Peri-op management Flashcards
Peri-op considerations for T1DM pt
Put patient on list first
Omit AM insulin if surgery is in morning
Start SLIDING SCALE (5% dextrose w 20mM KCl at 125ml/hr + 50U actrapid)
- continue sliding scale until tolerating food
- check glucose hourly
Peri-op consideration for T2DM pt (no insulin tx)
Omit any oral hypoglycaemic on AM of surgery
- if eating post-op: resume oral hypoglycaemic with meal
- if not eating: check fasting glucose + start sliding scale
what anaesthesia should be avoided in patients taking warfarin
Epidural, spinal, regional blocks
Peri-op Considerations for pts on warfarin
Low VTE risk: stop warfarin 5 days pre-op + restart the next day
High VTE risk: - 5 days preop - stop warfarin + start LMWH - 1 day preop - stop LMWH - Post op: start LMWH + warfarin (stop LMWH when INR>2)
What must you do for a pt on warfarin who needs emergency surgery?
Stop warfarin
IV Vit K
Request FFP to cover surgery
What medications must be given prior to anaesthesia
Analgesia
Anti-emetics
Antacids
Antibiotics
What cautions are taken at end of anaesthesia
- Change inspired gas –> 100% O2
- Reverse paralysis: neostigmine + atropine
3 Weak opioids?
Codeine
Dihydrocodeine
Tramadol
Strong opioids - name 3
Morphine
Oxycodon
Fentanyl
Complications of anaesthesia
Intubation:
- oropharyngeal trauma, oesophageal intubation!
- Urinary retention
- Pressure sores
Loss of muscle power:
- Corneal abrasion
- No cough –> atelectasis + pneumonia
Anaphylaxis: rare!
Maintenance fluids - NICE recommendations
25-30ml/kg/day of water
1mM/kg/day of Na, Cl, K
50-100g dextrose
what structure is commonly at risk of damage in colonic resection/gynae surgery?
ureters
Why does neurosurgery often –> electrolyte disturbance
SIADH –> hyponatremia
Pre-op planning - pt takes warfarin. what precautions must you take for their procedure?
- Avoid epidural/spinal/regional blocks
- Stop warfarin 5 days pre-op
- If low VTE riskL restart warfarin day after op
- if
Specific complications for DM patients
Risk of hypo due to NBM
INFECTION
IHD, PVD
Specific periop risks for a patient taking steroids
- precaution taken?
Infection
Poor wound healing
Adrenal crisis
IV hydrocortisone
Important points to note in Hx of pre-op assessment
- PC: SITE of surgery,
- PMH: DM, jaundice
- cardioresp: MI, HTN, asthma, COPD
- DH: steroids, insulin, warfarin, smoking, OCP, anaphylaxis
- Intubation risk: neck arthritis, dentures, loose teeth
Caution in OCP taking patients
stop 4 weeks prior to surgery
restart 2 weeks after
Pre-op investigations
Routine bloods: FBC, U+Es, LFTs, clotting, glucose
Others: TFTs, G+S, X-match (6 units for AAA, 4 units for gastrectomy)
Cardiopulmonary function:
- CXR, ECG, echo, PFTs, exercise test
NBM for how long pre-op
2 hours: fluids
6 hours: food
Bowel prep - indications? 2 types?
Indicated for most L sided colon surgeries
Macrogol
Picolax
Indications for pre-op abx prophylaxis
GI surgeries
Joint replacement
Interventions for DVT prophylaxis
Early mobilisation
TEDs
LMWH
Intermittent compression boots
Diabetes - what specific risks do they have for surgery?
Risk of hypo from NBM
Risk of high glucose as cortisol antagonises insulin
Infection
Cardiac probs
3 specific risks of surgery in patients with jaundcie
1) obstructive jaundice - big risk of AKI
2) coagulopathy
3) infection –> cholangitis
Pre-op management of patients with jaundice
1) check clotting
2) 1L 0.9% saline pre-op
3) Urinary catheter + monitor UO
4) Abx prophylaxis
Specific risk of surgery in patients w COPD
1) atelectasis
2) aspiration
3) pneumonia
Complications of anaesthesia
Propofol induction –> cardiorespiratory depression
Intubation –> oropharyngeal trauma, sore throat, oesophageal intubation
Loss of pain –> urinary retention, pressure sores, nerve palsies
Loss of muscle power –> corneal abrasion, atelectasis + pneumonia
Anaphylaxis - rare but serious!!
Indication for spinal/epidural anaesthesia
1st line for bowel resection!!!
- avoid in anti coagulated patients
Post-op interventions to enhance recovery after surgery
Aggressive pain + nausea Mx
Early mobilisation
Remove drains + catheters ASAP
General surgical complications
Immediate: primary/reactive haemorrhage, damage to local structures, oropharyngeal trauma
Early: Atelectasis, pneumonia Secondary haemorrhage (from infection) Anastomotic leak VTE Wound infection, dehiscence C diff colitis
Late:
Failure/recurrence
Scarring
Neuropathic pain
Post-op haemorrhage classification
Primary: starts during surgery
Reactive: due to increased CO + BP
Secondary: >24h after surgery, often from infection
Causes of post-op urinary retention
Drugs: opioids, anaesthesia, antimuscarinics
PAIN –> sympathetic activity
Social: hospital environment
Mx of post-op urinary retention
Analgesia
Catheterise
TWOC
Causes of pulmonary atelectasis?
Findings O/E?
Mx?
Causes: smoking, COPD, pain -> weak cough
O/E: dull bases + reduced AE, occurs WITHIN 48 HOURS
Mx: Analgesia, chest physio
Wound infection:
Timing?
RFs?
5-7 days post-op
RFs:
pre-op: DM, steroids, viscus perforation
operative: contaminated/dirty, duration, pre-op abx
post-op: contamination from staff
Wound dehiscence: Definition? Timing + presentation? RFs? Mx?
- Rupture of a wound along the suture line
- 10 days post-op, preceded by serosanguinous discharge
- RFs (same as incisional hernia?):
Pre op: DM, obesity, smoking, malnutrition, roids
During operation: surgical skill, site of incision
Post-op: High IAP, infection
Mx: ABC
- Place gauze soaked in warm saline over the wound
- Fast bleep surgical reg + warn theatre + anaesthetist
- Opioid analgesia
- Prep pt for surgery: G+S, X-match, clotting, stop warfarin
Specific complications w cholecystectomy
Recurrence of stones Bile leak CBD injury Conversion to open - common Loose stools
Complications of inguinal hernia repair
Early:
- seroma formation (common)
- infection
- urinary retention
Late
- Neuropathic pain
- Ischemic orchitis: RARE BUT SERIOUS
- Recurrence
Complications of colonic surgery
Early: Ileus Anastomotic leak C Diff colitis Abscess
Late:
Adhesions!!!!!
Incisional hernia
Causes of ileus
Bowel handling
Opioid analgesia
Electrolyte imbalance
Complications of splenectomy
Infection from encapsulated organism
Thrombocytosis –> VTE
Ileus
Complications of aortic surgery
Major bleed AKI Gut ischemia Aorto-enteric fistula Trash foot
Breast surgery - complications
Seroma
Lymphoedema
Skin necrosis
4 complications of prostatectomy
Retrograde ejaculation
Erectile dysfunction
Urinary incontinence
Prostatitis
Complications of thyroidectomy
Wound haematoma –> tracheal obstruction
R laryngeal nerve injury -> hoarse voice
Hypoparathyroidism
Hypothyroidism
Complications of hip replacement
Deep infection VTE Blood loss!!! Nerve injury - superior gluteal nerve, sciatic nerve Leg length discrepancy
Causes of post-op pyrexia
Early (<5 days):
- Physiological response
- Atelectasis
- Blood transfusion
Delayed (>5 days):
- Pneumonia
- VTE
- Wound infection
- Anastomotic leak
- Collection/abscess
Presentation of post-op collection
> 5 days post-op
Swinging fevers
Rigors
Peritonitis +/-shoulder tip pain
Mx of collection
Abx
Drainage - percutaneous or surgical
Most common causative organism of cellulitis
beta-haemolytic strep (ie strep pyogenes)
Prevention of post-phlebitic syndrome
Graduated compression stockings
What is wells score
Assesses probability of DVT
Low risk –> do D-dimer
High risk –> do Compression USS
