Surgery 2

Question 1

Pain management - drug misusers

Answer 1

• Pain management is a basic human right.
• Regular doses of methadone/buprenorphine does not provide an effective analgesic profile.
• Additional pain medication is required.

Question 2

Consequences of inappropriate pain management - drug misusers

Answer 2

• Relapse to addiction.
• Potentially fatal toxicity due to misjudged tolerance or drug interactions.
• Compromised medical care.

Question 3

Monitoring - drug misusers

Answer 3

• Pain score
• Respiratory depression

Question 4

Current guidlines - drug misuers

Answer 4

• Opioids are not contraindicated.
• Long-acting opioids are preferred.
• Wean as soon as possible.
• Buprenorphine can generally be continued

Question 5

Use of opioids

Answer 5

• Former addicts = small risk of exposure triggering relapse.
• Discuss with patient - they may prefer non-opioid analgesia.
• Support during and after discharge.

Question 6

Buprenorphine OST alternative treatment need

Answer 6

• Patients on buprenorphine OST may require alternative treatments to manage pain (non-opioid).
• Doses >12 mg may cause total blockage of µ-opioid receptor.

Question 7

Alternative non-opioid approaches

Answer 7

• Paracetamol
• NSAIDs
• Adjuvant medications (tricyclic antidepressants)

Question 8

Buprenorphine OST - incomplete blockage

Answer 8

• Opioids can be used, but higher doses required.
• If the patient wants to remain on buprenorphine = 6-8 hourly dosing regime to improve the pain management response.

Question 9

Venous Thromboembolism (VTE)

Answer 9

• Blood clot forms in vein.
• Commonly occurs in the deep veins of the legs (DVT).

Question 10

VTE - Clinical presentation

Answer 10

• Varies
• Often asymptomatic.
• Pain and swelling in the leg.

Question 11

Complications of VTE

Answer 11

• Pulmonary embolism (PE)
• Chronic venous insufficiency
• Venous ulceration
• Post-thrombotic limb

Question 12

Pulmonary embolism (PE)

Answer 12

1. Part or all of thrombus dislodged from site of origin
2. Travels in the blood to the lungs
3. Potentially fatal PE

Question 13

Post-thrombotic limb

Answer 13

• Chronic pain
• Swelling
• Skin changes

Question 14

VTE - Pharmacological treatment

Answer 14

• LMWH
• Heparin
• Dabigatran
• Rivaroxaban

Question 15

VTE - non pharmacological treatment

Answer 15

• TEDs
• Foot pumps
• Flowtron intermittent pneumatic compression (IPC)

Question 16

VTE - NICE Guidelines

Answer 16

1. Asses pt on admission for risk of VTE.
   
   • Bleeding risk vs. thrombotic risk
2. If needed, started pharmacological VTE prophylaxis ASAP.

Question 17

When is a surgical patient at risk of VTE

Answer 17

Surgical patients at risk if:

• Surgical procedure of more than 90 mins or 60 mins involving pelvis or lower limb.
• Acute surgical admission with inflammatory or intra-abdominal condition.
• Expected significant reduction in mobility.
• One or more VTE risk factors.

Question 18

Risk factors for VTE

Answer 18

• Cancer
• 60+
• Dehydration
• Obese
• One or more medical comorbidities
• History/family history of VTE
• HRT
• Pregnancy (or <6 weeks postpartum)

Question 19

PONV - at risk groups

Question 20

PONV - risk factors

Answer 20

• Age
• Young, Female
• non- smoker
• History of PONV or motion sickness.
• Anxiety level
• Obesity
• Non-compliance with pre-op fasting recommendations
• Duration and type of surgery
• Anaesthetic factors
• Use of pre/post-op opioids

Question 21

PONV - consequences

Answer 21

• Delayed administration of opioid analgesia.
• Wound disruption after abdominal/max fac surgery.
• Bleeding
• Dehydration and electrolyte imbalance.
• Interference with nutrition.
• Delay in mobilisation, recovery & discharge.
• Patient discomfort and distress.

Question 22

PONV - drugs

Answer 22

• Cyclizine
• Ondansetron/Granisetron
• Dexamethasone
• Metoclopramide/Domperidone
• Hyoscine
• Prochlorperazine
• Droperidol
• Aprepitant

Question 23

Cyclizine

Answer 23

• 1st line
• Antihistamine
• Antimuscarin properties

Question 24

Ondansetron/Granisetron

Answer 24

• 5-HT3 antagonists.
• Licensed for treatment and prophylaxis.
  
  • Short treatment for post surgery
• Usually recommended 2nd line after cyclizine.
• Post-op- CV risk (QT interval prolongation).

Question 25

Dexamethasone

Answer 25

- Generally not used unless there is significantly untreated nausea

Question 26

Metoclopramide

Answer 26

- dopamine antagonist - Gastro patient s - Max 5 days - Risk of neurological SE

Question 27

Domperidone

Answer 27

- Dopamine antagonist - Max 7 days - Risk of cardiac SE

Question 28

Droperidol

Answer 28

- Butyrophenone - Structurally related to haloperidol - Blocks dopamine receptors in the chemoreceptor trigger zone.

Question 29

Aprepitant

Answer 29

- NK1 antagonist - NK1 is a G protein-coupled receptor in CNS and PNS. - This receptor has a dominant ligand known as Substance P (SP). - SP, when activated sends impulses to vomiting centre of the brain.

Question 30

PONV - post op management

Answer 30

- Actively vomiting = avoid PO. - Cyclizine (IV or IM) - Metoclopramide (IV) - Ondansetron (IV) - Hyoscine (transdermal) - Prochlorperazine (buccal)

Question 31

Prochlorperazine - buccal

Answer 31

- Absorbed through the lining of mouth - Direct absorption into the systemic circulation, avoids first-pass metabolism. - Higher plasma conc.

Question 32

Non-pharmacological

Answer 32

- Adequate hydration and pain management. - Minimise use of GA - Minimise opioid use - Acupuncture - Ginger/ Mint - Wristbands