Pre and Post op care

Question 1

Which 5 things need to be monitored on patients who are on TPN?

Answer 1

1. Blood Glucose (TPN has high sugar content and can develop blood sugar derrangement)
2. Daily Electrolytes
3. Fluid balance input and output
4. Daily inspection of line and dressing - for infection
5. 4 hourly temperature and observations - again looking for signs of infection

Question 2

Why are patients on TPN given IV Pabrinex before TPN is started?

Answer 2

Patients are at risk of Wernicke’s encephalopathy as they will have been in a state of starvation so thiamine levels are low and will be depleted even further as feeding recommences

Question 3

What is pseudomembranous colitis?

Answer 3

Acute diarrhoea after antbiotic therapy often due to Clostridium dificile organisms

Question 4

When does Warfarin need to be stopped pre-surgery?

Answer 4

5 days prior and bridged with LMWH

Question 5

What does a patients INR need to be before surgery?

Answer 5

<1.5

Question 6

How can warfarin be reveresed if still high before surgery?

Answer 6

PO vitamin K

Question 7

How long before surgery does Clopidogrel need to be stopped before surgery?

Answer 7

7 days

Question 8

In elective surgery, how long before should patints stop any OCP or HRT? Why?

Answer 8

4 weeks before

due to DVT risk

Question 9

How should subcutanous insulin be modified before surgery?

Answer 9

Night before: reduce subcutanous basal insulin dose by 1/3rd

Switch to IV variable rate insulin on day of surgery

Whilst patient is NBM prescribe infusion of 5% dextrose and check BM ever 2hrs

Question 10

How should patients on long term steroids be managed pre-op and why?

Answer 10

MUST CONTINUE due to the risk of Addisonian crisis

Question 11

What should patients undergoing major GI surgery or lower limb joint replacement be discharged home with? (VTE prophylaxis)

Answer 11

• TED stockings
• 28 days of prophylactic LMWH (unless contraindicated)

Question 12

Most patients recieved enoxaparin (LMWH) prophylactically to reduced risk of VTE. Which surgeries is this not indicated in?

Answer 12

• Neck
• Endocrine

Question 13

What are some contraindications to the use of TED stockings?

Answer 13

• Peripheral vascular disease
• Peripheral neuropathy
• Recent skin graft
• Severe eczema

Question 14

How should oral hypoglycaemics used in T2DM be altered before surgery?

Answer 14

• Metformin - stop the morning of surgery
• All others - stop 24hrs before

Question 15

Which factors increase risk of aspiration under anaesthesia?

Answer 15

• Diabetes
• Diagnosed hiatus hernia
• Symptoms of acid reflux
• High BMI
• Not starved before theatre

Question 16

How can the need for giving donated blood be decreased in surgical patients?

Answer 16

• Correct any preoperative anaemia before surgery
• Adhere to guidelines for postoperative blood transfusions
• Perform surgery under regional rather than general aneasthesia if possible
• Use intra-operative cell salvage techniques (transfusion of own blood back into patient)

Question 17

Which type of blood should be transfused in anaemic patients?

Answer 17

Packed red blood cells

Question 18

How do you manage pre-op aneamia?

Answer 18

• Correct any cause e.g. iron replacement, EPO injection, B12
• May not need correction if congenital
• Investigate any underlying cause
• May be a pre-op anaemia clinic at hospital to refer to

Question 19

Do all patients need pre-op clotting status testing?

Answer 19

No - as not predictive of bleeding risk

only needs doing in those with positive bleeding history or in patients where you think they will have a reduced ablity to clot (sepsis, trauma, on anticoagulants, metastatic cancer, liver cirrhosis)

Question 20

In which surgeries is bowel prep required pre-op?

Answer 20

Left hemicolectomy, sigmoid colectomy or abdoinal-perineal resetion - phosphate enema on day of surgery

Anterior resection - 2 sachet of picolax day before or phosophate enema morning of surgery

Question 21

Why are irradiated blood products used? Which patient groups are they used in?

Answer 21

To reduce the risk of graft vs host disease

Used in:

• Patient’s recieving blood from 1st/2nd degree relative
• Hodgkin’s Lymphoma patients
• Recent haematopoietic stem cell transplants
• After anti-thymocyte globulin or alemtuzumab therapy
• Recieving purine analgoues for chemo (e.g. fludarabine)
• Intra-uterine transfusions

Question 22

Which cannulas must blood products be given by and why?

Answer 22

Green (18G) or Grey (16G) cannulae only

Otherwise cells haemolyse due to sheering forces in the narrow tube

Question 23

In what situations are packed red blood cells used?

How much does 1 unit of blood increase a patient’s Hb by?

Answer 23

• Acute blood loss
• Chronic anaemia (Hb <70g/dl) or symptomatic anaemia
• 1 unit of blood increased Hb by 10g/L

Question 24

In what situations are platelet transfusions used?

What is the duration 1 unit should be delivered over?

Answer 24

• Haemorrhagic shock in a trauma patient
• Profound thrombocytopenia (<20 x10⁹/L)
• Bleeding with thrombocytopenia
• Pre-op platelet level is <50 x10⁹/L
• Administer over 30 minutes

Question 25

Over what period should packed red blood cells be administered over?

Answer 25

Between **2-4hrs** Must be completed within 4 hours of coming out of stores

Question 26

In what situations is fresh frozen plasma given for? (FFP) Over what duration should it be administered?

Answer 26

* DIC * Any haemorrhage secondary to liver disease * All massive haemorrhages - commonly given after 2nd unit of packed red blood cells * Administer over **30 minutes**

Question 27

What is cryoprecipitate? What situations is it given in?

Answer 27

Blood product containing **fibrinogen, Von Willebrands factor (vWF), Factor VIII & fibronectin** Given in: * DIC with fibrinogen \<1g/L * von Willebrands disease * Massive haemorrhage

Question 28

What are risk factors for developing atelectasis in a surgical patient?

Answer 28

* Age * Smoking * Use of general anaesthesia * Duration of surgery * Pre-existing lung or neuromuscular disease * Prolonged bed rest * Poor post op pain control

Question 29

What is the mainstay of treatment in post of atelectasis?

Answer 29

* Chest physiotherapy * Deep breathing exercises * Pain control to allow deep breathing * Bronchoscopy may be needed if conservative measures are unsuccessful (not routine)

Question 30

What is post op fever defined as?

Answer 30

A temperature of **\>38^oC** for 2 consecutive post op days Or **\>39^oC** for 1 day

Question 31

What are some of the differentials for post op fever?

Answer 31

**5 W's** * **Wind** - possible chest infection (roughly post op day 2), general anaesthetic and ventilator can cause air stasis, not breathing deep enough * **Water** - UTI (roughly post op days 3-5), consider especially if catheter in place * **Walking** - possible VTE (occurs day 5-7), stress response to surgery and immobilisation * **Wound** - surgical site infection (post op day 10), consider intra-abdominal / thoracic collection * **Wonder about drugs** - check all IV cannulae sites, tranfusion reaction to blood? *

Question 32

What factors indicate severe sepsis?

Answer 32

* SBP \<90mmHg or MAP \<65mmHg * Drop in BP \>40mmHg * Lactate \>2 (indicates poor tissue perfusion) * Urine output \<0.5/mls/kg/hr for 2 consecutive hours * Drop in GCS or AMTS

Question 33

What is septic shock?

Answer 33

Severe sepsis that is **hypotensive** despite fluid resucitation

Question 34

What bloods would you request in a patient with post op fever?

Answer 34

* **FBC** - for WCC and differential (look at the **trend**), Hb (may be anaemic 2ndry to blood loss), platelets can indicate stasis or DIC * **U&Es** - any element of AKI or pre-renal renal failure * **LFTs** - assess HPB system/ liver injury as source of sepsis * **Blood cultures** - preferably **pre-abx** * **Wound swab** * **Urine MC&S** * **Sputum culture** (if producing any) - may need to ask chest physio for assistance * If suspecting **line sepsis** take blood culture from that line and send tip of line to lab

Question 35

What imaging should be requested in post op patient with surgery?

Answer 35

* CXR * AXR if had abdominal surgery * Early CT to evaluate for any collections

Question 36

Give some patient risk factors for post op nausea and vomiting

Answer 36

* Female * Age (younger patients affected more) * Previous PONV * Suffers with motion sickness * Non-smokers

Question 37

Give some surgical risk factors for post op nausea and vomiting

Answer 37

* Intra-abdominal laparoscopic surgery * Intracranial or middle ear surgery * Squint surgery * Gynaecological surgery * Prolonged operative time * Poor pain control post op

Question 38

Give some anaesthetic risk factors for post op nausea and vomiting

Answer 38

* Opiate analgesia or spinal anaesthesia * Inhalation agents (nitrous oxide, isoflurane) * Prolonged anaesthetic time * Intraoperative dehydration or bleeding * Over use of bag and mask ventilation

Question 39

What pre-op measures can be taken to reduce the risk of post operativ nausea and vomiting?

Answer 39

* **Anaesthetic measures** - reduce opiates, reduce volatile gases, avoid spinal anaesthetic * Prophylactic antiemetics * Demamethasone at induction of anaesthesia (8mg)

Question 40

How can you manage post-op nausea and vomiting?

Answer 40

**Conservative measures:** * adequate fluid hydration * adequate analgesia * consider NG tube to aid gastric decompression **Pharmaceutical measures:** * Impaire gastric emptying/ stasis - try **prokinetic agent (metoclopramide D antagonist)** or **domperidone** (dopamine antagonist) * Hyoscine (anti-muscarinic) can help to reduce secretions * **Opiod induced** N+V responds well to **ondansetron** (5HT3 receptor antagonist) or **cyclizine** (H1 receptor antagonist)

Question 41

How do you distinguish between demetia and delerium?

Answer 41

**Dementia:** * insidious * constant * can have good attention span * delusions and hallucinations less common **Delerium:** * acute onset * fluctuating time course * poor attention span * delusions and hallucinations more common

Question 42

Give smome risk factors for developing delerium

Answer 42

* Male * Age \>65 yrs * Multiple co-morbidities * Underlying dementia * Renal impairment * Sensory impairment (hearing or visual)

Question 43

What are some of the common causes of delirium?

Answer 43

* Hypoxia * Infection (UTI/ LRTI post op) * Drug induced (benzodiaxepines, diuretics, opiods, steroids) or drug withdrawl * Dehydration * Pain * Constipation * Urinary retention * Electrolyte imbalance

Question 44

What investigations form part of the confusion screen in patients with post op delerium?

Answer 44

* **Bloods** - FBC, U&E, Ca²⁺, TFTs, glucose * B12, folate * Blood cultures * Wound swabs * Urinalysis * CXR * CT head (if relevant)