CLINICAL- SURGERY Flashcards
What factors are looked into in a pre-clerking clinic/ pre-admissions clinic?
History (e.g. DVT, problems with anaesthetics)
Examination: ECG, Lung function
Weight- for medication doses e.g. dalteparin, gentamicin: may not be able to get out of bed after op to weigh.
Blood Pressure
Blood Glucose- diabetes management pre-op
Blood Test: for blood group incase of infusion, anaemia (anaemia= more blood needed, if Hb is low then they may need an IV IRON INFUSION before the Op)
MRSA screen- Nose swab; If they have it give them a sterile wash an nose cream
It is vital to get a complete accurate record of patients medications before their operation as they may be drowsy after it and there is risk of missing doses.
Accurate history is essential for surgery.
DOCUMENT ALLERGIES
Should get it from 2 sources: ask patient for medication before surgery, use a summary care record or repeat prescription.
Patients must FAST before operations.
They must not EAT 6 HOURS before surgery.
Why is this?
There is a risk of ASPIRATION OF Stomach contents during general anaesthetic. This could result in choking in surgery.
We need an empty stomach for general anaesthetics.
What is the general rule for giving medicines on the morning of surgery?
All regular medication (except anticoagulants and oral hypoglycaemics e.g. Metformin) should be given on the day of surgery with small sips of water
Can you think of any of the medicines we need to think twice about before giving them to patients on the morning of their surgery?
Warfarin Oral Hypoglycaemics INSULIN Anti-platelets e.g. Aspirin Cardiac medicines e.g. Digoxin STEROIDS- May need to give more if patient has Addisons Oral Contraceptives Lithium Tamoxifen (used in breast cancer)
How many days pre-op should we stop warfarin?
Stop on the evening of 6 DAYS before!!
What should a patient on warfarin’s INR be below for surgery to proceed?
Below 1.5
With patients on warfarin that need to have emergency surgery, their INR needs to be below 1.5 and there is not time to wait 5 days, what can we give to achieve this?
Vitamin K for reversal within 4-24 hours
BERIPLEX for reversal within 1 Hour
Allows blood to be become thicker so there is less risk of a bleed.
Only if the surgery can be delayed for 6-12 hours (says BNF).
When should LMWH be started and stopped with warfarin bridging before surgery?
LMWH can be used in patients with Moderate VTE risk (3-4 Chads Vasc) or High VTE risk (5-6 Chads Vasc).
Start LMWH 2 days after warfarin stopped.
Stop LMWH 24 hours pre op (if treatment dose)
[12 hours pre op if prophylactic dose].
Do not give on morning of surgery!
If patients are given a UFH infusion as their warfarin bridging method [for those that are assessed as HIGH RISK score 5-6 on Chads Vasc], when should this be started and stopped?
UFH infusion started 2 days after patients warfarin stopped (so 4 days pre-op). Patient needs to be brought into hospital to receive this. Should only be started when INR is less than 2 or 3.
Stop the IV UFH infusion 6 hours pre-op
What is the CHADSVASC scoring system used for?
To determine Risk of VTE in PATIENTS WITH AF!!!!!
It is often weighed up against their HASBLED score to see if Anticoagulation using heparins is needed after surgery, and what to use before surgery.
What does a CHADS VASc score of 0-2 indicate in patients with AF on warfarin requiring surgery?
Low risk of VTE
No need for LMWH to be initiated before surgery!
What does a CHADS VASc score of 3-4 indicate in patients with AF on warfarin requiring surgery?
Moderate risk of VTE
Start a therapeutic (treatment) dose of LMWH two days after stopping warfarin.
What does a CHADS VASc score of 5-6 indicate in patients with AF on warfarin requiring surgery?
HIGH risk of VTE
Either:
Start a therapeutic dose of LMWH 2 days after stopping warfarin
OR admit them to hospital for UFH infusion once INR is less than 2 or 3.
What does LMWH doses vary with?
Patient weight
When do we re-start warfarin post-operatively?
As soon as the surgeon deems the bleed risk to have gone [and is happy the patient won’t require more surgery!].
Until then, until the INR is in therapeutic range, the patient can be covered with LMWH/ UFH.
Post surgery, heparins can be used until the patient can start warfarin again [when INR therapeutic]. When is a prophylactic dose of LMWH used? What about a treatment dose of LMWH?
Prophylactic LMWH used if the patient has a LOW VTE risk
Treatment LMWH used if patient has a Moderate/HIGH VTE risk
Post surgery, heparins can be used until the patient can start warfarin again [when INR therapeutic]. When is UFH used?
When patients have a high VTE risk- mechanical heart valves.
When should we stop heparin post-operatively?
Once the patients INR has been therapeutic (in Target range) for 2 days.
There will be a heparin/ warfarin overlap as warfarin is started as soon as INR is therapeutic/ bleed risk is gone.
We can use the HASBLED score to determine patients bleed risk post op.
If they have a Low bleed risk: when should prophylactic LMWH (low clot risk) be started?
Low bleed risk: Evening post op
We can use the HASBLED score to determine patients bleed risk post op.
If they have a HIGH bleed risk: when should prophylactic LMWH (low clot risk) be started?
24-48 hours post op
We can use the HASBLED score to determine patients bleed risk post op.
If they have a Low bleed risk: when should therapeutic LMWH (High clot risk) be started?
Give a prophylactic dose of LMWH in the evening post-op
then give a treatment dose of LMWH 24-48 hours post op (whenever the surgeon feels risk of bleeding is lowest)
We can use the HASBLED score to determine patients bleed risk post op.
If they have a High bleed risk: when should therapeutic LMWH (High clot risk) be started?
Give a prophylactic dose of LMWH 24-48 hours before surgery and then a therapeutic dose 24-72 hours post operation (whenever the surgeon feels risk of bleeding is lowest).
What is the problems with NOAC’s in surgery?
THERE IS NO REVERSING AGENT for them: problem is they are requiring emergency surgery! (Cant give vit K like we do with warfarin!)
Also risks of bleeding
What should we do if a patient is on Dabigatran and requires emergency surgery?
Remember there is no established reversal agent…
1) STOP DABIGATRAN
2) Contact Haematologist/ surgeon/ Anaesthetist:
discuss with Surgeon the feasibility of delaying surgery, consider BERIPLEX
3) Take APTT, PT, FBC, renal function
4) Document time of Last Dabigatran dose
5) If APPT / PT is normal: there is no dabigatran anticoagulant effect present- fine to operate
6) APTT/ PT is PROLONGED: Dabigatran effects mat be present
7) Consider ORAL CHARCOAL is ingestion within 2 hours
8) Maintain patients blood pressure/ urine output
With Elective surgery, patients have their Dabigatran and Rivaroxiban stopped according to their RENAL FUNCTION.
Patients with good renal function (i.e. CrCl >80); should they stop their dabigatran/rivaroxiban earlier or closer to the surgery than patients with impaired renal function?
Patients with good renal function can keep on the dabigatran/ rivaroxiban closer to their operation.
Patients with poor renal function have to stop it earlier:
e.g. patients with a CrCl of under 30 have to stop Dabigatran/ rivaroxiban 6 days before major surgery with high risk of bleeding or 4 days before non-major surgery.
What patients require warfarin bridging therapy?
Patients stopping warfarin before surgery with a high risk of clotting:
Those with a VTE event within the last 3 months
AF with previous stroke/ TIA
Those with a mechanical heart valve (UFH required)
Should be given a treatment dose of LMWH.
This is all in the BNF
What do we usually do with Aspirin before surgery?
We usually carry on Aspirin if patient on it following a Stroke/ Myocardial Infarction (secondary prevention).
If its just being used for primary prevention then we stop it.
If patient has a very high bleed risk then stop it 7 DAYS before surgery.
Clopidogrel/ ticagrelor:
Usually stop 7 days before surgery unless bleed risk low.
But DO NOT STOP if there is high risk of a coronary stent clot!
What should we do with antihypertensives in surgery?
2 options:
can either continue antihypertensives through surgery and run risk of Hypotension: Monitor for drops in BP
or omit dose and run risk of hypertension: monitor through surgery, give IV beta blocker if spikes in BP occur.
Always continue beta blockers
Why should we always continue beta blockers through surgery?
Due to risk of rebound Tachycardia and arrhythmia associated with suddenly stopping a Beta blocker!!
People on steroids with pituitary- adrenal suppression may have their natural stress response impaired.
What should we do for these patients having Minor surgery?
Have their usual steroid dose on the morning of surgery
Recommence their usual oral dose after surgery
People on steroids with pituitary- adrenal suppression may have their natural stress response impaired.
What should we do for these patients having Moderate or Major surgery? (all from BNF)
Have their usual steroid dose the morning of surgery.
Should receive 25-50mg of hydrocortisone IV on induction
Should receive 25-50mg of hydrocortisone IV Three Times a Day for:
Moderate surgery: 24 hours post op
Major surgery: 48-72 hours post op
Then put them back on their normal dose
Says this in BNF! Under Glucocorticoid therapy: Adrenal suppression
Patients on Oral Hypoglyceamics (e.g. Metformin) for their diabetes: what should they do on the morning of surgery? What about after?
Omit their oral hypoglyceamic the morning of surgery.
There should be no more than one missed meal on the morning of surgery!
Afterwards: Re-introduce the usual diabetic regime when normal oral intake is resumed.
Patients on Long acting insulin for diabetes control: what should they do on day of surgery?
Continue their long acting insulin.
There should be no more than one missed meal on the morning of surgery!
Afterwards: Re-introduce the usual diabetic regime when normal oral intake is resumed.
What should patients on Biphasic Insulin do for diabetes control on the day of surgery? What about short/rapid acting insulin?
Halve the morning dose of biphasic insulin
Miss the morning and Lunch doses of short/rapid acting insulin.
There should be no more than one missed meal on the morning of surgery!
When is an Insulin sliding scale (VRIII) indicated in patients with diabetes??
When patients have to miss MORE than One meal (longer starvation period)- usually with Major Surgery
If hyperglycaemia (high Blood sugar) in patients missing only one meal
What should patients taking Combined Oral Contraceptives/ any contraceptive containing Oestrogen (so not POP’s) do if they are having elective surgery?
If it is:
Major elective surgery
Leg surgery
Surgery causing prolonged immobility
Then it is advised that contraceptive pills are stopped 4-6 weeks before the surgery.
This is because oestrogen containing contraceptives carry a 3 fold increase in VTE risk.
What should patients taking Combined Oral Contraceptives/ any contraceptive containing Oestrogen (so not POP’s) do if they are having emergency surgery?
Give thromboprophylaxis to minimise clot risk.
Oestrogen containing contraceptives carry a 3 fold increase in VTE risk.
Not enough time to stop them 4-6 weeks before to minimise VTE risk.
What should we do with Tamoxifen (used for breast cancer) in surgery?
It carries and increased VTE risk.
Consider stopping 3 weeks before major surgery
What are the risks of MAOIs (anti-depressants) in surgery (hint: think interactions Post surgery too!)
They have some pretty serious drug interactions:
Can interact with analgesics such as TRAMADOL given Post-operatively leading to an increase in Serotonergic activity.
HYPERTENSIVE CRISIS RISK
MAOI’s should be titrated down to stop 2 weeks before surgery
Caution with ANAESTHESIA if not stopped.
What kinds of things do we need to be thinking about after surgery?
VTE prophylaxis
Antibiotic prophylaxis
Post op Nausea and Vomitting
Post op Pain
Fluid balance: do we need to hydrate them
Nutrition- can they hold anything down? require TPN?
What PATIENT SPECIFIC risk factors are a risk for VTE?
Age Obesity History of DVT or PE Varicose Veins Clotting disorders
(remember this is VENOUS thromoembolism: clots in the VEINS) so things like smoking, previous Stroke etc won’t be relevant as these happen in arteries.
What surgical factors contribute to increased Risk of VTE?
Increased duration Orthopeadic surgery: hip or knee replacements Major limb amputation Immobility Dehydration
There are now only 2 categories for classifying VTE risk. What are these?
High risk:
One or more risk factors
Low risk: NO risk factors
All patients must be VTE risk assessed within ___ hours of admission into hospital.
They should then be re-assessed every ___ hours.
First risk assessment within 24 Hours
Re-assessed every 72 hours.
What can we do for VTE prophylaxis that doesn’t involve drugs or mechanical interventions?
MOBILISE the patient ASAP
AVOID DEHYDRATION!
Stop any medication which increase VTE risk (e.g. COC, HRT)
What can we do for VTE prophylaxis that involves mechanical interventions?
Use TEDs (stockings) but NOT IN STROKE Patients!
Use Intermittent Pneumatic Compression
When considering VTE prophylaxis, what must we ALWAYS take into account?
Their BLEEDING risk!!
What do we consider with assessing bleed risk in patients? (HASBLED)
Hypertension
Abnormal Kidney function
Stroke History
Bleed risk from medication (e.g. concurrent use of anticoagulants)
Labile INR (less than 60% in therapeutic range)
Elderly (over 65)
Drugs/ Alcohol use (anti-platelets, over 8 drinks of alcohol a week)
What do we use as VTE prophylaxis in patients considered LOW risk of VTE? (i.e. zero risk factors!)
Early mobilisation
Anti-embolism stockings - TEDS- if not contra-indicated (e.g. in stroke)
What do we use as VTE prophylaxis in patients considered HIGH risk of VTE? (i.e. 1+ risk factors!)
LMWH/ NOAC (Rivaroxiban, Dabigatran)
Poss UFH
Extended VTE prophylaxis is needed for patients with a fractured Neck of Femur (HIP FRACTURE). How long is this for?
For 4 weeks
Extended VTE prophylaxis is needed for patients who have had Abdominal or Pelvic cancer surgery. How long is this for?
4 weeks
How long should VTE Prophylaxis be given for patients who have a Lower limb plaster cast?
Given until its out of their cast
How long do we usually give VTE prophylaxis for post-op if its not a special case?
Until the patient returns to their normal mobility
For a patient having a Total Hip replacement (or major hip surgery), how long should VTE prophylaxis (using a NOAC; Apixaban, Dabigatran, Rivaroxaban) be used for afterwards?
5 WEEKS!
For a patient having a Total Knee replacement (or major knee surgery), how long should VTE prophylaxis (using a NOAC; Apixaban, Dabigatran, Rivaroxaban) be used for afterwards?
2 weeks!
What can we now use for VTE prophylaxis following Total Hip and Knee replacements?
Apixaban
Dabigatran
Rivoroxaban
Use for 5 weeks after Hip Op
Use for 2 weeks after Knee Op
How should PAIN be managed in Post-operative patients?
THE WHO ANALGESICS LADDER IN REVERSE!
Start with strong opioids e.g. Morphine,
Then step down to Weaker opioids: Tramadol, Codeine
Then step down to Paracetamol
PCA often used (patient controlled analgesia)
If Post-operative Nausea and Vomitting (PONV) isn’t managed properly, what can this cause?
Increased length of stay
Dehydration and electrolyte disturbance
Disrupts wounds (peoples stitches coming out if they’re throwing up)
Reduces medicines absorption
What are the risk factors of Post-Operative Nausea and Vomitting?
Sex: females have increased risk History of motion sickness Previous PONV Non smokers: increased risk (smoking can protect against PONV!) Duration/ type of surgery Opiates
What types of surgery increase the risk of PONV?
Gynaecological ENT Ophthalmic Breast Max-fax Urologic Laparoscopic surgery
When should prophylactic antiemetics be given to prevent PONV?
Most are best timed to be given 20-30 minutes before the planned end of surgery.
[Dexamethasone is an exception: should be given shortly after induction]
What are common antiemetics used for PONV?
ONDANSETRON
cyclizine
Dexamethasone
Prochlorperazine
What can we do if we think someone has a high risk of PONV?
Given them more than 1 antiemetic
The more you give, the more effective the outcome
The need for antibiotic prophylaxis in surgery depends on the classification of the procedure. What does a Clean procedure mean?
No break in sterile technique
Site not inflamed or infected: e.g. breast surgery.
Generally no antibiotic prophylaxis is needed with this.
What is a clean- contaminated procedure and what antibiotic prophylaxis is required?
Respiratory, gut or genitourinary tract entered but NO contamination encountered.
Antibiotics are required at induction and up to 24 Hours Post- Op
Contaminated procedures involved a major break in sterile technique, spillage from the GI tact or acute inflammation encountered
“Dirty” procedures involve Acute inflammation with Pus encountered, GI tract perforation or Old dirty wounds
What antibiotic Prophylaxis do we use for Contaminated or Dirty procedures?
Use antibiotics at induction and as a treatment course for 5-7 days post-operatively
What treatment is usually required if we manage to get a bone infection after Joint replacements??
IV antibiotic treatment for 6 weeks
This is because oral treatment wouldn’t get into the bones.
When antibiotics are given at induction of surgery, when exactly are they given? What is the preferred route?
Given 30 minutes to 1 hour before surgery
Re-administer if its long surgery
IV is the preferred route
