General/Uro/Gynae

Operations

Clinical

Laparotomy

Ovarian malignancy

Pre-operatively

Airway

Ascities > reflux risk

Respiratory

Effusions - assess exercise tolerance ?pre-op drain

Reduced FRC and V/Q mismatch

Cardiac

Paclitaxel & cisplatin cardiotoxic effects

Exercise tolerence

Pericardial effusions

Indwelling venous access?

Pharmacology

Paclitaxel & Cisplatin

Bone marrow suppression

Renal damage

LFT derrangemnet

Cardiotoxic

Diuretics

Antiemetics

Opioids

Haem

DVT risk

Liver dysfunction causing altered coagulation

Bleeding risk!

Micro

Marrow suppression

Renal

Chemotherapy damage...drug choices?

Liver

Chemotherapy damage....drug choices?

Nutrition

Malnutrition and dehydration risks

Postoperatively

Intraoperatively

CVS

Airway

Intubate - long, head down, abdominal, aspiration risk

Respiratory

Reduced FRC - good pre-ox with head up

Capnography and ABGs to target normal parameters

2 x large access ?CVC

A line

Cardiac output monitoring

Neuro

Pain - ?avoid PCM & NSAIDs ?epidural ?rectus sheaths

Haem

Bloods loss, ooze, coag abnormalities

DVT risk

Micro

Bonemarrow suppression - asepsis required

MSK

Care with positioning, ?bony mets

Renal

Catheterise

Drug choice

Metabolic

Long surgery - measure temp

ABG for lactate etc

Where?

Level 2 or 3

Resp

Oxygen support (esp as PCA)

CVS

?CO to guide IVF

Neuro

Pain Mx - acute pain team

Haem

DVT risk

Renal

U/o to guide fluids

Nutrition

Entral nutrition asap

Laparoscopy

Risks

Trocars

Visceral or vascular injury

CO2 embolus

Surgical emphysema

Head up position

Airway - accidental extubation

CVS - venous pooling, reduced venous return, hypotension

Neuro - reduced CPP

MSK - pressure points, pt movement

Pneumoperitoneum

Resp

Reduced FRC

Increased PaCO2 due to absorption

Barotrauma risk if using elevated pressures

CVS

Inflation causes autotransfusion from splanchnic vessels

IVC compression reduces venous return, SV falls, causing tachycardia

Aortal compression release humoral factors which increases SVR and CO -> increased myocardial workload

Neuro

Raised CO2 - cerebral vasodilation

CO reduced in head up position - reduced CPP

GI

Reflux risk

Compromised splanchnic flow

Haem

Venous stasis, DVT risk

Renal

Raised intra-abdo pressure - raised renal vascular resistance, reduced GFR and u/o

Minimising risks

Patient selection - CVS/RS reserve

Good surgical technique - reduced pressure/duration etc

A

Check tube position after moving/insufflation

B

Intubate, PPV, PEEP

C

Adequate volume, ionotropes>vasopressors

G

Consider a-line

Minimise FMV to reduce aspiration risk. Consider NGT to deflate stomach

Phaeochromacytoma

Characteristics

Symptoms

SoB/Reduced ET/orthopnoea

Palpitations/anginal CP

Headache/anxiety/visual disturbance

Nausea/vomiting/abdo pain

Sweating

Signs

Crepitations on chest

HTN/tachycardia/tachyarrhythmia

Tremor/HTN enchephalopathy/seizures/change in GCS

Weight loss

Investigations

Biochemical

Plasma & urine metanephrine, normetanephrine, dopamine & homovanillic acid

Radiological

MRI/CT confirm after biochem Ix

MIBG (meta-iodobenzylguanidine) scan assess extra adrenal tumours. MIBG is taken up by adrenergic neurones so concentrates in phaeos

General

Catecholamine secreting neuroendocrine tumours

Can be malignant (spread to liver), genetic (auto dominant/MEN/neuroectodermal dysplaisia ie Von Hippel-Lindau)

Secrete NA>A>dopamine (familial ones secrete adrenaline mostly)

Treatment

Pre operative

Alpha blockers

Overall

Reduce BP

Reduce SVR

Increase filling

Control tachycardia

Improve cardiac function

1 or 2 weeks preop

Reduce BP, increase intravasc capacity - pts need filling, reduce afterload, reduces surges with tumour manipulation

Non selective (phenoxybenzamine)

Irreversible

Blocks A1 so stops BP surges

Blocks A2 - prevents presynaptic NA reuptake so uninhibited release and tachycardia via B1

Stop a couple of days before operation

Selective A1

Doxazosin/Prazosin

Avoids tachycardia but are competetive so can be overwhelmed (by tumour handling)

Calcium channel blockers

Used in addition with A blocker if HTN resistant or solo if HTN is mild

Block NA-induced Ca2+ influx

Beta blockers

Control tachycardia (from A block or catecholamine release)

Start AFTER alpha blockers or B2 vasodilatory block cause worsening of HTN (with NA acting on alpha receptors, while heart loses B1 inotropy -> dysfuntion/failure)

B1 selective - metoprolol or atenolol

Hodgkin's Lymphoma

Renal Transplant

Pre-operative

CKD

A

B

?scelroderma

Fluid overload

Immunosuppresion ?chest infection

Continuous ambulatory peritoneal dialysis (CAPD) - drain to avoid splinting etc

C

IHD, HTN, ?LVF

Fistulae/vascaths

Calcified valvular lesions

ECG/ECHO/CPEX

Neuro

Autonomic neuropathy (uraemia & diabetes)

Endo

DM - VRII

?Steroid Rx - will need increase

Secondary hyperparathyroidism

Pharm

?Avoid sux if raised K+

VRII

Omit ACE-Is or angioII inhibs

Continue immunosuppressants if on

Haem

Anaemia

?PPI ?RSI

Check FBC, G&S etc

Thrombocytopenia

Renal

Assess fluid status

Check electrolytes

Intra-operative

Optimising transplant function

A&B

Optimise GE

C

Optimise filling (CO monitor, CVP)

Aim normotension

Adequate warming

Endo

Glucose control

Renal

Avoid nephrotoxics

Post-operative

Pain

Paracetamol

Avoid NSAIDs

Wound catheters

PCA - fentanyl and oxycodone do not accumulate in renal failure

Epidural

avoid hypotension

watch coagulation

Drugs to avoid

NSAIDs

Reduce renal perfusion & function

Nephrotoxic

Morphine

Metabolised in liver to active m-6-G

Drowsiness

Hypotension

Resp depression

Codeine/Dihydrocodeine

Renally excreted active metabolites

TURP

TURP Syndrome

Cause

Excessive absorption of glycine irrigation fluid (1.5%)

15min - 24h after starting surgery

Volume shifts cause CVS compromise

Hyponatraemia and hypoosmolality cause neuro complications

Free water enters brain causing oedema

Raised ICP

Glycine (inhib NT) toxicity causes nausea/headache/transient blindness

NMDA potentiation

Seizures & encephalopathy

Can give Mg2+ as stabilises NMDA Rs

Clinical Features

B

Tachypnoea/hypoxia/pul oedema

C

HTN + bradycardia -> acute CCF -> CVS collapse

Broad QRS, TWI due to hyponat

Neuro

Burning sensation of hands & face

Absence of signs of high block

GI

Nausea & vomiting

Intra-operative risks

Pressure of irrigation (Bag>70cm above pt)

Large volume irrigation

Low venous pressure

Surgery >1h

Large blood loss (veins open)

Capulsar/bladder perforation

Management

Emergency - Call for help!

Inform theatre team, finish op asap and stop further irrigation

A&B

100% O2

Auscultate chest, check sats

Intubation if needed

?IV furosemide or mannitol

C

Atropine, inotropes, pressors as needed

Stop IVF

Check blood Na, osmolal and Hb

A line

D

Manage seizures with Mg2+ and lorazepam

If Na < 120 or severe Sx, give 3% NaCl to increase by 1mmol/h - else can cause CPM

Level 2 or 3 care for supportive Rx

Head down position

Airway - airway oedema, accidental extubation

Neuro - cerebral oedema

Breathing - FRC and V/Q mismatch are worse

Well leg compartment syndrome

Reduce arterial supply

Compression from bracing in position

Reduce venous return from pneumoperitoneum

D

Time at horizontal every 2h or so

General

Cancer of lymph system

Presentation

Lymphadenopathy, hepatosplenomeg

B symptoms

Fever, night sweats, weight loss, fatigue

Staging

1

Single LN

2

2 or more LNs

3

LN both sides of diaphragm

4

Disseminated involving extralymph organs (liver)

If B symptoms present add B, if not add A

Treatment

Chemo/radiotherapy

Splenectomy due to size or hypersplenism (excessive blood cell and platelet destruction)

Anaesthetic Mx

A

Upper airway compromise from LNs etc

Potential compromise from mediastinal mass

Compression at tracheal or bronchial level

Meticulous assessment (+CT or bronch)

Chemo can cause mucositis - delicate tissues

B

Atelectasis risk due to airway collapse

Bleomycin can cause toxicity if exposure to high O2 concs

C

Compression of vessels can cause CVS collapse

Dysfunction due to chemo

Damage to vessels and valves from radiotherapy - ?ECHO

Central line access?

Neuro

Nerve/SC compression

Peripheral autonomic neuropathies due to chemotherapies (?delayed emptying ?RSI)

GI

?malnourished

Haem

Pancytopenia

?RA appropriate

Blood loss?

Renal

Dysfunction (chemo), nephrotic syndrome (obstruction, infiltration of parenchyma, amyloid)

Liver

Dysfunction - coag issues, drug metabolism

Splenectomy Vaccinations

At least 2 but ideally 4-6w preop

Haemophilus B

Pneumococcus

Meningitis B & C

Annually

Influenza

Idiopathic Thrombocytopenia Purpura

Splenectomy

Immunological functions

Synthesis of Abs and immune proteins that allow phagocytosis

Removal of Ab covered blood cells and bacterium

Monocyte reservoir

Specialise into dendritic cells or macrophages

Patient populations

Trauma

Haematological malignancies

Pts require vaccinations (see below)

Pre-operatively

Understand disease state

Anaemia

Chemotherapy

Chronic disease

Malignancy

?HLA matched products

Steroids

MDT

Haem/Onc/ITU/Surgical/Anaesthetic/Radiology

Surgical technique

Traumatic

Midline incision

Good access, rapid assessment of other viscera

Haematological

Left subcostal incision

Laparoscopic

Anterior approach

Lateral approach

Pre-operative issues

A

Swollen tissues due to haematomas

Difficult airway, non traumatic technique needed

CVS

Aim for minimal BP surges ?Remi

Neuro

Analgesia

Avoid neuroaxial due to low platelets

Avoid NSAIDs

Avoid BP surges with straining on tube

Risk of spont ICB

Endo

?Periop steroids

GI

Risk of haemorrhage

Haem

?platelet transfusion

X matched blood available

Micro

ABx prophylaxis

MSK

Padding to reduce bruise/bleed risk

Conservative

Rationale

Avoids major surgery

Retention of some splenic function

Principles

Haemodynamicly stable pts

CT to grade splenic injury - lower grades more amenable

Local interventional radiologist available for angioembolisation etc

Absence of need for laparotomy for other reasons

Hyperchloraemic metabolic acidosis

Seen with neobladder formation

Can manifest following further surgeries

Biochemically

Hyperchloraemia

Metabolic acidosis with normal lactate

Hypernatraemia

Hypokalaemia, hypocalcaemia & hypomagnesaemia

Carcinoid

Presentation

Pathogenesis

Tumours from enterchromaffin cells (neuroendocrine origin) GI or lung

Contain neurosecretory granules of hormones & biological amines

Histamine

Dopamine

Corticotrophin

Substance P

Serotonin

Neurotensin

Prostaglandins & kallikrein

Normally asymptomatic as liver metabolises

10% develop carcinoid syndrome

Due to liver metastases & systemic relase of serotonin and vasoactive substances

Lachrymation

Bronchospasm

Flushing

R sided valvular HD (TS)

Diarrhoea

Anaesthetic considerations

Avoid B1 and vasopressor agents due to unpredictable effects

NA can activate kallikrein -> bradykinin release and paradoxical fall in SVR

Tumour handling can cause mediator release and drop in BP

Mx with octreotide 20-50mcg or vasopressin or carefully titrated phenylepherine

Ketaserin (seretonin antagonist) can help with flushing preop