Peri-Operative and Post-Operative Care Flashcards
>25% of hospital inpatients may be malnourished
What ways may this have happened?
- Increased nutritional requirements
- (eg sepsis, burns, surgery)
- Increased nutritional losses
- (eg malabsorption, output from stoma)
- Decreased intake
- (eg dysphagia, nausea, sedation, coma)
- Effect of treatment
- (eg nausea, diarrhoea)
- Enforced starvation
- (eg prolonged periods nil by mouth)
- Missing meals through being whisked off, eg for investigations
- Difficulty with feeding
- (eg lost dentures; no one available to assist)
- Unappetizing food
>25% of hospital inpatients maybe malnourished
What should be asked in a Hx to establish this?
- recent weight loss,
- reduced intake,
- diet change,
- N&V,
- pain,
- diarrhoea
>25% of hospital inpatients maybe malnourished.
What maybe seen O/E of a patient who is malnouished/to check if they are?
- hydration,
- malnutrition
- skin hanging off muscles,
- not fat between fold of skin,
- hair rough & wiry,
- pressure sores,
- sores at corner of mouth,
- BMI <20,
- anthropomorphic indices (measurements to infer body composition, growth and development)
Although investigations into malnutrition are generally unhelpful what blood test maybe suggestive of malnutrition?
low albumin is suggestive
How can you prevent malnutrition in hospital?
assess nutrition & weight on admission & regularly after
- ensure meals are uninterrupted when possible
- provide appetizing food
- seek help from dietician
What is the name given to when nutrition is given into the GI tract and what methods of doing this are there?
enteral nutrition
- Nutrition PO where possible (all fluid diet can meet requirements),
- –> early post-op enteral nutrition has been shown to benefit patients & reduce complications
- Naso-enteric feeding:
- Nasogastric (NG - use when possible), naso-duodenal, naso-jejunal (NJ)
- Enterostomy feeding:
- Percutaneous endoscopic gastrostomy (PEG) - surgical opening through abdomen into stomach
- Percutaneous endoscopic jejunostomy (PEJ)
What type of feed is this?
undigested proteins, starched and long chain fatty acids
polymeric feed
What type of feed is this?
individual amino acids, oligo0 & monosaccharides needing minimal digestion
elemental feed
What are the benefits of enteral nutriton over parenteral?
Even if there is GI disease, studies show that enteral nutrition is
- safer,
- cheaper,
- and at least as efficacious
–>as parenteral nutrition in the perioperative period
What is the name given to (nutrition given IV via central venous line (or PICC line - peripherally inserted central catheter)?
When is this used?
parenteral nutrition
NOTE–> paraenteral nutrition has risks…
specialist advice vital; only considered if:
- Pt likely to become malnourished without it
- (i.e. GI tract not functioning e.g. bowel obstruction)
- & is unlikely to function for at least 7d
-
Supplementing other forms of nutrition
- (e.g. short gut syndrome, active Crohn’s)
- or used alone (TNP - total parenteral nutrition)
- Most regimens provide 2000kCal and 10-14g nitrogen in 2–3L
What complications of parenteral nutrition are there?
- Sepsis
- (staph epidermis/aureus, candida, pseudomonas, IE)
- Thrombosis
- (central vein thrombosis can result in PE or SVC obstruction)
- Metabolic imbalance:
- electrolyte abnormalities,
- deranged plasma glucose,
- hyperlipidaemia,
- deficiency syndromes,
- acid-base disturbance
- Mechanical:
- pneumothorax,
- embolism of IV line tip
What is the name of the syndrome that is basically a hypo-phosphataemic state?
& how does it occur
refeeding syndrome!
a life threatening metabolic complication of re-reeding (via ANY route) after a long period of starvation
Pathophysiology:
in starved state = catabolic and so body turns to fat and protein metabolism which means there is decreased circulating insulin and stores of phosphate (serum levels normal)
then when there is refeeding –> increased carbohydrate load so there is increased insulin and cellular intake of phosphate –> <0.5mmol/L within 4d
Refeeding = at risk of, rhabdomyolysis, red & white cell dysfunciton, resp insufficiency, arrhythmias, cardiogenic shock, seizures, sudden death…
who is at risk of hypo-phosphataemic state/refeeding syndrome?
how can you prevent this?
- cancer pts
- anorexia
- alcoholics
- GI surgery
- starvation
To prevent re-feeding syndrome: ID at-risk patients, monitor during re-feeding - check their glucose (as will drop with increased insulin), lipids, na, k phos, ca, mg, zn. Involve a nutritionist
What is the rx of re-feeding syndrome?
parenteral phosphate administration
e. g. 18mmol/d + oral supplementation
* [as pathophysiology of refeeding = STARVED STATE: i.e. catabolic state, body turns to fat & protein metabolism → ↓circulating insulin & ↓stores of phosphate (serum levels normal) –> REFEEDING: ↑carbohydrate load → ↑insulin & ↑cellular uptake of phosphate, hypo-physophataemic state (<0.5mmol/L) (within 4d)]*
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much na/k/cl do you need per day?
1 mmol each
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much energy do you need per day?
2000-2500kCal/d
or 20-40kCal/kg/d
(if over 4000 then => fatty liver)
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much nitrogen do you need per day?
0.2-0.4g
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much protein do you need per day?
0.5g
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much fat do you need per day?
3g
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much carb do you need per day?
2g
You need energy, nitrogen, protein, fat, carbohydrate, water & Na/K/Cl daily.
How much water do you need per day?
30-35mL (/kg/d)
What post operative complications can you get?
- pyrexia
- confusion (40%)
- SOB or hypoxia
- low / high BP
- oligouria
- N&V
- low Na
Why is pyrexia a post-operative complication?
What should you look for?
- often from atelectasis,
- tissue damage/necrosis
- or blood transfusions
Symptoms-wise look for causes of pyrexia:
- wind: chest infection
- water: UTI
- wound: infection
- walking: DVT in leg
- or other infections including peritonism, cannula site, menigism, endocarditis
What post op complications are these Ix for?
- FBC, U&E, CRP, cultures +- LFT
- Urine dip
- Consider:
- MSU,
- CXR,
- Abdo US/CT,
- echo if new onset murmur (endocarditis/valces)
For pyrexia as a post op complication
(often from atelectasis, tissue damage/necrosis or blood transfusions)
[Look for:
- Wind: Chest infection
- Water: UTI
- Wound: infection
- Walking: DVT in leg
- Other infections: peritonism, cannula site, meningism, endocarditis]
How many days after surgery is atelectasis likely to happen (& cause pyrexia as a post op complication)?
What is the Rx?
- Day 1-2 post op –> atelectasis
- give salbutamol/saline nebs & chest physio
How many days after surgery is pneumonia likely to happen (& cause pyrexia as a post op complication)?
What is the Rx?
Day 3-4: pneumonia –> abx, chest physio
How many days after surgery is anastomotic leak likely to happen (& cause pyrexia as a post op complication)?
What is the Rx?
Day 5-6: anastomotic leak –> return to theatre
How many days after surgery is wound infection likely to present (& cause pyrexia as a post op complication)?
What is the Rx?
Day 7-8: wound infection
- –> open up wound,
- abx,
- may need to return
How many days after surgery is DVT/PE likely to present (& cause pyrexia as a post op complication)?
What is the Rx?
Day 9-10:
DVT/PE –> LMWH then warfarin
40% pts get confusion post-operatively, what are the causes of this?
How would it present?
- hypoxia,
- drugs,
- urinary retention,
- MI/stroke,
- infection,
- alcohol withdrawal,
- liver/renal failure
(basically lots of things)
SSx: agitation, disorientation & attempts to leave hospital
How do you rx patients with post-op confusion?
- Gently reassure patient in well-lit surroundings
- Sedation (rarely)
(i guess also try to manage their underlying conditon if they have hypoxia, drugs, urinary retention, MI/stroke, infection, alcohol withdrawal, liver/renal failure causing their confusion)
a postop patient has SOB / hypoxia what underlying conditions should you check for?
E.g. hypoxia (w/o co2 retention = t1 resp failure, so inldues the lung P’s)
- Pneumonia including aspiration
- pulmonary collapse (atelectasis)
- PE
- Pneumothroax
- (asthma and pulm oedema)
& LVF (post surgery)
What post operative condition/symptom is this the Ix for?
FBC, ABG, CXR, ECG
what is the rx?
SOB/hypoxia as need to look for evidence of:
Look for evidence of:
- Pneumonia, pulmonary collapse or apsiration
- LVF
- PE
- Pneumothroax
Rx ==> O2 & monitor sats
Why may a post-op patient get low BP?
What should you look out for?
often from hypovolaemia, but beware cardiogenic & neurogenic causes (MI, PE),
consider sepsis & anaphylaxis
So look for signs of:
- shock,
- wounds, drains, (sepsis)
- signs of active bleeding (hypovolaemia)
Whick post-op complication is this the rx for?
Tilt head-down,
O2
Fluid replacement
Low BP
Which post-op complication is this the Rx for?
Continue Oral cardiac meds throughout peri-operative period (e.g. bblockers, digoxin)
why may this post-op complication happen?
high BP
Causes:
- pain,
- urinary retention,
- idiopathic HTN,
- inotropic drugs
Why may a post-op patient get low Na?
What is importnant in the rx of Na?
- over administration of fluids
- SIADH (dilute hyponatraemia) can be precipitated by
- peri-operative pain,
- nausea,
- opioids &
- chest infection
Rx: CORRECT SLOWLY - or risk of osmotic demyelination syndrome
Why may a post-op patient have oligouria?
or anuria?
oligouria in post op patient => lost fluid or AKI
anuria –> often blocked/malsited catheter
What post operative complication is this the Ix for?
- fluid challenge
for post op oligo/anuria
what symptoms of post op oligo/anuria should bne checked and what is the rx?
if a pt is experiencing oligo/anuria should look for signs of volume depletion
check if bladder is palpable e.g. retention
Rx:
- Fluids
- Catheterize & monitor fluid balance
- Stop nephrotoxic drugs if intrinsic renal failure suspected
What is the cause of post op N&V?
how do you investigate these?
mechanical obstruction – AXR, NGT
ileus
or emetic drugs – give anti-emetic (not metoclopramide as pro kinetic)
What is the purpose of surgical drains post-op?
- protect area of surgery against collection, haematoma & seroma formation (in breast surgery this can cause overlying skin necrosis)
- often put under suction or negative pressure
- removed when they stop draining
- protect sites where leakage may occur in the post-op period e.g. bowel anastomoses
- form a tract
- removed after ~1 week
- collect RBC from the site of operation which can then be auto-transfused within 6 hours (commonly in ortho)
What post op complications are the following risk factors for?
age, pregnancy, oestrogen (HRT, COCP), trauma, surgery, past DVT, cancer, obesity, immobility, thrombophilia
What signs would you expect and what Ix shoudl be done?
they are DVT risk factors
- Ix:
- Well’s score,
- d-dimer,
- US,
- underlying malignancy screen
- (urine dip, FBC, LFT, Ca2+, CXR +/- CT abdomen/pelvis, mammography if >40yrs)
- Rx:
- LMWH,
- warfarin,
- IVC filters,
- TED stockings
What post op complications are these RF for?
surgery, thrombophilia, leg fracture, reduced mobility, malignancy, oestrogen, previous PE
what Ix and Rx should be done?
Ix: Well’s score, d-dimer, CTPA (or VQ scan)
Rx: oxygen, morphine, anticoagulation, thrombolysis (massive PE), 2o prevention
a patient presents with mild fever, pitting oedema, calf warmth/tenderness/swelling/erythema
what Ix and rx should be done?
Ix: Well’s score, d-dimer, US, underlying malignancy screen (urine dip, FBC, LFT, Ca2+, CXR +/- CT abdomen/pelvis, mammography if >40yrs)
Rx: LMWH, warfarin, IVC filters, TED stockings
A patient presents with:
SoB, chest pain, haemoptysis, pyrexia, cyanosis, tachypnoea/cardia, RV heave, hypotension
what Rx and Ix should be done?
Ix: Well’s score, d-dimer, CTPA (or VQ scan)
Rx: oxygen, morphine, anticoagulation, thrombolysis (massive PE), 2o prevention
Post operatively a patient may get swollen legs - it is useful to see if the oedema is bilateral or unilateral… what would bilateral oedema imply? & what causes are there?
- Implies systemic disease with ↑venous pressure or ↓intravascular oncotic pressure (as fluid is moving into the cells/tissue)
- Distributed by gravity - sacral in sitting, legs in standing
- Causes:
- RHF,
- ↓albumin (renal or liver failure),
- venous insufficinecy
- (chronic has haemosiderin-pigmenting, itchy, eczematous skin +- ulcers),
- vasodilators,
- pelvic mass,
- pregnancy
Post operatively a patient may get swollen legs - it is useful to see if the oedema is bilateral or unilateral… what would UNILATERAL oedema imply? & what causes are there?
- VASCULAR:
- pain +- redness implies DVT or inflammation
- BONE/MUSCLE:
- tumours,
- necrotizing fasciitis,
- trauma (check sensation, pulses, pain),
- compartment syndrome
