7 Surgery - Management of post-op issues Flashcards
Patients factors increasing VTE risk (5)
Age Obesity Varicose Veins History of DVT/PE Clotting disorders
Surgical factors increasing VTE risk (3)
Immobility – bed rest or reduced mobility
Dehydration
Trauma or surgery - increased risk with:
(↑ duration, Type of surgery ↑ risk with pelvis or abdo surgery for cancer, Major limb amputation, Major trauma or orthopaedic surgery)
Medical factors associated with increase VTE risk
6
Malignancy Oestrogen therapy Pregnancy or post partum Co-morbidity Severe infection Lower limb paralysis
All patients must have VTE assessment with ……………….. of admission.
Reassed every ………………..
24H
72H
Non-pharma ways to reduce risk of VTE (3)
Hydrate
Mobilise ASAP
Stop meds that increase risk if possible
3 mechanical propylaxis of VTE methods
Compression stockings
Intermittent pneumatic compression
Foot impulse devices
If low risk of VTE what should be done for prophylaxis?
Early mobilisation and copression stockings (if not contrqaindicated)
If high risk consider
LMWH/NOAC
intermittent pneumatic compression during suregery
Assess bleed vs VTE risk with
Active bleeding Recent surgery Recent stroke Spinal intervention Concurrent use of anticoagulants Uncontrolled systolic hypertension
When do you stop VTE prophylaxis?
Continue until mobilized
Extend regime required for some procedures such as cancer/ #NOF/ lower limb cast
NOACs licenced for what surgery VTE prophylaxis?
Total hip/total knee replacement
Caution errors of duplication
NOACs licenced for what surgery VTE prophylaxis?
Total hip/total knee replacement
Caution errors of duplication
If pain is poorly managed…
↓ Recovery & ↑ length of stay ↓ Mobility & ↑ VTE risk ↓ wound healing ↑ BP & Pulse ↑ Anxiety & disturb sleep
e.g. of procedure specific pain relief
gabapentin/oxycodone with total knee replacement
PONV affects ….% of pt
30
What is the cause of PONV
6
- Anaesthetic agents
- Opioid analgesia
- Bowel surgery
- Antibiotics
- U&E disturbances
- Bowel obstruction
Problems with poorly managed PONV (4)
- ↑ length of stay
- Cause dehydration & electrolyte disturbance
- Disrupt wounds
- Reduce medicines absorption
Apfel scoring for PONV
1 point for: female History of motion sickness/PONV Non-smoker Opiate use
0 = 10% 1 = 20% 2 = 40% 3 = 60% 4 = 80%
What meds are usually used for PONVL (4)
ondansetron, cyclizine, dexamethasone or prochlorperazine
- number prescribe depends on risk factors
metoclopriamide is not v effective
why is their high bleed risk for spinal injurys
subdural epidural bleeds are catastrophic
How much does one antiemetic reduce PONV risk?
25%
- use this to work out how many to prescribe
When to administer anti emetics?
20-30mins before planned end of surgery.
Except dexamethasone which is given at induction
Vomiting centre has what receptors? What does each antiemetic target?
Cyclizine (antihistamine) Ondansetron (serotonin antagonist) Dopamine Antagonists: Metoclopramide Domperidone Prochlorperazine
~Infection risk depends on: (4)
- degree of contamination during surgery
- patient factors
- operation length
- surgeon skill
Types of procedures with infection risk
Clean:
No break in sterile technique, site not inflamed or infected eg breast surgery
Clean-contaminated:
Respiratory, gut or genito-urinary tract entered but no contamination encountered eg appendectomy
Contaminated:
Major break in sterile technique, spillage from GI tract or acute inflammation encountered
Dirty:
Acute inflammation with pus encountered / GI tract perforation / old dirty wounds
e.g. of surgery and antibiotic prophylaxis - CLEAN
No break in sterile technique, site not inflamed or infected eg breast surgery
None (unless implanting)
e.g. of surgery and antibiotic prophylaxis - CLEAN-CONTAMINATED
Respiratory, gut or genito-urinary tract entered but no contamination encountered eg appendectomy
At induction and 24h post op
e.g. of surgery and antibiotic prophylaxis - DIRTY
Contaminated:
Major break in sterile technique, spillage from GI tract or acute inflammation encountered
Dirty:
Acute inflammation with pus encountered / GI tract perforation / old dirty wounds
Contaminated or Dirty – at induction and treatment course for 5-7 days post op
Why should er try to avoid antibiotics?
They carry their own risk
c diff, resistance,
s/e
Choice of antibiotic regime depends on
Locally agreed policies
Microbiologists & Pharmacist
Choice depends on:
- Likely organism encountered – local resistance patterns - Cost-effectiveness - Pharmacokinetics – tissue concentration
What route is preferred for antibiotic prophy
High tissue concentration at time of incision
iv preferred route
Dose / infusion completed just before incision if iv
Re-administer if long surgery
Info on NBM post op
Following most surgical procedures, patients can eat and drink that evening
Post GI surgery may be NBM for several days / weeks or have impaired absorption
Regular medicines for underlying disease
- essential to be continued?
Consider alternative routes:
- parenteral - iv/im/sc
- transdermal
- rectal
- via feeding tube
- sub-lingual
Info on NBM post op
Following most surgical procedures, patients can eat and drink that evening
Post GI surgery may be NBM for several days / weeks or have impaired absorption
Regular medicines for underlying disease
- essential to be continued?
Consider alternative routes:
- parenteral - iv/im/sc
- transdermal
- rectal
- via feeding tube
- sub-lingual
4 things to consider post op
vTE propylaxis
Antibiotic prophylaxis
PONV
pain
