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Yr3 Surgery: General > Peri-Op Care: Pre-Op > Flashcards

Peri-Op Care: Pre-Op Flashcards

1
Q

Before going to theatre what 6 things need to be addressed/done?

A
  • Pre-operative assessment
  • Consent
  • Bloods
  • Fasting
  • Medication changes
  • VTE assessment
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2
Q

What is the purpose of a pre-op assessment?

A

To asess if pt fit to undergo specific operation. It is a chance to identify any co-morbidities that may lead to complications during the anaesthetic, surgery or post-operative period.

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3
Q

When is the pre-operative assessment done?

A

~2-4 weeks before surgery

*anaesthetist often repeats some of it on day of operation

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4
Q

What is involved in a pre-op assessment?

A
  • Full history
  • Examinations
    • General (to identify undiagnosed pathology)
    • Airway assessment
    • +/- examination of area relevant to operation
  • Investigations
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5
Q

Briefly outline what is involved in the airway assessment/examination

A
  • Degree of mouth opening (inter-incisor distance >3cm)
  • Dentition
    • Do they have teeth?
    • What is dentition like?
    • Any lose teeth,caps or crowns?
  • Mallampati classification
  • Neck flexion, extension, rotation and lateral flexion (if on max neck extension distance thyroid cartilage and chin <6.5cm indicates intubation may be difficult)
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6
Q

What must you explore in the pre-op assessment history?

A
  • Brief history presetnign complaint (what procedure having and why)
  • PMH asking specifically about:
    • Cardiovascular disease
    • Renal disease e.g. CKD and features of this such as anaemia, coagulopathy etc
    • Endocrine disease e.g. diabetes, thyroid
    • Any chance of pregancy?
    • Any chance of sickle cell disease in afro-carribean
  • Past surgical history
  • Past anaesthetic history
    • When? Any issues? Well intra- and post-op? Post op N&V?
    • Anyone in family had issues with anaesthetic (thinking malignant hyperthermia)
  • Medication history & drug allergies
  • Social
    • Smoking
    • Alcohol intake
    • Exercise tolerance
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7
Q

If a pt is malnourished with BMI of <18.5 or has significant unintentional weight loss what may they need prior to surgery?

A

Input from dietician for additional nutritiional support

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8
Q

What is the ASA grade and what does it correlate with?

Describe the ASA grading system

A

American Society of Anesthesiologists (ASA) grade is used to describe current fitness prior to undergoing anaesthesia and surgery and indicate the risk of post-operative complications and absolute mortality.

E= used in emergency operations

Absolute mortality risk for each grade:

  • I= 0.1%
  • II= 0.2%
  • III= 1.8%
  • IV= 7.8%
  • V= 9.4%
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9
Q

Pre-operative investigations will be guided by pt factors, and the nature of the procedure. If in doubt as to what investigations how could you find out? (3)

A
  • NICE traffic light table for pre-op investigations
  • Local guidelines
  • Anaesthetist
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10
Q

State some invesitgations that may be required pre-op and for each state why they may be required

A

Bloods

  • FBC: anaemia or thromobocytopenia; may require correction to reduce risk of CV events
  • U&Es: baseline renal function, help guide fluid management and drug doses
  • LFTs: liver disease can lead to clotting abnormalities, may alter drug doses
  • Clotting screen: will need correcting to decrease risk of bleeding
  • HbA1c: if known diabetic. Better idea of glycaemic control to help assess if likely to be complications
  • Group & save or crossmatch:in case pt needs blood transfusion

Bedside & others

  • MRSA swabs:i ALL pts
  • ECG: known or possible CVD
  • Echocardiogram: if known heart murmurs, cardiac symptoms or heart failure
  • Pregnancy test: if child-bearing age
  • ABG: if known respiratory disease
  • CXR: only if necessary (see separate FC)
  • Lung function testing: if known or possible respiratory disease
  • Sickle cell testing: only if pt is afro-carribean or has FH
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11
Q

Who would an echocardiogram be considered in as part of pre-op investigations?

A
  • Heart murmur
  • Cardiac symptoms
  • Heart failure
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12
Q

Which pts should a CXR be considered in during pre-op investigations?

A
  • Respiratory illness and not had CXR in 12 months
  • New cardiorespiratory symptoms
  • Recent travel from endemic TB areas
  • Significatn smoking history
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13
Q

State the typical fasting regime required prior to an operation

A
  • No food or feeds 6hrs prior to operation (this includes stopping any dairy hence must stop tea or coffee with milk)
  • No clear fluids (fully NBM) 2hrs prior to operation

*Aim is to reduce reflux during surgery which can lead to aspiration

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14
Q

Management of pre-op medications falls into 3 categories: stop, alter and start. Summarise which drugs you should:

  • Stop
  • Alter
  • Start

…. pre-operatively

A

Stop

  • Anticoagulants & antiplatelets
  • Hypoglycaemics
  • Oral contraceptives

Alter

  • SC insulin
  • Long term steroids

Drugs to start

  • LMWH
  • TEDstockings or intermittent pneumatic compression
  • Abx prophylaxis
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15
Q

State when you should stop the following drugs prior to surgery:

  • Warfarin
  • Clopidogrel
  • LMWH
  • DOACs
A
  • Warfarin: 5 days pre-op
  • Clopidogrel: 7 days pre-op
  • LMWH: 12hrs pre-op
  • DOACs: depends on renal function, usually stop for 3-5 half lifes- usually between 24-72hrs. Rivaroxaban & apixaban is ~2 days pre-op
  • Oestrogen containing contraceptives or HRT: 4 weeks prior

*CHECK IF YOU NEED TO STOP OTHER ANTIPLATELETS

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16
Q

Which pts, who regularly take warfarin, need bridging therapy prior to their operation?

What do we bridge them with?

A
  • High risk e.g. mechanical heart valves, recent VTE
  • Bridge with LMWH heparin or unfractionated heparin infusion. This can then be stopped shortly before surgery

NOTE: surgery may not go ahead if INR >1.5 so may have reverse warfarin with PO vitamin K if INR high evening before

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17
Q

Explain why we have to alter corticosteroids in surgical pts who are on long term corticosteroids

A

Pt undergiong surgery or sepsis will elicit a stress response in proportion to the extent of trauma and metabolic insult. The stress response involves activation of HPA axis and release of endogenous cortiosteroids. Long term steroid use can supress HPA axis resulting in inadequete adrenal response and an addisonian crisis; hence, peri-operative stress dose corticosteroid therapy is required.

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18
Q

Pts on long term corticosteroids (5mg for >2 weeks) need their steroid dose altering; discuss how we manage pts on long term corticosteroids both pre-op, intra-op and post-op (4)

A

*NOTE: teach me surgery says there are no definitive guidelines as it depends on type of surgery and pts pre-op prescription. Zero to finals suggests:

  • Wean them off steroids pre-operatively if possible
  • Switch to IV corticosteroids (5mg PO pred= 20mg IV hydrocortisone)
  • Additional IV hydrocortisone at induction, then continuous infusion throughout and then for immediate post-operative period (24hrs)
  • Double their normal dose once eating and drinking for 24-72hrs post-op (depending on operation)
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19
Q

Explain why the management of surgical diabetes is important

A
  • Stress of surgery increases blood sugar levels (stress response activates HPA axis, cortisol inhibits insulin)
  • Fasting may lead to hypoglycaemia

… hence it is important to mange these pts correctly to balance the two!

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20
Q

Discuss the management of surgical pts who are on insulin (4)

A
  • All pts with T1DM should be first on morning list
  • Night before surgery reduce SC basal insulin (long acting insulin) by 20% AND continue at this % throughout. Do not stop basal insulin.
  • Stop their short acting insulin whilst not eating AND commence IV variable rate insulin infusion
  • Continue sliding scale until pt is able to eat & drink. Once they are eating & drinking, you must OVERLAP the stopping of their sliding scale with starting their normal SC insulin
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21
Q

Discuss how you should overlap sliding scale and re-starting of SC insulin in insulin dependent diabetic surgical pt

A
  • Ony do this once they are eating & drinking
  • Give SC rapid/short actign insulin ~20mins before meal. NOTE: SC insulin may need adjusting due to factors such as post-op infections, not eating as much etc…
  • Stop their sliding scale ~30-60 mins after they have eaten
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22
Q

Explain how a sliding scale works; include what doses of insulin and dextrose you use

A
  • 50 units actrapid in ~50mL of 0.9% NaCl in a syringe driver. Rate (units/hr) dependent on plasma glucose
  • 5% dextrose infusion usually at rate of 125mL/hr
  • Get nursed to check plasma glucose every 1-2hrs and alter infusion rate accordingly
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23
Q

Discuss the management of type 2 diabetics controlled by oral hypoglycaemics

A

Certain oral-antidiabetic medications may need to be adjusted or omitted. If it is minor surgery may just continue normal regime. If it is major surgery:

  • Stop metformin on morning of surgery
  • All others stop ~24hrs prior to surgery
  • Monitor BMs and if it exceeds 15mmol/L (or if pt known to have poor control) put on IV variable rate insulin infusion and manage same as discusses for insulin dependent diabetics (monitor BMs, alter infusion, resume norma
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24
Q

Why must you stop the following medications during surgery:

  • Sulfonylureas
  • Metformin
  • SGLT2 inhibitors
A
  • Sulfonylureas: hypoglycaemia risk
  • Metforminc: lactic acidosis
  • SGLT2 inhibtors: diabetic ketoacidosis in dehydrated or uwell pts
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25
Q

If a pt’s T2DM is controlled by diet no action is required peri-operatively; true or false?

A

True

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26
Q

All pts admitted to hospital should have a VTE risk assessment done by the admitting doctor; what things are considered in a VTE risk assessment?

A
  • Mobility
  • Patient related factors that increase thrombotic risk
  • Assess bleeding risk
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27
Q

Why are surgical pts at risk of VTE?

A
  • Immobility following operation (stasis of blood in deep veins in leg as calf muscle pump not functioning)
  • Surgery is major trauma and part of body’s response to trauma is shift the thrombotic pathways in favour of thrombosis
28
Q

State some ways in which we can reduce VTE risk in surgical pts (7)

A
  • Pre- and post-op mobilisation
  • Maintain hydration
  • Stop pro-thrombotic drugs
  • LMWH e.g. dalteparin
  • DOACs e.g. apixaban, rivaroxaban (alternative to LMWH)
  • Anti-embolic compression stockings (TED stockings)
  • Intermittent pneumatic compression (flowtron boots)
29
Q

What VTE prophylaxis should all pts receive (except those with contraindications)?

State some contraindications to the above VTE prophylaxis

A
  • Anti-embolism compression stockings (TEDs)
  • Contraindications:
    • Peripheral vascular disease
    • Peripheral neuoropathy
    • Recent skin graft
    • Severe eczema
30
Q

Which pts should be discharged with TEDs and 28 days of prophylactic dose LMWH?

A
  • Major GI surgery for cancer
  • Lower limb joint replacement
31
Q

In UHL, there are two doses of prophylactic dalteparin; state these two doses

A
  • Low risk= 2500 units
  • High risk= 5000 units
32
Q

When does PE clasically occur following surgery?

A

10-12 days when pt straining at stool (venous pressure waves during straining cause thrombus to fracture & embolise to pulmmonary circulation)

33
Q

Bowel preparation, in form of laxatives or enemas, may be required pre-operatively to clear colon in colorectal surgery. Bowel preparation can cause fluid shifts and hence be harmful to which pts?

A
  • Elderly
  • Renal disease
  • Cardiac disease
34
Q

Which of the following surgeries require bowel preparation?

  • Upper GI, HPB, small bowel
  • Right hemicolectomy/right extended hemicoletomy
  • Left hemicolectomy, sigmoid colectomy, APR
  • Anterior resection
A
  • Upper GI, HPB, small bowel: none
  • Right hemicolectomy/right extended hemicoletomy: none
  • Left hemicolectomy, sigmoid colectomy, APR: phosphate enema on morning of surgery
  • Anterior resection: 2 sachets of stimulant (e.g.picosulphate) or osmotic (magneisum citrate) laxatives day before or phosphate enema on morning of surgery
35
Q

What must you explain to the pt when taking consent for a procedure?

A
  • What it involves
  • Benefits/why they need it
  • Risks and possible complications
36
Q

There are 4 different consent forms in the NHS; state what each one is for

A
  • 1- pt consenting to procedure
  • 2- parental consent on behalf of a child
  • 3- consent where pt won’t have consciousness impaired
  • 4- pt lacks capacity
37
Q

Pt’s may need pre-operative nutrition; describe the hierachery of feeding methods that should be followed

A
38
Q

Does a low serum albumin reflect nutritional state? Discuss.

A
  • Low serum albumin does not indicate poor nutritional state
  • Pts with severe anoerxia nervosa have normal serum albumin
  • Low serum albumin reflects:
    • Chronic inflammation
    • Protein losing eneteropathy
    • Protein urea
    • Hepatic dysfunction
  • Hence ‘feeding’ a pt to correct albumin is wrong; must treat underlying cause
39
Q

Discuss the surgical wound classification

A

Clean

  • No inflammation encountered
  • No break in sterile technique
  • Respiratory, alimentary or GU tract not entered

Clean-contaminated

  • Incision through respiratory, alimentary or GU tract under controlled conditions with no contamination required

Contaminated

  • Major break in sterile technique
  • Gross spillage from GI tract
  • Incision in which acute, non-purulent inflammation encountered
  • Open traumatic wounds more than 12-24hrs old are in this category

Dirty or infected​

  • Viscera are perforated
  • Acute inflammation with puss encountered
  • Traumatic wounds if treatment delayed >24hrs, faecal contamination or devitlaised tissue
40
Q

Antibiotic prophylaxis is effective for preventing surgical site infections however it also carries risk of adverse events e.g. C-diff, abx resistance etc… Therefore NICE have produced guidance on use of prophylactic abx surroudning surgery. NICE state abx prophylaxis is requiered in which surgeries?

A
  • Clean surgery involving the plasement of prosthesis or implant
  • Clean-contaminated surgery
  • Contaminated surgery
  • Surgery on dirty or infected wound (requires abx treatment aswell as prophylaxis)

Give prophylaxis centred around what is most likely causative organism.

41
Q

State 4 criteria for a surgery to be considered as a daycase

What ultimately decides whether a surgery can be daycase or not?

A
  • Minimal blood loss expected
  • Short operating time
  • No expected intra- or post-operative complications
  • No requirement for specialist aftercare

Whether it is done as daycase is down to pt:

  • Medical factors: e.g. co-morbidities
  • Social factors e.g. understand post op care, have someone to take them home and support them for first 24hrs
42
Q

What are the 3 reasons for fluid prescription?

A
43
Q

State some factors to consider when prescribing fluids for a pt

A
  • Aim
  • Weight & size of pt
  • Co-morbidities e.g. CKD, CHF
  • Most recent electrolytes
  • Underlying reason for admission*

*E.g. after some operations pts are kept deliberately on dry side whereas in other situations aggressive fluid prescribing is needed e.g. sepsis, bowel obstruction

44
Q

Why do septic pts require high volumes of fluids?

A
  • In septic pts the tight junctions between capillary endthelial cells break down and vascular permeability increases
  • Both water and proteins leak out of capillarys
  • Hence necessary to give large volumes of IV fluid to maintain intravascular volume even though total body water may be high
  • Must monitor fluid balance closely
45
Q

Discuss how fluid input & output changes in pts who are acutely unwell

A
  • Insensible losses (losses from non-urine sources) rise in pts who are unwell; may be febrile, tachypnoeic or having increased bowel output
  • Fluid input may decrease if not eating and drinking much
  • Hence mya need extra fluid compared to usual
46
Q

Remind yourself of the daily requirements of the following:

  • Na+
  • K+
  • Cl-
  • Water
  • Glucose
A

Na+ = 1-2mmol/kg/day

K+ = 0.5-1mmol/kg/day

Cl-= 1mmol/kg/day

Water = 30mL/kg/day

Glucose = 50-100g per day

47
Q

Remind yourself of the compositions of the following commonly used fluids:

  • 0.9% NaCl
  • Hartmanns
  • 5% dextrose
A

*= KCl can be added in 20mmol or 40mmol. Remember only infuse K+ at max 10mmol/hr

48
Q

How can we monitor a pt’s fluid status to ensure we are prescribing fluids correclty?

A
  • Fluid balance assessement (do they look dry, HR, BP, urine output, cap refill, raised JVP, skin tugor etc…)
  • U&E’s
  • Daily weights
  • Fluid input output chart (ensure have catheter for careful fluid balance)
49
Q

There are certain scenarios in which pts can lose electrolyte rich fluids. State some example circumstances and what electrolytes are lost

A
  • Vomiting (low K+ and Cl- and alkalosis)
  • Diarrhoea (low K+ and acidosis)
  • Dehydration (high urea:creatinine ratio, high PCV)
50
Q

What is a blood product?

A

Any part of blood that is collected from a donor for use in blood transfusion

51
Q

What is the NICE Hb threshold for giving a blood transfusion?

What is the target Hb post transfusion?

A
  • 70g/L (without any major haemorrhage or ACS)
  • Target = 70-90g/L
52
Q

Remind yourself of the different blood types

Who is the universal donor?

Who is the universal receiver?

A
  • Universal donor= O-
  • Universave receiver= AB+
53
Q

Discuss the process of requesting blood products

A
  • 3 points of identification
  • Consent pt
    • Many transfusion forms have script on that you must read
    • Complete a consent form
  • Label bottle at bedside (pre-printed stickers not allowed)
  • Check with pt or someone else that you have labelled things correctly
  • Complete transfusion request form at bedside
54
Q

Why must we give pregnant women and neonates up to 28 days old CMV negative blood?

A

CMV cause congenital infection that may lead to sensorineural deafness & cerebral palsy

55
Q

What observations must carried out when giving a pt a blood transfusion?

A

Observations at varying points:

  • Before transfusion
  • 15-20 minutes after it has started
  • 1 hour
  • Completion
56
Q

Each unit of blood must be prescribed individually; true or false?

Which cannulas can you administer blood products through and why?

Which giving set must you use?

A
  • True
  • 18G or 16G
  • Otherwise narrow tube may cause sheer stress and haemolysis
  • Blood giving set as this has filter in unlike normal giving sets
57
Q

For each of the following blood products, state what they contain:

  • Packed red cells
  • Platelets
  • FFP
  • Cyroprecipitate
  • Prothrombin complex concentrate
A
  • Packed red cells = red blood cells
  • Platelets = platelets
  • FFP = clotting factors
  • Cyroprecipitate = fibrinogen, VWF, factor VIII and fibronectin
  • Prothrombin complex concentrate = factor II, VII, IX, X (vit K dependent clotting factors)
58
Q

For each of the following blood products state when they would be used:

  • Packed red cells
  • Platelets
  • FFP
  • Cyroprecipitate
  • Prothrombin complex concentrate

*NOTE: idea is to be able to work it out based on knowing what each one contains

A

Packed red cells

  • Acute blood loss
  • Chronic anaemia (<70g/L or <100g/L in CVD) or symptomatic

Platelets

  • Haemorrhagic shock
  • Thromboctyopenia <20x109
  • Bleeding with thrombocytopenia
  • Pre-op platelets <50x109

FFP

  • DIC
  • Haemorrhage secondary to liver disease
  • All massive haemorrhages commonly after 2nd unit of packed red cells

Cyroprecipitate

  • DIC with fibrinogen <1g/L
  • Von Willebrands disease
  • Massive haemorrhage

Prothrombin complex concentrate

  • Warfarin reversal
59
Q

Stae some complications of packed red cell transfusions (4)

A
  • Clotting abnormalities: due to dilution effect hence we often give FFP and platelets concurrently in pts having >4 units of PRC
  • Electrolyte abnormalities:
    • ​Hypocalcaemia: chelation of calcim by calcium binding agent in preservatvies
    • Hyperkalaemia: partial haemolysis of RCCs and release of intracellular K+
  • Hypothermia: blodo products thawed and kept cool so may not be up to body temp by tiem of transfusion
60
Q

State 7 ACUTE transfusion related complications

A
  • Acute haemolytic reaction
  • Transfusion associated circulatory overload (TACO)
  • Transfusion related lung injury (TRALI)
  • Mild allergic reaction e.g. itching
  • Non-haemolytic febrile reaction
  • Anaphylaxis
  • Infective/bacerial shock
61
Q

For acute haemolytic reaction state:

  • What it is
  • Presentation
  • What test confirms diagnosis
  • Managment
A
  • Serious reaction due to blood incompatibility (usuallly due to ABO incompatibility). Donor red blood cells destroyed by recipients antibodies
  • Presentation:
    • Urticaria
    • Hypotension
    • Fever
    • Haemoglobinuria
    • Low Hb
    • Low haptoglobin
    • High LDH
    • High bilirubin
  • Positive direct antiglobuin test= CONFIRMS
  • Management:
    • Stop transfusion
    • Supportive measures
    • Inform blood bank
62
Q

For transfusion associated circulatory overload, discuss:

  • What it is
  • How it presents
  • Managment
A
  • Fluid overload as a result of infusion. Occurs in pts who are often already fluid overloaded
  • Presentation:
    • Dyspnoea
    • Features of fluid overload
  • Management:
    • Urgent CXR
    • Oxygen
    • Diuretics

*can give 20mg furosemide prophylacticallyin those at risk

63
Q
A
64
Q

For transfusion related acute lung injury, discuss:

  • What it is
  • How it presents
  • Management
A
  • Non-cardiogenic cause of pulmonary oedema
  • Dyspnoeic & features of pulmonary oedema on examination
  • Management:
    • High flow oxgyen
    • Urgent CXR
    • Specialist & intensive care input
65
Q

How would you treat the following acute complications of blood product transfusions:

  • Mild allergic reaction
  • Non-haemolytic febrile reaction
  • Anaphylaxis
  • Infective/bacterial shock
A
  • Mild allergic reaction
    • Antihistamines e.g. chlorphenamine
    • Continue transfusion under close observation
  • Non-haemolytic febrile reaction
    • Stop transfusion
    • Antihistamines e.g. chlorphenamine
    • Antipyretics e.g. paracetamol
  • Anaphylaxis
    • ​Stop transfusion
    • Usual anaphylaxis management
  • Infective/bacterial shock
    • ​Stop transfusion
    • Basic resuscitation measures
    • Blood cultures
    • IV abx

IN ALL SITUATIONS CONSULT A SENIOR

66
Q

State some potential delayed complications of blood product transfusions

A
  • Infection with blood bourne disease e.g. hepatitis b & C, HIV, syphilis, malaria, vCJD
  • Graft vs host disease due to HLA mismatch beween donor and recipient. Most common if get non-irradiated bood products to immuncompromised. Presents with fever, skin involvement, diarrhoea & vomitting
  • Iron overload most commonly in pts with repeated transfusions e.g. thalassaemia (get symptoms & signs like in hereditary haemochromatosis)

Yr3 Surgery: General (13 decks)

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