Pre/Intra/Post Op Management Flashcards
Anaesthetic airway examination (LEMON)
Look - obesity, open mouth Evaluate - 3-3-1 rule, mouth opening, anterior jaw subluxation, thyromental distance Mallampati score (view of uvula) Obstruction - FB, stridor Neck mobility
ASA Grading
1 - normal and healthy
2 - mild systemic disease
3 - moderate to severe systemic disease causing some functional limitation
4 - severe systemic disease, constant threat to life, functionally incapacitating
5 - moribund patient, not expected to survive 24hrs
6 - brain dead
Pre op Ix
bHCG ECG BGL FBC UEC CMP LFT group and hold + cross match coagulation screen CXR & spirometry if resp disease present
Drugs to stop before operations
CHOW
clopidogrel and other antiplatelets - 7 days prior
hypoglycemics (oral) - insulin sliding scale instead
OCP - 4 weeks before
warfarin - stop 5 days before
NOACs - stop 24-48hrs before
Drugs to start before/just after surgery
TED stockings
LMWH or UFH
Antibiotics - usually cefazolin and metronidazole
CI for mechanical VTE prophylaxis
severe PVD or ulcers
peripheral arterial bypass graft
severe leg oedema or pulmonary oedema
severe local disease ie infection
CI for pharmacological VTE prophylaxis
active major bleeding or recent bleed (<48hrs)
already anticoagulated
low platelets
bleeding disorder
recent stroke/TBI/tumour/bleed
conditions with bleeding risk eg peptic ulcer
VTE prophylaxis post op
non pharm - TEDs, intermittent pneumatic compression, early mobilisation, hydration
pharm - enoxaparin 40mg subcut OR NOAC eg rivaroxiban OR heparin 5000 units BD
Anaesthetic types for surgery
General Regional block Local block Topical Sedation
Insertion of ETT
- location, confirming placement, complications
Location - 2cm above carina
Placement - visualise it passing through cords, CO2 exhaled gas, auscultate chest, bilateral chest wall expansion, no abdominal distension
Complications - dental damage, laceration, laryngeal trauma, oesophageal intubation, aspiration, bronchospasm
Anaesthetic induction agents
propofol
ketamine
benzodiazepine
sodium thiopental
General post operative care (acute and long term)
Analgesia
Chest physio
VTE prophylaxis
Encourage moving and feeds
long term: 4-6 weeks to recover avoid heavy lifting keep site clean and covered F/U about 6 weeks
Consequences of poorly controlled pain
slower recovery - less likely to mobilise
increased complications - cannot breathe deeply –> atelectasis –> HAP
WHO analgesic ladder
- paracetamol +/- NSAIDs
- oral opioid - paracetamol and codeine
- opioids IV or subcut (add motility agent) - morphine or fentanyl
- contact anaesthetist
Positives and negatives of patient controlled analgesia (PCA)
Positive - tailored to individual requirement, controlled release (safe), accurate recording of how much is being administered
Negatives - prevents patient mobilising, can’t be used in those with poor manual dexterity or learning difficulties
Septic sources on surgical wards (5Cs)
chest infection cut - wound infection catheter collections - abscess cannula and central line
Types of post op bleeding in regards to time periods
primary - intra operative
reactive - within 24 hours of op
secondary - erosion of vessel due to spreading infection
Mx of tension haematoma post neck surgery
DRS - call surgeon, MET call
A - decompress by removing sutures and suction haematoma
B - 15L non rebreather O2
C - theatre for haemostats, IVF, IV blood products
Complications of post operative nausea and vomiting (PONV)
aspiration pneumonia low K and Na metabolic alkalosis suture dehiscence bleeding incisional hernia
Causes of PONV
pain infection metabolic - uremia, electrolyte disturbance, DKA post op ileum or bowel obstruction increased ICP medications
Causes of post op fever (5Ws)
<1 day - usually physiological and benign
post op day 1-2 (wind) - lung source, atelectasis, aspiration, pneumonia
POD 3-5 (water) - UTI
POD 5-7 (wound) - surgical site infection, IV line, superficial and deep abscess
POD 8+ (walk) - DVT and PE
Anytime (what did we do) - anastomotic leak, antibiotics, prosthesis, CNS infection, drug and transfusion reaction
Risk factors for anastomotic leak
surgical - emergency, long intra op time, oesophageal gastric and rectal anastomosis, ischaemia at suture line
patient - DM, immunosuppression, obesity, smoking, alcohol
Risk factors for paralytic ileus
patient - elderly, electrolyte derangement, opioids, anticholinergics, fluid overload
surgical - pelvic and abdo surgery, intestinal resection, handling bowel in operation, peritonitis
Causes of post operative oliguria
pre renal - hypovolemia (haemorrhage, dehydration)
renal - pre existing renal disease, ATN
post renal - blocked catheter, damage to ureters
What is gastric dumping syndrome
complication of gastric bypass surgery
early - excessive amount of hypertonic food in SI –> fluid shift into lumen –> distention, osmotic diarrhoea
late - excess sugar in SI –> excessive insulin spike –> low BGL
Components of crystalloid fluids - Hartmann’s, NSaline, dextrose
Hartmann’s - Na, K, Ca, Cl, lactate, doesn’t cause metabolic acidosis, used in maintenance
NSaline - NaCl, causes NAGMA, used in resuscitations
Dextrose (D5W) - glucose rapidly taken up by cells, causes dilutional hyponatremia
Crystalloids vs colloids
crystalloids:
- electrolytes with no macromolecules
- IV and ISF
- NS, Hartmann’s, D5W
Colloids:
- protein and non protein colloids
- IV only
- used in TBI
Calculating daily fluid requirement
replace fluid deficit (250-500ml fluid challenge then reassess) + maintenance rate (weight + 40ml/hr) x 24hrs + replace losses
Calculating maintenance fluid rates
4:2:1 rule for crystalloids:
4ml/kg/hr for 1st 10kg
2ml/kg/hr for 2nd 10kg
1ml/kg/hr for every extra kg
OR
weight + 40ml/hr (ideal weight if obese)
eg 70kg + 40ml = 110ml/hr = 2.6L/day
Amount of K and Na required / day in mmol/kg
K = 1mmol/kg/day
Na = 2mmol/kg/day
how to remember: Na has 2 letters, therefore 2 mmol
Indications for blood transfusion
Hb <70
Hb <80 and symptomatic
acute blood loss of >1,500 mL or 30% of blood volume
Causes of post operative delirium
Infection - sepsis, chest, cut (surgical site), cannula, collection, catheter, central line
Withdrawal from alcohol
Acute metabolic disturbance - hypoglycaemia, hypercalcemia, hyponatremia
CNS - ↑ICP, stroke
Hypoxemia
Acute vascular events
Toxins & drugs - anaesthetics, ketamine, anticholinergics, opioids
Pain - including urinary and faecal retention
General surgical complications to counsel patient on pre operatively
surgical
- infection
- haemorrhage
- adverse reaction to anaesthetic
- atelectasis and pneumonia
- MI and stroke
- DVT and PE
- death
anaesthetic
- n&v
- dizziness
- headache
- hypersensitivity reaction
- aspiration
- DVT/PE
