3. Signs of bleeding
4. Signs of HIT
5. Renal function

Question 21

Do patients who receive therapeutic anticoagulation require additional VTE prophylaxis?

Answer 21

Patients already receiving therapeutic anticoagulation (with rivaroxaban, dabigatran, apixaban or warfarin) do not require additional pharmacological VTE prophylaxis. In fact, adding pharmacological VTE prophylaxis increases their risk of bleeding.

Question 22

Do patients who are prescribed regular anti-platelet therapy continue with this prior to surgery?
Do they need VTE prophylaxis?

Answer 22

• In general, continue antiplatelets prior to surgery (VTE does not protect against aterial thromboses)
• Add in appropriate VTE (antiplatelets have limited efficacy against VTE)