Peri-Op Care: Post-op Flashcards
What is enhanced recovery after surgery (ERAS)?
Modern approach to help pts recover quicker following surgery. Guidelines consists of combination of evidence ased peri-operative care elements that are thought to reduce post-surgical complications, lenght of hosital stay and overall costs.
The ERAS protocol can be divided into three stages based on the pt journey; state each of the three stages and discuss what is involved in each
*NOTE: just know a few principles
Pre-Operative
- Pt education regarding surgery
- Ensure pt is as healthy as possible e.g. stop smoking, decrease alcohol, weight loss, healthy diet
- Optimising medical management
- Optimal pre-operative fasting guidelines
Intra-operative
- Minimally invasive surgery
- Multimodal and opiod sparing analgesia
- Multimodal post-op N&V prophylaxis
Post-operative
- Adequete analgesia to allow for early mobilisiation
- Early return to oral diet & fluid intake
- Avoiding drains & NG tubes where possible & early catheter removal
- Early discharge
What is EWS?
Why is it used?
A score above _____ is cause for concern
- Early warning score: tool/scoring system used in healthcare to help identify how unwell a pt is and also to help quickly identify any deteriorating pts
- Universal way of communicating how ill a pt is
- Score above 5 (or score >3 in one parameter)is cause for concern
There is good evidence that early post-operative feeding reduces post-operative complications; true or false?
True
ERAS is designed to start post-operative feeding ASAP coupled with other factors such as early mobilisation
It is now recognised that most surgical pts can safely tolerate enteral diet within _____ hrs of uncomplicated GI surgery without increasing the risk of complications
24hrs
Post-operative pain can be assessed subjectively & objectively; discuss what we mean by each
Subjectively
- Pt’s opinion e.g. Asking pt to grade their pain
Objectively
- Assessing for clinical features of pain e.g. tachycardia, tachypnoea, hypertension, sweating or flushing, agitation/unwillingess to mobilise
Outline what you should do when assessing post-operative pain in a surgical pt
- General inspection from end of bed
- History
- Operation they had
- Whether operation went well
- How recently have they had analgesia
- Was it effective
- Pain history: timing, location, associated symptoms, pain score
- Examination
- Observations
- Examine area (IF NEEDED)
- Ask pt to cough & take deep breath (if able to deep breath and cough unlikley to be severe pain. Important in abdo & thorax surgery)
When assessing whether a post-op pt is in pain you should assess them in two different scenarios/circumstances; state these
- Mobile
- When taking a deep breath
- When in bed
*could be pain free in bed but have pain when walking
Why is it important to control post-operative pain?(3)
- Enable pt to mobilise (decreased mobilisation, incresed risk DVT)
- Enalbe pt to ventilate their lungs properly hence reducing risk of chest infections & atelectasis
- Enable pt to consume adequete oral intake
… all of the above reduce the risks of post-operative complications
If a pt with renal impairment requires strong opiod analgesia, which ones should you consider?
- Fentanyl
- Oxycodone
… decreased renal clearance
What is PCA?
Considerations when in use on the ward
Advantages & disadvantages
- Patient controlled analgesia; IV infusion of an analgesic (usually strong opiod) attached to a pt controlled pump. Pt presses button when pain starts to develop and bolus of the analgesic is fiven. Button will stop responding for a set time after administering a bolus (lock out period) to prevent overdose.
- Careful monitoring with input from anaesthetist. Should have easy acess to the following on the ward: naloxone (for overdose), antiemetics, atropine (for bradycardia).
State some risk factors for PONV
Pt factors:
- Younger age
- Previous PONV
- Motion sickness
- Use of opiod analgesia
- Female
- Non-smoker
Surgical factors:
- Intra-abdominal laparscopic surgery
- Intracranial or middle ear surgery
- Gynaecological surgery
- Prolonged operative times
Anaesthetic factors:
- Use of volatile anaesthetics
- Opiate analgesia
- Spinal anaesthesia
- Prolonged anaesthetic time
- Intraoperative dehydration or bleeding
Remind yourself of some of the antiemetics that are available
- Antihistamines (H1): e.g. cyclizine
- Antimuscuranics: e.g. hyoscine hydrobromide
- 5hT3 receptor antagonists: e.g. ondansetron
- D2 antagonists: e.g. prochlorperazine
- Corticosteroids: e.g. dexamethasone
Prophylacti antiemetics are often given at end of procedure by anaesthetist; true or false?
True
State some prophylactic measures for PONV
- Prophylactic antiemetic therapy
- Adequete fluid hydration
- Adequete analgesia
- Reduce volatile gases, opiates and avoid spinal anaesthetics
- Consider NG tube to aid gastric decompression
Which pts should you avoid using the following antiemetics in:
- Ondansetron (5HT3)
- Dexamethasone
- Droperidol (D2)
- Prochlorperazine (D2)
- Cyclizine (H1)
- Metoclopramide (D2)
- Ondansetron: avoid in pts with risk of long QT
- Dexamethasone: caution in diabetic or immunocompromised
- Droperidol: avoid in pts with Parkinson’s disease
- Prochlorperazine: avoid in pts with Parkinson’s disease
- Cyclizine: caution in HF & elderly pts
- Metoclopramide: do not use in situations in which stimulation of peristalsis may be harmful e.g.bowel obstruction
What questions should you ask yourself when assessing a pt with PONV?
- What was operation? Is it likey to cause PONV?
- Which anaesthetic agents/post-op drugs used?
- Are there other factors contributing to nausea/could there be alternative cause e.g infection, post-op ileus, DKA, medications e.g. abx, CNS causes such as raised ICP, anxiety etc…
- Which antiemetic would suit this pt best? Ensure no contraindications to antiemetic you choose
What classes of antiemetic work well in the following situations:
- Impaired gastric emptying (except in bowel obstruction)
- Bowel obstruction
- Metabolic or biochemical disturbance
- Opiod induced N&V
- Impaired gastric emptying (except in bowel obstruction): prokinetic agents e.g. metoclopramide or domperidone (both D2 antagonists with action in bowel)
- Bowel obstruction: hysocine hydrobromid (antimuscarinic) can help to reduce secretions
- Metabolic or biochemical disturbance: metoclopramide (D2 antagonist)
- Opiod induced N&V: ondansetron (5HT3) or cyclizine (H1 antagonist)
Some local guidelines refer to what acupuncture point to reduce nausea?
P6 acupuncture point on inner wrist
MUST REVISE SEM 4 CPT ANTIEMETICS!!!
When are the following tubes usually removed:
- Drains
- NG tubes
- Catheters
- Drains: draining minimal or no blood or fluid
- NG tubes: no longer required for intake or for drainage of gas/fluid
- Catheters: when pt can mobile to toilet and careful fluid balance monitoring not required
State some common post-op complications that can occur
*There is a lot, just know a few
- Anaemia
- Atelectasis (collapse of lung due to underventilation)
- Infections (chest, UTI, wound site, sepsis)
- Wound dehiscence
- Ileus (particularly after abdo surgery)
- Haemorrhage
- DVT and PE
- Shock (due to hypovolaemia, sepsis or heart failure)
- Arrhythmias (e.g. AF)
- ACS
- Stroke
- AKI
- Urinary retention
- Delerium
What parameters are assessed in the qSOFA score?
What do the results indicate?
If a pt with known suspected infection scores 2 or more then they shoudl be investigated and managed for sepsis:
- Resp rate =/>22/min
- Systolic BP =100mmHg
- Altered mental status
State some parameters assessed in the SOFA (sequential organ failure assessment score)
What test can we used to assess current cognitive function of pt who we think may have delerium?
AMT (abbreviated mental test
<8 indicates cognitive impairment
Compare delerium & dementia
Haemorrhage is a common post-op complication; it can be primary, reactive or secondary. We can classify hypotensive shock into 4 classes; brielfy outlien each class.
*Hint: think about blood loss, BP change, resp ate changes etc…
*Added this FC to highlight topic from teaching session. If a pt has normal BP but looks dry you would give them fluids. As you can see hypotension is a later sign of hypovolaemia hence don’t let it stop you giving fluids if pt seems otherwise dry
Remind yourself of the CURB65 score
State some causes of ARDS
When are the following post-op complications most likely to occur:
- Atelectasis
- Pneumonia
- Haemorrhage
- UTI
- Anastomotic leak
- VTE
- Surgical site/intrabdominal infection/collection
- Wound dehiscence
- Post-op urinary retention
- Post-op renal failure
- Delirium
**NOTE: this does not mean cannot occur outside these time frames but can be useful to help you determine most likely diagnosis
- Atelectasis: 24hrs
- Pneumonia: 3/5-7 days
- Haemorrhage: secondary haemorrhage 7-10 days
- UTI: 3/5-7 days
- Anastomotic leak: 5-7 days
- VTE: 10-14 days
- Surgical site/intrabdominal infection/collection: 5-7 days
- Urinary retention: 1-7 days
- Renal failure: 1-7 days
- Delirium: depends on underlying cause (many of above could cause)
State some causes of pyrexia in post-op patient
- Atelectasis
- VTE
- Infection
- Chest
- UTI
- Wound
- Intra-
- Lines
- Anastomotic leak
- Inflammatory response to surgery
- Iatrogenic (e.g. drug induced)
- Secondary to prosthetic implantation
