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
Discuss the management of post-operative anaemia
Post-op FBC should be done to measure Hb. Treatment is based on individual factors, individual preferences and local guidelines:
- <100g/L = start oral Fe
- <70g/L = blood transfusion in addition to oral Fe
Pts with symptoms of anaemia, underlyinc CVS or resp disease may need transfusion with higher Hb levels.
Define sepsis
Life threatening organ dysfunction caused by dysregulated host reponse to infection
What two scoring systems can be used in sepsis?
What does each system indicate?
- SOFA: used to determine level of organs dysfunction and mortality risk in ICU pts
- Qsofa: identify pts with suspected infection who are at increased of poor outcome outside intensive care unit
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)
The common sources of pyrexia in a surgical pt can be remembered using the seven C’s; state these
- Chest (infection)
- Cut (wound)
- Catheter (UTI)
- Collections (abdo, pelvis etc…)
- Calves (DVT)
- Cannula (infection)
- Central line (infection)
Delerium is a common post-operative complication, particulary in the elderly, remind yourself of:
- Definition
- Two/three types
- Common causes
- Acute confusional state with a fluctuating course that is characterised by disturbed consciousness and reduced cognition.
- Types:
- Hypoactive (most common): lethargy & reduced motor activity
- Hyperactive (most recognised): agitation & increased motor activity
- Mixed
- Common causes:
- Hypoxia
- Infection
- Drug induced e.g. benzodiazepines, opiates, steroids
- Dehydration
- Pain
- Constipation
- Urinary retention
- Electrolye abnormalities e.g. hyponatraemia, hypernatraemia, hypercalcaemia
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
What investigations should you consider in pt with post-op delerium?
- Plasma glucose
- Bloods
- FBC
- U&Es
- TFTs
- Ca2+
- Blood cultures
- Wound swabs
- Urinalysis
- CXR
- CT head (only if relevant)
Discuss the management of post-op delerium; consider non-pharmacological and pharmacological measures
Conservative
- Quiet area
- Clocks to orientate them in time and place
- Regular routines
- Regular sleeping patterns
- Encourage oral intake
- Monitor bowels
Pharmacological
- Sedatives e.g. haloperidol (oral initially if possible) as 1st line or lorazepam 2nd line
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
State some reasons as to why surgical pts are predisposed to deveoping lower respiratory tract infections/pneumonia
- Reduced chest ventilation (reduced mobility results in ability to fully ventialte lungs leading to accumulation of fluid secretions which can subsequenlty become infected)
- Change in commensals
- Debilitation (pts undergoing surgery are likley to be sick or have co-morbidities- compromising their immune systems)
- Intubation (major risk factor for HAP)
What is VAP?
- Ventilator associated pneumoia
- HAP that occurs >48hrs after tracheal intubation
- Most common in those who had endotracheal tube inbubation
Remind yourself of the CURB65 score
Remind yourself of the abx treatment for HAP
- Mild-moderate: oral co-amoxiclav
- Severe: Piperacillin/tazobactam (trade name Tazocin)
For aspiration pneumonia, discuss:
- What it is/why it occurs
- Where in lungs likely to affect
- Risk factors in surgical pts
- Management
- Aspiration of gastric contents into pulmonary tissue resulting in chemical pneumonitis. Only becomes infection if oropharyngeal bacteria are aspirated into lung tissue aswell
- Right middle or lower lung lobes due to bronchi anatomy
- RF:
- Reduced GCS e.g. secondary to anaesthesia
- Prolonged vomitting without NG tube
- Underlying neurological disease
- Oesophageal strictures or fistul
- Post-abdo surgery
- Misplaced NG tube
- Management is mainly preventative; identify pts at risk and put precautions in palce e.g. NG tube. Involve SALT. Treatment is with abx similar to HAP.
Majority of pts will develop some degree of atelectasis. For atelectasis discuss:
- What it is
- Pathophysiology in post-op pts
- Clinial features
- Managment
- Partial collapse of small airways
- Combination of airway compression, alveolar gas resorption intra-operatively and impairment of surfactant production. Reduced airway expansion & subsequent accumulation of secretions will predispose to complications eg.. infections. Most cases develop within 24hrs of operation.
- Features:
- Hypoxaemia
- Tachypnoeic
- Fine crackles over affected area
- Low grade fever
- Management:
- Deep breathing exercises
- Chest physiotherapy
- Treat complications
Define ARDS
Acute respiratory distress syndrome is form of acute lung injury characterised by sever hypoxaemia in absence of cardiogenic cause. Inflammatory damage to alveoli resutls in pulmonary oedema, respiratory compromise and acute respiratory failure.
*Basically pulmonary oedema due to non-cardiogenic cause
State some causes of ARDS
Discuss the pathophysiology of ARDS
Three phases:
- Exudative phase: initial tissue injury causes cytokines and other inflammatory mediators are released causing diffuse alveolar and endothelial injury
- Proliferative phase: fibroblasts and type 2 pneumocytes restore alveolar-capillary membrane integrity
- Fibrotic phase: extensive fibrin deposition leads to scarring of lungs and long term morbidity which may require oxygen or ventilation
State clinical feautres of ARDS
- Wrosening dyspnoea
- Hypoxia
- Tachypnoea
- Inspiratory crackles
- Acute onset <7 days
Use Berlin criteria to aid diagnosis as many conditions have similar presentation
Briefly outline managment of ARDS
- ITU
- Ventilatory support
- Consider ECMO
- Treat underlying cause
Define an anastomotic leak
Who should you suspect an anastomotic leak in?
- Leak of luminal contents from a surgical join
- Any pt who is not progressing as expected or deteriorates after surgery should be considered to have an anastomotic leak until proven otherwise
State some factors that increase risk of anastomotic leak including pt & surgical factors
Most risk factors are anything that will impair healing of anastomosis
Pt factors
- Medications e.g. corticosteroids, immunosupressants
- Smoking
- Alcohol excess
- DM
- Obesity or malnutrition
- Cardiovascular disease/PAD
Surgical factors
- Emergency surgery
- Longer intra-operative time
- Peritoneal contamination
- Oesophageal-gastric or rectal anastomosis
Describe clinical features of anastomotic leak- highlight main ones and state when pts usually present
Symptoms usually occur 5-7 days post-op
- Abdo pain
- Fever
- Delerium
- Prolonged ileus
- Tachycardia
- +/- signs of peritoneims
What investigations are required for a suspected anastomotic leak?
- CT abdomen & pelvis (or TAP if throacic anastomosis) with contrast= DEFINITIVE
- Urgent bloods:
- FBC
- U&Es
- LFTs
- CRP
- Clotting screen
- Repeat G&S
- VBG (to assess tissue perfusion)
Discuss the management of anastomotic leaks- split your answer into immediate and definitive management
Immediate
- NBM
- Broad spec IV abx
- IV fluids
- Urinary catheter
Definitive
Depends on extent of leak, contamination & pt staus.
- Minor leaks with collection <5cm: mange with IV abx
- Leak with larger colections: percutaneous drainage
- Septic or multiple collections:
- Exploratory laparatomy
- Wash out
- Large drain insertion
- If colorectal anastomosis leak a stoma will be formed
What is post-op ileus?
Deceleration or arrest in intestinal motility following surgery
*in majority of pts it is innocent however could be sign of intra-abdominal pathology hence must rule out other causes.
State some risk factors for post-op ileus
Pt factors:
- Increased age
- Electrolyte derangment
- Neurological diseawse
- Anti-cholinergic medications
Surgical factors
- Opios
- Pelvic surgery
- Extensive intra-operative intestinal handling
- Peritoneal contamination
- Intestinal resection
State clinical features of post-op ileus
Delay in return of normal bowel function
- Failure to pass faeces or flatus
- Bloating and distention
- N&V
- High output NG
- Absent bowel sounds (whereas in mechanical obstruction there is typically tinkling bowel sounds)
What investigations are required in suspected post-op ileus?
Aim of investigations to rule out more serious pathology
- Routine bloods
- FBC
- U&Es
- LFTs
- CRP
- Electrolytes (Calcium, phosphate, magnesium)
- CT abdomen & pelvis with oral contrast
Discuss the managment of post-op ileus
Management is conservative:
- NBM
- IV fluids
- Strict fluid balance chart
- Daily bloods inlcuding electrolytes
- Encourage mobilisation
- Reduce any bowel mobility reducing agents
Once it settles may have watery stool for first few bowel movements
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
