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): 1. Physiological response 2. Atelectasis 3. 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
Outline general Pre-op care?
Past medical history
-MI? Asthma? Diabetes? HTN? Rheumatic fever? Epilepsy? Jaundice?
Assess cardiorespiratory system
WHO surgical checklist
Neck stability
Thrombosis prophylaxis
Mark correct side for surgery
Investigations
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“PAWN TMI”
For past medical history bit
“MAD Hypertense REJ”
