Periop Flashcards
why is a pre operative assessment important
To highlight any potential problems that could be faced in surgery depending on co morbidities, allergies etc.
Identify high risk patients
Allows you to know which conditions need to be optimised before surgery and any additional precautions that need to be taken
Gives an opportunity for patient to express concerns/questions
Who conducts a pre op assessment and when?
anaesthetist:
elective surgery - 2 weeks before
urgent cases - day of surgery
emergency cases - simultaneously with resuscitation
Briefly what should you include in a pre op assessment?
full history including FHx
examination of CVS/resp and any relevant pathologies and mallampati score
ASA grade and identify high risk patients.
Investigations
review assessment with clinician
what should be covered in a history in a pre op assessment?
reason for surgery and site for op and type of procedure discussed with patient.
full history of presenting complaint i.e. reason for surgery
PMHx: comorbidities, previous surgeries and any problems (PONV, reactions). Specifically ask about:
- BP and exercise tolerance (judge risk of MI)
- COPD/asthma - ensure oxygenation will be good. triggers, control, hosp admissions, steroids?
- renal: blood loss and contrast can impair kidney function
- diabetes - what type? how is it managed? related problems?
- pregnant?
DHx: need to assess what needs to be stopped and inform patient.
allergies? medical and any at all because some food allergies are correlated to allergies to anaesthetic agents
FHx: any bad reactions to anaesthetics - often inherited e.g. malignant hyperpyrexia
SHx: drinking and alcohol - are they dependant i.e. withdrawal symptoms during surgery?
think about ethnicity - afrocaribean and undiagnosed sickle cell/keloid scars
what type of disease is malignant hyperpyrexia?
autosomal dominant
What is included in the examination of someone pre op?
A airways: check the mallampati score i.e. how well will they be intubated. Any loose teeth? Ask them to extend and laterally flex neck to assess range of movements.
B: breathing: resp rate, O2 sats, lungs clear?
C: circulation: BP, pulse, cap refil, heart sounds? warm/cold and clammy?
D: Glasgow coma scale/ ASA grade
what scoring system is used for predicting ease of intubation?
Mallampati score
grade 1: can see all of soft palate and uvula
grade 2: can see all of uvula
grade 3: can see base of uvula
grade 4: cant see any soft palate/uvula
what investigations would you want to do pre op?
depends on the type of operation (i.e. minor or major surgery) and the ASA grade of patient (i.e. how high risk they are. but some investigations include:
FBC : anaemic or thrombocytopenia U&Es: kidney function to assess how well they will tolerate fluid loss/ contrast LFTs Clotting MSRA swab urinalysis and preg test ECG CXR
when is a CXR or ECG indicated pre op ?
ECG: only if history of CVS disease or going for major surgery
CXR: lung disease, smoker, come back from country with high TB prevalence
what investigations are done in ASA 1 in a
a) minor
b) moderate
c) major surgery
minor - none
moderate - none
major: consider U and Es if at risk of AKI and consider ECG in those >65 if no ECG results in last 12 months
FBC in all major surgery ASA 1-3
what investigations are done in ASA 2 in a
a) minor
b) moderate
c) major surgery
minor = none moderate = consider ECG/ U and Es severe = FBC, ECG, U and Es
what investigations are done in ASA 3/4 in a
a) minor
b) moderate
c) major surgery
minor: consider ECG and U and Es
moderate: ECG and U and Es. Consider FBC, clotting, Lung function/ ABG
severe: FBC, U and Es, ECG. consider clotting , Lung function/ABG
what planning and preparation is done before surgery (after the pre op assessment)?
reassure patient - may be anxious
prepare - NBM for milk/foods 6hrs and water for 2 hours before
may need a bowel prep
Alter prescriptions
group and save/ Xmatch
referral after surgery - i.e. should they go to HDU, ITU or back to the ward
Discuss with patient the plan and let them ask questions.
pre medications
what is the difference between group and save and cross match? when is each required in regards to surgical patients?
group and save - patients blood is taken and tested for antigens and atypical Abs. Recommended when blood loss is not anticipated but as precaution.
cross match: patients blood is mixed with donors to check for any reaction. This is the second stage before blood transfusion can go ahead. this takes 45mins - 1 hour and is done prior to surgery if blood loss is anticipated.
Why is a patient made NBM before surgery?
there is risk of pulmonary aspiration which will lead to inflammation of the lungs (pneumonitis) and possibly infection (pneumonia)
some people have a slow absorption so a minimum of 6 hours NBM for food/milk is recommended.
in emergency surgery, patients will not have been NBM, how are the risks minimised by anaesthetist?
cricoid pressure applied during induction and intubation.
A cuffed endotracheal tube is then used. The cuff prevents aspirate into lungs.
what are the indications for ITU after surgery?
high ASA grade
long operating time
CVS, major vascular or intrathoracic surgery
emergency procedure
need for renal dialysis or intubation post op
list the drugs that should be stopped before surgery?
clopidogrel hypoglycaemics warfarin COCP and HRT ACEi and diuretics herbal medications
Why would you alter the following medications in surgery? How many days do they need to be stopped?
a) clopidogrel
b) aspirin and dipyramadole
c) hypoglycaemics
d) COCP/ HRT
clopidogrel is stopped 7 days before because of powerful antiplatelet affects and thus risk of bleeding
aspirin and dipyramidole do not need to be stopped because they have short half life so easily reversed and have a cerebrovascular benefit
hypoglycaemics (not insulin) stopped day before surgery - due to risk of hypoglycaemia during surgery. (long acting sulphonylureas stop 2-3 days before)
COCP/HRT - risk of DVT - stop 4 weeks before and commence 2 weeks later.
herbal medication can affect platelet function - stop 2 weeks before
why is metformin a problem during surgery? what precautions are taken?
firstly can lead to hypoglycaemia
secondly fluid loss/contrast can result in reduced kidney function which can result in poor clearance of metformin and the risk of lactic acidosis
therefore U and Es are checked 48-72 hours post op to see if it is safe to restart metformin
should warfarin be stopped during surgery?
yes - but further precautions may need to be taken depending on the reason the individual is on warfarin.
AF - stop warfarin 5 days pre op and check INR day before surgery
prosthetic heart valve: stop warfarin 5 days pre op and wait for INR to get to 2. Start IV unfractionated heparin and keep INR between 2-3. stop heparin 4 hours pre op and restart post op
previous DVT: stop warfarin 5 days pre op , high dose LMWH day before surgery
what INR is required for surgery?
<1.5
how can you adjust INR if it remains high the evening before surgery?
if there are 3 hours of more vitamin K can be given
either orally - a long time
or if shorter time IV infusion of 1-5mg vit K over 3 hours (cant go quicker due to risk of cardiac arrest)
if emergency and no time for Vit K infusion can instead give beriplex.
what is beriplex?
a solution of synthetic clotting factors:
factors 2,7,9, 10 and protein C
how are insulin and steroids altered for surgery?
subcutaneous insulin is switched to IV variable rate
corticosteroids should not be stopped (risk of adisonian crisis) but instead switch to IV hydrocortisone (5mg corticosteroids = 20mg IV hydrocortisone)
which drugs should be continued throughout surgery and why?
aspirin - cerebrovascular protection
statins - shown to reduce mortality
B blockers - suddenly stopping can result in rebound angina/MI
steroids - addisonian crisis
antihypertensives (except ACEi and diuretics)
transdermal GTN
thyroxine
why is it important that steroids are not stopped during surgery?
sudden ceasation can result in addisonian crisis (due to suppression of HPA axis) and the symptoms of this can often be mistaken for trauma in surgery
Antihypertensives are continued throughout surgery. if a patient becomes hypotensive, what can the anaesthetist do?
antihypertensives have a long half life so cant be reversed
however the anaesthetist can give nor-adrenaline to bring BP back up.
what drugs are usually started In surgery?
LMWH - except neck and endocrine surgery
Abx prophylaxis - esp orthopaedic, vascular or GI surgery
fluids
what DVT prophylactic measures are taken and how do they differ depending on surgery?
LMWH heparin (delteparin) given to all patients >20 yrs undergoing abdominal surgery - started
LMWH is given to all major GI, lower limb surgery for 28days pre-op plus TED stockings
high risk patients (OCP, previous DVT, obese, malignancy, amputes, pregnant) a larger dose of delteparin
laparoscopic procedures require delteparin
vascular other than nect require delteparin
do not give delteparin to neck or endocrine surgery
what Abx prophylaxis is given in colonic surgery?
gentamicin and metronidazole - due to gram negatives in bowel
Augmentin (penicillin) - for gram positives on skin and for laryngeal intubation
when are TED stocking (AES stockings) given?
all patients except vascular surgery or other contraindications e.g. Peripheral vascular disease, peripheral neuropathy, severe eczema, recent skin graft.
what is the difference between TED and intermittent pneumatic compression books?
TED are also known as anti-embolism stockings (AES) which are tight stocking to help flow of blood back up the legs.
intermittent pneumatic compression boots create a pressure wave to help move blood up. can be used in general surgery or vascular surgery depending on patient and anaesthetic preference.
which patients may need a bowel preparation? which preparations are used when?
patients undergoing colorectal surgery to reduce risk of infection.
upper abdo/small bowel and left hemicolectomy - no bowel prep required
right hemicolectomy/sigmoidocolectomy and abdoperineal resection - phosphate enema morning of surgery
anterior resection: 2 sachets of picolax day before surgery
what is the disadvantage of patients having bowel preparations?
fluid shift which can be harmful esp in those that are elderly or renal/cardiac problems and thus can increase post op recovery time.
list the 6 premedications used before anaesthesia
anxiolytics amnesia anti emetics antacids anti-autonomic analgesia
in premedication what anxiolytics can be given and why?
can give benzodiazepines (diazepam, lorazepam etc)
relax the patient
B blockers can also reduce anxiety
in premedication what drugs can allow amnesia?
lorazepam also allows a degree of anterograde amnesia
reduces post op distress
in premedication what anti-emetics can be given and why?
hycosine and anti-histamine can reduce anti-emetic effects of anaesthetics
metoclopramide increases gasrric emptying
reduce risk of N and V
in premedication what antiacids can be given and why?
ranitidine or omeprazole
Can help to reduce acidity in stomach which reduces N and V
esp if emergency situation and no time for NBM or opioids have delayed gastric emptying or hiatus hernia and at risk of regurgitation.
in premedication what anti autonomics can be given and why?
hycosine
anticholinergics can prevent the vasolytic effects on heart and reduce salivation
antiadrenergics - reduces tachycardia and hypertension
what is the problem with using hycosine as an anti-autonomic / anti emetic?
dry mouth and confusion post op
in premedication what analgesics can be given and why?
paracetamol, NSAIDS, opioids to reduce pain post op and reduce amount of anaesthetic agent required.
overall what is the use of pre-medications?
reduce risks e.g. aspiration
relax patient
reduce amount of anaesthetic needed
Define ASA
a) grade I
b) grade II
c) grade III
a) normal healthy patient
b) mild systemic disease
c) severe systemic disease
define ASA
a) grade IV
b) grade V
c) grade VI
d) grade E
a) severe systemic disease that is a constant threat to life
b) without surgery they will die
c) brain dead whose organs are being removed
E- emergency surgery
why are elderly patients considered as high risk? How can we minimise complications for these patients?
reduce immune and repair responses
more vulnerable to fluid losses and dehyrdration and malnutrition
usually comorbidities and polypharmacy
manage by involving different specialities
book high dependency unit bed
start feeding ASAP after surgery
why are pregnant patients considered as high risk? How can we minimise complications for these patients?
some of the anaesthetic agents could be teratogenic so need to find best drug regime
risk of preterm and induction of labour in 3rd trimester
increased risk of DVT - reduced by prophylaxis
reduced LOS tone and so more at risk of aspiration - reduced by less feeding
risk of supine hypotension (IVC compression by uterus)
list examples of high risk patients
Natural: elderly, pregnant
Disease: diabetes, CVS disease , COPD and asthma , renal/ hepatic impairment, obesity , recent stroke
Medications: , smoking, COCP emergency case, patients on steroids
associated with surgery: thyroid surgery, previous problems with anaesthetics
the COCP increases risk of VTE especially for what surgeries? in emergency cases how is this risk dealt with?
pelvis, lower limb and cancer
increased thromboprophylaxis period post op
why are patients on steroids considered as high risk? How can we minimise complications for these patients?
risk of addisonian crisis because of reduced stress response to surgery (because suppression of HPA) therefore may become hypoglycaemic, hypotensive and nausea and vomiting.
also steroids reduce immune responses so poor wound healing. also osteoporosis.
ensure you continue with IV hydrocortisone throughout surgery
give dextrose and fluids
how does a previous MI effect surgery? and what precautions are taken to reduce risks?
increases risk of another MI in surgery
put into HDU after surgery, antiplatelet medication is recommended
how can a murmur effect surgery and what precautions are taken to reduce this?
increases mortality rate in surgery
best to fix the murmur before surgery if possible
how can hypertension effect surgery and what precautions are taken to reduce this?
increases risk of IHD, MI, CVA, renal failure, LVF
so need to check all these - record BP, urine output (blood and protein), U and Es, glucose, ECG, ECHO, exercise stress test and angiography before and after
how does angina effect surgery and what precautions should be taken?
increases risk of MI, arrhythmias, valve disease, HTN, diabetes, PVD or CVD
do echo, stress test, ECG , angiography
how does smoking affect surgery? what precautions are taken to reduce these effects?
reduced immune responses, platelet aggregation, reduces oxygen carrying capacity (hypoxic risk to organs), reduced mucociliary escalator and reduced lung compliance
stop 6 weeks prior to surgery for best results but minimum of 7 days
post op - mobilise ASAP and thromboprophylaxis
how are asthmatic patients assessed and managed for surgery?
need to assess severity, exercise tolerance, triggers, medications, whether they smoke , medications and previous hospitalisation.
spirometry, ABG, chest xray
nebulisers and physio post op.
how are COPD patients assessed and managed for surgery?
get good history - severity, smoking history, frequent exacerbations? exercise tolerance? cor pulmonale? medication?
spiromentry, ABG, chest xrya
nebulisers and physio post op
how does the length of the procedure complicate surgery?
increases risk of PONV, local infection and paralytic ileus
how are people with hepatic and renal impairment managed for surgery?
more precaution to prevent hypovolaemia and hypotension
avoid nephrotoxin drugs
reduce drug dose due to reduced clearance
dialysis before surgery if needed.
how long should surgery be avoided for in those with recent stroke? what further precautions can be taken in patients with previous strokes?
6 weeks
control BP
thromboprophylaxis if ischaemic but not if haemorrhagic
what extra precautions should you take with obese patients before surgery?
detailed airway assessment - may require xray
detailed history of related problems and control
why is thyroid surgery high risk?
near the airways so risk of compression
risk of SVC obstruction
right largyngeal nerve risk of damage
what problems may someone have with anaesthesia?
anaphylaxis
suxamethonium apnoea
malignant hyperpyrexia
difficult intubation
what are the complications of anaemia during surgery?
anaemic patients bleed more - because blood is less viscous if less RBC
poor wound healing
therefore correct anaemia before surgery
why is a FBC important before surgery?
anaemia can complicate surgery
neutropenia can increase infection risk
also check if any bleeding disorders or FHx of bleeding disorders before surgery.
why is diabetes and surgery a problem?
problems associated with comorbidities:
- small vessels disease, renal impairment, peripheral neuropathy and increased risk of infection/ poor healing
- HTN and IHD
- obesity
medications can cause hypoglycaemia during surgery
ketoacidosis is associated with high morbidity and mortality so needs to be ruled out.
what investigations should be done in diabetics before surgery?
Check for co-morbidities FBC, U and Es, HbA1c and glucose urine - ketones and sugars ECG
need to know about normal management - insulin, diet and how well.
how are type 1 diabetics specially handled for surgery?
put down for first on list - i.e. morning surgery and omitted night before.
made NBM over night and insulin dose reduced by 1/3 night before
in the morning, normal SC insulin given and then IV variable insulin rate infusion pump is started.
need to give dextrose 5% whilst NBM also give pottasium
nurse checks BM every 2 hour and insulin adjusted accordingly
continued after surgery and then before first meal give SC insulin and stop infusion 30-60mins later (overlap)
how are type II diabetics handled for surgery?
depends on how they normally manage diabetes
diet controlled - no intervention required
stop hypoglycaemics
if BM is >12mM on 2 separate occasions then use IV variable rate insulin infusion pump and 5% dextrose
how does the time for stopping metformin differ from other hypoglycaemics?
metformin stopped morning of
other oral hypoglycaemics stopped 24 hours before surgery
how do we manage diabetic patients undergoing emergency surgery?
check for ketoacidosis and correct
check BMs and use algorithm to correct until BS <20mM (unless life threatening )
use IV insulin sliding scale for all patients to optimise BS control
briefly outline what care occurs immediately post operatively?
- assess patients progress - ABCD
- identify a pain management technique
- identify level of care and observation needed
- send to recovery before wards - until stable
what happens post op on wards?
Assess they are mobilising, passing urine, opening bowels, eating and drinking.
- check obs chart regularly
identify any problems and potential problems
plan discharge
advise patient about going back to work, driving, lifting heavy objects.
what do they monitor in recovery after op?
level of consciousness Oxygen sats blood pressure resp rate heart rate and rhythm pain
what investigations should be done post op and why?
FBC and U and Es on day 1, 2 and 5
- in case of anaemia, raised WCC, monitor INR
- check electrolytes and alter fluids accordingly
pulse oximetry
blood pressure
possible CXR if chest drains (after inserted and after removed) or pneumonia etc
what is the minimum criteria for discharging a patient from the recovery area?
fully conscious and able to maintain their own airway
adequate breathing and oxygenation
stable CVS with minimal bleeding
adequate pain relief and emesis controlled
warm - do not return if hypothermic
oxygen and IV therapy prescribed if needed.
list some common post operative problems
hypoxemia
hypotension hypertension MI haemorrhage VTE
PONV
ileus
confusion, delirium, agitation
hypothermia and shivering
surgical wound dehiscence
surgical wound infection
hypoxaemia is one complication of surgery. How can we monitor for this? and when does a surgical patient usually present with this?
pulse oximetry. if severely down can then do an ABG to get more accurate readings.
usually immediately after surgery (in recovery) and can last up to 3 days post op.
what are the causes of hypoxaemia after surgery?
alveolar hypoventilation - airway obstruction (tongue, swelling), resp depression (due to anaesthetics), pain or neuromuscular blocks.
V:Q mismatch
- anything that reduces ventilation.
- CO is reduced due to anaesthetic agents.
- pneumonia, P.E, heart failure.
diffusion hypoxia:
- N20 diffuses faster than O2 and reduces PaO2 in alveoli
increased demand: fever and shivering.
shock
severe anaemia
how can hypoxaemia in post op be managed?
high flow oxygen
correct any airway obstruction and aim to correct any other causes:
- chin lift/ jaw thrust
- vasopressors for shock
- blood transfusion if severely anaemic
CXR to check for pneumonia/ P.E/ pneumothorax
how is hypotension post op diagnosed?
compared to reading pre-op
what are the causes of post op hypotension?
commonest cause = hypovolaemia (due to blood loss or fluid loss - from tissue damage and oedema)
reduced myocardial contraction
vasodilation (e.g. after spinal or epidural anaesthetics)
cardiac arrhythmias
how do you manage post op hypotension?
depends on cause
mostly due to hypovolaemia in which case: oxygenation, IV fluids, consider X match blood. ABG to assess organ underperfusion. if internal haemorrhage need surgical assistance.
if due to reduced CO: give O2, ECG. may need ionotropes and ITU
vasodilation- give fluid, vasopressors and oxygen.
cardiac arrhythmia - treat cause. / anti arrhythmics
give examples of early surgical complications i.e. occur in recovery?
PONV hypoxaemia airway compromise confusion/ delirium pain hypothermia bleeding
give examples of surgical complications that present a few days later on the ward?
MI
P.E/ DVT
pneumonia
ileus
give examples of late surgical complications?
adhesions
obstruction
wound breakdown
for abdominal surgery when can a person drive post op?
minimum 14 days and then after they must be able to emergency stop
what type of surgery uses a kochers incision?
gall bladder / liver
what type of incision is used for caesarean section? what other ops use the same incision?
Pfannenstiel incision - along pubic hair line.
also for pelvic, bladder and prostate surgery.
what is a midline scar usually a sign of?
midline laparotomy - most abdominal operations.
what type of scar will a transplanted kidney leave? what other ops leave this scar?
Rutherford Morrison - low down in iliac fossa
also for caecostomy and sigmoid colostomy
whats a lanz incision usually for?
open appendectomy
what does a median sternotomy scar suggest?
open heart surgery
transplants , valve surgery, congenital defects , CABG (look for vein harvesting on leg too)
what scars are left after lung surgery?
axillary thoracotomy scar
posterolateral thoracotomy scar
anterolateral thoracotomy scar.
which anaesthetic agent is associated with hepatitis?
Halothane
can vary from mild derangement of LFTs to fulminant hepatitis
when should halothane be avoided?
previous reaction
family history of reaction
liver problems - because of risk of hepatitis with halothane
had halothane in the last 3 months
how would you treat mild and moderate hypokalaemia?
mild - oral potassium supplement or advise to eat banana
moderate: IV fluids with 20mM K+ or 40mM depending on how low
what are patient factors that increase the likelihood of PONV?
anxiety, female, non smoker, previous PONV, travel sickness sufferer
what are the surgical factors that increase the likelihood of PONV?
laparoscopic ENT - middle ear intracranial gynaecological prolonged procedure GI
what causes hypertension post op?
pain, hypoxia, confusion, hypercapnia
how do we manage post op hypertension?
compare BP to presurgical reading
may need to give antihypertensives or B blocker
reduce things that may be causing it e.g. pain
what are the anaesthetic factors that increase the risk of PONV?
N20, opiates, inhaled agents (isoflurane)
spinal anaesthesia
overuse of bag and mask ventilation - gastric dilation
intraop dehydration and bleeding
if a patient is identified at being at risk of PONV, what precautions are taken?
given anti-emetic before they emerge
how do we treat PONV?
NBM - to reduce aspiration
treat any pain, ensure good hydration etc
give anti-emetic
fluid to replace any losses
name 6 classes of antiemetics
5HT3 antagonist antihistamines anticholinergic dopamine antagonist steroid Butyrophenones
how long do different parts of the bowel take to recover after surgery?
small bowel - 0.24 hours
stomach - 24-48 hours
large bowel - 48 -72 hours
how can you assess post op ileus in a patient?
ask patient if they have passed wind
investigate: electrolute levels, abdo Xray
what factors worsen post op ileus?
abdominal surgery
opioids
how do we treat post op ileus?
reduce opioids
keep well hydrated
maintain electrolyte imbalances
encourage mobilisation
when do MI post op mainly occur?
3 days post op
How can we minimise chance of MI post op?
ECG before and risk assessment and aim to reduce any risk factors.
what can cause confusion post op?
drugs - benzodiazepines, opioids, steroids, anticholinergics , H2 blockers
infection - UTI, pneumonia, sepsis
metabolic disturbances - electrolytes, sugars, acid, hypoxia
organ failures - ammonia, urea and bilirubin can all cause confusion
age
cerebral problems - dementia, stroke
what is delirium?
an acute disturbed state of mind characterised by restlessness, confusion and delusions
how do you manage post op cognitive disorder(POCD)?
POCD is a term to describe post op confusion, delirium, anxiety.
risk assessment before hand to identify high risk optimise fluid status check metabolises and correct calm post op conditions IV haloperidol
what are the problems with giving haloperidol post op to treat delirium, agitation and confusion?
it can work as an antipsychotic (dopamine antagonist) however increases QT and thus can lead to arrhythmia
what are the indications for thromboprophylaxis
patient factors: >60 yrs, dehydration, personal history or 1st degree relative with history of VTE
other diseases: known thrombophilia, active cancer or cancer treatment, obese, significant co-morbidities (heart disease, resp, inflammatory disease), varicose veins with phlebitis
medications: HRT/ COCP
type of surgery: knee or hip replacement , mobility will be reduced , hip fracture , total surgery time > 90mins or lowerlimb/pelvis >60mins. requires critical care admission
what are the contraindications to thromboprophylaxis?
bleeding problems: thrombocytopenia , untreated haemophila/ von willebrands , DIC, acute liver failure
medications: use of anticoagulants
risk of bleeding: stroke , uncontrolled hypertension >230
, active bleeding
neurosurgery, spinal surgery, eye surgery, lumbar puncture/ epidural/ spinal expected in next 12 hours
name 2 LMWHs?
delteparin
enoxaparin
when should heparin not be given?
contraindications to thromboprophylaxis
previous allergy to heparin or heparin induced thrombocytopenia
how can the risk of VTE be minimised perioperatively?
LMWH, Ted stockings or intermittent pneumatic compression boots.
give those at high risk extended period of LMWH
after surgery keep checking for calf tenderness and swelling.
ensure early mobilisation (achieved by good post op pain and PONV control) and good hydration
how does VTE prophylaxis in general surgery compare to vascular and endocrine?
general surgery: delteparin at 6pm day before, AES, intermittent pneumatic compression boots in theatre. day case no prophylaxis but day laparoscopic receive half the dose of delteparin either pre or post op
vascular: delteparin 6pm day before unless thoracic outlet surgery, carotid. NO AES fitted. pneumatic compression boots sometimes
endocrine: no delteparin but do have AES
what factors in surgery can result in renal complications?
hypovolaemia
sepsis
drugs
contrast dye
how do we prevent renal failure post op?
identify high risk patients - i.e. underlying CKD
maximise hydration
eliminate nehrotoxin medication where possible
avoid intraop hypotension
treat electrolyte imbalances
surgical wound dehiscence is one complication post op. explain the different types of dehiscence.
simple: skin wound fails alone
burst abdomen: separation of abdominal wall closure with protrusion of abdominal contents
what are the risk factors that can lead to surgical wound dehiscence ?
patient factors: age, male, diabetes, steroids, smoking, obesity and malnutrion
intra op - emergency surgery, abdo surgery, poor surgical technique, wound infection, length of op
post op: extensive cough, poor tissue perfusion (hypotension), prolonged ventilation
what is the most common cause of surgical wound dehiscence ?
infection?
how do you manage a surgical wound dehiscence ?
Start with SNAP:
S - skin/ sepsis - needs to be prioritised
N: nutrition - if due to lack of nutrition - start
A: anatomy - how has it occurred
P: plan procedure
open wound, debridement (remove dead, pus)
give ABc
often put a saline soaked gauze and pack or negative pressure wound therapy - heal by secondary intention (cant suture because infection needs to come out)
why are surgical patients pre-disposed to pneumonia?
reduced chest ventilation due to anaesthetics e.g. opioids - accumulation of secretions eventually become infected. (opioids also inhibit cough reflex)
change in commensals from being in hospital
co-morbidities compromise immunity
intubation
immobilisation
wound pain makes coughing/ breathing more difficult - reduced clearance of secretions - another reason to control post op pain
may also be at risk of aspiration pneumonitis/pneumonia due to PONV , also reduced Glasgow coma scale due to anaesthesia.
why is metoclopramide sometimes used in pneumonia post op?
it is a prokinetic and can stimulate coughing to clear any chest infections.
what type of infections can occur post op?
pneumonia UTI bacteraemia and sepsis intra abdominal abscess surgical wound infection prosthetic implant infection cannula site infection
how are UTIs caused post op?
use of catheters
other risk factors include age, diabetes, female
how can UTIs post op be avoided?
don’t use catheter when not needed
good aseptic technique
remove as earliest possible opportunity
when should a UTI be considered?
any patient with sepsis, acute urinary retension and delirium
what causes bacteraemia post op?
surgical site infection
cannulas
Central venous lines
UTIs
for the different post op complications categorise them into when they are most likely to occur?
immediately post op: airway obstruction/ hypoxaemia, hypotension/hypertension, hypothermia haemorrhage, PONV, pain
few days later: stroke, MI, urinary retention. renal failure/impairment
week - 2weeks later: chest infection, UTI, DVT, secondary haemorrhage, wound dehiscence/infection
state 7 Cs of infection sources in surgical patients?
chest catheter cut cannula calf - DVT collection - abscess central line
what organism is mainly responsible for intraabdominal abscesses ?
how would you treat this?
mainly Ecoli from bowel spillage (or enterococci)
metronidazole and ciprofloxacin
how can surgical site infections be minimised?
shower before surgery
hair removal actually increases risk - if required do this immediately before procedure.
Abx prophylaxis
sterile procedure - sterile equiptment and clean skin with iodine before.
laminar airflow in the room
scrubbing technique good and 3 times.
what factors increase the risk of wound infection?
very similar to wound dehiscence
patient factors:
immunosuppressed - extremes of ages, steroids, diabetes, smoking, poor nutrition
surgical: poor closure of wound, inadequate sterilisation, preop shaving, length of op. insertion of surgical drain
what bacteria mainly cause surgical site infections?
coag neg staphylococcus - e.g. staphylococcus epidermis = most common S.aureus enterococcus E.coli - after bowel surgery pseudomonas aeruginosa
how do you classify a wound depending on cleanliness?
clean
clean -contaminated - clean but not 100% non contaminated in surgery e.g. emergency surgery
contaminated - non purulent inflammation
dirty - purulent inflammation
what are the clinical features of a surgical site infection?
usually appears 2-7 days post op
erythema, localised pain, pus/discharge, wound dehiscence, pyrexia
how are surgical site infections classified by depth of infection?
superficial - skin and subcutaneous tissue
deep - deep soft tissues e.g. muscle
organ space - most serious
how do you manage a surgical site infection?
investigations: swabs, imaging, FBC/CRP, blood cultures
remove sutures to allow pus to drain
drain pus
depending on bacteria they are treated differently
mostly use penicillins because due to Staphylococcus. unless GI then metronidazole
closely monitor for signs of sepsis
what Abx prophylaxis is required for bowel surgery and vascular surgery? and orthropaedic
bowel: gentamicin and metronidazole both IV and IV amoxicillin
vascular: flucoxacillin IV, gentamicin IV ad amoxicillin IV
orthopaedic: IV flucoxacillin
note: in varicose vein surgery - no Abx needed.
what organisms are mainly involved in cannula site infections?
Coag neg staphyl - epidermis
S. aureus
how do you treat staphylococci infections?
penicillins and cephalosporins however often MRSA
MRSA treated with vancomycin
if VRSA (vancomycin resistant) then need telcoplanin
what are the causes of post op breathlessness?
acelectasis P.E pneumonia anaphylaxis pulmonary oedema - renal failure/ fluid overload
what are the causes of post op pyrexia?
atelectasis pneumonia UTI P.E surgical site infection prosthetic infection - loose joint, swelling
what are specific complications of appendectomy?
surgical wound infection
abscess and sepsis
bleeding
fistula
what are the specific complications of bowel resection?
bleeding
infection
anastomotic leak
adhesions
what are specific complications to a laparoscopic cholecystectomy?
bleeding
infection
leakage of bile into abdomen
pneumonia
what are the specific complications of inguinal hernia repair?
cutting vas deferens
ischaemic orchitis - swelling and necrosis of testis
what are specific complications of carotid endartectomy?
stroke, MI, wound haematoma
damage to hypoglossal or glossopharyngeal nerve
what are the complications of limb vascular bypass surgery?
blood clots, haematoma, false aneurysms
repurfusion syndrome and compartment syndrome.
what are the indications to a central line?
allows accurate measure of central venous pressure - good for haemodynamiccal unstable patients who need close monitoring
delivery of drugs that are not good for peripheral delivery (noradrenaline - highly vasocontrictive so would cause gangrene of arm)
long operation
take blood samples for blood gases
delivery of parenteral nutrition
what are the contraindications to central lines?
coagulopathy - risk of excessive bleeding from insertion
patients who have had recent internal vein cannulation or a pacing wiring inserted
avoided if thyromegaly or previous head and neck
what veins can be used for a central line?
internal/external jugular vein
femoral
subclavian
what are the complications of central lines?
infection
pneumothorax
thrombosis
misplacement into carotid artery
what are arterial lines for?
ABGs can be taken and arterial BP can be recorded with greater accuracy.
(venous lines usually for giving, arterial for measuring)
what are the complications of arterial lines?
infection
inflammation
bleeding
painful to insert
what could cause low pulse oximetry?
lung pathology
P.E
congenital heart defect in child
how long should delteparin be prescribed post op in hip vs knee surgery?
hip 28-35 days post op
knee - 10-14 days post op
for all surgery start delteparin 6-12 hours post op and usually continue until mobile.
why may a post surgical patient present with lymphedema?
removal of lymph nodes
e.g. after massectomy and upper limb lymphoedema due to removal of axillary nodes
what should a patient be made aware of before consenting to surgery?
- Details of diagnosis, prognosis and likely prognosis if left untreated
- the different options of treatment/management including the option not to treat.
- the purpose of the investigation/treatment, details of procedure and details of any side effects
what can sudden diuresis on day 2-3 post op suggest?
recovery from post op ileus (absorption of water from bowel )
when is unfractionated heparin used?
renal failure patients
how long is heparin given post op for those with:
a) elective hip replacement
b) knee replacement
c) hip fracture?
a) 28-35 days
b) 10-14 days
c) 28-35 days
what checks are made just before induction of anaesthetic and surgery?
Patient has confirmed: Site, identity, procedure, consent
Site is marked
Anaesthesia safety check completed
Pulse oximeter is on patient and functioning
Does the patient have a known allergy?
Is there a difficult airway/aspiration risk?
Is there a risk of > 500ml blood loss
what other conditions can lead to paralytic ileus?
stroke MI chest infections AKI (surgery)
what are the guidelines to when LMWH is given and stopped ?
in general:
2 hours pre op
everyday until they leave
(some also take it home with them)
