Care of the surgical patient Flashcards
Pre-operative history
History of the PC
PMH, PSH & PAH
Drug history
Family history
Social history
Pre-operative examination
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
ASA grade
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
Pre-operative investigations
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)
Types of blood products
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
Group and save vs crossmatch
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
Acute transfusion complications
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
Delayed transfusion complications
Infection
Graft vs host disease – HLA-mismatch between donor and recipient
Iron overload
Acute haemolytic reaction
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
Transfusion associated circulatory overload
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
Transfusion related acute lung injury (TRALI)
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
Reasons why fluids are prescribed
Resuscitation
Maintenance
Replacement
Fluid status assessment
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
Fluids daily requirements
Water – 25-30mL/kg/day
Na+ - 1mmol/kg/day
K+ - 1mmol/kg/day
Glucose – 50-100g/day
Crystalloids vs colloids
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
Nutritional assessment
All patients admitted to hospital should be screened for malnutrition and have their nutritional state assessed
MUST – malnutrition universal screening tool
Hierarchy of feeding
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
Patients with intestinal failure nutrition
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
Enhanced recovery after surgery (ERAS)
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
Drugs to stop before surgery
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
Drugs to alter before surgery
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
Pre-operative steroid prescribing
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
Drugs to start before surgery
Low molecular weight heparin
Anti-embolic stockings
Antibiotic prophylaxis – orthopaedic, vascular GI surgery will often require prophylactic antibiotics
Diabetes mellitus perioperative care
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
Bowel preparation for general surgery
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
