Peri operative care.txt

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Peri operative care.txt
2010-05-03 10:48:53
peri op new

peri op new
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  1. Give 5 ways of preventing a post op PE ?
    • TEDS (thromboembolic deterrent stockings)
    • Pneumatic calf compression
    • LMW Heparin at prophylactic dose
    • stop HRT, pill pre op
    • ask about FH of thromboembolism and consider for inv for thrombophilia
  2. Give 5 symptoms of PE?
    • breathlessness
    • pleuritic chest pain
    • haemoptysis
    • syncope
    • dizziness
  3. Give 8 signs of PE
    • tachycardia
    • tachypnoea
    • pyrexia
    • cyanosis
    • raised JVP
    • pleural effusion
    • pleural rub
    • hypotension
  4. what signs of a cause of PE would you look for?
    • DVT - swollen leg
    • scar from recent surgery
  5. what are the main RF for PE? in categories
    • surgery: major abdo, pelvis, hip or knee replacement
    • obstetrics: late pregnancy, post partum, C section, pill, HRT
    • Lower limb problems: fractures, varicose veins (valves not working)
    • Malignancy
    • Prolonged bed rest, reduced mobility
    • Previous PE
  6. What is the treatment for a PE?
    • Anticoagulation:
    • 1. LMW heparin (dalteparin SC)
    • 2. start oral warfarin 10mg
    • stop heparin when INR is >2
    • continue warfarin for a minimum of 3 months, aiming for INR: 2-3
  7. what would you consider if pt develops emboli despite adequate anticoagulation?
    vena caval filter
  8. which test may help EXCLUDE a PE?
    D dimer test - do in pts with a low clinical probability of PE, to exclude it. NB it cannot prove there is a PE though
  9. What are the signs of a PE on CXR?
    • often normal!
    • decreased vascular markings
    • small pleural effusion
    • wedge shaped area of infarction
    • atelectasis
  10. what are the 2 most sensitive and specific tests for diagnosing PE?
    • VQ perfusion scan
    • CT pulmonary angiography
  11. what are the signs on ECG of a PE?
    • tachycardia
    • RAD
    • RBBB
    • RV strain pattern in V1 to V3: dominant R wave, inverted T wave, ST depression
    • rare: SI, QIII, TIII: deep S waves in I, pathological Q waves in III, inverted T waves in III
  12. With anaphylaxis do you get facial pallor or flushing?
  13. What are the cardiovascular effects of anaphylaxis?
    • tachycardia
    • arrhythmias
    • hypotension
  14. what are the respiratory effects of anaphylaxis?
  15. for an anaphylactic reaction, what must you immediately administer and hOW MUCH?
    adrenaline, 1:1000
  16. What are the signs of anaphylaxis in terms of ABC and skin?
    • airway: swelling, hoarseness, stridor
    • breathing: O2 sats < 92, cyanosis, rapid breathing, wheeze, confusion, fatigue
    • circulation: pale, clammy, low BP, faintness, drowsy/coma
    • Rash, facial flushing
  17. Once adrenaline given, what other measures can be taken?
    • lie patient FLAT, raise legs
    • establish airway and 2 iv access
    • high flow oxygen
    • iv fluid challenge: 500mL crystalloids NOT COLLOIDS
    • anti-histamine: chlorphenamine 10mg
    • steroids: iv hydrocortisone 200mg
  18. What things do you need to monitor in anaphylaxis
    • pulse oximetry
    • ECG
    • blood pressure
  19. A 72-year-old man who underwent AAA repair presents with a very low urine output postoperatively. His BP is stable. what is the diagnosis?
    Acute tubular necrosis
  20. Name a major type of intrinsic renal failure and what causes it?
    • Acute tubular necrosis
    • ischaemia: due to hypoperfusion
    • nephrotoxins: drugs (aminoglycosides, amphoterecin B, tetracyclines), radiological contrast agents, uric acid crystals, Hburia in rhabdomyolysis, myeloma
  21. A 54-year-old man has just had a hernia operation and is in the recovery room when he is found to be very restless despite a smooth recovery. There seems to be a swelling in his lower abdomen. whats the diagnosis?
    urinary retention: clues restless post op
  22. A 68-year-old man underwent a total cystectomy. During the first postoperative night he was not producing a satisfactory urine output despite adequate hydration. You involved a senior colleague, and after adequate resuscitation the patient’s urine output slowly picked up. Now, the following day, he has started diuresing. diagnosis?
    ATN: clue diuresis after adequate resuscitation
  23. What happens to the urea:creatinine ration in dehydration?
    goes up, i.e. as there is a lower body water content, the urea concentration goes up
  24. With a patient undergoing hemicolectomy and needing prep bowel prep what are all the sources of fluid loss?
    • 1. NBM: pre op starvation - dehydration
    • 2. bowel prep fluid loss
    • 3. daily fluid requirement
    • 4. intraoperative blood and fluid loss
    • 5. fluid loss from through evaporation of open laparotomy wound 1L in 1h
    • 6. insensible losses: increased with fever
    • 7. losses in drains via NG tube
    • 8. post op vomiting and diarrhoea
    • 9. haemorrhage: primary - at time of op, reactionary in first 48h due to bv rupture or unseal
    • 10. post op paralytic ileus with accum of intraluminal fluid
    • 11. septic shock with dilated vessels and leakage of fluid out into interstitial space
    • 12. third space losses e.g. pancreatitis fluid accum in peritoneal cavity
  25. What is the stress response to surgery?
    • neurohumoral response (Catecholamines, ADH, cortisol, aldosterone) in direct proportion to the magnitude of surgery
    • leads to catabolic state with salt and water retention and potassium loss
  26. What are your daily requirements of Na, K and water?
    • water: 3L
    • Na: 150mmols
    • K: 60mmols
  27. What are the signs if you give too much iv fluid to a patient? (3 categories)
    • signs of R heart failure: tachycardia, increased JVP, PERIPHERAL oedema
    • signs of L heart failure: tachycardia, breathless, wheeze (cardiac wheeze), PULMONARY oedema
    • electrolyte imbalance: check U&Es
  28. What are the signs if you give too little fluid and which fluid compartments suffer accordingly? (2 categories)
    • dehydration (depletion of ICF): thirst, dry mucous membranes, headache, listlessness, decreased skin turgor
    • hypovolaemia (depletion of intravasc compartment): tachycardia, tachypnoea, clammy, anxiety, low BP, reduced UO, delayed cap refill, decreased pulse pressure
  29. What are the signs of acute loss of 15%
  30. What are the signs of acute loss of 15-30%
  31. What are the signs of acute loss of > 40%