Peri-op care and prep before investigations Flashcards
complications of bowel preparation in colorectal surgery?
dehydration
perforation
liquefying bowel contents which are spilled during surgery
electrolyte loss, leading to seizures and hyponatraemia
higher rate of post-op anastamotic leakage
importance of nutrition?
wound healing
reduced infections
faster recovery
reduced loss of muscle mass
daily calorie requirement?
30kcal/Kg/day
types of enteral feeding?
supplements nasogastric tube nasojejunal tube percutaneous endoscopic gastrostomy jejunostomy
complications of enteral feeding?
aspiration
re-feeding syndrome
complications of total parenteral nutrition?
line thrombosis
sepsis
metabolic imbalance, fluid o.load, electrolyte imbalance, liver damage
mechanical e.g. pneumothorax, e.g. with SC line
describe re-feeding syndrome
Occurs in the severely malnourished Hypophosphatemia Cellular dysfunction Cardiac arrhythmia Prevent by close attention to K, PO, Mg
3 components to consider in hypotensive ptnt post op?
reduction in circulating volume (preload)
reduction in CO- reduced myocardial contractility, arrhythmias, valvular dysfunction
vasodilatation (afterload)
most common cause of hypotension after surgery?
hypovolaemia e.g. bleeding in surgery, continued bleeding, tissue damage causing oedema, or evaporation during prolonged surgery on body cavities e.g. abdomen and thorax.
how is hypovolaemia post op diagnosed?
reduced peripheral perfusion- CRT >2s, cold clammy skin, in absence of fear, pain and hypothermia
tachycardia- PR>100bpm of poor volume
hypotension, and narrow pulse pressure- DBP elevated due to compensatory vasoconstriction
inadequate urine output- <0.5ml/kg/h, should be measured hrly with catheter.
causes of a reduced urine output post op, other than hypovolaemia?
blocked catheter
hypotension
hypoxia
renal damage intraoperatively e.g. in AAA surgery or hysterectomy
most common causes of oliguria and anuria?
oliguria- hypovolaemia
anuria- blocked catheter
in which ptns might hypovolaemia post op not be detected?
young, fit ptnt who can lose up to 15% of blood volume without detectable signs
ptnt on beta blockers may not be seen as having tachycardia
management of hypovolaemia post op?
ensure adequate oxygenation and ventilation
give IV fluid
X match blood
stop any external haemorrhage with direct pressure
monitor CVP if cardiac function is in question
arterial blood sample- lactic acidosis?
why might a ptnt have adequate oxygen sat.s despite inadequate ventilation?
receiving O2 therapy
features indicating L ventricular dysfunction post op?
tachypnoea tachycardia poor peripheral circulation- cold clammy hands, CRT>2s distended neck veins, raised JVP basal crepitations on lung auscultation wheeze with productive cough triple rhythm on heart auscultation
management of L ventricular dysfunction post op?
sit ptnt upright give 100% O2 monitor ECG, BP, and SpO2 can give fluid challenge if diganosis unclear, an improvement in circulatory status suggest hypovolaemia if sure of diagnosis, can give a diuretic and restrict fluids initially monitor CVP trends care in critical care area use of inotropes and vasodilators
most common arrhythmia after anaesthesia and surgery?
sinus tachycardia (>100bpm)
usually result of pain or hypovolaemia
if assoc with pyrexia, may be early indication of sepsis
what might development of an unexplained tachycardia post anaesthesia rarely be the 1st sign of?
malignant hyperthermia/hyperpyrexia
tment of sinus tachycardia post-op?
give O2
analgesia
adequate fluid replacement
possible beta blocker if persists
causes of sinus bradycardia post op?
inadequate dose of anticholinergic given with neostigmine to reverse NMB
excessive suction to clear pharyngeal or tracheal secretions
traction on viscera in surgery
excessive high spread of epidural or spinal anaesthesia
development of acute inferior MI
excessive beta-blockage preop or intraop
medication used intraoperatively to reverse epidural or spinal aneasthesia induced hypotension?
ephedrine hydrochloride
most common supraventricular tachycardia post op?
AF
usually due to IHD or presence of sepsis
if ptnt has sinus bradycardia post op, and low BP, what medication should be given?
atropine, 0.5mg IV
consider adrenaline infusion if no response
O2 should also be given
how is hypotesion secondary to regional aneasthesia corrected?
give fluids
use of vasopressors e.g. ephedrine
or combination of both
give O2
minimum criteria for discharge from recovery area?
fully conscious and able to maintain own airway
adequate breathing
stable CVS, with minimal bleeding from surgical site
adequate pain relief
warm
presentation of post op confusion?
agitation
disorientation
attempts to leave hosp, esec. at night
how to treat post op confusion?
gently reassure patient
may need sedation to examine them- midazolam, or haloepridol
reassure relatives that it is common, and reversible
tests in hypoxic/dyspnoeic ptnt post op?
FBC- pneumonia ?rasied WCC
ABG
CXR- fluid overload
ECG- MI, PE- R axis deviation, RBBB
sit up ptnt and give O2
pulse oximetry
most common form of infection post op?
wound infection
types of infections post op?
wound infection peritonism chest infection UTI cannula site eryhtema menigism endocarditis
common causative organisms of post op wound infections?
staph aureus pseudomonas aeruginosa E coli staph epidermidis enterococcus faecolis
tment of anuria post op?
most likely due to blocked catheter, so flush or replace catheter
