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Y5 Emergency Medicine > 5 - Pre and Post Op Assessment > Flashcards

5 - Pre and Post Op Assessment Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Pre-operative assesments for elective surgery are done 2-4 weeks before a surgery. What is looked at in this assessment?

https://teachmesurgery.com/perioperative/preoperative/assessment/

A
  • Full history
  • Full examination
  • Airway examination inc ASA
  • Blood tests including FBC, U+E, LFTs, Clotting, Group and Save
  • Urine analysis
  • Pregnancy test
  • Further tests
  • Risk assess for DVT and make VTE plan
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2
Q

What are important parts of the PMHx to enquire about in a pre-op assessment?

A

- CVD :hypertension, the presence of exertional chest pain, syncopal episodes, or orthopnoea

- Respiratory disease: able to lie flat for a prolonged period? any chronic cough? are key as these may preclude spinal anaesthesia; also screen for symptoms and signs of OSA

- Renal disease: baseline renal function and any renal-specific medications

- Endocrine disease:specifically diabetes, thyroid disease, GORD (aspiration risk)

- Sickle cell disease

- Pregnancy

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3
Q

What is looked at in a full examination and airway examination in a pre-operative patient?

A

Full Exam
- Cardio
- Resp
- Abdo

Airway
- Mallampti
- ASA grades

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4
Q

What are the different ASA grades? (think about smoking, BMI, diabetes, HTN, COPD)

A
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5
Q

What are some blood tests done before surgery in a pre-op assessment?

A
  • FBC
  • U+Es
  • LFTs
  • Clotting
  • G+S
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6
Q

What are some further investigations you may do for a patient depending on their history in the pre-op assessment?

A

- Pregnancy test

- ECG: history of cardiovascular disease or undergoing major surgery

- ECHO:heart murmur, ECG changes, signs or symptoms of heart failure

- Spirometry: If COPD or poor lung function

- CXR: only when necessary

- Urinalysis

- MRSA Swabs: all pts nostril and perineum

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7
Q

Using some common operations, which ones should you group and save and cross-match for?

A

Minor day surgery e.g carpal tunnel needs no group and save

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8
Q

What is the general management plan in an elective pre-op assessment?

A

RAPRIOP
- Reassurance
- Advice
- Prescription
- Referral (ITU or HDU bed)
- Investigations
- Observations
- Patient understanding and follow-up

GET CONSENT FORM SIGNED

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9
Q

What advice do you need to give someone about eating and drinking before surgery?

A

Avoid aspiration pneumonia:

  • Stop eating and drinking dairy 6 hours before
  • Stop clear fluids 2 hours before
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10
Q

What drugs need to be stopped before surgery and when?

A

CHOW

- Clopidogrel: stopped 7 days prior

- Hypoglycaemics

- Oral contraceptive pill (OCP) or HRT: 4 weeks before due to DVT risk

- Warfarin: 5 days prior and switch to LMWH. Need INR<1.5

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11
Q

What drugs need to be altered before surgery?

A

Subcutaneous insulin: switched to IV variable rate insulin infusion

Long-term steroids: must be continued, due to risk of Addisonion crisis if stopped
If the patient cannot take these orally, switch to IV (5mg PO prednisolone = 20mg IV hydrocortisone)

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12
Q

What drugs need to be started before surgery?

A
  • LMWH
  • TED stockings
  • ?Abx prophylaxis
  • ?Bowel prep
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13
Q

When do DOACs and Aspirin need to be stopped before surgery?

A

Aspirin: can continue

DOAC: day before if low risk bleeding surgery, 2 days before if high risk bleeding surgery. If CKD double the time for both scenarios

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14
Q

How are type 1 diabetics managed before surgery?

A
  • First on morning list
  • Night before surgery, reduce s/c basal insulin dose by 1/3rd
  • Omit morning insulin and commence IV VRII (sliding scale)
  • Continue until the patient is able to eat and drink
  • Give SC rapid acting insulin ~20 minutes before meal and stop IV infusion ~30-60 minutes after they’ve eaten.
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15
Q

How are type 2 diabetics managed before surgery? (see image)

A
  • First on list
  • If missing more than one meal or insulin dependent need VRII
  • Stop sulfonylureas and SGLT2 inhibitors morning of. Risk of hypoglycaemia and DKA
  • Stop metformin only if risk of AKI
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16
Q

Which operations need bowel prep?

A
  • Left hemi-colectomy, sigmoid colectomy, or AP resection:Phosphate enema on the morning of surgery
  • Anterior resection: 2 sachets of picolax the day before or phosphate enema on the morning of surgery
  • Right sided colectomy or Upper GI need none
17
Q

Who do you need to be careful giving bowel-prep to and what advice should you give them?

A
  • Elderly or cardiac or renal disease as fluid shifts. Need IV fluids
  • Do not take oral medications 1h before or after administration
  • If taking COCP need 1 weeks of extra contraception to cover
18
Q

How do you decide the order to book operations in?

A
  • Children and elderly first
  • Diabetics first
  • Dirty before clean
  • Longer more complex before short
19
Q

As an FY1 what do you need to ensure is done for an inpatient before surgery?

A
  • Adequately fasted
  • Bloods done inc G+S and cross match if needed
  • VTE prophylaxis
  • Abx prophylaxis
  • Op site marked
  • Consent form is done
20
Q

What are some risk factors for VTE in a surgical in-patient?

A
21
Q

What do you need to check before discharging a day case surgery?

A
  • Are observations normal?
  • Have they eaten and drank without vomiting?
  • Have they passed urine?
  • Have they mobilised?
  • Have they got adequate pain relief?
  • Have they got any questions?
  • Have they got a follow up booked?
22
Q

What advice do you need to give patients after discharging them from day case surgery?

A
  • Self-certify for a week then go to GP for sick note
  • Tell them stitches are disolvable
  • Can shower and drive 48h after surgery
  • Do not fly for 6 weeks folloing major surgery
23
Q

How do you structure the review of an inpatient who is post-op?

A

IMPORTANT CARD

24
Q
A
25
Q

At what HbA1c (mmol/L) is someone classed as prediabetic and diabetic?

A

Pre-Diabetic: 42 - 47

Diabetic: 48 or more

26
Q

What is the target HbA1c for diabetics?

A
27
Q

What are two late complications of abdominal surgery?

A
  • Small bowel obstruction
  • Incisional hernia
28
Q

What is reactive bleeding?

A

Bleeding within 24 hours of the operation.

During surgery patients often become relatively hypotensive and vasoconstricted.

In the post-operative period, as blood pressure rises and vasodilatation occurs, a damaged blood vessel may subsequently begin to bleed.

29
Q

How does atelectasis present and how can this be prevented?

A
  • Normal parameters but low-grade pyrexia, usually early complication
  • Need adequate analgesia and breathing exercises
  • Higher risk of this in abdominal surgery
30
Q

Why do people often have oxygen through a nasal cannula post op?

A

Lowers the risk of myocardial infarction

31
Q

Why does hyponatraemia cause confusion?

A

Cerebral oedema - the brain is swollen

32
Q

What are some causes of post op confusion?

A
  • Hypoxia
  • Sepsis
  • Infection
  • Electrolyte disturbance
  • Drug induced (e.g analgesia)
33
Q

ADD POST OP COMPLICATIONS AND SIDE EFFECTS OF COMMON OPERATIONS

A
34
Q

What are the 3 phases of an operation that need abiding to by the WHO surgical checklist?

A
35
Q

What happens in the sign in part of the WHO surgical checklist?

A
  • Patient has confirmed: Site, identity, procedure, consent
  • Site is marked
  • Anaesthesia safety check completed
  • Pulse oximeter is on patient and functioning
  • Does the patient have a known allergy?
  • Is there a difficult airway/aspiration risk?
  • Is there a risk of > 500ml blood loss (7ml/kg in children)?
36
Q

What is a long term complication of mechanical ventilation?

A

Tracheo oesophageal fistula

Can lead to recurrent pneumonia

37
Q

What should you use to clean surgical wounds and when can a patient shower after surgery?

A

Sterile saline up to 48 hours after surgery then tap water after this if surgical wound has separated or has been surgically opened to drain pus

Patients may shower safely 48 hours after surgery

38
Q

How is wound dehiscence managed?

A
  • Cover wound with saline gauze
  • IV broad-spectrum abx
  • Return to theatre

Y5 Emergency Medicine (14 decks)

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