peri operative

Question 1

Pre-op assessment

1. When do patients have their pre-op assessment
2. What must you find out when taking a pre-op history
3. Pre-Operative Examination

Answer 1

1. 2-4 wks before their date surgery
2. PC:

PC and procedure

PMH:

Cardiovascular disease: HTN & exercise tolerance -> risk of a cardiac event increased during anaesthesia

Respiratory disease, adequate planned oxygenations reducing risk of ischaemic evens peri-op

Renal disease:effect/causes e.g. anaemia, coagulopathy, biochemical disturbances

Blood loss of IV contrast given during some procedures can cause significant renal dysfunction, so care may be taken

Endocrine disease, specifically diabetes mellitusandthyroid disease

often require specific changes

Female of reproductive age – could they be pregnant?

African or Afro-Caribbean descent – could they have undiagnosed sickle cell disease?

Past SHx

Past Anaesthetic Hx:

Any issues? Were they well post-operatively? Has the patient experienced to any previous post-op N+V?

DHx/Allergies

FHx

Malignant hyperpyrexia

*An autosomal dominant condition -> muscle rigidity (despite neuromuscular blockade) followed by a rise in temperature (requires senior input and support if present)

Social Hx

Smoking history and alcohol intake and their exercise tolerance

3. General examination (cardio, resp, abdo)

Anaesthetic exam & Airway examination (to predict the difficulty of intubation)

Question 2

1. What grade directly correlates with post op complication risk? What does each grade mean?
2. Pre-op Ix? What decides which pre- op tests should be performed

Answer 2

American Society of Anaesthesiologists Grade

Depends on Co-morbidities, age, seriousness of the procedure

https://www.nice.org.uk/guidance/ng45/resources/colour-poster-2423836189

Question 3

Which blood tests would the team perform pre op and why?

Answer 3

FBC

Check for undiagnosed anaemia or thrombocytopenia

U&Es

Assess the baseline renal function, which will indicate potential co-morbid status and help inform any potential IV fluid management intra-operatively

LFTs

Assessing liver metabolism and synthesising function, may help direct medication choice and dosing

Clotting Screen

Any indication of deranged coagulation, such as iatrogenic causes (e.g. warfarin), inherited coagulopathies (e.g. haemophilia A/B), or liver or renal impairment, will need identifying and correcting before surgery

G&S or Cross-Match (X-match)

Question 4

What is group&save and crossmatch

Answer 4

Question 5

What imaging would the team perform pre op and why?

Answer 5

Electrocardiogram (ECG): Hx of CVD, major surgery, can provide a baseline if there are post-operative signs of cardiac ischaemia

N.B An echocardiogram (ECHO) can be considered if the person has (1) a heart murmur (2) cardiac symptom(s) (3) signs or symptoms of heart failure.

Chest X-ray: should not be performed routinely

Indications include:

Respiratory illness who have not had a CXR within 12 months

New cardiorespiratory symptoms

Recent travel from areas with endemic TB

Significant smoking Hx

If a patient has a chronic lung condition, spirometry may be of use in assessing current baseline and predicting post-operative pulmonary complications in these patients.

Question 6

Are there any other important pre op tests besides bloods, ECG and imaging?

Answer 6

1. Pregnancy testing: women of reproductive age; carry out a pregnancy test with the woman’s consent if there is any doubt about whether she could be pregnant.
2. Sickle Cell Test: any member of their family with sickle cell disease, or is African or Afro-Caribbean descent, strongly consider performing a sickle cell test.
3. MRSA Swabs: taken from the nostril ± perineum ± other sites for MRSA colonisation. If this is isolated, antiseptic hair and body wash,
4. Urinalysis: suspicion of ongoing glycosuria or UTI

tetracyclinealone (doxyclycline) alone

or a combination of rifampicin and fusidic acid can be used for skin and soft-tissue infections caused by MRSA;

clindamycin alone is an alternative.

A glycopeptide (e.g. vancomycin) can be used for severe

above CI linezolid. As linezolid is not active against Gram-negative organisms, it can be used for mixed skin and soft-tissue infections only when other treatments are not available; linezolid must be given with other antibacterials if the infection also involves Gram-negative organisms. A combination of a glycopeptide and fusidic acid or a glycopeptide and rifampicin can be considered for skin and soft-tissue infections that have failed to respond to a single antibacterial.

Tigecycline and daptomycin are licensed for the treatment of complicated skin and soft-tissue infections involving MRSA.

Question 7

Explain the airway examination

Answer 7

Check for:

• Facial abnormalities & receding mandible (retrognathia)

Ask the patient to open their mouth and assess:

• Their degree of mouth opening (favourable if inter-incisor distance is > 3cm).
• Their teeth, mainly do they have teeth? If so, what is their dentition like? Are any teeth loose?
• Their oropharynx, maximally protrude their tongue. A Mallampati classification, which correlates with difficulty of intubation, can be assessed.

Neck:

• Ask the patient to flex, extend and laterally flex the neck to see their ROM.
• Maximally extend their neck and measure the distance between the thyroid cartilage and chin (the thyromental distance); if this is <6.5cm (~3 finger breadths), it indicates that intubation may be difficult.

Question 8

Suggested Ix for Day Case patients include:

Answer 8

• ECG – All patients >70yrs or a history of chest pain, HTN, or a heart murmur
• LFT’s – Any alcohol intake over the expected amount
• U&E’s – All patients >60yrs, currently taking antihypertensives, history of DM or renal problems, or a urine sample >1+ protein
• Sickle cell test – If Afro Caribbean (and not previously tested)
• CXR – Any recent pneumonia, to discuss with anaesthetist
• TFTs – Patients on thyroxine or having thyroid surgery
• FBC – All patients >60yrs, or history of anaemia, any bleeding disorder, or sickle cell trait

For DM patients, perform a routine HbA1c; if >69mmol then discuss with anaesthetist regarding the need to defer the surgery

Question 9

1. A useful tool for structuring your management plan is RAPRIOP
2. Why do patients fast?

Answer 9

1. Reassurance

Advice:

• Stop eating – 6hrs before
• Stop dairy products (including tea and coffee) – 6hrs before
• Stop clear fluids – 2hrs before

Prescription

Referral

Investigations

Observations

Patient understanding and follow-up

2. *Fasting ensures that the stomach is empty of contents. This reduces the risk of pulmonary aspiration, which can occur during the perioperative period, which can lead to both aspiration pneumonitis (inflammation caused by very acidic gastric contents, leading to desquamation) and aspiration pneumonia (due to secondary infection following pneumonitis or direct aspiration of infected material).

Question 10

Drugs To Stop ‘CHOW’

Answer 10

Clopidogrel – stopped 7 days prior to surgery -> bleeding risk Aspirin and other anti-platelets can often be continued

Hypoglycaemics – DM

OCP or HRT – 4 wks -> DVT risk. Advise the patient to use alternative means of contraception.

Warfarin – ~ stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose LMWH

Surgery will often only go ahead if the INR <1.5, so you may have to reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before

Question 11

Drugs to alter

If the patient is on 10mg of pred PO how much do they need during the op?

Answer 11

Subcutaneous insulin – may be switched to IV variable rate insulin infusion.

Long-term steroids – must be continued, due to the risk of Addisonion crisis if stopped

If the patient cannot take these orally, switch to IV (a simple conversion rate is 5mg PO prednisolone = 20mg IV hydrocortisone)

Question 12

What drugs should we start

When might these drugs be contra indicated

Answer 12

LMWH – the admitting doctor should complete a VTE Risk Assessment and prescribe appropriately

• Most patients will receive this, with the exception of those with either contraindications or who are having neck or endocrine surgery
• Patients undergoing major GI surgery for Ca (including oesophageal, gastric, pancreatic, liver and colonic resections) and lower limb joint replacement should be discharged with TEDs and 28 days of prophylactic dose LMWH

TED stockings – all patients (except vascular surgery patients), need to be prescribed but check for contraindications (especially in the elderly). Contraindications include severe peripheral vascular disease, peripheral neuropathy, recent skin graft, severe eczema.

Abx prophylaxis – orthopaedic, vascular, or GI surgery

Question 13

Diabetes Mellitus

1. T1DM
2. T2DM

Answer 13

1.

• First on the morning list and they may need admitting on the night before the operation (depending on how major the procedure is)
• On the night before surgery, reduce their SC basal insulin dose by 1/3rd.
• Omit their morning insulin and
• commence an IV VRII pump, which is a syringe driver that usually contains 49.5mL of normal saline with 50 units of Actrapid.
• Whilst the patient is NBM, you will also need to prescribe an infusion of 5% dextrose, ~ given at a rate of 125mL/hr
• Check BM every 2hrs and to alter the infusion rate
• Continue until the patient is able to eat and drink. Once they are doing so, you must overlap their IV variable rate insulin infusion stopping and their normal SC insulin regimens starting. To do this, give their SC rapid acting insulin ~20 minutes before a meal and stop their IV infusion ~30-60 minutes after they’ve eaten.

2.

• If diet controlled, no action is required peri-operatively.
• If controlled by oral hypoglycaemics, metformin stopped on the morning of surgery, whilst all others should be stopped ~24 hrs before the operation. Then be put on IV VRII & 5% dextrose as described above and managed peri-operatively the same as a Type I diabetic.

Question 14

What is bowel preparation?

who may need it?

why is it less commonly used?

Answer 14

laxatives or enemas to clear their colon pre-operatively.

The exact protocol will vary between hospitals but a general guide is:

• Upper GI, HPB, or small bowel surgery: none required
• Right hemi-colectomy or extended right hemi-colectomy: none required
• Left hemi-colectomy, sigmoid colectomy, or abdo-peroneal resection: Phosphate enema on the morning of surgery
• Anterior resection: 2 sachets of picolax the day before or phosphate enema on the morning of surgery

fluid shifts can be harmful to patients who are elderly or have cardiac or renal disease,

can prolong patient recovery and length of stay.

Question 15

Fluid management

1. The reasons for fluid prescription are:

important questions to ask

2. Describe the fluid compartments
3. How to fluid resus patients

Answer 15

1. 5 Rs:

• Resuscitation
• Routine maintenance
• Replacement
• Redistribution
• Reassessment

Aim: resuscitation, maintenance, or replacement?

Weight and size of the patient?

Co-morbidities present that are important to consider, such as HF or CKD?

What is their underlying reason for admission*?

What were their most recent electrolytes?

2. Plasma osmolality is 290mOsmol/kg

* Total body water = 60% of weight (e.g. 70kg human) = 42L

* 2/3 intracellular (including RBCs) = 28L

* 1/3 extracellular = 14L

o 75% interstitial = 10.5L

o 25% plasma / intravascular = 3.5L

BASE FLUID RESUS WHEN >90 HR

Question 16

Serum

1. A 1% solution contains?
2. So how many grams would a 5% solution contain in 1 litre?
3. The molecular weight (molar mass) of glucose is 180g/mol. How many moles in 1 litre of a 5% solution? How many millimoles in 1 litre of a 5% solution? What is the calculated osmolality therefore of a 5% dextrose solution?
4. How to calculate osmolality?

Answer 16

1. 1 gram of solute per 100ml of solvent

2. 5g in 100ml

50g in 1L

3.

* Molecular weight of glucose is 180g/mol.

o How many moles in 1L of 5% solution?

* 5% = 50g in 1000mL

* No. of moles in 1000mL = 50g ÷ 180g/mol = 0.278mol

o How many millimoles in 1L of 5% solution?

* 0.278mol × 1000 = 278mmol

o What is the calculated osmolality of 5% dextrose solution?

* Calculated osmolality = 2 Na + Glucose + Urea (mmol/L)

* In 5% dextrose (aka glucose), calculated osmolality = 278mOsm/L

4. Calculated osmolality = 2 Na + Glucose + Urea (mmol/L)

* Some people, add another 2 K+ to the calculation, but this shouldn’t change it too much (2*4 = 8)

Question 17

What would the osmolality be if you are salt losing, what would it be if you are water losing?

Answer 17

Question 18

Q1: If 1 gram of dextrose produces 14 kJ energy. How much energy is provided by 1 litre of a 5% dextrose solution? How many kJ does an average adult need? What happens to the dextrose given intravenously in a 5% dextrose solution?

2. Do you think that the water in Normal Saline is distributed amongst total body water or just extracellular water?

Answer 18

2. Saline is distributed extracellularly as Na and Cl cannot freely pass through plasma membrane.

1000mL will stay mostly in the extracellular compartments:

* 75% interstitial = 750 mL

* 25% plasma / intravascular = 250 mL

Question 19

What factors may increase an individual’s water losses

Answer 19

Question 20

Explain how you would decide what to give for routine maintenance

What would you do for obese patients?

When would you consider prescribing less fluid (20–25 ml/kg/day fluid)?

Answer 20

25–30 ml/kg/day of water and

1 mmol/kg/day of potassium, sodium and chloride and

50–100 g/day of glucose to limit starvation ketosis

Obese: adjust the IV fluid prescription to their ideal body weight. Use lower range volumes per kg (patients rarely need more than a total of 3 litres of fluid per day) and seek expert help if their BMI is more than 40 kg/m2.

• are older or frail
• have renal impairment or cardiac failure
• are malnourished and at risk of refeeding syndrome

Question 21

Consequences of fluid mismanagment

Answer 21

• Hypovolaemia (reduced UO <0.5ml/kg/hr, inc in urea/creatinine
• pulmonary oedema (breathlessness, Coarse crackles: Discontinuous, brief, popping lung sounds. Compared to fine crackles they are louder, lower in pitch and last longer. They have also been described as a bubbling sound. Typically inspiratory and particularly wet sounding)
• hyponatraemia < 130 mmol/l
• hypernatraemia > 155 mmol/l
• peripheral oedema
• hyperkalaemia >5.5 mmol/l
• hypokalaemia <3.0 mmol/l

Question 22

Describe the two fluid regimens

Calculate the daily totals of water, sodium, chloride, and potassium for regimens 1 and 2.

Answer 22

Regimen 1

• 1L Normal saline over 8 hours
• 1L 5% dextrose + 20 mmol KCl over 8 hours
• 1L 5% dextrose + 20 mmol KCl over 8 hours

Regimen 2

• 1L Dextrose-saline + 20 mmol KCl over 8 hours
• 1L of Dextrose-saline + 20 mmol KCl over 8 hours
• 1L of Dextrose-saline + 20 mmol KCl over 8 hours

Na+ (mmol) 150 90

K+ (mmol) 40 60

Cl- (mmol) 190 150

Dextrose (g) 100 120

Question 23

NICE CG174 1.4.1 state that for maintenance:

Answer 23

* Water = 25-30mL/kg/day

* Na+, K+, Cl- = 1mmol/kg/day (or as I like to remember, “worth your weight in salt(s)”)

* Glucose = 50-100g/day minimum, just to limit starvation ketosis

Question 24

Why do we match rhesus group?

Answer 24

A RhD- patient will make RhD antibody if they are given RhD+ blood. Clearly, this will not matter for the patient; a RhD- patient, who is given RhD+ blood, and therefore makes anti-D, cannot then go on to attack their own red blood cells as they do not have RhD present on their RBC membrane.

However, this does cause potential problems during pregnancy as anti-D antibodies can cross the placenta, such as may occur in the following example:

• A woman is born with RhD- blood. Her partner is RhD+ and she becomes pregnant with a fetus that is also RhD+. During childbirth, she comes into contact with the foetal (Rh+ve) blood and develops antibodies to it.
• She later becomes pregnant with a second child that is also Rh +ve.
• The woman’s anti-D antibodies cross the placenta during this pregnancy and enter the foetal circulation, which contains RhD+ blood, and bind to the foetus’ RhD antigens on its RBC surface membranes.
• This causes the foetal immune system to attack and destroy its own RBCs, leading to foetal anaemia. This is termed haemolytic disease of the newborn (HDN).

Question 25

ABO group meaning which blood group can be donated universally which blood group can accept all blood groups

Answer 25

Universal donor: **O-ve – this blood can be given to anybody (**recipient can have both A, B and Rhesus antibodies in their circulation, but they will likely not reject this donor blood, as there are no ABO or Rh antigens to attack) Universal Acceptor: **AB +ve** – you can give this recipient any donor blood, irrespective of the ABO or Rhesus status. The recipient does not have any A, B, or Rhesus antibodies in their circulation and therefore cannot mount an immune response to the donor blood.

Question 26

1. What is the purpose of G&S? 2. What is the purpose of Crossmatch (X-match) 3. Who should be given CMV-Negative Blood Products and why? 4. Why do we give irradiated blood products and who do we give it to?

Answer 26

1. Determines the patients blood group screens for atypical antibodies ~40 minutes 2. Physically mixing the patient’s blood with the donor’s blood (check for immune reaction) ~40 minutes, in addition to the 40 minutes required to G&S the blood (which must be done first) 3. pregnancy, intra-uterine transfusions, and to neonates (up to 28days) Congenital infection that may lead to **sensorineural deafness** and **cerebral palsy** (poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation, vision, hearing, swallowing, and speaking) 4. Reduce the risk of **graft-versus-host-disease** in at risk populations e.g: * Those receiving blood from **first or second-degree** family members * Patients with **Hodgkin’s Lymphoma** * Recent **haematpoietic stem cell** (HSC) transplants * After **Anti-Thymocyte Globulin** (ATG) or **Alemtuzumab** therapy * Those receiving purine analogues (e.g. fludarabine) as **chemotherapy** * **Intra-uterine** transfusions

Question 27

1. What is graft versus host disease? 2. What are the signs and symptoms

Answer 27

graft reacts against the host. The graft is the donated marrow or stem cells. The host is the person receiving the transplant. GvHD can cause diarrhoea, skin rashes and liver damage. GvHD happens when particular types of white blood cell (T cells) in the donated bone marrow or stem cells attack your own body cells. This happens because the donated cells (the graft) see your body cells (the host) as foreign and attack them. 2. please read cancer research website Acute within 100days ~ 2-3weeks It can be mild or severe, and often starts with a rash on: the palms of your hands the soles of your feet your ears your face The rash may be itchy or painful. It may also affect your mouth, gut (digestive system) and liver. This can cause: diarrhoea sickness loss of appetite yellowing of the skin (jaundice) Chronic GvHD It may affect your: skin, gut, liver, mouth, eyes, lungs, vagina, joints

Question 28

_Administering Blood Products_ 1. If a patient requires more than one unit of blood, each unit must be prescribed individually. Whilst the patient is receiving the transfusion, there are specific **observations** timings that should be carried out: 2. Remember to ensure that all of the above products are administered through a ? rather than a normal fluid giving set. A blood giving set contains a filter in the chamber, whereas a normal fluid giving set does not.

Answer 28

1. Before the transfusion starts. 15-20 minutes after it has started. At 1 hour. At completion. 2. blood giving set

Question 29

Packed red cells 1. Major constituents 2. Indications 3. Duration over which is administered 4. How much does one unit change Hb 5. A patient had a blood tranfusion 48hrs ago, will they need a G&S again? if not why not.

Answer 29

1. **Red blood cells** 2. (i) Acute blood loss; (ii) Chronic anaemia, where the Hb ≤70g/L (or ≤100g/L in those with cardiovascular disease) or symptomatic anaemia 3. **2 - 4 hrs**. It must be **completed within 4 hrs** of coming out of the store **4. 1 unit** should increase a patient’s Hb by **10g/L**. 5. No, Patients given RBCs may produce autoantibodies to donor surface antigens (of which there are many, other than ABO and RhD). Because of this, before any future transfusions, a **new G&S** will need to be sent (unless the last G&S was sent and processed **within around 3 days** of the most recent transfusion).

Question 30

Platelets 1. Major constituents 2. Indications 3. Duration over which it is administered 4. Increase platelet levels by?

Answer 30

1. i Platelets 2. (i) Haemorrhagic shock in a trauma patient; (ii) Profound thrombocytopenia (**\<20 x 10⁹/L**; normal range 150 – 400); (iii) Bleeding with thrombocytopenia; (iv) Pre-operative platelet level **\<50 x 10⁹/L** 3. **30 minutes** **1 ATD** (adult therapeutic dose) of platelets should increase platelet levels by around **20-40 x 10⁹/L.**

Question 31

**Fresh Frozen Plasma (FFP)** 1. Major constituents 2. Indications 3. Duration over which it is administered

Answer 31

1. Clotting factors 2. (i) **DIC** (ii) Any **haemorrhage** secondary to **liver disease**; (iii) All massive haemorrhages (commonly given after the **2nd unit of packed red cells**) 3. **30 minutes**

Question 32

Cryoprecipitate 1. **Major constituents** 2. Indications 3. Duration

Answer 32

**1.** Fibrinogen, von Willebrands Factor (vWF), Factor VIII and fibronectin **2.** (i) DIC with fibrinogen \<1g/L; (ii) von Willebrands Disease; (iii) Massive haemorrhage **3.** over which it is administered – Stat

Question 33

_Peri-op nutritional support_ 1. How do you assess for malnutrition? 2. What is the heirarchy of feeding methods?

Answer 33

Malnutrition universal screening tool (MUST tool) Disease-related cachexia is usually obvious with bedside observation, noting features such as muscle wasting, loose skin, and the patient’s usual clothes no longer fitting\*. Expert input from a Registered Dietitian (RD). Tools used to assess nutritional state are weight, Body Mass Index (BMI), Grip Strength, Triceps Skin Fold thickness and Mid Arm Circumference. BMI = Weight(kg) / Height(m)2 (normal range 18.5-24.9 kg/m2) \*Additional features such as aphthous ulcers, angular cheilitis, and pressure sores can provide additional clues 2.

Question 34

_Intra-Operative Nutrition_ The introduction of ***Enhanced Recovery After Surgery (ERAS)*** was revolutionary engendering real change and is now an established part of surgical practice. The basic tenets behind ERAS consist of: think this is the same as the enhanced recovery program

Answer 34

Reduction in ‘**Nil By Mouth**’ times (fluids up to 2 hours pre-surgery) Pre-operative **carb loading** **Minimally invasive** surgery Minimising the use of **drains and nasogastric tubes** Rapid reintroduction of **feeding** post-operatively Early **mobilisation** **MF DICN**

Question 35

_Post-Operative Nutrition_ How long does it take post op patients to safely tolerate an enteral diet? within 24 hours of uncomplicated gastrointestinal surgery without increasing the risk of post-operative complications.

Answer 35

Within 24hrs of uncomplicated GI surgery without inc the risk of post op complications

Question 36

**Enterocutaneous fistula** 1. Causes: 2. Signs and symptoms 3. Diagnosis 4. Treatment 5. How do we deal with their malnutrition?

Answer 36

1. Bowel surgery Other: Infection, perforated peptic ulcer, perforated peptic ulcer, inflammatory bowel disease, Crohn's disease or ulcerative colitis 2. Enterocutaneous fistulas (ECFs) can cause contents of the intestines or stomach to leak through a wound or opening in the skin. It also can cause: Dehydration Diarrhea 3. Abdominal CT scan Barium enema, if the fistula involves the colon Barium swallow, also called an esophagram. This test is a series of X-rays of the esophagus. You drink a liquid containing barium, which coats the inside of your esophagus. The barium causes changes in the shape of the esophagus to show up on the X-rays. Fistulogram, which involves injecting contrast dye into the opening of the skin of an ECF and taking X-rays. 4. * ~ heals on its own after a few weeks or months * otherwise a complex surgery is required to close the fistula and reconnect the gastrointestinal tract * Patients with ECFs often need specialized wound care, nutritional rehabilitation and physical rehabilitation 5. proportion of ECF that will heal spontaneously with PN is relatively small ~ support nutrition prior to surgery

Question 37

The modern nutritional management of ECF is dependent upon?

Answer 37

The level of the fistula\* High fistula (jejunal) -\> enteral or parenteral nutrition, Low fistulae (ileum/colon) -\> low fibre diet. Thus imaging is often critical to deciding how the fistula should be managed effectively.

Question 38

1. The nutritional support and treatment for High Output Stoma (HOS) is dependent upon: 2. The presence of ? can drive stoma output independent of the length of any residual bowel. 3. Medical Management Once active disease or infection has been excluded, then a reduction in stoma output can be achieved by:

Answer 38

1. image 2. persistent disease or systemic infection 3. * Reduction in hypotonic fluids to 500ml/day * Reduction in gut motility with high dose loperamide and codeine phosphate * Reduction in secretions with high dose proton pump inhibitors (a twice daily dose) * Use of WHO solution to reduce sodium losses * Low fibre diet to reduce intraluminal retention of water

Question 39

1. What is a high stoma output? 2. A high stoma output may occur if: 3. Guidance on how to reduce your stoma output Your stoma output may be reduced by: 4. Drinking too much ordinary fluid will increase your stoma output and make you become more thirsty and dehydrated. You can reduce your output by:

Answer 39

1. When your large bowel (colon) is removed, the small bowel is not as efficient at absorbing fluid and you may experience a high output from your stoma. Ii your output is high and you are losing more than 1500ml per day from your stoma, you are at greater risk of becoming dehydrated. However over time your small bowel (ileum) is usually able to adapt to maintain hydration. 2. * Your stoma is newly formed * Your bowel is affected by disease or treatment * Your bowel is shortened by formation of a temporary stoma (for example after pouch formation) 3. * Drinking less fluid and replacing it with an oral rehydration solution (such as the St Mark’s electrolyte mix detailed below) * Increasing your salt intake * Reducing your fibre intake * Taking medication to reduce your output 4. * Limiting the amount of ordinary fluids that you drink (for example fruit juice, squash, fizzy drinks, water, tea or coffee) to about 1 litre (about 6 cups per day) * Drinking a rehydration solution like St Mark’s electrolyte mix to help your body absorb fluid and salt. http://www.stmarkshospital.nhs.uk/wp-content/uploads/2014/05/High-output-stoma-2014.pdf

Question 40

_Enhanced recovery after surgery_ 1. Focus on 2. Surgical side, key elements in ERAS include: 3. The ERAS protocol can be divided into the 3 stages of the patient journey, each comprising several elements: explain each element

Answer 40

1. * Patient engagement, * pre-surgical medical opt, * optimal anaesthetic protocols, * post-op nausea prophylaxis 2. * minimally invasive surgery, * avoiding dehydrating bowel preparations if possible, * early removal of drains and catheters, * early postoperative mobilisation 3. image

Question 41

_Day case surgery (return home on the same day, 70% of surgeries_ 1. Advantages of day case surgery are: 2. Prep for daycase 3. For a surgical procedure to be considered for day case surgery, it must meet the following criteria: 4. Give examples of daycase surgical procedures

Answer 41

* Shorter inpatient stays * Lower infection rates * Reduced waiting lists * Cheaper than surgery requiring an overnight stay NBM, medication rv Minimal blood loss expected Short operating time (\<1 hour) No expected intra-operative or post-operative complications No requirement for specialist aftercare

Question 42

The selection of a patient for day surgery should be based upon social and medical factors:

Answer 42

* **Social factors** – a patient must **understand** the planned procedure, **consent** appropriately, and understand the following **post-operative care** -\> sufficient provisions to have a responsible adult escort them home and provide support for the first 24 hrs of post-op care. * **Medical factors** – a patient’s health must be suitable for a day case procedure, remembering that some stable chronic diseases (e.g. DM or asthma) can often be better managed as a day procedure to minimise any disruption to their daily routine Note: Whilst ASA status, age, and BMI will all lend towards determining a stance on a patient’s degree of health, these should not be solely used in making such a decision.