AS - Surgery Pre-Op Assessment Flashcards
Pre-op Checks for surgery?
Operative fitness: cardiorespiratory comorbidities
Pills
Consent
History: MI, Asthma, HTN, Jaundice. Complications of anaesthesia: DVT, Anaphylaxis.
Ease of intubation: neck arthritis, dentures, loose teeth.
Clexane: DVT prophylaxis (heparin)
Site: correct and marked.
Surgical evaluation of the abdomen
Lie patient flat with arms down. Patient may be rolled right or left. Ask patient to cough during inspection to reveal hernias. Stand patient up to examine groin only if necessary. Inspect Palpate Percuss Auscultate
Background paperwork for patient surgery?
- Medical notes
- Check blood results - Clotting for anticoagulated patients
- K+ for patients with renal failure
Ca2+ for parathryroidectomy patients. - Consent forms
- Drug chart
Patient prep?
- Blood products
- Bowel prep
- Anaesthetic premed
Can patient have AED when they has surgery?
Give as usual
Post-op may need IV or NGT
Can patient have OCP when theh has surgery?
No. Stop 4 weeks before major/leg surgery.
Restart 2 weeks post-op if mobile.
Can a patient have B-Blocker when they have surgery?
Continue as normal
What pre-op investigations are required?
Routine: FBC, U+E, G+S, clotting, glucose
Specifics:
- LFTs: liver, EToH, Jaundice
- TFT: thyroid disease
- Se electrophoresis: Africa, West Indies, Med.
ECG used for >65
renal disease may need FBC + EG.
CXR NOT ROUTINELY USED.
Cross-match
- Gastrectomy: 4U
- AAA: 6U
Prophylactic medications for pre-op - Clean bowel surgery?
Antiobiotic - Check hospital guidelines.
e. g ‘Clean’ bowel surgery like appendicitis, colonic resection = - Cefuroxime 1.5g IV + metronidazole 500mg IV
- IV amoxicillin 500mg IV + metronidazole 500mg IV.
Prophylactic medications for pre-op - Clean hepatobiliary surgery ERCP, open biliary surgery?
Gentamicin 120mg IV + amoxicillin 500mg IV + metronidazole 500mg
Prophylactic medications for pre-op - Clean gynaecological surgery?
Metronidazole 500mg IV or 1g PR
Prophylactic medications for pre-op - Clean Elective orthopaedic surgery
Flucloxacillin 1g IV
Prophylactic medications for pre-op - Clean vascular surgery
Flucloxacillin 500mg IV + gentamicin 120mg IV + amoxicillin 500mg IV.
Thromboprophylaxis pre-op?
- TED stockings - Reduce stasis infrapopliteal veins.
- Heparin. Activates antithrombin III. Prophylaxis: 5000U SC od.
Treatment: IV 2000U Loading, 2000U/h. Check APTT 6hr after starting and 6-12 hr thereafter. Maintain APTT 50-70 - LMWH. Activates antithrombin III. SC injection.
= Prophylaxis: 20-40mg SC Clexane od. - Treatment: 2mg/kg SC in two divided doses.
Clotting cascade drugs?
- Heparin
- LMWH: Clexane - 20-40mg prophylaxis. Treatment = 2mg/kg SC in two divided doses.
Antiplatelet drugs - not used as VTE prophylaxis .
Aspirin (300mg PO OD)
Dipyridamole (75mg PO QDS)
Clopidogrel (75mg PO OD)
Risk stratification for DVT Prophylaxis.
Low-risk: Early mobilisation
Medium risk: Early mobilisation + TEDS + 20mg enoxaparin
High: Early mob + TEDS + 40mg enoxaparin + intermittent compression boots perioperatively.
Prophylaxis started @ 1800 post-op .
May continue medical prophylaxis at home (up to 1mo)
NBM surgery?
> 2hr for clear fluids. Black coffee includes this.
> 6hrs for solids.
What is the required bowel prep?
Needed in left-sided operations:
- Picolax: picosulphate and Mg Citrate
Klean-Prep: Macrogel
Not usually needed in right-sided procedures.
Necessity is controversial as benefits of minimising post-op infection might not outweigh risk.
- Liquid bowel content spilled during surgery
- Electrolyte disturbace
- Dehydration
- Increased rate of post-op anastomotic leak
Given day before examination.
Required not to eat 24hr before examination.
- Day before procedure and day of procedure.
ASA Grades?
- Normally healthy
- Mild systemic disease - current smoker, obesity, well controlled diabetes.
- Severe systemic disease that limits activity (1 or more systemic diseases) = Poorly controlled diabetes, HTN, COPD, ESRD.
- Systemic disease which is a constant threat to life. MI recent, CVS accidents, DIC, ARD, ESRD not undering dialysis.
- Moribund: not expected to survive 24hr even with op.
Specific pre-operative complications? Diabetes
Increased risk of post-operative complications
- Surgery –> stress hormone –> Antagonise insulin
- Pts are NBM
- Increased risk of infection
- IHD and PVD
Specific pre-operative management Diabetes
- Dipstick: proteinuria
- Venous glucose
- U+E= K+.
What are the practical points of dealing with insulin dependent DM?
- Put the patient first in the list and inform the surgeon and anaesthetist,
- Some centres prefer to use GKI infusions.
- Sliding scales may not be necessary for minor ops. If in doubt, liase with diabetes specialist nurse.
What is the management of insulin with IDDM patients?
- ± stop long-acting insulin the night before.
- Omit AM insulin if surgery is in the morning.
- Start a sliding scale 5% Dex with 20mmol KCL 125ml/hr. Infusion pump with 50u actrapid. Check CPG hrly and adjust insulin rate.
- Check glucose hrly: aim for 7-11.
- Post-op: Continue sliding-scale until tolerating food. Switch to SC regimen around a meal.
Management pre-op of non-insulin dependent DM?
- If glucose control poor (fasting >10mM): treat as IDDM
- Omit oral hypoglycaemics on AM of surgery
- Eating post-op: resume oral hypoglycaemics with meal
- No eating post-op: Check fasting glucose on AM of surgery. Start insulin Sliding scale.
Consult specialist team re restarting PO Rx.
Management pre-op NIDDM diet controlled?
Usually no problem
Pt may be briefly insulin-dependent post-op.
- Monitor CPG
Minor surgery re diabetic pre-op?
Oral controlled: Give normal regimen
Insulin controlled: Omit pre-operative insulin day of surgery; monitor blood sugar every 4h; restart normal insulin once oral diet is established.
Avoid cannulating foot.
Major surgery re diabetic pre-op
Oral controlled: Omit long-acting hypoglycaemics preoperatively. Monitor BS Every 4hr. If BS exceeds 15mmol/L, start IV insulin regimen.
Insulin-controlled: Commence sliding scale IV preoperatively once NBM and continue until normal diet resumed. Check BS 4hrly. Restart normal insulin regimen (initially half dose) once oral diet is established.
Emergency surgery re diabetic pre-op
Check for existing ketoacidosis.
IF present use medical treatment algorithm to control BS and postpone surgery until BS <20 unless condition is life-threatening.
Use iV insulin sliding scale for all patients to optimise BS control. A typical IV sliding scale (Actrapid with 5% dextrose) is:
- BS <4mmol/L infusion 0.5u/h + consider medical review
- BS 4-15mmol/L, infusion 2.0U/h
- BS 15-20mmol/L, infusion 4.0U/h
BS >20, infusion 4 + cnsult diabetes team + consider DKA treatment
Risk of patients on steroids for surgery?
Poor wound healing
Infection
Adrenal crisis
Management of a patient who uses steroids for surgery
Increase steroid to cope with stress
Consider cover if high-dose steroids within last year
Major surgery:
Hydrocortisone 50-100mg IV with pre-med then 6-8hrly for 3ds
Minor: as for major but hydrocortisone only for 24hr
Management of patients with jaundice for surgery?
Best avoided
Use ERCP instead
Risk of operating on patients with Jaundice
- Patients with obstruction have increased risk of post-op renal failure so need to maintain good UO.
- Coagulopathy
- Increased risk of infection: may develop cholangitis
Pre-op management of jaundice?
- Avoid morphine in pre-med
- Check clotting and consider pre-op vitamin K
- Give 1L NS pre-op (unless CCF) –> moderate diuresis
- Urinary catheter to monitor UPO
- Abx prophylaxis e.g cef and met
Intra-op management of jaundice
Hrly UO monitoring
NS titrated to output
Post-op
Intensive monitoring of fluid status
Consider CVP + frusemide if poor output despite NS
Anticoagulated patients management surgery?
- Balance risk of haemorrhage with risk of thrombosis
- Consult surgeon, anaesthetist and haematologist
- Very minor surgery can be undertaken without stopping warfarin if INR <3.5
- Avoid epidural, spinal and regional blocks if anticoagu
- In general, continue aspirin/clopidogrel unless risk of bleeding is high - then stop 7d before surgery.
Low thromboembolic risk: e.g AF - Anticoagulation
- Stop warfarin 5d pre-op: need INR <1.5
- Restart next day
High thromboembolic risk: valves, recurrent VTE. - Anticoagulation
Must bridge with LMWH
- Stop warfarin 5d pre-op and start LMWH
- Stop LMWH 12-18hr pre-op
Use mechanical prophylaxis
- Restart LMWH 6h post-op
- Restart warfarin next day
- Stop LMWH when INR >2
LMWH = patients with normal renal function. Given as one daily subcut. Binds antithrombin.
Unfractionated - binds anthrombin III with thrombin + factor Xa. Activity measured using APTT. Reversed with protamine.
Dabigatran
- Orally administered direct thrombin inhibitor.
- No monitoring.
Emergency surgery coagulation
- Discontinue warfarin
- Vitamin K 5mg slow IV
- Request FFP or PCC to cover surgery
Risk of patients with COPD and smoking for surgery?
- Basal atelectasis
- Aspirations
- Chest infection
Smoking - reduced immune funciton. Increases platelet aggregation. Reduced oxygen-carrying capacity of blood per unit volume. Increased upper aerodigestive mucosal secretions.
Reduced mucociliary escalator function.
Pre-op management of patients with COPD
- CXR
- PFTs
- Physio for breathing exercises
- Quit smoking (4 weeks prior to surgery)
Mitigating the effects of smoking in post-operative period?
Active + recently stopped smokers should receive extra attention to preventing risk
- Ensure patient remain well hydrated until oral intake is restored.
- Use preoperative chest physio + education on breathing and coughing techniques.
- Mobilise as soon as possible post-operatively.
- Consider use of epidural anaesthesia to improve compliance with post-operative physio.
- Use preoperative + post-operatie saline nebs 5ml qds
Principles and practical conduct of anaesthesia?
Aim: Hypnosis, analgesia, muscle relaxation
Induction: e.g IV propofol
Muscle relaxation
- Depolarising: suxamethonium
- Non-depolarising: vecuronium, atracurium (reversed with sugammadex)
Airway control: ET tube, LMA
Maintenance - Usually volatile agent added to N2O/O2 mix (halothane, enflurane)
- End of Anaesthesia
Change inspired gas to 100% O2
Reverse paralysis: neostigmine + atropine (prevent muscarinic side effects).
What drug is used for anaesthesia induction?
Ketamine
- Makes you sick
- Little myocardial depression - for those who are haemodynamically unstable.
What drugs are used for muscle relaxation?
- Depolarising: suxamethonium
- Non-depolarising: vecuronium, atracurium
What drug is used for maintenance of anaesthesia?
Volatile agents such as halothane or enflurane.
IV propofol
Pain on IV injection
Proven anti emetic properties
Maintains sedation.
The 7 As of pre-medication of anaesthesia?
Anxiolytics and Amnesia: e.g temazepam
Analgesia: e.g opioids, paracetamol, NSAIDs
Anti-emetics: e.g ondansetron 4mg/metoclop 10mg
Antacids: e.g lansoprazole
Anti-sialogue e.g glycopyrolate (decreased secretions)
Antibiotics
What is regional anaesthesia and where is it used?
- May be used for minor procedures or if unsuitable for GA
- Nerve or spinal blocks. CI: local infection, clotting abnormalities
= Use long-acting agents: e.g bupivacaine
Complications of Anaesthesia?
Propofol Induction
- Cardioresp depression
- Suxamethonium apnoea. AD mutation - lack of specific acetylcholinesterase in plasma.
Intubation
- Oropharyngeal injury with laryngoscope
- Oesophageal intubation
Loss of pain sensation
- Urinary retention
- Pressure necrosis
- Nerve palsies
Loss of muscle power
- Corneal abrasion
- No cough –> atelectasis + pneumonia
Malignant hyperpyrexia
- Rare complications due to halothane or suxamethonium
- AD inheritance
- Rapid rise in temperature + masseter spasm
- Tachycardia, muscle rigidity, rhabdomyolysis, hyperthermia, arrhythmia.
- Rx: Dantrolene + cooling
Anaphylaxis
- Rare
- Possible triggers = antibiotics, colloid, NM blockers: e.g vecuronium
Necessity of analgesia?
Pain = autonomic activation --> Arteriolar constriction --> decreased wound perfusion --> Impaired wound healing Pain = decreased mobolisation --> Increased VTE risk and decreased function Pain = Decreased resp excursion and decreased cough --> Atelectasis and pneumonia
General guidance for pain management?
- Give regular doses at fixed intervals
- Consider best route: oral when possible
- PCA should be considered: morphine, fentanyl
- Follow stepwise approach
- Liaise with Acute Pain Service
Pre-op pain management?
Epidural anaesthesia. e.g bupivacaine
End-op pain management
Infiltrate wound edge with LA
Infiltrate major regional nerves with LA
Post-Op stepwise pain management?
Stepwise approach:
Non-opioid ± adjuvant
- Paracetamol
- NSAIDS - ibuprofen 400mg/6h PO max. diclofenac 50mg PO/75mg IM.
Weak opioid + non-opioid±adjuvants
- Codeine
- Dihydrocodeine
- Tramadol
Strong opioid + non-opioid ± adjuvants
- Morphine: 5-10mg/2h max
- Oxycodone
- Fentanyl
Indications for spinal or epidural anaesthesia?
Decreased SE as drugs more localised 1st line for major bowel resection Caution - Respiratory depression - Neurogenic shock --> Decreased BP
Enhanced recovery after surgery?
- ERAS commonly employed in colorectal and orthopaedic surgery
Aims of ERAS?
- Optimise pre-op prep for surgery
- Avoid iatrogenic problems (ileus)
- Minimise adverse physiological/immunological responses to surgery such as:
1) increased cortisol and decreased insulin (absolute or relative)
2) hypercoagulability
3) immunosuppression - Increased speed of recovery and return to function
- Recognise abnormal recovery and allow early intervention
Pre-op ERAS?
Aggressive physiological optimisation
- Hydration
- BP (increased/decrease)
- Anaemia
- DM
- Co-morbidities
Smoking cessation: >4 weeks before surgery
Admission on day of surgery, avoid prolonged fast
Carb loading prior to surgery: e.g carb drink
Fully informed patient, encouraged to participate in recovery
Intra-operative: decrease physical stress
- Short-acting anaesthetic agents
- Epidural use
- Minimally invasive techniques
- Avoid drains and NGTs where possible
Post-op: early return to function and mobilisation
- Aggressive management of pain and nausea
- Early mobilisations and physiotherapy
- Early resumption of oral intake (inc carb drinks)
- Early discontinuation of IV fluids
- Remove drains and urinary catheters ASAP.
General complications of surgery: Immediate (<24hrs)
- Intubation –> Oropharyngeal trauma
- Surgical trauma to local structures
- Primary or reactive haemorrhage
General complications of surgery: early (1d-1month)
- Secondary haemorrhage
- VTE
- Urinary retention
- Atelectasis and pneumonia
- Wound infection and dehiscence
- Antibiotic associated colitis
General complications of surgery: late (>1month)
- Scarring
- Neuropathy
- Failure or recurrence
General-post op complications: Haemorrhage classification
Primary: continuous bleeding starting during surgery
Reactive: bleeding at the end of surgery or early post-op. Secondary to increased CO and BP.
Secondary: Bleeding >24hr post-op. Usually due to infection
Clinical signs of significant post-op bleed?
Tachypnoea Tachycardia Hypotension (patients can have normal BP but be bleeding) Clamminess Cold peripheries Dizziness Confusion
On examination signs of significant post-op bleed?
Evidence of external bleeding Swelling Discoloration/bruising Tenderness around surgical site Peritonism
Classification of haemorrhagic shock?
Class 1 = Blood loss <750ml. HR <100, BP normal, RR 14-20, UO >30.
Class 2 = Blood loss 750-1500ml. HR 100-120, BP normal, RR 20-30, UO <20-30.
Class 3 = Blood loss 1500-2000ml. HR 120-140, BP decreased, RR 30-40, UO 5-20ml/hr.
Class 4 = Blood loss >2000ml. HR >140, BP decreased, RR >40, UO<5.
Practical tips for major haemorrhage?
- Re-assess regularly to ensure your management is effective
- Make use of the team around you to delegate tasks.
- All critically ill patients need continuous monitoring such as: BP, 3-Lead ECG, Oxygen Sats, HR, RR.
- communication
- Call for help early (SBAR handover)
- Ensure to prescribe medications/fluids
- Ensure you document everything.
Examination of suspected haemorrhage?
- If patient unconscious, check pulse + if breathing.
- If patient is unconscious or unresponsive and not breathing - start BLS and call 2222.
- Do an AVPU, how do they look. What is their breath like.
- Prep - Check operation + intraoperative blood loss.
A-E Assessment of post-operative bleed: A
- Airway. Look for speaking/evidence of stridor. If Head and Neck surgery consider senior surgical help ASAP.
- Maintaining airway. –> Head tilt, chin lift. Jaw thrust.
- Consider nasopharyngeal airway/oropharyngeal airway.
A-E Assessment of post-operative bleed: B
Breathing - O2 Sats of 95-98.
RR - Tachypnoea is very sensitive marker. (less haemoglobin therefore increased RR)
- Auscultate both lungs. Reduced air entry bilaterally. Unilateral reduced air entry. Palpate + percuss to assess chest expansion.
- Consider investigations such as ABG/Chest X-ray.
- High-flow oxygen through non-rebreathe mask.
- If patient unconscious + RR inadequate give assisted ventilation through bag-valve mask (BVM).
- Ventilate at rate of 12-15 breaths per minute (one every 4 seconds)
A-E Assessment of post-operative bleed: C
- Pulse - Check if tachy.
- BP - Hypotension
- Surgical drains/blood in situ
Check Cap refil time, clammy/pale. Pulse (tachycardic), BP: normal or hypotensive.
Intervention:
- Get IV access = 2 large bore. Need 18G cannulas so blood can run through quickly.
Urgent blood transfusion
- Ask for major haemorrhage guidelines
Administer IV fluids. Max 1-2 litres of fluid given. If becomes hypotensive again, they will need blood products too.
- Restore circulatory volume, correct electrolyte imbalances, perfuse kidneys.
Investigations
- Bloods/ G+S/CM. FBC, CRP, U+E, LFTs, Clotting.
- Record ECG
A-E Assessment of post-operative bleed: Disability
Blood glucose level
Assess pupils (size, equal, reactive to light)
Assess level of consciousness AVPU/GCS.
A-E Assessment of post-operative bleed: Exposure
inspection: UO , Temperature, Catheterise, Reverse hypothermia.
A-E Assessment of post-operative bleed: Document + Review
ABCDE findings + interventions and response the patient had.
A-E Assessment of post-operative bleed: Discuss
- Does the patient require further surgery for haemostasis
- Further assessments, investigations
- Does the patient need referral to HDU/ICU
- Should they be referred for a review by specialist doctor
- Changes to underlying conditions
Post-op Urinary retention causes?
Drugs: Opioids, epidural/spinal, anti-AChM
Pain: sympathetic activation –> Sphincter contraction
Psychogenic: hospital environment
Risk factors for post-op UO?
Male Increased age Neuropathy: e.g DM, ETOH BPH Surgery type: hernia/anorectal
Management of UO?
Conservative - Privacy - Ambulation - Void to running taps or in hot bath - Analgesia Medical - Catheterise ± gent 2.5mg/kg IV stat - TWOC = if failed, may be sent home with silicone catheter and urology output.
What is pulmonary atelectasis?
- Occurs after every nearly GA
- Mucus plugging + absorption of distal air –> collapse
- No new air can be absorbed, so existing air is absorbed and airway collapses.
What are the causes of pulmonary atelectasis?
- Pre-op smoking
- Anaesthetics increase mucus production and decrease mucociliary clearance
- Pain inhibits respiratory excursions and cough
What is the px of post-op pulmonary atelectasis
- Within first 48hrs
- Mild pyrexia
- Dyspnoea
- Dull bases with decreased air entry
CXR - Should be able to see air bronchograms etc.
What is the management of pulmonary atelectasis?
Good analgesia to aid coughing
Chest physiotherapy
Wound infections post-op complications bacteria/length of time
5-7 days post-op
Organisms = S.aureus and coliforms (e.coli, Klebsiella)
- Pain and discharge in wound
- Malaise, anorexia and fever.
Classifications of operation wounds?
Clean: incise uninfected skin w/o opening viscus
Clean/Cont: Intra-op breach of viscus (NOT COLON)
Contaminated: breach of viscus + spillage or opening of colon
Dirty: site already contamined - faeces, pus, trauma
Risk factors for wound infection pre-operatively?
Pre-operative
- Increased age
- Comorbidities: e.g DM
- Pre-existing infection: e.g appendi perforation
- Pt. colonisation e.g nasal MRSA
Risk factors for wound infection operatively?
- Operation classification and wound infection risk
- Duration of procedure
- Technical: pre-op Abx, aseptic
Management of wound infection?
- Send any discharging pus for MCS + Bloods
- Regular wound dressing
- Abx (anti-staph: Flucloxacillin 1g + 500mg QDS. Can add broad-spectrum + anaerobic cover: metronidazole 500mg IV TDS + Cefuroxime 1.5g IV
- Abscess drainage
What is wound dehiscence?
Dehisced surgical wounds are defined by the separation of the incision line prior to complete healing resulting in an open wound.
What is the presentation of wound dehiscence?
- Occurs 10d post-op
- Preceded by serosanguinous discharge from wound
Causes of wound dehiscence?
- Secondary to wound infection + physiological factors of patient (immunocompromised/suppressed).
Risk factors of wound dehiscence?
- Pre-operative Factors? Increased Age Smoking Obesity, malnutrition, cachexia Comorbs: eg BM, Uraemia, chronic cough, Ca Drugs: steroids, chemo, radio
- Operative factors
Length + orientation of incision
Closure technique: follow Jenkin’s rule
Suture material - Post-operative factors
Increased IAP: e.g prolonged ileus –> Distension
Infection
Haematoma/seroma formation
What is Jenkin’s rule?
It is a rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound edge
Wound haematoma?
Localised collection of blood beneath wound or at site of surgery, usually characterised by swelling and discoloration.
- If this happens after vascular, flap or procedures on the limb or neck, get senior help (to avoid ischaemia, compartment syndrome, airway obstruction, flap failure, ongoing haemorrhage).
- apply firm pressure followed by pressure dressing
- Check clotting and FBC and treat appropriately
- Withhold heparin
- Surgical management is the same as for haemorrhage
Management of wound dehiscence
- Call senior for help
- Replace abdo contents and cover with sterile soaked gauze (soak in 0.9% saline).
- IV abx: cef + met
- Opioid analgesia
- Call senior and arrange theatre
- Repair in theatre (Wash bowel, debride wound edges, close with deep non-absorbable sutures)
May require VAC dressing or grafting
Specific post-op complications for cholecystectomy?
- Conversion to open: 5%
- CBD injury: 0.3%
- Bile Leak
- Retained stones (Needing ERCP)
- Fat intolerance/loose stools
Specific post-op complications for inguinal hernia repair?
Early
- Haematoma/seroma formation: 10%
- Intra-abdominal injury (lap)
- Infection: 1%
- Urinary retention
Late
- Recurrence (<2%)
- Ischaemic orchitis: 0-5%
- Chronic groin pain/ paraesthesia: 5%
Specific post-op complications for appendicectomy?
- Abscess formation
- Fallopian tube trauma
- Right hemicolectomy (e.g for carcinoid or caecal necrosis)
Specific post-op complications for colonic surgery?
Early:
- Ileus
- AAC (acute acalculous cholecystitis)
- Anastomotic leak
- Enterocutaneous fistulae
- Abdominal or pelvic abscess
Late
- Adhesions –> Obstruction
- Incisional hernia
What causes a post-op ileus?
Causes: Bowel handling, anaesthesia, electrolyte imbalance
What is the presentation of a post-op ileus?
Distention, constipation ± vomiting, absent bowel sounds.
Management of post-op ileus?
IV fluids + NGT for decompression.
TPN if prolonged
Reduce opiate analgesia + encourage mobilisation
Post-op specific complications for anorectal surgery?
- Anal incontinence
- Stenosis
- Anal fissures
Post-op specific complications for short gut surgery?
- Short gut syndrome (<250cm)
- Leads to diarrhoea, dehydration, malnutrition and weight loss.
(indications included Crohn’s disease).
Post-op specific complications for splenectomy?
- Gastric dilatation (sndry to gastric ileus). Prevent this with NGT
- Thrombocytosis –> VTE (lack of sequestering in spleen)
- Infection: encapsulated organisms
Post-op specific complications for vascular arterial surgery?
- Arterial surgery: thrombosis and embolisation
- Anastomotic leak
- Graft infection
Post-op specific complications for aortic surgery?
- Gut ischaemia
- Renal failure
- Aorto-enteric fistula (An aortoenteric fistula is a connection between the aorta and the intestines, stomach, or esophageus. Leading to bloody stool/diarrhoea)
- Anterior spinal syndrome (paraplegia) - due to ischaemia from aorta
- Emboli –> Distal ischaemia (trash foot)
Post-op specific complications for breast surgery?
- Arm lymphoedema
- Skin necrosis
- Seroma
Post-op specific complications for urological surgery?
- Sepsis (instrumentation with infected urine)
- Urinoma: extravasation of urine (encapsulated region of extravasated urine)
Post-op specific complications for prostatectomy
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation
- Prostatitis
Post-op specific complications for ENT thyroidectomy surgery?
Thyroidectomy
- Wound haematoma –> Tracheal obstruction
- Recurrent laryngeal nerve trauma (hoarse voice)
(transient in 1.5%, permanent in 0.5%, R commonest).
- Hypoparathyroidism –> hypocalcaemia
- Thyroid storm
- Hypothyroidism
Post-op specific complications for ENT tracheostomy?
- Stenosis
- Mediastinitis (retrosternal pain, fever but can radiate to scapula)
- Surgical emphysema
Post-op specific complications for fracture repair?
- Mal/non-union
- VTE
- Dislocation
- Nerve injury: sciatic, SGN
- Leg length discrepancy
Post-op specific complications for cardiothoracic surgery?
- Pneumo-/haemo-thorax
- Infection: mediastinitis, empyema
Causes of early post-op pyrexia?
Early: 0-5d post op
- Blood transfusion
- Physiological: SIRS from trauma: 0-1d
- Pulmonary atelectasis: 24-48hrs
- Infection: UTI, superficial thrombophlebitis, cellulitis
- Drug reaction
Causes of delayed post-op pyrexia?
Delayed: >5 day post op
- Pneumonia
- VTE: 5-10d
- Wound infection: 5-7d
- Anastomotic leak: 7d
- Collection: 5-20d
5W of post-op pyrexia = Wind = atelectasis (1day) - Water = UTI (3 days) - Wound = 5 days - infection -Walking (7 days) = DVT/PE .
Examination of post-op febrile patient?
- Obs chart, notes, drug chart
- wound
- Abdo + DRE
- Legs
- Chest
- Lines
- Urine
- Stool
Investigations for post-op febrile patient?
Urine: dip + MCS
Blood: FBC, CRP, Cultures ± LFTs
Cultures: Wound swabs, CP tips for culture
CXR
Pneumonia as a cause of post-op pyrexia? How?
- Anaesthesia –> Atelectasis
- Pain –> Decreased cough
- Surgery –> Immunosuppression
Management of pneumonia causing post-op pyrexia
- Chest physio: encouraging coughing
- Good analgesia
- Abx
Presentation of collection causes post-op pyrexia?
- Malaise
- Swinging fevers, rigors
- Localised peritonitis
- Shoulder tip pain (if subphrenic)
Locations of a collection post op?
Pelvic: presents @ 4-10 days post-op Subphrenic: presents @ 7-21 d post-op Paracolic gutters Lesser Sac Hepatorenal recess (Morrison's space) Small bowel (interloop spaces)
Investigations for collection?
- FBC, CRP, Cultures
- US, CT
- Diagnostic lap
Management of collections?
- Abx
- Drainage/washout
What is cellulitis?
- Acute infection of the subcut connective tissue
Most likely cause of cellulitis?
B-Haemolytic Strep + staph. aureus
Presentation of cellulitis?
- Pain, swelling, erythema and warmth
- Systemic upset
- ± lymphadenopathy
Management of cellulitis?
- fluclox PO
- Facial = metronidazole
Epidemiology of DVT?
DVT occurs in 25-50% of surg patients
Virchow’s Triad
Blood contents (Hypercoagulability) - Surgery = increased platelets and increased fibrinogen Blood flow - Vessel Wall integrity
Avoiding complications in surgery?
WHO checklist - Before anaesthesia, before incision of skin, before patient leaves operating room.
Prophylactic antibiotics
Assess DVT/PE
MARK site of surgery
Use tourniquets with cautions
Remember danger of end arteries and in siutations where they occur dont use adrenaline and avoid monopolar diathermy.
- Be wary of potential coupling injuries when using diathermy during laparoscopic sugery.
- Inferior epigastric artery is favourite target of laparoscopic ports and surgical drains.
Damage to thoracic duct during what surgery
During thoracic surgery e.g. Pneumonectomy, oesphagectomy
Damage to parathyroid during what surgery
difficult thyroid surgery
Arrhythmias following cardiac surgery?
Susceptibility to hypokalaemia (K+ <4.0 in cardiac patients)
Neurosurgical electrolyte disturbance
SIADH following cranial surgery causing hyponatraemia
Ileus following gastrointestinal surgery
Fluid sequestration and loss of electrolytes
Pulmonary oedema following pneumonectomy
Loss of lung volume makes these patients very sensitive to fluid overload
gastrograffin enema?
Rectal anastamotic leaks
Peritoneal fluid for U+E?
Ureteric injury
Recent surgery is a contraindication to what?
Thrombolysis and that some patients on IV heparin should be switched to LMWH.
Local anaesthetic agents - Lidocaine?
Local anaesthetic and a less commonly used antiarrhythmic (affects Na channels in the axon)
Hepatic metabolism, protein bound, renally excreted
Toxicity: due to IV or excess administration. Increased risk if liver dysfunction or low protein states. Note acidosis causes lidocaine to detach from protein binding.
Local anesthetic toxicity can be treated with IV 20% lipid emulsion!!!
Interacts with Beta blockers, ciprofloxacin, phenytoin.
Increased doses may be used when combined with adrenaline to limit systemic absorption. DO not give to digital areas due to risk of ischaemia.
Local anaesthetic agents? Cocaine?
Supplied for local anaesthetic purposes as a paste.
given in 4 and 10%.
Topically via nasal mucosa.
Caused marked vasoconstriction. Used mainly in ENT surgery.
Local anaesthetic agents? Bupivacaine
Longer duration than lignocaine.
Use for topical wound infiltration at the conclusion of surgical porcedures with long duration.
Local anaesthetic agents? Prilocaine?
Less cardiotoxic and used for IV regional anaesthetic
Dose of lignocaine?
3mg/kg.
With adrenaline 7mg/kg
Dose of bupivacaine?
2mg/kg
with adrenaline 2mg/kg
Prilocaine dose?
6mg/kg
With adrenaline 9mg/kg.
Max dose of the local anaesthetics? q
Lignocaine 1% plain - 3mg/ Kg - 200mg (20ml)
Lignocaine 1% with 1 in 200,000 adrenaline - 7mg/Kg - 500mg (50ml)
Bupivicaine 0.5% - 2mg/kg- 150mg (30ml)
Use of adrenaline with local anaesthetic?
Adrenaline may be added to local anaesthetic drugs. It prolongs the duration of action at the site of injection and permits usage of higher doses (see above). It is contra indicated in patients taking MAOI’s or tricyclic antidepressants. The toxicity of bupivacaine is related to protein binding and addition of adrenaline to this drug does not permit increases in the total dose of bupivacaine, in contrast to the situation with lignocaine.
Anaemia day before surgery?
A haemoglobin of 58 g/L will need to be corrected prior to surgery and this will only be achieved in such a short time frame by arranging a blood transfusion. Iron transfusions or oral iron supplements would be recommended over a longer time frame of weeks to months had this been detected earlier.
Thiopental IV anaesthetics?
Caused laryngospasm
Highly lipid solube so quickly affects brain.
Inhaled anaesthetics?
Halothane
- Hepatotoxicity
- myocardial depression
- Malignant hyperthermia- reverse with dantrolene.
Post thyroidectomy - oculogyric crises with diffuse muscle spasm?
IV calcium management as patient is hypocalcaemic tetany.
Central line?
Insertion is more difficult. Need ultrasound.
INternal jugular route.
Do not allow particularly rapid rates of infusion.
Tunneled lines? - HIckman
Tunneled lines such as Groshong and Hickman lines are popular devices for patients with long term therapeutic requirements.
Most reliable long term.
internal jugular vein and then tunneled under the skin
A cuff of woven material is sited near the end and helps to anchor the device into the tissues. These cuffs require formal dissection to allow the device to be removed. Tunneled lines can be linked to injection ports that are located under the skin. These are especially popular in paediatric practice.
PICC line?
Peripherally inserted central cannula
Referred to as PICC lines, these are popular methods for establishing central venous access. Because they are inserted peripherally they are less prone to major complications relating to device insertion than conventional central lines.
NG tube feeding?
NG tube - Via fine bore nasogastric feeding tube. Complications related to aspiration of feed or misplaced tube.
May be safe to use in patients with impaired swallow. Contraindicated in head injury.
Nasojejunal feeding
Avoids problems of feeding pooling in stomach (risk of aspiration)
Insertion of feeding tube more technically complicated
Safe to use following oesophagogastric surgery
Feeding jejunostomy?
- Surgically sited feeding tube
May be used for long term feeding - Low risk of aspiration and thus safe for long term feeding following upper GI surgery
- Main risks are those of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis
Percutaneous endoscopic gastrostomy?
Combined endoscopic and percutaneous tube insertion
May not be technically possible in those patients who cannot undergo successful endoscopy
Risks include aspiration and leakage at the insertion site
TPN?
The definitive option in those patients in whom enteral feeding is contra indicated
Individualised prescribing and monitoring needed
Should be administered via a central vein as it is strongly phlebitic
Long term use is associated with fatty liver and deranged LFT’s
14G cannula vs 20G cannula?
Consider a smaller one if patient is stable as smaller and less painful.
Wound healing stages?
Haemostasis
- Minute to hours following injury
- Vasospasm in adjacent vessels, platelet plug.
Inflammation
- 1-5 days
- Neutrophiles.
Regenration
- 7-56 days.
- Fibroblasts
Remodelling
- 6 weeks-1yr
- Collagen fibres
- Microvessels regress leaving a pale scar.
Drugs that impair wound healing
- NSAIDS
- Steroids
- Immunosuppressive agents
- Anti neoplastic drugs.
Hypertrophic scars?
Excessive amount of collagen.
Keloid scar?
Excess collagen within scar.
Pass beyond boundaries of original injury.
Isolated fever in well patient in first 24hr following surgery
Physiological reaction to operation.
Need to rule out infection and thrombosis. Wound infection is not possible this close to surgery (Mastectomy is clean).
Pneumonia or PE is unlikely given the lack of chest signs
Causes of post-op pyrexia?
Early (0-5 days)
Blood transfusion Cellulitis UTI Physiological systemic inflammatory reaction (within a day following operation) Pulmonary atelectasis
Late causes (>5 days) include:
- VTE
- Pneumonia
- Would infection (presenting with systemic signs)
- Anastomotic leak
When can patients shower after surgery?
48hr after
How to avoid post-op adhesions
Laparoscopic surgery over open.
Types of depolarising NM blocking drugs?
Binds to nicotinic acetylchline receptors = persistent depolarisation.
Eg Succinylocholine - Suxamethonium.
Leads to malignant hyperthermia and hyperkalaemia.
Used for rapid sequence induction for intubation. Can cause fasciculation.
Contraindicated in patients with penetrating eye injuries, acute narrow angle glaucoma.
What are the Non-depolarising NM blocking drugs?
Competitive antagonist of nicotinic acetylcholine receptors
eg - tubcurarine, atracurium, pancuronium, vecuronium .
leads to hypotension
Reversal = Acetylcholinesterase inhibitors = neostigmine.
Which drug can slow down fracture healing?
NSAIDs.
Investigations for an anastomotic leak?
Abdo CT. If patient is on steroids etc risk factor for developing anastomotic leak.
Abdo X-ray not as helpful for soft tissue.
Call consultant to come in and take patient to theatre immediately.
Patient developed DIC. After general resus what should be administered?
Fresh frozen plasma.
Cause of new onset AF following GI surgery?
Anastomotic leak.
Excess fluid administration of 0.9% NaCl?
Risk of hyperchloraemic acidosis.
What is pseudocholinsterase deficiency (suxamethonium apnoea)
Abnormality in production of plasma cholinesterases.
Increased duration of action of muscle relaxants.
Respiratory arrest is inevitable unless patient can be mechanically ventilated safely while waiting for circulating muscle relaxants to degrade.
Thermoregulation in peri-operative period impairment?
Administration of unwarmed IV fluid or gases.
Exposure to cold theatre environment
Use of cool skin prep
Use muscle relaxants
Spinal or epidural preventing peripheral vasocontriction.
This leads to more bleeding than usual, cold temperature and low BP.
Risk factors for perioperative hypothermia?
ASA grade of 2 or above Major surgery Low Body weight -large volumes of unwarmed IV fluids Unwarmed blood transfusion.s
If lower than 36, warming should commence.
Use Bair HUgger from onset of anaesthesia.
Warm fluid s>500ml.
Check patients temperature every 15 mins after operation.
Complications for perioperative hypothermia?
Coagulopathy: reduced ability to clot. Prolonged recovery from anaesthesia Reduced wound healing Infection Shivering.
Contra-indication for use of LMA?
Being non-fasted.
Provides poor control against reflux of gastric contents.
Contra-indications for NPA?
Basilar skull fracture
What is an oropharyngeal airway?
Easy to insert and use
No paralysis required
Ideal for very short procedures
Most often used as bridge to more definitive airway
What is a laryngeal mask?
Widely used
Very easy to insert
Device sits in pharynx and aligns to cover the airway
Poor control against reflux of gastric contents
Paralysis not usually required
Commonly used for wide range of anaesthetic uses, especially in day surgery
Not suitable for high pressure ventilation (small amount of PEEP often possible)
Eg - inguinal hernia repair - give sevoflurane = swift onset of anaesthesia and recovery. Muscle paralysis is not required.
What is a tracheostomy?
Reduces the work of breathing (and dead space)
May be useful in slow weaning
Percutaneous tracheostomy widely used in ITU
Dries secretions, humidified air usually required
Facilitate long term weaning - percutaneous device.
What is an endotracheal tube?
Provides optimal control of the airway once cuff inflated
May be used for long or short term ventilation
Errors in insertion may result in oesophageal intubation (therefore end tidal CO2 usually measured)
Paralysis often required
Higher ventilation pressures can be used
Undergoing laparotomy. Rapid sequence induction to occlude oesophagus. Cuffed endotracheal tube is inserted.
Oesophagogastrectomy complains of chest pain and chest drain has brisk bubbling?
Damage to the lung substance may produce an air leak. Air leaks will manifest themselves as a persistent pneumothorax that fails to settle despite chest drainage. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury.
20 yr old in ITU post perforated appendicitis is deteriorating with deranged LFTs?
Portal vein thrombosis
- Intra-abdominal sepsis
63 yr old with Ivor-Lewis oesophagogastrectomy for carcinoma has pale opalescent liquid in chest drain?
Chyle leak
Damage to the lymphatic duct may occur during this procedure and some surgeons administer a lipid rich material immediately prior to surgery to facilitate its identification in the event of iatrogenic damage.
Which anaesthetic agent has the strongest analgesic effect?
Ketamine
Long term mechanical ventilation consequences?
Risk of developing a tracheo-oesophageal fistula.
This in turn increases the risk of ventilator-associated pneumonias and aspiration pneumonia.
Blood loss in surgery unlikely management?
Group and Save
Eg. Hysterectomy, appendicetomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomy
Blood loss likey in surgery?
Cross match 2 units
Salpingectomy for ruptured ectopic pregnancy or THR.
Blood loss definite in surgery ?
Cross match 4-6 units.
Total gastrectomy, oophorectomy, oesophagectomy, Elective AAA repair, cystectomy, hepatoectomy.
2% strength liquid medicine means how much in 100ml?
2g in 100ml
20ml = 400mg (as 2g = 2000mg).
Types of VTE prophylaxis?
Mechanical = Intermittent pneumatic compression devices.
Pharmacological - Fondaparinux, LMWH, UFH
Management of risk of VTE patients?
If risk of VTE outweights risk of bleeding.
Low risk = VTE stockings.
High risk = pharmo prophylaxis. - This means they get ted stockings and heparin 6hr before.
For certain procedures (knee and hip replacement) - Pharm VTE prophylaxis is recommended.
- Elective hip = 10 days LMWH then aspirin for 28 days.
Or LWMH for 28 days with stockings.
Or rivaroxaban
- Elective knee = aspirin for 14 days. or LWMH for 14 days with stockings or rivaroxaban.
- Fragility fracture of pelvis, ip = LMWH or fondaparinux continue until the person no longer has significant reduced mobility relative to their normal or anticipated mobility.
WHO Checklist - Sign in?
Before induction
WHO Checklist time out?
Before first incision
WHO checklist sign out?
After last incision and before patient leave operating room.
Patient is NBM. 2 days post op. Her epidural fell out leaving her in significant pain. On call anaesthetist unable to come but put it back.
This morning she is pain free but complaining of shortness of breath. Also has fever 38.2
Day 1-2: ‘Wind’ - Pneumonia, aspiration, pulmonary embolism
Day 3-5: ‘Water’ - Urinary tract infection (especially if the patient was catheterised)
Day 5-7: ‘Wound’ - Infection at the surgical site or abscess formation
Day 5+: ‘Walking’ - Deep vein thrombosis or pulmonary embolism
Any time: Drugs, transfusion reactions, sepsis, line contamination.
Identification and management of post-op fever is common problem.
Insufficient analgesia means lady has signficant abdo pan, restricting patient’s breathing leading to both atelactasis and RTI.
More likely to be be RTI.
