Ward Visit After Major Surgery

Question 1

Which patients should be visited by the anaesthetist in the ward?

Answer 1

1. ASA 3,4,5
2. Epidural or PCA
3. CVL
4. Complicated intra-operative course

Question 2

Name the surgical regions with pain scores > 2 and duration of opioid use (days) ≥ 2

Answer 2

Thoracotomy

Laparotomy

Question 3

Describe assessment and management of PCA in ward

Answer 3

Clinical: Pain/sedated

Demands: few/many

Successful attempts: few/many

Usual initial settings: Morphine 1mg bolus with lock out time of 5 minutes, no background

Side effects: NV, pruritis, sedation

If high successful attempts and pain still severe –> increase bolus

If high successful attempts and sedated –> increase lock out time

If low demand and low successful attempts and in pain –> re-educate

Question 4

If the sensory block is inadequate with a functioning epidural, what actions can be taken

Answer 4

Bolus 3 - 5 ml and increase infusion rate

Question 5

What action should be taken if block is unilateral

Answer 5

Withdraw catheter 1 - 2 cm and give bolus dose

Question 6

If the sensory block is adequate in an epidural and analgaesia is inadequate, what action should be taken?

Answer 6

Consider other causes of pain (i.e. non-Standard surgical pain)
- Compartment syndrome
- Haemorrhage
- Infection
Obtain surgical review

Question 7

What anaesthetic related factors cause pruritis and what is the treatment

Answer 7

Epidural or spinal opioids

Mild - reassure

Severe: Chlorphenamine 4mg PO or 10 - 20 mg IV

Question 8

What actions should be taken if the epidural becomes disconnected

Answer 8

Any disconnected catheter should be considered contaminated. This contamination risk increases with increasing time to discovery.

Therefore, all catheters should be removed unless the epidural is essential and reinsertion would be problematic or impossible.

If the catheter is left in place, clean it with iodine, alcohol and sterile water and reattach a new filter. Consider a dose of antibiotic. Follow up the patient closely and remove the epidural at earliest opportunity.

Question 9

What are the initial considerations in a patient with an epidural that develops hypotension

Answer 9

Check the fluid status
Check the block height

Consider fluids and decreasing epidural infusion rate

Exclude surgical cause - e.g bleeding

Question 10

What should be done if increasing or complete motor block occurs?

Answer 10

Stop infusion
Watch for signs of block wearing off
If block wears off restart infusion at a reduced rate and consider decreasing the infusion concentration.

If motor block persists ≥ 2 hours or becomes progressive –> consider CNS damage –> MRI to exclude epidural hematoma/abscess

Question 11

What is the classic triad of symptoms for a spinal epidural abscess

Answer 11

Fever
Backache
Neurological deficit

Other

• Pus at skin entry site
• erythema > 1cm in diameter
• Local tenderness

Question 12

What actions should be taken in the case of a suspected spinal epidural abscess?

Answer 12

1. CRP, WCC, Blood cultures
2. Swab skin entry point
3. Send epidural catheter tip for culture
4. Start broad spectrum A/B
5. MRI
6. Neurosurgical opinion

Question 13

How long does a peripheral nerve block usually provide pain relief

Answer 13

2 - 18 hours depending on the site and drugs used

Question 14

Describe and classify the incidence of persistent peripheral nerve blockade

Answer 14

> 1 week (occur in 1 - 5% of blocks)

Of these 95% recover after 1 month
And 99% recover within a year

Question 15

What is the incidence of permanent nerve damage subsequent to peripheral nerve blocks

Answer 15

1:5000 to 1:30 000

Question 16

How can nerve damage occur during peripheral nerve blockade

Answer 16

1. Direct nerve injury by needle
2. Stretching or compression of the nerve
3. Hematoma
4. Inadequate blood supply
5. Infection

Exacerbated by pre-existing medical conditions: Diabetes/Atherosclerosis

Question 17

What actions should be taken in the instance of persistent neuropathy subsequent to peripheral nerve blockade

Answer 17

Refer to neurologist for nerve conduction studies/MRI

Question 18

Why is the Early Warning System effective

Answer 18

It allows early detection of a problem as it collaborates multiple small changes for early recognition rather than one marked change in one such as a drop in BP which can be a pre-terminal event

Question 19

What is the most sensitive indicator of a patient’s well being

Answer 19

Respiratory Rate

Question 20

What is the incidence of PONV after GA

Answer 20

25 - 30%

Question 21

Give a step wise approach to a patient with PONV

Answer 21

1. Exclude hypovolaemia, hypotension, hypoxia, dehydration, tachycardia other illness related causes of N and V
2. Ensure opioid sparing agents are used (Paracetamol & NSAIDS)
3. Ensure minimum dose of opioid to achieve pain control
4. ? Surgical cause - ? distended abdomen + aspirate NG tube
5. ? Prophylactic antiemetic prescribed
6. Prescribe antiemetic from a class different to the prophylactic drug used

Question 22

What is the most common cause for hypoxia after surgery and what is the treatment

Answer 22

Atelectasis

• Rx: Humidified O2 + Nebulized BD + physiotherapy + ensure adequate analgaesia

Question 23

Describe the presentation of Atelectasis

Answer 23

Tachypnoea, dyspnoea, tachycardia, pyrexia, hypoxaemia

Question 24

Describe a typical presentation of aspiration.

Summarize the treatment

Answer 24

Usually a history in keeping
Hypoxia
Wheeze

Rx:

1. Increase FIO2
2. HDU/ICU: CPAP/IPPV
3. Send sputum and blood for culture
4. Give antibiotics if indicated

Question 25

Describe risk factors for pneumothorax

Answer 25

1. Bullous lung disease
2. CVL insertion
3. Brachial plexus block

Question 26

Describe the classical presentation of PE

Answer 26

Sudden SOB with:

• Pleuritic chest pain
• Cyanosis
• Hypotension
• Haemoptysis
• Raised JVP

Question 27

Describe the presentation of small PE

Answer 27

Tachycardia, SOB and a low grade pyrexia.

Question 28

What is ARDS

Answer 28

ARDS is a non-specific inflammatory lung condition with many underlying causes. It is frequently associated with organ failure elsewhere. Hypoxia may be severe.

You should give oxygen and seek help from ICU.

Question 29

Define oliguria and classify the causes.

Answer 29

Oliguria is defined as urine output less than 0.5 ml/kg/h and is a sign that normally indicates an underlying disorder. It is important to firstly diagnose the cause correctly, in order to manage the oliguria successfully.

The cause may be:

Prerenal
Renal
Postrenal

Question 30

Describe three common causes of pre-renal oliguria

Answer 30

Hypovolaemia
Heart failure
Renal hypoperfusion (NSAIDS)

Question 31

What causes intrinsic renal disease

Answer 31

Prolonged pre-renal failure

Nephrotoxic drugs

Question 32

What are the most common causes of postrenal oliguria in a postoperative patient

Answer 32

Obstructed urinary catheter

BPH

Question 33

Which maintenance fluid should be avoided in children and why

Answer 33

4% glucose with 0.18% NaCl

- Hypotonic and high risk of life threatening hyponatraemia in kids is significant

Question 34

An 80-year-old man is on the ward. He is day 1 post laparotomy for small bowel obstruction and has an epidural in situ.

He is alert with a heart rate of 110 bpm. He has a respiratory rate of 14 breaths/min, blood pressure of 85/50 mmHg and urine output of 35 ml/h. He has a temperature of 38.0°C.

Is his EWS high (>4), medium (3-4) or low (1-2), and what is the relevant management?

Select one answer from the options, then select Submit.

Possible answers:
A. Low EWS, he needs further observation in 1 hour
B. Medium EWS, he needs review by a doctor
C. Medium EWS, he needs further observation in
1 hour
D. High EWS, he needs immediate intensive care

Answer 34

A. Incorrect.

B. Correct.

C. Incorrect.

D. Incorrect.

His EWS is 3 and he needs review by a doctor.

The level of his epidural should be assessed. He is probably hypovolaemic and requires a fluid bolus. He should then be reassessed after the fluid bolus.