1
Q
Principles of trauma informed care
A
CCVEST
- Safety - everyone should feel safe
- Trustworthiness - decisions should e fully informed
- Collaboration - remove power imbalance when making informed decisions
- Empowerment - building on a patients strengths to be involved in their own care
- Voice and choice - choice is central, and the patients voice should be heard
- Culture, historical and gender issues - implementing protocols that recognise minority groups
2
Q
Drugs used in hormonal therapy in gender reaffirmation (and anaesthetic considerations)
A
Oestrogen
○ Increased VTE risk
○ Increased PONV
○ May be affected by sugamadex use
○ Reduced serum albumin, increasing free drug fraction (e.g. increasing risk of LA toxicity)
Cyproterone - synthetic progesterone and anti-androgen
○ Adrenocortical suppression
○ Fulminant liver failure
Spironolactone - anti androgenic
○ AKI
○ Hyperkalaemia
○ Volume depletion
Bicalutamide - anti-androgen
○ CYP3A4 inhibitor - increased warfarin effect
Testosterone
○ Erythrocytosis
○ Sleep apnoea
○ Hypertension
3
Q
Surgical options or gender reaffirmation
A
Surgical options for transgender women:
- Breast/chest surgery - augmention/implants
- Genital surgery: Penecotmy and orchidectomy then vaginoplasty, clitooplasty and vulvoplastry
- Facial feminisation surgery and thryoid cartilage surgery
Surgical options for transgender men:
- Mastectomy
Hysterectomy with BSO, vaginectomy , then phallopasty, scrotoplasty and testicular implants
4
Q
Airway concerns in those who have had gender reaffirmation surgery
A
- Chondrolaryngoplasty - makes cricothyroid palpation more difficult for FONA
- Recurrent laryngeal nerve injury when reshaping thyroid cartilidge
- Airway oedema may be present if vocal cord surgery
- Airway anatomy remains in keeping with sex at birth
5
Q
Anaesthetic considerations for penetrating eye injury
A
Normal IOP 10-21mmHg
- RSI if unfasted
- Minimise rise in intra-occular pressure
○ Avoid sux if possible
○ Maintain normal PaO2/PaCO2
○ Avoid sympathetic stimulation (consider remi) - Full muscular relaxation with TOF monitoring to prevent extra-occular muscles contracting
- Consider deep extubation
- Anti-emetics to reduce PONV
- Positional factors (tight tube ties, head positoning etc)
6
Q
Drugs to reduce IOP
A
Acetazolamine - CA inhibitor
Mannitol - osmotic diuresis reducing vitreous humour
Timolol - reduce aqueous humour production
Latanoprost - increase aqueous humour drainage
7
Q
Risk factors for AAA
A
- Age>65
- Male
- Smoker
- Peripheral vascular disease
- HTN
8
Q
EVAR vs open for AAA surgery
A
- Avoids GA in co-morbid patients
- Reduced wound size aiding post op recovery
- Reduced post operative opioid requirement
- Reduced blood loss
- Earlier ambulation resulting in improved recovery
9
Q
Reasons an EVAR may be difficult under LA
A
- Significant back pain resulting in patient movement and difficult stent placement
- Agitation due to cerebral hypoerfusion
- REBOA causes lower limb ischaemic pain
- Aorto-uni-iliac graft requires femero-femoral crossover after
- Chronic conditions preventing lying down for prolonged time
10
Q
Reasons for cardiovascular compromise on induction
A
- Loss of sympathetic response to pain
- Myocardial depressant effects of anaesthetic agents
- Abdominal wall relaxation reducing any tamponade effect
11
Q
Reasons for ongoing bleeding post AAA repair
A
- Endoleak type 1 (continued bleeding above or below graft)
- Insidious bleeding from puncture sites
- Endovascular injury during stent/wire placement
- Coagulopathy post large volume bleed and resuscitation
12
Q
Post operative complications of an EVAR
A
- Abdominal compartment syndrome (pressure >20mmHg with organ failure)
- Ischaemic colitis
- AKI
- Cholesterol embolus
- Lower limb ischaemia
13
Q
What are the causes of AKI post EVAR - how can these be mitigated?
A
Causes
○ Plaque embolus into renal artery
○ Stent obstruction to renal arteries
○ Bleeding and hypotension
○ High contrast load during procedure
How to minimise
○ Cardiac output monitoring to prevent hypovolaemia
○ Avoid nephrotoxics
○ Awareness of CKD and reducing contrast load - use IV bicarb
- Meticulous surgical technique
14
Q
Describe the effects of aortic cross clamping including risks, and how risks can be mitigated
A
Effects
- Immediate increase in afterload - increases myocardial O2 demand
- Loss of venous capaitance of lower limb with increased circulating volume - increase risk of pulmonary oedema and raised ICP
- Renal, mesenteric, spinal cord and leg ischaemia (depending on clamp location)
- Aortic damage at site of cross clamp
- Embolism is clamped over atheromatous aorta
Reducing risks
○ Deepen anaesthesia to reduce affects of afterload increase
○ Vasodilate with GTN or remifentanil
○ Heparinise prior to cross clamping
- ○ Ensure adequate oxygenation to reduce myocardial stress
- Not clamping atheromas
- Use shunts
15
Q
Describe the effects of unclamping aortic cross clamping including risks, and how risks can be mitigated
A
Effects
- Sudden decrease in afterload = hypotension
- Sudden reducion in aortic root pressure = poor coronary perfusion = MI or arrest
- Reperfusion and recirculation of metabolic waste products causes systemic vasodilation
- Circulating volume sequestered in capacitance vessels of legs
Reducing risk
○ Gradual release of clamp
○ Adequate intravascular repletion before release
○ Vasoconstrictors and inotropes
○ Increase minute ventilation to compensate for metabolic acidosis from reperfusion
- Early treatment of arrythmias
16
Q
How can spinal cord ischaemia be minimised during AAA surgery
A
- CSH drain to minimise CSF pressure (SC perfusion = MAP - CSF pressure)
- Minimising clamp duration
- Lowest possible clamp site to allow radicular perfusion
- Maintenance of MAP with volume + pressors/tropes
17
Q
Reasons for a shunt insertion during carotid endarterectomy
A
- Routine use by some surgeons
- Under LA - If neurology detected
- Under GA as neurology cannot be assessed
18
Q
Regional techniques for carotid endarterectomy
A
- Local infiltration to skin
- Superficial cervical block
○ Posterior border of middle third of SCM - Deep cervical block
19
Q
Advantages and disadvantages of LA for carotid endarterectomy
A
Advantages
- Awake patient - monitor for neurology
- Earlier recovery
- Lower need for shunt - reduces embolic complications
- Artery closed at a normal BP - reduces post op haematoma
- General GA avoidance
Disadvantages
- Potentially moving patient
- May need to convert to GA
- Regional block risks
- Phrenic nerve palsy
20
Q
Reasons for haemodynamic instability during carotid endarterectomy
A
- Vagal nerve stimulation (runs in carotid sheath) - bradycardia and hypotension
- Impaired carotid sinus reflex due to clamping
- Compensatory hypertension with reduced cerebral perfusion
- Sympathetic stress of the surgery if awake
21
Q
Minimising stroke risk in carotid endarterectomy
A
Haemorrhagic - appropriate BP control
Ischaemic - Use of shunts
Embolic - Heparinisation (ACT 240s) and perioperative anti platelets
22
Q
Benefits of laparoscopic surgery (vs open)
A
- Reduced tissue damage (reduces stress response)
- Reduced incision size improves post op pain and opioid requirements
- Reduced SSI risk
- Faster recovery to normal E+D
- Reduced gut handling reduces post op ileus
- Better visualisation - reduced surgical errors
- Reduced blood loss
23
Q
Contraindications for laparoscopy
A
- Severe heart failure - increased vascular resistance likely to push into failure
- R to L cardiac shunt - shunt will increase with raised ventilatory pressures
- Raised ICP
- Retinal detachment
- Uncorrected hypovolaemia
24
Q
Risks in a laparoscopy
A
Surgical
- Damage to organs on trochar/veress insertion
- Haemorrhage due to trochar/veress insertion
- Accidental insufflation of gas into vessel - air embolism and circulatory collapse
Anaesthetic
Respiratory
- Hypoxaemia due to limited diaphragm movement
- Post operative atelectasis
- High CO2 due to systemic uptake of insufflation gas
- Raised airway pressures result in barotrauma
Cardiac
- Excessive pneumoperitoneum impedes venous return (IVC) and haemodynamic instability
- Impaired venous drainage increases risk of VTE
- Peritoneal stretch may induce vagal bradycardia or asystole
- Higher SVR so reduced CO
Neurological
- Raised intrathoracic pressure reduces venous drainage so increases ICP
- Increased pCO2 increases brain vasodilation increasing ICP
25
Catecholamine synthesis pathway
○ Phenylalanine (Phenylalanine hydroxylase)
○ Tyrosine (Tyrosine hydroxylase)
○ DOPA (DOPA decarboxylase)
○ Dopamine (Dopamine hydroxylase)
§ Broken down by COMT and MOA to homovanyllic acid
○ Noradrenaline (PNMT)
§ Broken down by COMT to normetanephrine then MOA to vanylylmandelic acid
○ Adrenaline
Broken down by COMT to metanephrine then MOA to vanylylmandelic acid
26
How can you test for a pheochromocytoma?
○ Biochemical
§ Urinary homovanylic acid (dopamine breakdown)
§ Urinary normetanephrine (noradrenaline breakdown)
§ Urinary metanephrine (adrenaline breakdown)
○ Radiological
§ MRI/CT
§ MIBG Scintography (radioactive analogue or noradrenaline taken up by phaeochromocytomas and visible on gamma camera)
27
How should a patient be pre-optimised for phaemochromocytoma surgery?
§ Optimise blood pressure, heart rate and rhythm
□ Alpha blockers
® Phenoxybenzamine (long acting non-selective alpha blocker) - Started 2 weeks before surgery but stopped 2 days before due to long duration of action.
® Non-competitive action prevents norarenaline surges causing hypertension but may lead to post-operative hypotension
® Action on a2 receptors may cause drowsiness
□ Beta blockers
® Selective B1 antaognists (atenolol) often used to help with tachycarrythmias
® Started after alpha blockers to prevent compensatory hypertension
□ Calcium channel blockers
® Prolonged release nicardipine used after alpha blockers for those in which BP remains uncontrolled
§ Optimise glucose control
§ Optimise electrolytes
Correction of volume depletion
28
How should intra-operative BP swings be managed in phaeochromocytoma?
§ Hypotension
□ Noradrenaline first then Vasopressin
□ V1 agonism = systemic vasoconstriction
□ V2 agonism = increased water re-absorption at the DCT and CD
§ Hypertension
□ Avoid drugs stimulating catecholamine release (ketamine, ephidrine, metoclopramide)
□ Avoid catecholamine release due to pain and surgical stress (magnesium, remi, dexmed)
□ Avoid cathecholamine release from tumour (minimise handling and low pneumo pressures)
Treating hypertensive surges (phentolamine, sodium nistroprusside/GTN, nicaridpine, esmolol)
29
What is ECT? Indications?
- Indications
○ Severe medication resistance depression & catatonia
○ Mania
○ Schizophrenia (including in the pregnant patient)
- Induced tonic clonic seizure of 15-20 seconds
- Treatment course includes 12 episodes over 6 weeks
30
Patient considerations for those undergoing ECT
- Capacity difficult to assess - may be under section
- Medical history likely to be difficult to gain
- Comorbidities that may make them unsuitable
○ cardiac ischaemia, failure or valvular disease
○ raised ICP or IO pressure
○ uncreated cererbral aneurysm
○ unstable fracture or C-spine
- ICDs or implanted devices may need turning off
Fasting status/reflux assessment
31
Cardiovascular effects of ECT
- Brief parasympathetic response - 15 secs (risk of brady/asystole)
- Prominent sympathetic response - increased HR/BP leads risk of cardiac ischaemia
Post procedure myocardial stunning - risk of LV failure
32
Drugs used in patients hacing ECT that may affect anaesthetic conduct
- Lithium
○ Prolongation of neuromuscular drugs
○ Reduced release of brainstem catecholamines - reduced anaesthetic agent
○ Renally excreted - NSAIDs reduce excretion
○ Cardiac arrythmias
- Fluoxetine
○ Risk of serotonin syndrome with
§ Serotonin reuptake inhibitors: fentanyl, tramadol
§ Seorotonin antagonists: ondansetron
○ Cytochrome 2D6 inhibitor - prevents conversion of codeine to morphine
Reduces platelet activity, risk of bleeding if given with NSAIDs
33
NICE guidelines for FNOF
- Aim to operate within 36 hours of admission (on day or next day) on a planned trauma list
- Orthogeriatric review within 72 hours
- Mobilisation on day or day after surgery
- Pre-op abbreviated mental test score
- Post op 4AT score
When to cancel a procedure
○ Hb<80 (Aim for >90 or >100 if IHD)
○ Na <120 or >150
○ K <2.8 or >6.0
○ Uncontrolled diabetes
○ Uncontrolled/acute onset left ventricular failure
○ Correctable cardiac arrythmia with ventricular rate >120
○ Reversible coagulopathy
Pain management assessment
○ Immediately on presentation
○ Within 30 mins of giving pain relief
○ Hourly until settled on the ward
Regularly throughout admission as part of nursing assessment
34
Factors increasing mortality in FNOF
○ Advanced age
○ Male
○ Pre-morbid neurological dyfsunction
○ Anaemia
○ Malignancy in last 20 years
Institutional living prior to injury
35
Anaesthesia principles for FNOF
○ Aim for regional
○ Keep MAP>80
○ Avoid long acting sedatives/opioids
○ Intrathecal dosing: <10mg bupivacaine and no opioids
GA: Aim for spontaneous breathing and minimal depth of anaesthesia
36
Risk factors fr bone cement implantation syndrome
○ Increasing age
○ Significant cardiovascular disease
○ Diuretic use
Male sex
37
Grading of bone cement implantation syndrome
○ Grade 1 - sats <94% or BP drop 20%
○ Grade 2 - sats <88% or BP drop 40%
Grade 3 - requires CPR
38
Methods if preventing bone cement implantation syndrome
○ Surgical
§ Avoiding use of cement
§ Surgeon informs anaesthetic team when implanting
§ Wash and dry femoral canal
§ Apply cement in retrograde fashion
§ Void vigorous pressurisation
§ Insertion of femoral venting canal
○ Anaesthetic
§ Ensure adequate BP and preload - aim 20% of preinduction BP
§ Monitor for haemodynamic compromise or loss of etCO2
§ Prepare vasopressors in case of cardiovascular collapse
39
Elective hip surgery ERAS
- Pre-op
○ Hip school/pre-rehab - increasing pre op strength and ROM
○ Stopping smoking
○ Stopping alcohol
○ Correcting anaemia
○ Reduce per-op fasting to minimum + carb drinks
- Intra-op
○ GA + neuraxial best results
○ Short acting spinals to prevent post op immobility/orthostatic hypotension
○ Avoidance of intrathecal opioids (unless special circumstances)
○ Single dose dexamethasone
○ Local infiltration
○ Nerve blocks
§ PENG - articular branches of femoral, obturator and accessory obturator
§ QL
§ ESP
○ TXA (give IV prophylaxis + surgical site)
○ Multimodal analgesia
- Post-op
○ Early mobilisation
○ Early return to normal diet
○ Criteria based discharge
Regular audit and improvement
40
Causes of renal failure
- Pre-renal
○ Diabetes (Most common)
○ Hypertension
- Renal
○ Glomerulonephropathies
○ Primary malignancy
○ Chronic UTI
○ Hereditary conditions (PKD)
- Post-renal
Recurrent/chronic obstructive uropathies
41
Cardiac co-morbidities associated with renal failure
- Hypertension due to RAAS failure
- Ischaemic heart disease (hypertension, poorly controlled diabetes and systemic inflammation)
- LV failure due to increased fluid retention (high pre-load)
- Uraemic cardiomyopathy
- Arrythmias due to electrolyte imbalances
Anaemia - reduced EPO production, anaemia of chronic disease, blood loss from dialysis
42
Indications and pre-operative considerations of dialysis
- Indications
○ Acidosis
○ Electrolyte imbalances
○ Ingestion of drugs
○ Overload
○ Uraemia
- Anaesthetic considerations of patients on dialysis
○ Recent heparin use
○ Fistula locations
○ Volume status (?need for pre-procedure dialysis)
○ Acid base status (?need for pre-procedure dialysis)
○ Electrolyte balance (?need for pre-procedure dialysis)
Recent heparinisation
43
How to optimise renal graft function prior to transpantation
- Recipient
○ Avoidance of hypotension
○ Starting immunosuppression intraoperatively - Rituximab (Anti CD20)
§ Causes anaphylaxis, angiodema, arrythmias
○ Avoiding nephrotoxic drugs
○ Avoidance of hypovolaemia (CO monitoring considered)
- Donor
○ Minimise warm ischaemic time (time from removal of blood supply to cooling)
§ Max 30 minutes
○ Minimise cold ischaemic time (time from cooling to reperfusing and warming within host)
Max 48 hours
44
Anatomy of the pancreas
- Head and Body divided when crossing over the SMA/SMV
- Uncinate is directly anterior to aorta and gonadal arteries - not always attached to main pancreas
- Arterial supply
○ Head and Uncinante receive blood from
§ Anterior/Posterior superior pancreaticoduodenal artery (from the gastroduodenal artery)
§ Anterior/Posterior inferioir pancreaticoduodenal artery (from the SMA)
§ The communicating artery (bridges the two arcades) is located in between the main and accessory pancreatic duct
○ Neck, Body and Tail
§ Supplied by the splenic artery
Gives off the dorsal pancreatic artery and great pancreatic artery
45
Symptoms of pancreatic cancer
○ General - fatigue, weight loss, jaundice, back pain, indigestion
○ Neuroendocrine:
§ Insulinoma - Hypoglycaemia
§ Glucagonoma - Hyperglycaemia
§ Gastrinoma - Zollinger-Ellison syndrome (gastric ulcers, oesophagitis, diarrhoea)
VIPoma - Diarrhoea, dehydration
46
Treatment of pancreatic cancer
- Treatment
○ Contact with the SMA or SMV dictates resectability
○ Abutment or venous encasement is a borderline for surgery
○ Arterial encacement is a contraindiciation
○ Neoadjuvant chemotherapy may lead to a tumour becoming resectable
- Surgical resection
○ Whipples - Head cancers.
§ Removes Gallbladder, Distal stomach, duodenum, distal common hepatic duct and head of pancreas
§ Creates three anastaomsis: gastrojejunostomy, pancreaticojejunostomy, hepaticojejunostomy
○ Distal pancreatectomy - body onwards
Removes body of pancreas and sometimes spleen (arterial supply dependent)
47
Anaesthetic considerations for pancreatic surgery
- Anaesthetic considerations
○ Pre-op
§ Anaemia - optimise pre-op (no evidence that transfusions improve outcomes, but iron may)
§ Nutritional deficiency and sarcopaenia
□ Nutritional intervention if weight loss >15% or BMI <18.5
§ Smoking and alcohol high risk factors - encourage abstencne
§ Glycaemia control - may be diabetic prior or as a consequence of disease
§ Neuro-endocrine tumours and their consequences should be managed
§ Avoid billiary drainage unless bilirubin >250
○ Intra-op
§ HOP tumours may cause gastric outlet obstruction and risk of aspiration (RSI required)
§ Careful fluid balance to promote anastamotic healing
§ High risk of bleeding due to proximity of major vessels
§ Somatostatin analogues - used to reduce neuroendocrine secretion and formation of pancreatic fistula
□ Cause delayed gastric emptying, bradycardia and ADH effect
§ Analgesic options
□ Thoracic epidural, TAP, wound catheters,
○ Post-op
§ Pancreatic fistula - into the periotenum which erodes tissues and blood vessels causing major haemorrhage or organ damage
§ Intraabdominal abscess formation
§ Anastamotic leak
§ Early (surgical complication) or late (due to anastamostic leak or fistula)
§ Delayed gastric emptying
48
Causes of acute traumatic coagulopathy
- Severe tissue damage
- Shock related tissue hypoperfusion
Inflammatory response activating anticoagulant, fibrinolytic systems and platelet dysfunction
49
Immediate resuscitation priorities in trauma
- Damage control surgery
○ Indications for surgery: Shock index >1, lactate >2.5, abnormal FAST
○ Aiming for initial control of haemorrhage or contamination, with definitive surgery later
- Permissive hypotension
○ MAP >50, Systolic >70 until bleeding stopped (tolerated for 1 hour)
- Blood product resuscitation
○ Correction of coagulopathy
○ Correction oh hypothermia
○ Correction of acidosis
○ Correction of electrolytes
50
Targets for haemorrhage management
- Hb>70
- Plt >50
- Fibrinogen >2
Calcium >1mmol/L
51
Blood product components
- PRC - red cells
- FFP - All clotting factors,
Cryo - factor VIII, XIII, vWf, fibrinogen
52
ATLS bleeding/shock categories
- Class I
○ <15% blood volume
○ normal haemodynamics
- Class II
○ 15-30%
○ HR >100
○ Normal BP
○ Anxious
- Class III
○ 30-40%
○ HR 120
○ BP drops
○ Confused
- Class IV
○ 40% +
○ HR >140
○ BP low
Significant drop in GCS
53
TEG interpretation
TEG:
- RKAML
- Reaction time - time to form clot (clotting factors)
- K time - time to reach a clot of certain strength (fibrinogen)
- Alpha angle - speed of fibrinogen accumulation (fibrinogen)
- Maximum amplitude - highest vertical amplitude (platelets/DDVAP)
Lysis at 30 mins - % reduction of height at 30 minutes (TXA)
54
Anaesthesia for TURP
-GA
- Neuraxial block level T10 required
○ Sympathetic fibres (hypogastric nerve) T10-12
○ Parasympathetic fibres (pelvic nerves) S2-4
Somatic (pudendal nerves) S2-4
55
What is TURP syndrome? What are the symptoms?
- Symptoms
○ Respiratory - hypoxia due to pulmoanry oedema
○ Cardiovascular - initial hypertension due to fluid overload - subsequent arrythmias and failure with cardiovascular collapse
○ Neurological - confusion and seizures due to cerebral oedema and glyceine (excitatory neurotransmitter
- Intra-operative risk factors
○ Large volume high pressure fluid
○ Low venous pressure
○ Prolonged surgery
○ Increased blood loss
○ Large volume prostate
56
Why is Glycine used for TURP?
Glycine
○ Non-conductive (Used as irrigation solution when monopolar diathermy is used (as saline conductive)
○ Transparent
○ Hypotonic - if excessive amounts absorbed, causes significant fuid overload and hyponatraemia
57
Management of TURP
○ Furosemide
§ Reduces overload but worsens hyponatraemia
○ Rapid correction of hyponatraemia causes cerebral oedema, seizures and CPM
§ Aim for 5mmol/L in first hour to resolve symptoms
§ Aim for 10mmol/L over 24 hours
58
How is lymphoma categorised?
- Hodkins
○ B cell cancer with Reed Sternberg cells.
○ Often spreads in contiguous predictable fashion.
○ Better prognosis
- Non-Hodgkins
○ B or T cell
Variable spread and pattern
59
Anaesthetic considerations for patients with lymphoma
- Airway
○ Mucositis from chemotherapy
○ Difficult airway due to cervical lymph node compression
○ Tracheal compression due to mediastinal lymph node compression - may be dynamic and only evident on laying flat
- Breathing
○ Atelectasis due to bronchial compression by lymph nodes
○ Recent (last 1-2 months) bleomycin treatment risks oxygen toxicity by increasing radial production (aim sats 88-92%)
○ Radiation pneumonitis or fibrosis post radiation treatment
- Circulation
○ Radiation induced cardiomyopathy or pericarditis
○ Compression of major vessels by large nodes
○ Difficult access if prior chemotherapy
- Haematology
○ Pancytopaenia due to hypersplenism and bone marrow disease
○ Need for irradiated blood due to risk of graft versus host disease
§ Host immune system cannot clear donated blood T cells
§ Donated T cells attack host (bone marrow) causing widespread inflammation and pancytopaenia
○ Difficulty crossmatching due to multiple previous transfusions
- Renal
○ Acute/chronic disease due to chemotherapy
○ Lymphocytic infiltration leading to acute/chronic disease
60
Functions of the spleen
- White pulp
○ Storage of macrophages, B and T cells
○ Pathogens (or APCs) enter and stimulate B and T cells to function (product antibodies or kill directly)
○ Important for encapsulated pathogen response (pneumococcal, HIB and meningitides)
- Red pulp
○ Phagocytosie old/damaged blood cells
Reserve of RBCs - can be released in severe hypovolaemia
61
Spleen trauma management
- Splenectomy should be avoided where possible
○ Maintenance of immunological function
○ Major surgery with significant bleeding risk
- Considerations for splenectomy vs consdervative
○ Access to IR embolisation of bleed
○ CT grading of splenic damage
○ Haemodynamic stability
○ Haemodynamic instability or grade 5 laceration should proceed for emergent surgery
High grade injuries with haemodynamic stability should be considered for IR
62
Splenectomy prophylaxis
- Elective - start prophylaxis 2 weeks before splenectomy
- Emergency - start prophylaxis 2 weeks after splenectomy
- Vaccinations
○ One dose of Men ACWY, Men B and pneumococcal
○ Further Men B 4 weeks later
○ Annual influenza
○ 5 yearly pneumococcal
- Antibiotics
Phenoxymethylpenicillin for 2 years minimum
63
Perioperative considerations of liver disease
- Respiratory
○ Ascites = increased risk of aspiration, basal atelectasis causing hypoxia and poor VQ matching, and reduced FRC
○ Hepatic hydrothroax
○ Hepatopulmonary syndrome - chronic liver disease causing vasodilator release causing AV shunting
- Cardiovascular
○ Cirrhotic cardiomyopathy
○ Hyperdynamic circulation - high CO with low SVR
- CNS
Encephalopathy
64
What is TIPS and what are the complications?
○ Intra-operative
§ Arrythmais during passage through RA
§ IJV puncture complications (bleeding, pneumothrax, IC injury)
§ Massive haemorrhage due to PV damage
○ Post-operative
§ Hepatic encephalopathy
§ Precipitation of heart failure
§ Stent occlusion/thrombosis
Contrast nephropathy
65
What are the risk factors for liver failure post liver resection?
○ High ASA
○ High age
○ Obestiy/metabolic syndrome/diabetes
○ Pre-existing liver dysfunction (high MELD/CP score)
Low future liver volume (20% required uusally, 50% if cirrhotic)
66
How can blood loss be minimised during liver surgery?
○ Maintain CVP <5cm H2O
○ Minimise PEEP
○ Prevent hypervolaemic circulation (excessive fluid)
○ Reverse trendelemberg position
○ Furosemide
- Pringle manouvre - clamping the hepatoduodenal ligament (clamps portal vein and hepatic artery)
○ Used to reduce bleeding
○ Causes liver ischaemia if left too long (ischaemic transaminitis)
○ Splanchnic circulation becomes congested (bowel ischaemia, and gut bacterial translocation)
○ Blood pooling in splanchnic circulation, reduced preload
Release leads to lactate and potassium washout (metabolic acidosis and hyperkalaemia)
67
Factors increasing VTE risk in abdominal surgery for malignancy
- Pro-coagulant factors released by tumour cells
- Abdominal masses preventing venous drainage
- Chemotherapy causing endothelial damage releasing procoagulant factors
- Long term lines
Often require surgery (prolonged)
68
Benefits of neuraxial in abdominal cancer surgery
- Avoiding opioids - supress inflammatory response and increase risk of spread
- Reduces stress response (and immune response suppression) reducing risk of spread
- Major surgery - increased pain and PONV
- Local anaesthetic has direct reduction in cancer progression
Reduction in VTE
69
What is HIPEC? What are the risks?
- Chemotherapy placed directly into peritoneal cavity - used in advanced ovarian and peritoneal malignancy. Peritoneum barrier prevent systemic uptake of chemotherapy agents into systemic circulation.
- Risks
○ Hyperthermia
○ Electrolyte imbalance
○ Coagulopathy
○ AKI
Hyperglycaemia
70
What are the ERAS components to reduce SSI?
- Prophylactic antibiotics within 60 minutes of incision
- Intraoperative temperature management
- Chlorhexidine skin prep
- Early drain removal
- Avoidance of hyperglycaemia
71
Indications for pelvic exenteration surgery?
- Locally advanced/recurrent pelvic surgery (rectal, anal, sarcoma, ovarian, endometrial, cervical, vaginal and bladder)
Pelvic abscess with persistent sepsis
72
What is pelvic exenteration?
Removal of 2 or more continuous compartments
○ Central - major pelvic organs
○ Anterior - urogenital organs
○ Posterior - sacrum and nerve roots
Lateral (x2) - major vessels and nerves of lower limbs
73
Types of intra-operative radiotherapy
- Types
○ Radiation
○ Orthovoltage
○ Brachytherapy
- Considerations
○ Transfer to location under GA to provide radiotherapy
○ Patient must be still during application (paralysis vs deep anaesthesia)
Staff must leave operating theatre whilst radiotherapy applied
74
Anaesthetic considerations for patients with abdominal malignancy
- Airway
○ Massive ascites increases risk of aspiration
- Breathing
○ Massive ascites reduces FRC and causes basal atelectasis (poor V/Q matching)
○ Pleural effusions may be present and impact ventilation
○ Bleomycin and oxygen interaction leading to increased radical toxicity - aim sats 88-92% if had in last 2 months
- Circulation
○ Chemotherapy agents may cause cardiotoxic effects
○ Pericardiac effusions or tamponades
○ Difficult venous access or indewelling lines may be present from chemotherapy
○ May have massive hypovolaemia on removal of ascites - consider Aline CVC and CO monitoring
- Neurological
○ Paracetamol and NSAIDs may be contraindicated in liver/renal failure
○ Consider regional
○ Thrombocytopaenia may preclude spinal, epidural or paravertebral
○ Use fentanyl/oxycodone in poor renal function
- Haematological
○ Chemotherapy agents may cause bone marrow suppression (pancytopaenia)
○ Increased VTE risk - procoagulant factors released, venous compression, chemotherapy, long lines
○ Ensure crossmatched if anaemic and thrombocytopaenic - risk of significant bleeding on viscera removal
- Renal
○ Risk of renal disease from chemotherapy agents
- Nutrition
Likely to be malnourished due to anorexia/asictes/N+V - may need dietician input to optimise prior
Final FRCA
flashcards
Decks in class (8)
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