Pre-Op Flashcards
What can the trauma of surgery lead too
Stress Fluid shift in body Blood loss CVS / respiratory / renal failure Decreased FRC due to GA so post-op oxygen
What is pre-op important for
Assess and identify high risk patients and minimise risk Establish baseline Establish severity of disease Exclude any serious issue that will affect analgesia Dx unknown or suspected conditions Inform and support patient decisions Get consent Guide management
What do you want to know in the Hx
Known co-moridities
- Exacerbations / Ax / home oxygen / use of steroid
Unknown co-morbid
Ability to withstand stress
- ETT
- Cardio / resp disease
Drugs and allergy
Previous surgery and anaesthesia
FH - malignant hyperthermia or cholinesterase
SH - drug / smoke / alcohol
Potential anaeshteitc problems - is neck / jaw immobile / teeth stable
What increases likelihood of airway issue
Reflux
Obesity
Pregnancy
FH
What do you want to confirm before op
How have they been in time leading up
Confirm drug and allergies
Fasting
What happens for an elective operation
Assess CVS system and exercise tolerance
Bloods
- FBC, U+E, LFT, finger tip blood glucose in most
- G+S
- DO clotting in liver / renal / DIC / anti-coagulation
- Blood glucose if DM
Drug levels as appropriate
Urinanalysis
Pregnancy test
Sickle cell if from area
TFT if thyroid disease
Assess for DVT risk
Thromboprophylaxis plan
MRSA screen - decolonize carrier
CXR = not routine - if cardiorespiratory disease
ECG if >65 / DM / renal or poor ETT
Lateral Spine X-ray if RA / Down’s / AS as risk of atlanto-axial instability
Risk assessment tools
OK
What are NICE guidelines for risk
ASA grade
Surgery grade
Co-morbid
ASA 1
Otherwise healthy
No smoking or alcohol
ASA 2
Mild - mod systemic disturbance
No functional limitation
Current smoker / social alcohol / obesity / well controlled DM or high BP
ASA 3
Severe systemic disturbance / disease Functional limitation Poor controlled DM / BP COPD / asthma / end stage renal Previous MI
ASA 4
Life threatening
Recent MI / CVA or severe reduction n EF
ASA 5
Moribund
Not expected to survive without operaiton
Rupture AAA / ischaemic bowel
ASA 6
Organ retrieval
What does cardiac risk index look at
High risk surgery IHD CCF Cerebrovascular DM Renal failure
If cardio procedure what do you get / what other tests can be done
ECG ETT ECHO +- stress May have angio prior PFT
If CVS issue what are options
GA = high risk of myocardial depression
Regional - may not cover
Spinal - watch for CI
If resp procedure what do you get
O2 sats ABG CXR or CT chest - not routine Peak flow FVC and gas transfer
E+D prior to surgery
Foods / solid >6 hours
Clear fluid >2 hours
What do you do if DM prior to surgery
If diet or tablet controlled = omit and check BG regularly
If poor control or insulin = sliding variable rate IV insulin infusion
Put first on list
May need K supplementation
Treat as hypo if <4
Pre-op meds
Most continue as normal
esp inhalers / angina / epilpesy
If on steroids what do you need to do
Supplement with hydrocortisone as surgery will increase stress
What do you do if on anti-coagulant
VTE risk assessment
Withhold warairn
Use short acting e.g. LMWH
Withold LMWH the evening before and use TEDS
Anaemia pre-surgery
Blood transfusion to correct
IV iron will take too long
If refuse then can give IV iron
Oral iron is possible but will take 2-4 weeks to work
Operations with high risk of transfusion needing X-match 4-6 units
Total gastrectomy Oophorectomy Oesophagectomy Elective AAA reapir Cystectomy
Operations which may need transfusion so X-match 2 units
Salpingectomy for rupture
THR
Operations unlikely to need transfusion so G=S
Hysterectomy Appendectomy Thyroid ELective LSCS Lap chole
How does paralytic ileus present post surgery
Vomiting
Absent bowel
CRP raised anyway as post surgical response
What causes and what is associated
No peristalsis Chest infection MI Stroke AKI
What are nutrition options post surgery
Oral - early feeding good NG - If entubated soon NJ Feeding jejunostomy PEG TPN
What is CI in head injury
NG as risk of worsening
What is benefits of NJ over NG
Insertion is more complicated but avoids risk of aspiration / food pooling in stomach
What can be used long term
Feeding jejunostomy
1st line in most if longer term
Low risk of aspiration
What is main risk
Displacement
Leakage = peritonitis
Risk of PEG
Aspiration
When do you use TPN
If enteral CI
What are SE
Phlebitis
Fatty liver
Deranged LFT
What are early causes of post op pyrexia
Blood transfusion
Infections - Cellulitis / UTI - have low threshold
Pulmonary atelectasis - needs prompt physio
Physiological
What are later causes
VTE
Pneumonia
Wound infection
Anastomotic leak
How do you avoid surgical complications
WHO checklist
Ax
DVT risk + prophylaxis
When do you carry out checklist
Prior to induction
Incision
Patient leaves operation room
What does checklist involve
Site marked Confirm identity Confirm procedure Confrim consent Anaesthesia check complete Pulse oximeter on Allergies Airway / aspiration risk >500ml blood loss risk
What are complications of surgery
Bleeding Haemorrhagic shock Infection Confusion Arrhythmia following cardiac Electrolyte imbalance Ileus Fluid and electrolyte loss Pulmonary oedema Anastomotic leak MI Nerve damage
What can cranial surgery cause
SIADH = hyponatraemia
Who is very sensitive to oedema
After pneumonectomy as lose lung volume
What are baseline investigations in any acutely unwell
Bloods- FBC, U+E, LFT,, CRP, Ca, clotting
Blood culture
ABG
ECG +- enzyme
Urinanalysis
Consider CXR / USS / CT depeniding on finding
What ae specialist test
CT for abscess / leak Gastrograffin enema for rectal leak Doppler for DVT CTPA for PE Peritoneal fluid ECHO if effusion
What is a CI to thrombolysis
Recent surgery
What is thermoregulation in perioperative period
Temp management 1 hour prior to 24 hours after
When is hypothermia more common
If under anaesthesia ASA 2+ Major surgery LBW Large volume of unwarmed infusion Unwarmed blood
If temp <36 pre op
Active warming before induction
Do not move to there unless time critical
How do you measure temp intra op
Oesophageal probe
Axillary / sublingual
What should be used if high risk of >30 minutes
Forced air warming device
If fluid >500ml
Warm all
What happens post-op
Document temp every 15 minutes till in ward
Do not transfer if <36
May develop hyperthermia due to fever
What are complications of hypothermia
Coagulopathy - reduced clotting so increased loss Prolonged recovery Reduced wound healing as constriction Infection Shivering increases metabolic rate
What increases risk of VTE
Surgery >90 mins or >60 if LL Abdominal inflammation Reduction mobility 3+ days Hip / knee replacement or fracture 60+ Known malignancy Thrombophilia Previous thrombosis BMI >30 HRT / OCP Varicose veins
What are general RF
Dehydration
Co-morbid
Critical care
Pregnant or <6 weeks post partum
What is mechanical prophylaxis
Early amputation
Compression stocking
When is compression CI
PAD
What is options for therapeutic
LMWH SC daily
Unfractioned heparin IV
Dabigatran
Benefits of unfractioned
IV
Rapid onset and decline on stopping infusion
How do you measure
APTT
How do you reverse
Protamine sulphate
When is dabigatan used
Hip and knee
No active monitoring required
CI
If risk of active bleeding
What do you have as prophylaxis if RF
Mechanical and therapeutic
How long
Stat 6-12 hours after op
Elective hip = 28 days
Elective knee = 14 days
Hip fracture = until mobile / 28 day s
If patient N+V post op what should you think
Any mechanical obstruction
Ileus ?
Emetic drugs - opiates / anaesthesia
What should you consider
AXR
NGT
What should you aim for UO post op
> 30ml / hr in adults
If UO decreased what do you look for
Blocked or malted catheter
Incorrect fluid replacement
Urinary retention
AKI
What do you do
Review fluid chart Examine fluid status Examine bladder Fluids to establish normovolaemia Cathterise for accurate monitoring Correct issue
If dyspnea or hypoxia post op what do you do / what tests
Sit patient up and give O2
Monitor sats
Examine for evidence of pnuemonia / collapse / aspiration / LVF / PE
Do FBC, ABG, CXR, ECG and enzymes
What can cause LVF post op
MI
Fluid overload
What are risks of surgery in jaundice patient
Coagulopathy - decreased vit K
Sepsis
Renal failure
What should you do prior
ERCP to relieve
