In terms of the Hierarchy of Feeding, briefly explain why you would use the following feeding methods:
1. Oral nutritional Supplements (ONS)
2. Nasogastric tube feeding (NGT)
3. Gastrostomy feeding (PEG/RIG)
4. Jejunal feeding (jejunostomy)
5. Parenteral nutrition (IV)
- Oral nutritional Supplements (ONS) - if unable to eat sufficient calories e.g. come in malnourished due to difficulty caring for self
- Nasogastric tube feeding (NGT) - if unable to take sufficient calories orally or dysfunctional swallow e.g. post-stroke
- Gastrostomy feeding (PEG/RIG) - if oesophagus blocked/dysfunctional e.g. oesophageal cancer
- Jejunal feeding (jejunostomy) - if stomach inaccessible or outflow obstruction e.g. bowel obstruction
- Parenteral nutrition (IV) - if jejunum inaccessible or intestinal failure (IF) e.g. intestinal fistula
State 2 methods that can be used to confirm the correct placement of an NG tube
- pH aspirate - should be pH<5
- Erect chest x-ray - tip of NG tube descend in the midline, bisect the carina and should be below the diaphragm
Outline the following terms:
- Fistula
- Adhesions
- Tenesmus
Fistula - an abnormal connection between 2 epithelial surfaces
Adhesions - scar-like tissue inside the body that binds surfaces together
Tenesmus - sensation of needing to open the bowels without being able to produce stool
List the 4 components required to demonstrate capacity
- Understand the decision
- Retain the information
- Weigh up pros and cons
- Communicate their decision
List some of the principals that will enhance recovery post-surgery
- Early mobilisation
- Adequate pain relief
- Early return to oral nutrition and hydration
- Avoiding drains and tubes
- Return to home quickly
- Minimally invasive surgery
- Good preparation prior to surgery
List risk factors for post-operative nausea and vomiting
- Previous nausea and vomiting or motion sickness
- Female
- Young age
- Non-smoker
- Use of volatile anaesthetics
- Use of post-operative opiates anaesthetics
List signs of hypovolaemia
- Hypotension
- Tachycardia
- Tachypnoea
- Dry mucous membranes
- Cold peripheries / increased capillary refill time
- Reduced skin turgor
- Feeling thirsty
- Reduced urine output
- Sunken eyes
- Reduced body weight
List signs of fluid overload
- Peripheral oedema
- Pulmonary oedema (SOB, reduced O2 sats, bi-basal crackles)
- Raised JVP
- Increased body weight
Explain how surgery affects steroids in the body and how this changes steroid prescription
- Surgery elicits a stress response in proportion to the extent of trauma and metabolic insult
- This causes activation of the HPA axis, resulting in an increase in the release of corticosteroids
- Patients on steroid therapy for plus 2 weeks may experience HPA axis suppression
- These patients are at risk of acute adrenal insufficiency after the operation due to their reduced ability to mount a sufficient endogenous steroid response
In these patients, peri-operative stress-dose corticosteroid therapy is required
What is a normal D-dimer value?
Age x 10
Outline both local and systemic factors that affect wound healing
Local:
- Type of wound
- Location of wound
- Size of wound
- Blood supply
- Presence of infection
- Medications
- Presence of a foreign body / contamination
Systemic:
- Age
- Other comorbidities e.g. CV disease or diabetes
- Nutrition
- Obesity
Define an abscess
An abscess is a localised collection of purulent material (dead cells and exudate), walled off by a zone of acute inflammation and granulation, in response to an infectious source
List common surgical purulent pathogens
- Staphylococcus aureus
- Streptococcus pyogenes
- E Coli
List 5 causes of post-operative pyrexia (5 Ws mnemonic) and roughly when they occur (how many days/weeks after)
- Wonder drugs: Anaesthesia
- Wind: Pneumonia and atelectasis (1-2 days post-op)
- Water: UTI (>3 days)
- Wound: Infections (> 5 days)
- Walking: DVT (>1 week)
Pyrexia can also be caused by a developing abscess post-operatively
Outline the drugs that need to be altered around the time of surgery
- Cardiovascular drugs:
- Clopidogrel: stopped 7 days before surgery
- Warfarin: stopped 5 days before surgery (replace with LMWH until the night before)
- ACE inhibitors: stopped day before surgery - Diabetes drugs:
- Insulin: held on the day of surgery (only short-acting)
- Sulfonylureas: held on the day of surgery (due to the risk of hypoglycaemia)
- Metformin: given as normal for short procedures (held if long surgery, and variable-rate insulin prescribed - Oral contraceptive pill should be stopped 4-6 weeks before surgery, and re-started at least 2 weeks after surgery (when the patient is mobile)
What’s the name of the scoring system used to rank ease of intubation
Mallampati classification (class 1-4)
Outline how to decide whether a post-op wound infection is mild or severe
Mild:
- NO fever
- Erythema
Severe:
- Fever
- Discharge or evidence of abscess
Outline how to manage mild and severe post-op wound infections
Mild (erythema, no fever)
- Oral antibiotics
- Analgesia
- Regular wound dressing
Severe (discharge, fever, evidence of abscess)
- IV antibiotics
- Wound swabs
- Reopen wound if abscess present
- Allow wound to heal by secondary intention
Outline why refeeding syndrome occurs on a metabolic level
Occurs in patients who have had a very low nutritional intake for a long period of time
On refeeding and increasing nutritional intake, there is a rapid switch from catabolism to anabolism (from breaking down, to building up)
This uses up many of the electrolytes, faster than they can be replaced - leading to a deficiency in electrolytes and other substances
Outline which electrolytes are affected in refeeding syndrome
POMP
Po -phosphate (low)
M - magnesium (low)
P - potassium (low)
Outline the INR target range for Warfarin
Target 2.5 (range: 2 - 3)
Outline the INR target range for Warfarin, specifically for metallic valve replacements
Target 3 (higher)
Specifically:
Aortic valve 2-3
Mitral valve 2.5-3.5
Outline what to do in the following INR ranges for Warfarin:
1. INR between 5 and 8, no bleeding
2. INR between 5 and 8, minor bleeding
3. INR > 8, no bleeding
4. Any major bleed
- INR between 5 and 8, no bleeding
- Omit Warfarin for 1-2 doses, then reduce dose - INR between 5 and 8, minor bleeding
- Stop Warfarin, give IV vitamin K, restart Warfarin when INR < 5 - INR > 8, no bleeding
- Stop Warfarin and daily INR testing, oral vitamin K if at high risk of bleeding - Any major bleed
- Stop Warfarin, give IV vitamin K and blood products: prothrombin complex concentrate
