Year 3 - Diseases > Surgery > Flashcards

Surgery Flashcards

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1
Q

Why is surgical pre-op assessment performed?

A

Confirm site/side of the surgery

Identify risk

  • Airway
  • Anaesthetic
  • (Surgery should have already occured)
  • Post operative
  • Special tests
  • Measure body weight, height, BMI

Modify risk

  • Pre op interventions
  • Make decisions on medication (aspirin/metformin)
  • Advice on fasting, stop smoking, consider risk of alcohol withdrawal
  • Make decisions on post-op care (ICU/HDU)
  • Antibiotics day of surgery
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2
Q

Describe additional considerations in surgical assessment

A
  • Stop smoking for at least 24 hours before surgery
  • Ask about problems with anaesthetics, and family problems with anaesthetics (malignant hyperpyrexia, myasthenia gravis)
  • Know all drugs the patient is taking
  • Stop drinking - ask about volume of alcohol in case of withdrawals
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3
Q

What is an ASA score?

A
  • American society of anaesthesia
  • 1 is healthy patient
  • 2 minor systemic disease (obesity, smoking, pregnancy)
  • 3 severe systemic disease (poorly controlled DM, HTN, alcohol dependence)
  • 4 severe systemic disease, constant threat to life (recent MI, sepsisi, severely reduced EF)
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4
Q

Give examples of different magnitudes of surgery

A

Minor

  • Skin lesion
  • Breast abscess

Intermediate

  • Inguinal hernia
  • Varicose veins
  • Knee arthroscopy

Major

  • Thyroidecotomy
  • Colonic resection
  • Joint replacement
  • Adrenalectomy

Major plus
- Cardiac surgery

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5
Q

Describe examination of the patient

A
  • Obs (HR, BP, temp, O2 sats)
  • Airway (neck extension/flexion, mouth opening, mallampati, jaw protrusion)
  • CV (rate, rhythm, murmur)
  • Respiratory
  • Abdo
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6
Q

Describe mallampati grading

A
  • Class 1 you can see hard and soft palate, uvula and pillars
  • Class 2 you can see hard palate, soft palate and uvula
  • Class 3 you can see hard palate and soft palate
  • Class 4 hard palate only
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7
Q

Which investigations do you do before surgery?

A

ASA 1

  • Nothing if minor or intermediate surgery
  • ECG, FBC and U&E only if major complex surgery

ASA 2

  • Renal function and ECG if intermediate
  • FBC, ECG and renal function additionally if major or complex

ASA 3/4

  • ECG and kidney function in minor surgery
  • In intermediate surgery, FBC, haemostasis, kidney function, ECG, lung function, ABG
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8
Q

List special reactive tests based on medications

A
  • BP medication check U&E
  • Antiplatelets check FBC
  • Anticoagulants FBC/coagulation
  • Diabetes medication HbA1c
  • Thyroid medications TFT
  • Anaemia medications FBC
  • Discuss pregnancy test with patient
  • HbA1c only if known diabetic with no result in last 3 months
  • Sickle cell only if family history
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9
Q

Describe medication advice for surgery

A
  • Blood thinners may need to be stopped (anticoagulants and/or antiplatelets always in thyroid surgery)
  • Diabetic meds may need to be stopped
  • ACE-I stopped on the day of the surgery, B-blockers continued
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10
Q

How long should you avoid solid food and liquids pre-surgery?

A
  • 6 hours

- Nil by mouth for 2 hours

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11
Q

Define acutely unwell

A
  • New onset
  • Deranged physiology
  • Unstable
  • May be shocked
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12
Q

Define sepsis

A

Life threatening condition of circulatory failure, causing inadequate oxygen delivery to meet cellular metabolic needs and oxygen consumption requirements

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13
Q

List the types of shock

A
  • Hypovolaemia (haemorrhage or dehydration)
  • Distributive (sepsis, neurogenic)
  • Cardiogenic (arrythmia, pump failure)
  • Obstructive (tamponade, pneumothoax)
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14
Q

What is third spacing?

A

Fluid, rather than being in the intravascular space, being lost to extravascular tissues

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15
Q

List surgical conditions causing patients to become acutely unwell

A

Perforations, obstructions, infections and inflammation, trauma, haemorrhage, ischaemia

  • Booerhaves
  • Gastric ulcer
  • Duodenal ulcer
  • Gallstone
  • Diverticulitis
  • Malignancy
  • Appendicitis
  • Adhesions/hernia
  • Diverticulitis/ malignancy
  • Renal stones
  • Bleeding from ulcers, AAA
  • Trauma
  • Thrombus/embolus, strangulated hernia, limb thrombus/embolus
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16
Q

List causes of a patient becoming acutely unwell post-operative

A

Direct (specific)

  • GI resection and anastamosis causing leakage
  • Cholecystectomy causing biliary tree injury (leak, stenosis, occlusion)
  • AAA repair leading to haemorrhage or ischaemia
  • Secondary haemorrhage

Indirect consequence (general)

  • MI, arrythmia, tamponade
  • Atelectasis (collapse of a lung), pneumonia, PE, pneumothorax
  • ARF
  • glucose derrangement/ addisons/ drugs/ withdrawal
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17
Q

What is ABCDEFG?

A

Airway (look listen feel, head lift + jaw thrust, give high flow oxygen)
Breathing (look feel listen - rate, expansion, percussion, breast sounds)
Circulation (feel, perfusion, cap refill, HR, BP, abdo exam, give IV cannula, bloods and fluid)
Disability (AVPU, limbs, neuro)
Exposure (injuries/rashes, anaphylaxis)

DEFG - don’t ever forget glucose (check and replace)

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18
Q

List tests done in acutely unwell post-op patient

A
  • ECG
  • Urine
  • Blood gas (oxygenation, lactate)
  • FBC, renal function, electrlytes, clotting, group and save
  • Chest x ray
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19
Q

Describe POSSUM scoring

A
  • Enter patient physiological and operative variables
  • Risk discussion with patient
  • More invasive monitoring during operation
  • Over 5% mortality risk in HDU/ITU post operative
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20
Q

List types of airway adjuncts/devices

A
  • Bag mask ventilation
  • Oropharyngeal airways
  • Supraglottic devices sit above the level of the vocal cords. iGel is heat sensitive and mould to the airway, they are protective against aspiration but not suitable for abdominal surgery or high pressure procedures
  • Endotracheal tubes are the definitive airways, they have a balloon at the end, inserted with a laryngoscope into the trachea and balloon is inflated below the level of the cords. Form a definitive airway used in GAs and ALS
  • Guedels are airway adjuncts used alongside bag mask ventilation and can be used in the unconscious patient during BLS, not suitable for a long procedure, they keep the tongue from blocking the airway
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21
Q

Explain the WHO pain ladder

A
  • Step 1 non-opioid (aspirin, paracetamol, NSAID)
  • Stage 2 weak opioid (eg. codiene)
  • Stage 3 strong opioid
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22
Q

List anti-emetic drugs used alongside pain relief

A
  • Ondansetron (5HT3R antagonist)
  • Cyclizine (H1 R antagonist)
  • Dexamethasone (corticosteroid)
  • Metoclopramide (central DA2 R antagonist)
  • Prochlorperazine (DA antagonist)
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23
Q

Describe temperature control in surgery

A
  • Keep temp over 26 degrees
  • Bair hugger (warm air blanket) if over 30 mins procedure
  • If longer, consider fluid warming
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24
Q

How is severe bronchospasm managed outside of theatre?

A
  • Oxygen
  • Salbutamol
  • Hydrocortisone
  • Ipatropium
  • Theophylline/aminophylline
  • Magnesium
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25
List symptoms and signs of anaphylaxis
- Airway swelling (throat and tongue, feeling the throat is closing up, hoarse voice, stridor) - Breathing problems (SOB, wheeze, tired, confusion due to hypoxia, cyanosis, respiratory arrest) - Circulation (pale, clammy, tachycardia, hypotension, collapse, decreased consciousness, ECG changes and cardiac arrest)
26
Describe treatment of anaphylaxis
- Adrenaline IM NOT IV - Establish airway - High flow oxygen - IV fluid - Chlorphenamine and hydrocortisone - Monitor pulse oximetry, ECG and blood pressure
27
When are blood transfusions performed?
- Hb below 70g/L | - Unless CVD
28
Define SIRS
- Systemic inflammatory response syndrome - Changes of sepsis with no infective focus Two of - High temp/low temp - Heart rate over 90 - Resp rate high or PaCO2 low - WBC high
29
When is ABG measured
- Obtain and interpret oxygenation levels - Assess for potential respiratory derangements - Assess for potential metabolic derangements - Monitor acid-base status - Assess carboxyhaemoglobim - Assess lactate - Electrolytes and haemoglobin - One off sample or repeated
30
List contraindications to ABG
- Local infection - Distorted anatomy - Presence of arterio-venous fistulas - Peripheral vascular disease of the limb - Severe coagulopathy or recent thrombolysis
31
List sampling errors in ABG
- Presence of air - Collection of venous rather than arterial blood - Improper quantity of heparin in the syringe - Delay in transplantation
32
List complications of ABG
- Haematoma - Nerve damage - Arteriospasm - Aneurysm of artery - Fainting or vasovagal response
33
List goals of oxygen therapy
- Relieve hypoxaemia - Maintain oxygenation of tissues - Assessed by SpO2 and SaO2 - In a way which prevents excessive CO2 accumulation - Reduce work of breathing (CPAP) - Ensure adequate clearance of secretions and limit the adverse events of hypothermia (increases blood loss) and insensible water loss by use of optimal humidification
34
List modes of oxygen delivery
- Nasal cannulae used in non-acute situations with mild hypoxia, 24-20% oxgen at a flow rate of 1-4L/min - Hudson facemask 30-40% oxygen, flow rate 5-10L/min - Venturi mask delivers 24-60% oxygen, different flow rates with different colours, often used in COPD - Non-rebreather mask used for acutely unwell patients, delivers 60-90% oxygen with 15L/min flow rate, the valve stops rebreathing of expired air - CPAP high pressure with tight fitting mask, positive pressure all the time used in type 1 resp failure (eg. pulmonary oedema) - BiPAP high pressure on inspiration and lower on expiration, used in type 2 respiratory failure (eg. COPD exacerbation)
35
List arteries that can be sampled for ABG analysis
- Radial artery - Ulna artery - Dorsalis pedis artery - Femoral artery
36
Describe trauma history
- Allergies - Medications - PMH/ pregnancy - Last meal - Events
37
List causes of post-op pyrexia
- <24 hours systemic inflammatory response or pre-existing infection - 24-72 hours pulmonary atelectasis and chest infection - 3-10 days UTI, DVT, PE, Wound, collection, anastamotic leak
38
Describe suitability for day case surgery
- Minimal blood los exoected - Short operating time (<1 hour) - No expected intra-operative or post-operative complications - No requirement for specialist aftercare - Social: patient must understand, and have an adult who can provide support for first 24 hours - Medical: health must be suitable
39
Describe general NICE guidelines for pre-operative investigations
- Pregnancy test on day of surgery - Test for sickle cell if family history - HbA1c tested before surgery in diabetics if not tested in the past 3 months - No routine CXR, urine dip, or echo (unless cardiac symptoms)
40
List indications for invasive BP moniting
- Induced, ongoing or anticipated hypotension, or wide variations in blood pressure - End-organ disease requiring precise pressure regulation - The need for frequent or multiple blood gas measurements - The need for continuous monitoring of cardiac output and stroke volume, where the placement of a pulmonary artery catheter is impractical - Situations when noninvasive methods of blood pressure monitoring are unreliable or difficult, such as with burns, trauma, or dysrhythmias
41
Compare colloids and crystalloids
- Colloids have small molecules, are cheaper and provide immediate fluid resuscitation. They may increase oedema - Colloids are larger mollecules, cost more, and provide swifter expansion into the intravascular space. They have risk of anaphylactic reactions, abnormal haemostasis.
42
When is regional anaesthesia prefered?
In orthapedic surgery, reduces blood loss
43
What is done in anaemic patients pre-op?
- Correct pre operatively, oral iron premedication started early.
44
Describe cell salvage methods
- Blood collected from drains intraoperatively or post op - Reduces need for transfusion of donated blood, and reduces risks of transfusion related reaction/ transmission of infection
45
How are post-op fluids calculated?
- 4mls/kg first 10kg, 2mls/kg 2nd 10kfg, 1ml/Kg remaining weight - Sodium 1-2mmol/kg daily requirement - Potassium 0.5-1mmol/kg daily requirement
46
Describe gelatins, dextrans, dextrose, and hartmanns solution
- Gelatins are colloidal solutions with a molecular weight of approximately 30,000. No longer regularly in use. - Dextrans are synthesised from sucrose and have average molecular weights of 40,000 (Dextran 40) or 70,000 (Dextran 70). No longer regularly in use. - Dextrose 5% will distribute throughout the total body water - Hartmann’s solution is a ‘balanced’ salt solution containing lactate, which is metabolised by the liver to bicarbonate. It is balanced because it is has less chloride than normal saline and closer to electrolyte contents of plasma.
47
Describe sliding scale for diabetics
- Gradual change in daily insulin given based on BM measurement - Used where patietns undergo a period of starvation.
48
List questions asked in a pre-op history
- Confirm name, date of birth, procedure and if they’ve been told what mode of anaesthesia to expect. Past Medical History: - Cardiovascular: palpitations, arrhythmias, MI, heart failure - Respiratory: asthma / COPD [check control, recent steroids, previous hospital / ITU admissions] - GORD: check if on PPI and if they can lie flat without acid entering throat - Neurological: seizures/epilepsy [check frequency, drug levels], strokes - Diabetes: what medication, complications – retinopathy, nephropathy, neuropathy, HbA1c (<80 for elective surgery to proceed) - If children: pregnancy complications, NICU admissions, developmental delays, immunisation status - If Afro-Caribbean: check sickle cell status Drug History - history of all medications taken. In particular: - Anticoagulants [when was last dose] - Oral Contraceptive / Hormone Replacement - Antihypertensives - Diabetic medications - Allergies [Check wristbands] Previous Surgeries / General Anaesthetics: - Any complications with previous general anaesthetics (GAs)? [Common: post-operative nausea & vomiting] - Did you stay in longer than expected? Were you admitted to HDU/ITU - Major complications: malignant hyperthermia, anaphylaxis, suxamethonium apnoea Exercise Tolerance: - How far can you walk before you need to stop? Can you climb more than 1 flight of stairs? - Do you get chest pain, SOB, leg pain when walking? Are you able to lie flat? - Any recent infections or changes to your health? Social History: smoking, alcohol, recreational drugs Fasting status: when was your last meal [>6 hours] and drink? [>2 hours clear fluid, >6 hours milk, >4 hours for breastmilk] Any metalwork in your body? [Cannot place diathermy pads over metal, and diathermy affects pacemaker] Dentition : any loose teeth, crowns or caps. [Loose teeth more likely to be damaged during intubation] ICE – Address any concerns the patient may have
49
List and describe the various airway assessments
- Beard or Edentulous [more difficult to bag-mask ventilate; use guedel airway] - Good mouth opening [<3cm increases difficulty of intubation] - Receding mandible & prominent upper incisors [increases difficulty of intubation] - Craniofacial abnormalities - Mallampati grade [I – Easy to IV – difficult intubation] - High BMI & Short/Fat Neck [increases difficulty of intubation] - Thyro-mental distance [tip of jaw to thyroid notch; <7cm increases difficulty of intubation] - Full range of neck movement [limited increases difficulty of intubation]
50
List the induction agents
- Ketamine (1-3mg/kg) - Propofol (2-3mg/kg) - Thiopental (3-5mg/kg)
51
List the opioids
- Alfentanil (10mcg/kg) - Fentanyl (1mcg/kg) - Morphine (0.1mg/kg) - Remifentanil (infusion 15-45mcg/kg/hr)
52
List the muscle relaxants
- Atracurium (0.5mg/kg) - Rocuronium (0.5-1.2mg/kg) - Vecuronium (0.1mg/kg) - Suxamethonium ( DEPOLARISING - 1-1.5mg/kg)
53
Lis the muscle relaxant reversal agents
- Neostigmine/ glycopyronium (2.5mg+500mcg) | - Sugmmadex (2/4/16 mg/kg)
54
List LAs
- Lidocaine (3 mg/kg) | - Bupivacaine (2mg/kg)
55
List the emergency drugs in anaesthesia
- Metaranimol (0.5mg bolus) - Ephedrine (3mg bolus) - Atropine (bradycardia) - Glycopyrronium (200mcg bolus) - Suxamethonium (up to 2mg/kg)
56
Describe the types of intraoperative ventillation
- Volume controlled is where the amount of air per breath is set on the ventilator, and the ventilator will use any required pressure to achieve that tidal volume - Pressure controlled is dictated by the amount of pressure put into the lungs, which eans tidal volume varies based on lung compliance
57
List pros and cons of volume vs pressure controlled ventillation
Volume - Constant tidal volume - Pressure depends on lung compliance so high risk of barorauma - Low risk of pressure trauma Pressure - Low risk of barotrauma - High risk of volutrauma (as stretchy lungs can cause high TV)
58
List common monitoring devices used during surgery
- Pulse Ox (HR, rhythm, oxygen sats) - ECG - BP (non-invasive/ invasive) - Capnography (measures CO2 in exhaled breath - end tidal CO2, resp rate, marker of lung perfusion, cardiac output and adequacy of airway)
59
List commonly used anti-emetics
- Dexamethosone - Droperidol - Granisetron (serotonin antagonist) - Metoclopramide (dopamine antagonist) - Ondansetron (serotonin antagonist)
60
List methods of measureing patient temperature
- Pharyngeal/ rectal probe | - Tympanic membrane
61
Describe multimodal anaestesia
- Combination of analgesics for pain relief - Commonly local anasthetics, opioids, NSAIDs, acetamoniphen and alpha 2 agonists - This increases pain relief and reduces side effects Slight pain – Paracetamol Mild pain – Paracetamol + NSAID Moderate pain – Paracetamol + NSAID + Codeine Severe – Paracetamol + NSAID + Morphine (PCA + NCA)
62
List the five steps to safer surgery
1. Briefing (intro team, order of lists, cncerns) 2. Sign in (before induction, confirm patient, procedure and consent check site is marked, allergies, airway issues, blood loss, check machine) 3. Timeout (before start of surgery - intro, pt info, discuss issues) 4. Sign out (before patient leaves, confirm recording of the procedure) 5. Debriefing ( at the end, evaluate list, learn from incidents and remedy any problems)
63
Describe VTE prophylaxis before surgery
- Assess VTE risk (risk of bleeding vs risk of clot must be considered, specific risks for clotting include surgical time over 90 mins, hip or knee replacement, acute surgical admission, or surgery that will significantly reduce mobility) - Local anaesthetic reduces risk of VTE - Not routinely offered unless limitation fo mobility - LMWH, aspirin and anti-embolism stockings may be used.
64
Describe simple airway manouvres
- Chin lift | - Jaw thrust
65
Describe rapid sequence induction
- Little time as possible with airway unprotected. - Thiopentone and suxamethonium (now rocuronium and propofol) - Cricoid pressure to prevent gastric aspiration, endotracheal tube placement
66
List characteristics of thiopental
- Short acting barbituate used in anaesthesia - No analgesic or muscle relaxing property - Decreases cerebral blood flow and therefore cerebral oxygen demand
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