Perioperative / Pre op Flashcards
consent discussion 4 things
informed consent
explain risks vs benefits
optimise patient fitness and preparedness
check anaesthesia type and WHO doing
pre op checks to perform
Operative fitness (cardioresp comorbidities)
Pills taking
Consent
History (prev complications and surgery / significant PMH)
Ease of intubations (neck arthiritis, dentures)
Clexane (prophylaxis)
Site - marked + checked
OP CHECS
operation and anticoag
balance risk
avoid epidural, spinal and reigonal
antiepiletpics and operation
continue, ensure IV or NGT arranged if can’t do oral intake post op
OCP and HRT and operation
stop 4 weeks before major or leg surgery
restart 2 weeks after if mobile
beta blockers and surgery
give
typical pre op investigation bloods panel
routine = FBC, UE, G+S, clotting, glucose
do FTs if relevant
electrophoresis if at risk group
MRSA swabs
which ops need extra cross match
gastrectomy 4 units
AAA repair 6 units
special investigations pre op for certain conditions
any cardioresp comorbidities:
CXR, echo, ECG
any RA or anksond - lateral C spine
typical pre op prep
NBM 2 hours+ for clear fluids, 6 hours for solids
bowel prep for left sided bowel ops
macrogol or picolax
up to surgeon, follow advice
when is prophylactic antibiotic used?
GI surgery and joint replacement, give 15 mins pre op
biliary cef met
appendix cef met
vascular coamox
MRSA vanc
DVT prophylaxis by risk level
low early mobilise
medium TEDS + 20mg enoxaparin
high risk TEDS + 40mg enoxaparin with compression boots post op
ASA grade descriptors
- healthy
- mild systemic
- severe systemic
- severe systemic with constant threat to life
- <24 hours to live
diabetes op risk
more risk of infection and vascular disease
need change to insulin dose proabably due ot cortisol rise
do dipstick for proteinuria, venous glucose, check UEs and K+ pre op
insulin and operations type 1
stop long acting the night before
omit AM insulin if morning surgery
start sliding scale and check glucose hourly
post op diabetic type 1
continue sliding scale until tolerating food, switch to subcut around first meal
describe sliding scale insulin regime
actrapid infusion pump 50 units
check cap gluc hourly and adjust rate
5% dextrose + 20mmol KCl mixed in, rate of 125ml/hr
if in doubt, speak tot the diabetes specialist nurse!!!
type 2 diabetes and operation
manage as type 1 if fasting >10mM glucose
omit oral hypoglycaemics on AM of surgery
resume with first meal
if not eating after op do sliding scale and refer to specialists
on steroids and operation
poor healing, infection, risk of adrenal crisis
managing someone on steroids with op
up steroid
major surgery - hydrocortisone 50-100mg IV pre med then 8 hrly for 3 days
only for one day if minor surgery
jaundiced patient and op
avoid, only ERCP investigatio
increased op risk of obstructive jaundice
higher risk of post op renal failure and coagulopathy and infection
changes to pre op for jaundice and ERCP
avoid morphine, check clotting carefully and consider vit K
1 litre normal saline pre op unless heart failure
urinary catheter
abx prophylaxis
close urine moiniotirng in op and titrate fluids closely
furosemide, CVP if struggling with urine output after
anticoagulated patients and operations
balance risk
don’t need to stop warfarin if INR <3.5 and minor procedure
avoid epidural and blocks
continue aspirin, clopidrogrel unless high bleeding risk - then stop one week pre op
major op and warfarin
low clot risk
low clot risk
stop 5 days pre and get INR <1.5
restart warf next day
major op and warfarin
high clot risk
stop warfarin 5 days prior and replace with LMWH
stop LMWH 12 hours pre op
restart LMWH 6 hrs post op
then warfarin next day, continue enox until INR>2
emergency surgery and warfarin
stop taking
vit K 0.5mg slow IV
request FFP for surgery
COPD surgery risks
atelectasis
aspiration
chest infection
COPD pre op
CXR, pulmonary function tests, physio, stop smoking 4 weeks prior to op
anaestheisa start/maintenance/end
induction with propofol
muscle relaxation
depolarising: suxamethonium
non depol: atracurium
airway: endotracheal tube or laryngeal mask airway (iGel)
maintaining anaesthesia:
gas- halothane, enflurane
ending anaesthesia
switch gas to 100% oxygen
reversal:
neostigmine
+ atropine to prevent muscarinic side effects
typical pre-med for an operation
temazepam opioids, paracetamol, NSAIDs antiemetics lansoprazole glycopyrolate anti secretions Abx
complications of anaesthesia
cardioresp depression airway trauma retention palsies atelectasis/pneumonia risk malignant hyperpyrexia anaphylaxis
malignant hyperpyrexia
rare auto dominant reaction to halothane or suxamethonium
v high temp, masseter spasm
give danatrolene and cool
pain relief principles with surgery
oral is always best if poss
regular / PCA
follow stepwise approach to increasing
if difficult ask acute pain service for advice
should have local in wound and regional nerves at end of surgery too
stepwise pain relief
non opioids
paracetamol max 500mg every 6 hrs
ibuprofen max 400mg every 6 hrs
diclofenac max 50mg every 8 hours
weak opioids
codeine
dihydrocodeine
tramadol
opioids
morphine 10mg 4 hourly (max?)
oxycodone
fentanyl
risks x2 of spinal or epidural anaesthesia
resp depression
neurogenic shock, low BP
ERAS protocol
enhanced recovery after surgery
evidence based approach
used for colorectal/ortho surgery mainly
about optimising pt condition
pre op, peri op, post op means of promoting fast recovery
Pre-op: optimise BP, hydration, ensure not anaemic stop smoking 4 weeks prior admit on day if poss carb-loading pre op patient centred
peri-op: use shortest acting agents limit op time limit invasiveness minimise drains
Post-op: mobilise early!! good pain and nausea control physio off IV to oral ASAP urinary cath + drains for minimum time possible
immediate
early
late
surgical complications
Immediate (<24h)
- tubing trauma
- trauma to surrounding structures in surgery
- bleeding
Early (1-30 days)
- secondary bleed
- clots
- retention
- atelectasis and pneumonia
- wound infection / breakdown
- abx complications (colitis)
Late (>1month)
- scarring
- neuropathy
- op failure or recurrence of problem
classify operative bleeding
primary - in op
reactive - immediately post op
secondary - 1 day + post op, usually infection
urinary retention and surgery risk factors
various drugs BPH male hernial/anorectal op neuropathies
categorising risk factors for surgical complications
same approach for preventing complications categorising
split into pre op
operative
and post op
causes of early and late post op pyrexia
within 5 days atelectasis sepsis transfusion reaction drug reaction sepsis not resolved by op
later pneumonia VTE infection of wound leaking anastomosis collection formed
approach to post op patient with a fever
obs, notes, drug chart
examine
wound abdo DRE legs chest lines urine stool
urine dip and culture
FBC, CRP, cultures, LFTs
wound swabs / line swabs
CXR
presentation post op collections
swinging fevers
localised peritonitis
shoulder tip referred pain
DVT
peaks 5 days post op
warmth, erythema, swelling, pain in calf
post op SOB
atelectasis pain not controlled pneumothorax PE pneumonia
post op low UO
blocked or misplaced catheter
hypovolaemia
vomiting post op
emetic drugs
ileus
obstruction
consdier NGT antiemetiics
hypotensive post op
tilt head back
assess fluid status
hypovol bleeding sepsis overload neurogenic shock
hypertension post op
may be drug omission
or urinary retention
pain
acute confusion post op
sedating drugs sensory deficit low oxygen states infection retention of stool or urine hydration issues electrolytes glucose withdrawal
