Peri Op Flashcards
Specific questions to ask in pre op assessment
Complete history and
Previous surgeries (complications and PONV)
CV and resp review
Ask specifically
HYT
Asthma - steroids too for severity
DM - management and co morbidities
Fx - reaction to GA
Smoking/ rec drus/ alc
Will abstinence post op cause issues?
When to stop Clopodigrel
7 days
When to stop Aspirin
dont
When to stop statin
dont
When to stop BBs
dont
When to stop oral hypoglycaemics
1 days before as nil by mouth
When to stop OCP/HRT
4 weeks
When to stop corticosteroids
Dont stop - replace 5mg pred with 20mg IV hydrocortisone
When to stop warfarin
5 days for AF (unless paroxsymal) no heparin
5 days for PE/ DVT with LMWH cover day before op
5 days for mechanical heart valve with heparin cover- admit 2/3 days before and give IV heparin APTT between 2-3 adn stop 4 hours before. IV more protective than LMWH
When to stop herbal medicines
Antiplatelet so 2 weeks
When to stop metformin
DO not stop unless using contrast - lactic acidosis. Restart 48-72 hrs if Us &Es ok
When may an ileus occur?
0-24 hrs small
24-48hrs stomach
48-72 colon to recover
Who should get LMWH pre proceedure and how much?
All over 20 have abdo surgery - not head and neck surgery. 2,500 units deltaparin SC OD.
If not use mechanical instead e.g. stockings
Who should get extra LMWH and how much?
Preggers Amputee OCP DVT/ PE past Obese Intra-abdominal malignancy
5000 units delta OD IM
What antibiotics prophylaxis can be given and when
Bowel surgery =
- Co amoxiclav (amoxicillin and clavulanic acid)
- Metronidazole and cefuroxime (second gen ceph)
Surgery that requires antibiotic prophylaxis is:
clean surgery involving the placement of a prosthesis or implant (no mucosa involved)
clean-contaminated surgery
contaminated surgery
surgery on a dirty or infected wound (requires antibiotic treatment in addition to prophylaxis). [NICE clinical guideline 74 recommendations 1.2.11 (key priority for implementation) and 1.2.16]
“Clean — an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary and genitourinary tracts are not entered.
Clean-contaminated — an incision through which the respiratory, alimentary or genitourinary tract is entered under controlled conditions but with no contamination encountered.
Contaminated — an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category.
Dirty or infected — an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered during the operation (for example, emergency surgery for faecal peritonitis), and for traumatic wounds where treatment is delayed, and there is faecal contamination or devitalised tissue present”
Ways to reduce infection risk pre op
Preop showering (day before or day of)
Theatre wear
Staff theatre wear
Do not used nasal decontamination for staph aureus routinely
Do not use mechanical bowel prep routinely
Consider Abx - unless tounique often IV on starting anaesthesia
Post op reduction of infection
Sterile saline for wound cleansing up to 48hrs - tap water ok after even if still open
After 48hrs fine to shower
Do not use topical antimicrobials
Specialist wound care serivices e.g. no gause for healing with secondary intention
Prophylaxis for surery with RF or prosthetic heart valve
• Will depend on nature of procedure
– Laryngeal intubation the problem is strep viridans,
Give amoxicillin.
– If having gastrointestinal, urinary or gynaelogical
procedure add in gentamicin
• Consult BNF for latest advice
Drugs given post proceedure
Opiates
NSAIDs
Renal impairment due to fluid and sodium retention
Good for postop analgesia
Stematil (prochlorpermazine
Anti emetic
(similar to chlorpromazine)
What increases post op complications from opiates and treatment?
Constipation (give senna)
Resp dep (more with liver and kidney disease due to build up)
Give naloxone
What is Anexate
Flumazanil reverses benzos in resp depression
Why might a patient post op become dystonic?
Stematil (prochlorpermazine
Anti emetic
Causes acute dystonia (procyclidine IV for treatnment) (similar to chlorpromazine)
Give the adverse effects of pain
CVS Tachy HypertensionIncreased myocardial O2 demand Resp Decreased vital capacity, Decreased functional capacityDecreased tidal volume Chest infections Basal atelectasis - alveolar collapse (consolidation is fluid filled) GI N/V Ileus Other Urinary retention DVT PE
Respiratory early complications
Hypoventilation and upperairway obstruction
Oropharyngeal: Decreased muscle tone, secretions, sleep apnea, foreign body, oedema, wound haematoma, neuromuscular disease.
Laryngeal: Laryngospasm (common from tracheal exubation), secretions, oedema, bilateral recurrent palsy, tracheal collapse
Hypoxia
Supply of O2
Hypoventilation: Atelectasis from pain or too much O2 and shrinkage of alveoli
V/Q Matching: pneumonia, PE< HF
Shunt: _
Inadequate delivery - Shock, severe anaemia
Excessive consumption - fever, shivering, hyper metabolic state
Pain
Abnormal utilisation - Cyanide poisoning
Treat cause and with O2, monitor sats
Atelectasis (pain)
Neuro comps early
Hypoglycaemia and not waking
Drugs
Diabetic is risk factor for brain injury
Pain Hard to measure Bad Many dimensions Physical Functional - agg/ reliev, disab Behavioural - rubbing, guarding, grimacing Affect - dep Cognition - understanding
Confusion/ agitation Hypothermia and shivering
Gi comps middle
PONV Ileus Intra abdominal surgery Drugs (Urinary retention)
Factors that increase PONV
Patient factors: child, female, anxiety, motion sickness, history
Surgical factors
Gynae, ENT, c(operation to rectus muscle), GI, breast, long duration
Anaesthetic factors
Gases, opioids, pain, dehydration
Adverse effects
Dehydration, oral medication, delayed discharge, aspiration, distress, poor surgical outcome
Management PONV
Prevention Treat pain Hydration Anti-emetics Ondansetron Cyclizine/ Proclorpermazine Dexamethasone
CVS comps Middle
Low BP - drugsw, epidurals, vol loss How can you tell if hypertension is due to hypovolaemia? Hypertension - Pain, pre op BP MI Day 3 most common Pre op ECG important Risk factors Prevention VTE DVT/PE
How can VTE be avoided/ treated after surgery
Risk assess before
Early mobilization, hydration, pain/vomiting control
Resp middle comps
Pneumonia
PE
Late complecations
Obstruction Adhesion Wound break down Dehiscence - wound coming apart at surgical incision Graft failure
Continue antihypertensives before surgery?
Yes CCBs and BBs
Not diuretics or ACEi
Give the ASA (American society of anaesthesiologists) grade/status
I. A normal healthy patient
II. A patient with mild systemic disease (obesity 30-40)
III. A patient with severe systemic disease
IV. A patient with severe systemic disease that is a constant threat to life
V. A moribund patient who is not expected to survive without the operation.
VI. A declared brain-dead patient whose organs are being removed for
donor purposes
The addition of an ‘E’ indicates emergency surgery.
How long for DVT prophylaxis
Until discharge
Criteria for nurses to send patient from recovery to ward
Fully conscious, able to maintain airway
Resp and sats are satisfactory
CVS stable with no cardiac irrgulaity/ bleeding. Pulse and BP acceptable.
Pain and emesis controlled, suitable analgesic and antiemetic prescribed
O2 and IV prescribed
Main classes of drugs used in anaesthesia. MoA. How to prescribe
5HT antagonists e.g. Ondansetron, (Metaclopramide) - Blocks vagal afferent and central vomiting centre
Dopamine (D2) antagonist e.g. Prochloperazine, Metaclopramide (also anticholin), Domperidone - increase gastric emptying, antagonises chemoreceptor trigger zone in medulla. D2 can cause Prolactin and extrapyradimal.
H1 antagonists e.g. Cyclizine (also antimuscurinic) - motion sickness and opioid. Acts on vomiting centre
Corticosteroid e.g. dexameth (unknown MoA), not licensed for PONV, used in surgery
Prochlorperazine first line unless risk of extrapyramidal.
Cyclizine can be first line but CI in HF (low BP).
If first doesn’t work use one with different MoA.
Metoclopramide ineffective for PONV
Side effects cyclizine
sleepiness, dry mouth, constipation, and trouble with vision.[5] More serious side effects include low blood pressure and urinary retention
Define pain and why important to treat
An unpleasant experience specific to the individual assoc with actual or potental damaged and described in terms of such damage (chronic >3 months prehaps without identifiable cause)
Better pt outcomes
