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General/Uro/Gynae - Coggle Diagram

- - - - 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
        
        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
      - Intraoperatively
        
        CVS
        
        2 x large access ?CVC
        
        A line
        
        Cardiac output monitoring
        
        Airway
        
        Intubate - long, head down, abdominal, aspiration risk
        
        Respiratory
        
        Reduced FRC - good pre-ox with head up
        
        Capnography and ABGs to target normal parameters
        
        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
  - - - 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
      - 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
    - - 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
        
        Consider a-line
      - G
        
        Minimise FMV to reduce aspiration risk. Consider NGT to deflate stomach
      - D
        
        Time at horizontal every 2h or so
  - - - 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
    - - 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
    - - 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)
    - - Pre operative
        
        Alpha blockers
        
        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
      - Overall
        
        Reduce BP
        
        Reduce SVR
        
        Increase filling
        
        Control tachycardia
        
        Improve cardiac function
  - - - CKD
        
        A
        
        ?scelroderma
        
        B
        
        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)
        
        ?PPI ?RSI
        
        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
        
        Check FBC, G&S etc
        
        Thrombocytopenia
        
        Renal
        
        Assess fluid status
        
        Check electrolytes
    - - Optimising transplant function
        
        A&B
        
        Optimise GE
        
        C
        
        Optimise filling (CO monitor, CVP)
        
        Aim normotension
        
        Adequate warming
        
        Endo
        
        Glucose control
        
        Renal
        
        Avoid nephrotoxics
    - - 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
  - - - 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
  - - - 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
    - - Trauma
      - Haematological malignancies
        
        Pts require vaccinations (see below)
    - - Understand disease state
        
        Anaemia
        
        Chemotherapy
        
        Chronic disease
        
        Malignancy
        
        ?HLA matched products
        
        Steroids
      - MDT
        
        Haem/Onc/ITU/Surgical/Anaesthetic/Radiology
    - - Traumatic
        
        Midline incision
        
        Good access, rapid assessment of other viscera
        
        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
      - Haematological
        
        Left subcostal incision
        
        Laparoscopic
        
        Anterior approach
        
        Lateral approach
  - - - 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
    - - 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
    - - 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
- - - - 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)
    - - 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
    - - At least 2 but ideally 4-6w preop
        
        Haemophilus B
        
        Pneumococcus
        
        Meningitis B & C
      - Annually
        
        Influenza
  - - - 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
  - - - Hyperchloraemia
      - Metabolic acidosis with normal lactate
      - Hypernatraemia
      - Hypokalaemia, hypocalcaemia & hypomagnesaemia