Peri-operative Care Flashcards
Why is the pre-operative assessment important
It is an opportunity to identify co-morbidities that may lead to patient complications during the anaesthetic, surgical, or post-operative period.
Patients scheduled for elective procedures will generally attend a pre-operative assessment how long before the date of their surgery.
2-4 weeks
How long before surgery should a patient ideally have a pre-operative assessment?
2-4 weeks
What is the most important additional test that should be performed for a woman of reproductive age prior to proceeding with surgery?
Pregnancy test
What classification is used to assess the potential difficulty of a patient’s airway for intubation?
Mallampati scoring - startifies the difficulty of endotracheal intubation based on anatomic features
Name the components of the pre-operative assessment
Pre-operative history
Pre-operative examination
Routine investigations
What two distinct examination are performed as part of the pre-operative examination
General examination (to identify any underlying undiagnosed pathology present) a
Airway examination (to predict the difficulty of airway management e.g. intubation).
What grading system is used to assess the risk of post-operative complications and absolute mortality?
American Society of Anaesthesiologists (ASA) grade
Name some of the blood tests done as part of the pre-operative investigations
FBC
U+E
LFT
Conditon specific eg. TFTs, Hb1Ac
Clotting
G+S +/- cross matching
FBC is a pre-operative blood investigation.
Why are we using FBC
predominantly used to assess for any anaemia or thrombocytopenia
U+Es is a pre-operative blood investigation.
Why are we using U+Es
Assess the baseline renal function, which help inform fluid management and drug decisions
LFTs is a pre-operative blood investigation.
Why are we using LFTs
assessing liver metabolism and synthesising function, useful for peri-operative management; if there is suspicion of liver impairment, LFTs may help direct medication choice and dosing
Group and Save v Cross-Match
G&S - determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies; the process takes around 40 minutes and no blood is issued
Cross match - involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places; if it does not, the donor blood is issued and can be transfused in to the patient i.e. blood is issued
When would we use Group and Save over Cross match in pre-operative assessmsnet
G&S is recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected
When would we use Cross match instead of Group and Save in pre-operative assessmsnet
When blood loss is anticipated
What cardiac investigations are completed as part of the pre-operative assessment
ECG
Echocardiogram (ECHO) - very useful information for the anaesthetist as it helps to risk stratify and tailor the intra-operative care of the patient
What respiratory investigations are completed as part of the pre-operative assessment
Spirometry - for patients with chronic lung conditions or those with symptoms and signs of undiagnosed pulmonary disease
What investigations checking for infection is completed as part of the pre-operative assessment
Urinalysis
MRSA swabs
What is deemed by “nil-by-mouth”
Nil-by-mouth is most operations is deemed no food for 6 hours pre-operatively and no clear fluids 2 hours pre-operatively
What are the different components of the pre-operative management plan
RAPRIOP
R - Reassurance
A - Advice
P - Prescription
R - Referral
I - Inevestigations
O - Observations
P - Patient understanding and follow up
Why is reassurance an important stage of the pre-operative management
It almost goes without saying that most patients are anxious about their upcoming surgery. Recognition of this fact and a kind word will make a big difference to a wary patient.
Why is fasting before surgery important
Fasting ensures that the stomach is empty of contents.
This reduces the risk of pulmonary aspiration, which can occur during the perioperative period, which can lead to both aspiration pneumonitis (inflammation caused by very acidic gastric contents, leading to desquamation) and aspiration pneumonia (due to secondary infection following pneumonitis or direct aspiration of infected material).
What two conditions can follow pulmonary aspiration, if people do not fast before surgery
Aspiration penumonititis
Aspiration pneumonia
All pre-operative patients should be given advice regarding fasting.
How long before surgery should a patient stop eating
6 hours before
All pre-operative patients should be given advice regarding fasting.
How long before surgery should a patient stop dairy products e.g. tea and coffee
6 hours before
All pre-operative patients should be given advice regarding fasting.
How long before surgery should a patient stop clear fluids
2 hours before
The management of the pre-operative drug regime falls into three categories; prescriptions to stop, prescriptions to alter, and prescriptions to start.
Name the 4 most common medications that need to be stopped
“CHOW”
C- Clopidogrel
H - Hypoglycaemic
O - Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT)
W- Warfarin
How long before surgery is clopidogrel stopped
Stopped 7 days prior to surgery due to bleeding risk
How long before surgery is Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) stopped
Stopped 4 weeks before surgery due to DVT risk
Advise the patient to use alternative means of contraception during this time period.
How long before surgery is Warfarin stopped
Usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular weight heparin
Surgery will often only go ahead if the INR is less than what value?
<1.5
Surgery will often only go ahead if the INR <1.5.
If the INR is > 1.5 how would you manage it
Reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before
Patients with long term steroids cannot stop these prior to surgery. If they cannot take these orally, they need to be switched to IV.
What is 5mg PO prednisolone switched to
5mg PO prednisolone = 20mg IV hydrocortisone
The management of the pre-operative drug regime falls into three categories; prescriptions to stop, prescriptions to alter, and prescriptions to start.
Name the 3 medications that need to be started prior to surgery
Low molecular weight heparin
TED stocking
Antibiotic prophylaxis - generally prescribed by anaesthetist or surgeon
Patients whos diabetes is managed by insulin.
What changes must you do to the insulin prior to surgery
On the night before surgery, reduce their subcutaneous basal insulin dose by 1/3rd.
Omit their morning insulin and commence an IV variable rate insulin infusion pump (commonly termed ‘sliding scale’)
Whilst the diabetic patient (who is managed with insulin) is nil by mouth, you will also need to prescribe what infusion
5% dextrose
Before a patient can go home. They must be stopped IV variable rate insulin insulin and started back on their normal insulin dose.
When does this
Continue until the patient is able to eat and drink
Once they are doing so, you must overlap their IV variable rate insulin infusion stopping and their normal SC insulin regimens starting.
To do this, give their SC rapid acting insulin ~20 minutes before a meal and stop their IV infusion ~30-60 minutes after they’ve eaten.
When should metformin be stopped before surgery
The morning of surgery
When should oral hypoglycaemic medication be stopped
Metformin - morning of surgery
Rest - 24 hours before
Bowel preparation may be required in some surgeries.
Is bowel preparation required for upper GI surgery
No
Bowel preparation may be required in some surgeries.
Is bowel preparation required for hepato-pancreato-biliary (HPB) surgery
No
Bowel preparation may be required in some surgeries.
In what surgeries is phosphate enaemia used on the morning of surgery
Left hemi-colectomy
sigmoid colectomy
abdominal-perineal resection
Bowel preparation may be required in some surgeries.
In what surgeries is 2 sachets of picolax the day before or phosphate enema on the morning of surgery
Anterior resection
Part of the pre-operative management is referral.
What does this mean?
Referral - as to whether they need a HDU or ITU bed
Where possible, in the pre-operative period, when should the oral contraceptive pill be stopped?
4 weeks before to reduce the risk of VTE post-operatively
In blood transfusions, there are two important blood groups.
Name these groups
ABO blood system
Group D of the rhesus system.
Define the term “Rhesus D group”
‘RhD+’ or ‘RhD-‘
refers the presence or absence of Rhesus D surface antigens on the red blood cells (RBC).
Which is most common in the poputation
a) Rhesus +ve
b) Rhesus -ve
a) Rhesus +ve
Approximately 85% of the population is RhD+ (they have RhD antigens present)
If we say a person is Rhesus +ve.
Is the Rhesus D surfaces antigens presence or absence on the RBC?
The Rhesus D surfaces antigens presence on the RBC
If we say a person is Rhesus -ve.
Is the Rhesus D surfaces antigens presence or absence on the RBC?
The Rhesus D surfaces antigens absent on the RBC
Which Rhesus group (+ve or -ve) will make Rhesus antibodies if they are given the wrong blood
A RhD- patient will make RhD antibody if they are given RhD+ blood
What happens if a RhD+ patient is given RhD- blood?
Nothing
What happens if a RhD- patient is given RhD+ blood?
They make anti-D antibodies
They do not attack their own RBCs as they do not have the Rhesus present
However, anti-D antivodies can cross the placenta and attack a RD+ve foetal blood
A woman is born with RhD- blood. Her partner is RhD+ and she becomes pregnant with a fetus that is also RhD+. During childbirth, she comes into contact with the foetal (Rh+ve) blood and develops antibodies to it.
She later becomes pregnant with a second child that is also Rh +ve.
The woman’s anti-D antibodies cross the placenta during this pregnancy and enter the foetal circulation, which contains RhD+ blood, and bind to the foetus’ RhD antigens on its RBC surface membranes.
What condition does this lead to in the foetal?
Haemolytic disease of the newborn
What ABO group is the universal donor
O -ve
No AB or Rhesus antigens on the donor RBC surface membrane
What ABO group is the universal acceptor
AB +ve
At every stage of requesting blood products, strict adherence to the procedures in place is required to prevent the patient being given incorrect blood.
How many points of identification is required to check that you are with the correct patient
3
Name
Date of Birth (DOB)
Patient number
Cytomegalovirus is a common congenital infection that may lead to sensorineural deafness and cerebral palsy.
CMV negative blood should be given to which patient groups
Women during pregnancy
Intra-uterine transfusions
Neonates (up to 28 days)
Whilst the patient is receiving the transfusion, there are specific observations timings that should be carried out.
When should observations be carried out
Before the transfusion starts.
15-20 minutes after it has started.
At 1 hour.
At completion.
Blood products should only be administered through a which type of cannulas and why?
green (18G) or grey (16G) cannula
Otherwise the cells haemolyse due to sheering forces in the narrow tube.
When blood is harvested from donors, it is separated into its constituent parts.
Name the 4 types of blood products
- Packed Red cells
- Plaetlets
- Fresh frozen plasma (FFP)
- Cryoprecipitate
Blood products are administered through what kind of giving set?
A blood giving set - it contains a filter in the chamber, whereas a normal fluid giving set does not.
What are the Major constituents of the packed red cells (blood product)
Red blood cells
What are the Major constituents of the plaetlets (blood product)
Platelets
What are the Major constituents of the Fresh frozen plasma (blood product)
Clotting factors
What are the Major constituents of the Cryoprecipitate (blood product)
Fibrinogen, von Willebrands Factor (vWF), Factor VIII and fibronectin
Is this true?
A woman is Rhesus -ve and her first child is Rhesus +ve. The child is at risk of foetal anaemia
False
The women can make Rhd antibodies during the 1st child however it is only subsequently children that are risk of foetal anaemia
Which ABO group is the universal donor?
O -ve
In blood transfusion, which ABO type is deemed the universal recipient?
AB positive
What is the name of the screening tool for malnutrition
Malnutrition Universal Screening Tool (MUST) score
What is the equation for Body Mass Index (BMI)
BMI = Weight(kg) / Height(m)2
As a general principle, it is always best to give enteral nutrition via the oral route wherever possible. However for many patients it may not be possible to administer sufficient calories via this route and alternative nutrition support strategies will need to be considered.
As determined by the hierachy of feeding methods, what is the most appropriate route of nutrition support for patients unable to eat sufficient calories
Oral nutritional Supplements (ONS)
As determined by the hierachy of feeding methods, what is the most appropriate route of nutrition support for patients unable to take sufficient calories orally or dysfunctional swallow
Nasogastric tube feeding (NGT)
As determined by the hierachy of feeding methods, what is the most appropriate route of nutrition support for patients with oesophagus blocked/dysfunctional
Gastrostomy feeding (PEG/RIG)
As determined by the hierachy of feeding methods, what is the most appropriate route of nutrition support for patients with stomach inaccessible or outflow obstruction
Jejunal feeding (jejunostomy)
As determined by the hierachy of feeding methods, what is the most appropriate route of nutrition support for patients with jejunum inaccessible or intestinal failure
Parenteral nutrition
Parenteral nutrition means feeding intravenously (through a vein)
Why is nutritional assessment important
Malnourished patients make poor surgical candidates
Where possible, which feeding routes should be used to optimise a patient’s nutritional status pre-operatively?
Oral feeding
Enhanced Recovery After Surgery (ERAS) is a modern approach to help people recover more quickly following surgery.
What are the components of the Enhanced Recovery After Surgery (ERAS)
Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
Pre-operative carbohydrate loading
Minimally invasive surgery
Minimising the use of drains and nasogastric tubes
Rapid reintroduction of feeding post-operatively
Early mobilisation
What requirements must be meet for a surgery to be classified as a “day case”
Minimal blood loss expected
Short operating time (<1 hour)
No expected intra-operative or post-operative complications
No requirement for specialist aftercare
What are the 5 W’s that can cause post-operative fever
Wind
Water
Walk
Wound
Wonder about drugs
What is the surgical pause/time out
Verbally confirm the identity of the patient, the operative site and the procedure to be performed
Just prior to surgery
What are M+M meeting
The Morbidity & Mortality (M&M) meeting is a forum where adverse outcomes can be discussed.
They have the potential to improve patient outcomes, quality of care, attitudes towards patient safety and they contribute to the education of clinical staff
The WHO Surgical Safety Checklist (2009) is carried out for each operation. The aim is to reduce the risk of human error.
Name the 3 stages the checklist is completed at
Before the induction of anaesthesia
Before the first skin incision
Before the patient leaves theatre
The WHO Surgical Safety Checklist (2009) is carried out for each operation. The aim is to reduce the risk of human error.It involves multiple members of the team (e.g., theatre nurse, anaesthetist and surgeon) checking essential factors.
Name some of the factors that it checks?
Patient identity
Allergies
Operation
Risk of bleeding
Introductions of all team members
Anticipated critical events
Counting the number of sponges and needles to ensure nothing is left inside the patient
