7 Surgery - Management of post-op issues Flashcards by user delete

Patients factors increasing VTE risk (5)

Age
Obesity
Varicose Veins
History of DVT/PE
Clotting disorders

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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)

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Medical factors associated with increase VTE risk

Malignancy
Oestrogen therapy
Pregnancy or post partum
Co-morbidity
Severe infection
Lower limb paralysis

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All patients must have VTE assessment with ……………….. of admission.

Reassed every ………………..

24H

72H

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Non-pharma ways to reduce risk of VTE (3)

Hydrate
Mobilise ASAP
Stop meds that increase risk if possible

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3 mechanical propylaxis of VTE methods

Compression stockings
Intermittent pneumatic compression
Foot impulse devices

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If low risk of VTE what should be done for prophylaxis?

Early mobilisation and copression stockings (if not contrqaindicated)

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If high risk consider

LMWH/NOAC

intermittent pneumatic compression during suregery

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Assess bleed vs VTE risk with

Active bleeding
Recent surgery
Recent stroke
Spinal intervention
Concurrent use of anticoagulants
Uncontrolled systolic hypertension

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When do you stop VTE prophylaxis?

Continue until mobilized

Extend regime required for some procedures such as cancer/ #NOF/ lower limb cast

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NOACs licenced for what surgery VTE prophylaxis?

Total hip/total knee replacement

Caution errors of duplication

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NOACs licenced for what surgery VTE prophylaxis?

Total hip/total knee replacement

Caution errors of duplication

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If pain is poorly managed…

↓ Recovery &amp; ↑ length of stay
↓ Mobility &amp; ↑ VTE risk
↓ wound healing
↑ BP &amp; Pulse
↑ Anxiety &amp; disturb sleep

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e.g. of procedure specific pain relief

gabapentin/oxycodone with total knee replacement

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PONV affects ….% of pt

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What is the cause of PONV

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

4 things to consider post op

vTE propylaxis Antibiotic prophylaxis PONV pain