Care of the surgical patient

Question 1

Pre-operative history

Answer 1

History of the PC
PMH, PSH & PAH
Drug history
Family history
Social history

Question 2

Pre-operative examination

Answer 2

Two distinct examinations:
1) General examination – CVS, resp or abdominal signs, to identify any underlying undiagnosed pathology present
2) Airway examination – to predict the difficulty of airway management, Mallampati score

Question 3

ASA grade

Answer 3

Directly correlates with their risk of post-operative complications & absolute mortality
I – normal healthy patient
II – mild systemic disease, well controlled medical conditions
III – severe systemic disease, uncontrolled chronic conditions
IV – severe systemic illness that is a constant threat to life
V – moribund, who is not expected to survive without the operation

Question 4

Pre-operative investigations

Answer 4

Blood tests – FBC, U&Es, LFTs, condition-specific blood tests, clotting screen, group and save +/- cross-matching
Cardiac investigations – ECG, echo, myocardial perfusion scans for patients with untreated IHD
Respiratory investigations – spirometry (chronic lung conditions), plain CXR are uncommon
Other tests – urinalysis, MRSA swabs, cardiopulmonary exercise testing (high risk patients undergoing major surgery)

Question 5

Types of blood products

Answer 5

Packed red cells – RBCs, administered over 2-4 hours
Platelets – administered over 30 mins
Fresh frozen plasma (FFP) – administered over 30 mins
Cryoprecipitate – administered stat

Question 6

Group and save vs crossmatch

Answer 6

Group and save – determines the patient’s blood group and screens the blood for any atypical antibodies
Crossmatch – involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes place
G&S must be done first, both take ~40 mins each

Question 7

Acute transfusion complications

Answer 7

Acute haemolytic reaction
Transfusion associated circulatory overload (TACO)
Transfusion related acute lung injury (TRALI)
Other complications – mild allergic reaction, non-haemolytic febrile reactions, anaphylaxis, infective/bacterial shock

Question 8

Delayed transfusion complications

Answer 8

Infection
Graft vs host disease – HLA-mismatch between donor and recipient
Iron overload

Question 9

Acute haemolytic reaction

Answer 9

Serious reaction caused by transfusion of the incorrect blood type
Donor RBCs are destroyed by the recipients performed antibodies, resulting in haemolysis
Urticaria, hypotension, fever
Positive direct antiglobulin test will confirm the diagnosis
Inform blood bank what has happened, stop transfusion & begin supportive measures

Question 10

Transfusion associated circulatory overload

Answer 10

Present with dyspnoea and features of fluid overload
Obtain an urgent CXR
Treatment is via oxygen and diuretic therapy
Patients at risk of overload can be prescribed 20mg furosemide prophylactically during the transfusion to prevent this

Question 11

Transfusion related acute lung injury (TRALI)

Answer 11

Form of acute respiratory distress syndrome
Patients are dyspnoeic and have features of pulmonary oedema on clinical examination
Patients have a high mortality -> start patients on high flow oxygen & obtain an urgent CXR, getting specialist and intensive care input urgently

Question 12

Reasons why fluids are prescribed

Answer 12

Resuscitation
Maintenance
Replacement

Question 13

Fluid status assessment

Answer 13

Fluid depleted patients:
- Dry mucous membranes and reduced skin turgor
- Decreasing urine output
- Orthostatic hypotension
- Increased CRT, tachycardia, low BP
Fluid overloaded:
- Raised JVP
- Peripheral/sacral oedema
- Pulmonary oedema

Question 14

Fluids daily requirements

Answer 14

Water – 25-30mL/kg/day
Na+ - 1mmol/kg/day
K+ - 1mmol/kg/day
Glucose – 50-100g/day

Question 15

Crystalloids vs colloids

Answer 15

Crystalloids – used more widely than colloids, used very commonly in the acute setting, in theatres and for maintenance fluids eg. saline, dextrose, Hartmann’s solution
Colloids – have a high colloid osmotic pressure, but no significant benefit/effect in practice

Question 16

Nutritional assessment

Answer 16

All patients admitted to hospital should be screened for malnutrition and have their nutritional state assessed
MUST – malnutrition universal screening tool

Question 17

Hierarchy of feeding

Answer 17

If unable to eat sufficient calories – oral nutritional supplements
If unable to take sufficient calories orally/dysfunctional swallow – NGT feeding
If oesophagus blocked/dysfunctional – gastrotomy feeding (PEG/RIG)
If stomach inaccessible or outflow obstruction – jejunal feeding (jejunostomy)
If jejunum inaccessible/intestinal failure – parenteral nutrition

Question 18

Patients with intestinal failure nutrition

Answer 18

Often need parenteral nutrition
Timing of surgery is crucial & is helpful to remember the mnemonic SNAP for such cases:
- Sepsis – any overwhelming infection present must be corrected otherwise feeding will be largely useless
- Nutrition – once the infection is corrected, suitable nutritional support should be provided
- Anatomy – define the anatomy of the GI tract so that surgery can be planned
- Procedure – definitive surgery once any infection eradicated, the patient nourished & the anatomy defined

Question 19

Enhanced recovery after surgery (ERAS)

Answer 19

Reduction in nil by mouth times
Pre-operative carbohydrate loading
Minimally invasive surgery
Minimising the use of drains and nasogastric tubes
Rapid reintroduction of feeding post-operatively
Early mobilisation

Question 20

Drugs to stop before surgery

Answer 20

CHOW
Clopidogrel – 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
Hypoglycaemics
Oral contraceptive pill or HRT – stopped 4 weeks before surgery due to DVT risk, advise to use other contraception
Warfarin – usually stopped 5 days prior to surgery

Question 21

Drugs to alter before surgery

Answer 21

Subcutaneous insulin – may be switched to variable rate intravenous insulin infusion
Long-term steroids – must be continued due to risk of Addisonian crisis, if patient cannot take these orally, switch to IV

Question 22

Pre-operative steroid prescribing

Answer 22

Patient will elicit stress response in proportion to the extent of trauma and metabolic insult
Patients on steroid therapy for > 2 weeks may experience HPA axis suppression, patients with confirmed/suspected HPA axis suppression -> risk of acute adrenal insufficiency peri-operatively
Peri-operative stress-dose corticosteroid therapy is warranted

Question 23

Drugs to start before surgery

Answer 23

Low molecular weight heparin
Anti-embolic stockings
Antibiotic prophylaxis – orthopaedic, vascular GI surgery will often require prophylactic antibiotics

Question 24

Diabetes mellitus perioperative care

Answer 24

Should be first on the list, to avoid prolonged fasting
BM levels should be checked regularly during the procedure
Patients on insulin will often need their doses adjusting pre-operatively, any prolonged/major surgery will need a variable rate IV insulin infusion (continued for a short period post-operatively as well)
Oral hypoglycaemics should be stopped the day before the surgery

Question 25

Bowel preparation for general surgery

Answer 25

Upper GI, HPB, small bowel surgery – none required
Right hemi-colectomy, extended right hemi-colectomy – none required
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 surgery