Care of the Surgical Patient Flashcards
What are the types of surgeries?
Day surgery - accounts for 80% of elective procedures
Planned surgeries - elective
Unplanned surgeries - emergency
What are the types of surgical procedures?
Open surgery - done using staples and stitches to close incisions
Keyhole surgery - done through small incisions in the skin with a fibre optic light source (minimally invasive)
Laproscopic surgery - keyhole surgery but is done within the abdomen/peritoneum
Microsurgery - operates on tiny structures like the arteries, nerves and eyes
What are the grades of elective surgery?
Grade 1 - minor = removal of skin lesion/drainage of breast abscess
Grade 2 - intermediate = removal of varicose vein/tonsillectomy
Grade 3 - major = full hysterectomy/thyroidectomy
Grade 4 - complex/major = total joint replacement /neuro or cardiac surgery
What physiological changes happen due to surgery?
Changes to blood pressure - rise in NA/A release, blood loss, dehydration, constriction of arterioles in skin and organs or dilation in blood vessels in skeletal muscle
Cortisol release - not possible if on steroids as natural steroid is suppressed
hyper coagulopathy
insulin resistance
antidiuretic hormone secretion - water retention
anaesthetic drugs effects
How does increased secretion of antidiuretic hormone cause hyponatraemia? What must be done to avoid this?
physiological change due to surgery
ADH causes the insertion of aquaporins in the DCT and CD
- increasing the amount of water reabsorbed by osmosis
- thirst increases water intake and ADH reduces water output by making urine more concentrated
- this additional water dilutes the plasma, reducing sodium concentration and plasma osmolality
Fluid replacement may be needed
What are the stages of the surgical patient pathway? What is the preoperative period?
primary care referral, surgical outpatients, pre-operative assessment, hospital admission, theatre and recovery, post-operative care and discharge
Peri-operative period is the period of a patients surgical procedure. It includes pre-operative (BEFORE), intra-operative (DURING) and post operative (AFTER).
Why do patients need MRSA screening during their pre-operative assessment?
The principle objectives of screening for MRSA are:
- To identify patients who are carriers of MRSA
- To subsequently manage the care of MRSA positive patients to reduce the risk of them developing infection
- To reduce the risk of transmission of MRSA to other patients.
How should patients on steroids be managed before having surgery?
Patients on steroids prior to surgery require steroid injections pre-op and intra-op
- the body is unable to respond with normal cortisol replacement
- risk of developing adrenal insufficiency
avoid by treating with hydrocortisone IV until able to resume normal steroid dose
What is adrenal insufficiency?
Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism
- not enough cortisol or aldosterone
symptoms - fatigue, muscle weakness, weight loss, abdominal pain, irritability
What does Nil by mouth (NBM) mean? What is it needed?
For pre-operative patients it means
- no food (milk for 6-8hrs), no drinks (water for 2 hrs) by mouth or NG tube
- medicines can be taken upto 2 hrs before with water
There is risk of vomiting due to surgery
- increases risk of aspiration of stomach contents in the lungs
= aspiration pneumonia
What medicines may need to be stopped before surgery?
medications associated with bleeding risk or VTE risk
anti diabetics/insulin
antihypertensives - ACEIs, ARBs and diuretics
= blood pressure can be lowered due to anaesthetics/opiates/blood loss so may not be needed, can be associated with risk of AKIs
herbal and homeopathic preparations
What should be assessed when deciding whether or not to continue anticoagulants or anti-platelets?
anticoagulants
- type of surgery and blood loss, length of surgery, HASBLED score. drugs that promote bleeding
anti-platelets
- VTE risk, indication for AC/AP, CHADVasc score, drugs increasing clotting
What are the types of low and high risk procedures for bleeding?
LOW (is always localised)
minor dental, cataract surgery, intra-articular injections
HIGH
localised bleeding - plastic/cosmeticsurgery, ocular, cardiac pacemaker insertion/ablation
major bleeding - cardiac surgery, orthopaedic surgery, major trauma
How long in advance do the following drugs need to be stopped when having surgery?
- warfarin, aspirin/clopidogrel, DOACs, LMWH, NSAIDs and garlic/gingko
warfarin - 5 days
aspirin/clopidogrel - 5-7 days
DOACs - usually 1-4 days (depends on DOAC and CrCl)
LMWH - 12-24hrs
NSAIDs - 1-7 days
garlic/gingko - 2 weeks
How long in advance should NSAIDs be stopped?
short acting NSAIDs - can be stopped the day before
= dexibuprofen, diclofenac, ibuprofen, tolfenamic acid
long acting NSAIDs - should be stoped 5x half lives before
- naproxen = 4 days
- ketoprofen = 2 days
