Care of the surgical patient Flashcards
Preoperative fasting
Fasting ensures that the stomach is empty of contents. This reduces the risk of pulmonary aspiration, which can occur during the perioperative period, which can lead to both aspiration pneumonitis (inflammation caused by very acidic gastric contents, leading to desquamation) and aspiration pneumonia (due to secondary infection following pneumonitis or direct aspiration of infected material).
Stop eating
6 hours before
Stop clear fluids
2 hours before
why do diabetic patients need special consideration before surgery
- Stress of surgery can increase BM (due to stress increasing steroid production)
- HOWEVER usually patients are asked to fast before surgery, however for diabetics= risk of hypoglycaemia (greater than hyperglycaemia).
Management is dependent on they way that their Type II DM is controlled.
If diet controlled, no action is required peri-operatively.
If, however, the patient is controlled by oral hypoglycaemics:
- Metformin (lactic acidosis) should be stopped on the morning of surgery,
- Whilst all others should be stopped ~24 hours before the operation.
- sulphonyureas
- glicazide
- These patients will then be put on IV variable rate insulin infusion along with 5% dextrose as described above and managed peri-operatively the same as a Type I diabetic.
if a patient has poorly controlled type 2 diabetes they may need to be put on an
Variable rate insulin infusion (insulin sliding scale)
In patients on insulin going for surgery
- Continue a lower dose (BNF recommends 80%) of their long-acting insulin
- Stop short-acting insulin whilst fasting or not eating, until eating and drinking again
- Have a variable rate insulin infusion alongside a glucose, sodium chloride and potassium infusion (“sliding-scale”) to carefully control their insulin, glucose and potassium balance
which patients on long term corticosteroids will need to take additional steroids
if on >5mg of oral prednisolone
pathophysiology of needing higher dose of steroids if having surgery
- Surgery adds additional stress to the body, which normally increases steroid production
- HOWEVER, in patients on long-term steroids, there is adrenal suppression that prevents pt from creating extra steroids required to deal with stress
management of patients on >5mg of steroids
- Additional IV hydrocortisone at induction and for the immediate postoperative period (e.g., first 24 hours)
- Doubling of their normal dose once they are eating and drinking for 24 – 72 hours depending on the operation
reassurance to patient before surgery
It almost goes without saying that most patients are anxious about their upcoming surgery. Recognition of this fact and a kind word will make a big difference to a wary patient.
drugs to stop before surgery
CHOW
Clopidogrel
Hypoglcycarmics
Oral contraceptives or hormone replacement therapy (HRT)
Warfarin
Clopidogrel stopped when
stopped 7 days prior to surgery due to bleeding risk.
Aspirin and other anti-platelets can often be continued and minimal effect on surgical bleeding
Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) stopped when
stopped 4 weeks before surgery due to DVT risk.
Advise the patient to use alternative means of contraception during this time period.
Warfarin
usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular weight heparin
- Surgery will often only go ahead if the INR <1.5
- May have to reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before
drugs to starts
-
LMWH
- Most pt will have this, with the exception of those with contraindications or having neck or endocrine surgery)
- 28 day prophylactic LMWH if GI surgery for cancer or lower limb joint replacement
- TED stockings
-
Antibiotics prophylaxis
- Orthopaedic, vascular or GI
- Prescribed by anaesthetics or surgeons
bowel preparation
- Patients having colorectal surgery may need bowel preparation (laxatives or enemas) to clear their colon pre-operatively.
- Bowel preparation is used less frequently, as the fluid shifts can be harmful to patients who are elderly or have cardiac or renal disease.
which bowel surgeries require bowel prep
Left hemi-colectomy, sigmoid colectomy, or abdominal-perineal 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
pre operative assessment includes
- History
- Examination
- ASA grade (risk from anaesthesia)
- Investigations
preoperative investigations
- ECG if there is known or possible cardiovascular disease
- Echocardiogram if there are heart murmurs, cardiac symptoms or heart failure
- Lung function tests may be required if there is known or possible respiratory disease
- Arterial blood gas testing may be required if there is known or possible respiratory disease
- HbA1C (within the last 3 months) for people with known diabetes
- U&Es for patients at risk of developing an acute kidney injury or electrolyte abnormalities (e.g., taking diuretics)
- FBC may be required if there is possible anaemia, cardiovascular or kidney disease
- Clotting testing may be required if there is known or possible liver disease
- LFTs
- Cardiopulmonary exercise testing (CPEX)- high risk patients undergoing major surgery. Involves a graded intensity period on a stationary bicycle whilst wearing mask, as well as ECG monitoring (VO2 max and anaerobic threshold)
more specific tests to do prior to
group and save
crossmatching
group and save
- determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies.
- The process takes around 40 minutes and no blood is issued.
- A G&S is recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected.
crossmatching
- involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places. If it does not, the donor blood is issued and can be transfused in to the patient.
- This process also takes ~40 minutes, in addition to the 40 minutes required to G&S the blood (which must be done first).
- A X-match is done if blood loss is anticipated, but the surgeon will usually inform you of this..
which microbial tests are done routinely
covid swab
MRSA- Topical antibiotics, such as mupirocin and fusidic acid
past medical history
- Cardiovascular disease
- HTN
- Exercise tolerance is useful indicator of CVS fitness- can help predict risk of post-op complications and level of cate needed post-operatively
- Screening questions may elucidate undiagnosed disease e.g. presence of chest pain, syncopal episodes, orthopnoea
- Respiratory
- An adequate oxygenation and ventilation is essential in reducing risk of acute ischaemic events in the peri-op period
- Questions inc whether patient is able to life flat for prolonged periods of time or has a chronic cough (may preclude spinal anaesthesia)
- Screen for OSA
- An adequate oxygenation and ventilation is essential in reducing risk of acute ischaemic events in the peri-op period
- Renal disease
- Including baseline renal function
- Any renal specific medications
- Endocrine
- DM
- Thyroid
- Gastro-oesophageal reflux (GORD)
- Aspiration of gastric contents can be fatal
- Pregnancy- females of repro age
- Sickle cell disease- could they have undiagnosed sickle cell disease, esp if their country of birth does not have routine screening for sickle cell
- Malnourished <18.5- Input of dietician and additional nutritional support
post anaesthetic history
- Has patient had anaesthesia before?
- If so what type?
- Were there any problems?
- Did the patient experience any post-op N and V?
ASA grade
Classified physical status or patient for anaesthesia . patient given a grade to describe current fitness prior to undergoing anaesthesia
- ASA I – normal healthy patient
- ASA II – mild systemic disease
- ASA III – severe systemic disease
- ASA IV – severe systemic disease that constantly threatens life
- ASA V – “moribund” and expected to die without the operation
- ASA VI – declared brain-dead and undergoing an organ donation operation
- E – this is used for emergency operations
principles of pain management
WHO pain ladder
ABO group
Refers to presence of A and/or B antigens on the surface of RBC
- Universal donor: O-ve – this blood can be given to anybody, irrespective of the recipient’s blood group, because there are no AB or Rhesus antigens on the donor RBC surface membrane. The recipient can have both A, B and Rhesus antibodies in their circulation, but they will likely not reject this donor blood, as there are no ABO or Rh antigens to attack.
- Universal Acceptor: AB+ve – you can give this recipient any donor blood, irrespective of the ABO or Rhesus status. The recipient does not have any A, B, or Rhesus antibodies in their circulation and therefore cannot mount an immune response to the donor blood.
