Pre-Op Management Flashcards
What is RAPRIOP?
Reassurance, Advice, Prescription, Referral, Investigations, Observations, Patient.
What advice is given to the patient pre-op?
All pre-operative patients should be given advice regarding fasting:
- Stop eating- 6 hours before
- Stop dairy products (including tea and coffee)- 6 hours before
- Stop clear fluids- 2 hours before
Why does a patient need to fast before an operation?
Fasting ensures that the stomach is empty of contents. This reduces the risk of pulmonary aspiration, which can occur during the perioperative period, which can lead to both aspiration pneumonitis (inflammation caused by very acidic gastric contents, leading to desquamation) and aspiration pneumonia (due to secondary infection following pneumonitis or direct aspiration of infected material).
What drugs need to be stopped before surgery?
These commonly stopped medications can be remembered as ‘CHOW’.
- Clopidogrel
- Hypoglycaemics
- Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT)
- Warfarin
When does clopidogrel need to be stopped before surgery?
Stopped 7 days prior to surgery due to bleeding risk. Aspirin and other anti-platelets can often be continued and minimal effect on surgical bleeding.
When does oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) need to be stopped before surgery?
Stopped 4 weeks before surgery due to DVT risk. Advise the patient to use alternative means of contraception during this time period.
When is warfarin stopped before surgery?
Usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular weight heparin.
Surgery will often only go ahead if the INR <1.5, so you may have to reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before.
What drugs need to be altered before surgery?
- Subcutaneous insulin
- Long-term steroids
How are long-term steroids need to be altered before surgery?
Must be continued, due to the risk of Addisonion crisis if stopped.
If the patient cannot take these orally, switch to IV (a simple conversion rate is 5mg PO prednisolone = 20mg IV hydrocortisone).
What drugs need to be started before surgery?
- Low molecular weight heparin
- TED stockings
- Antibiotic prophylaxis
Briefly describe the use of low molecular weight heparin in surgery
The admitting doctor should complete a VTE Risk Assessment and prescribe appropriately.
Most patients will receive this, with the exception of those with either contraindications or who are having neck or endocrine surgery.
Patients undergoing major GI surgery for cancer (including oesophageal, gastric, pancreatic, liver and colonic resections) and lower limb joint replacement should be discharged with TEDs and 28 days of prophylactic dose low molecular weight heparin (in the absence of contraindications).
Briefly describe the use of TED stockings in surgery
All patients (with the important exception of vascular surgery patients) will receive below knee TED stocking. These need to be prescribed but check for contraindications (especially in the elderly). Contraindications include severe peripheral vascular disease, peripheral neuropathy, recent skin graft, severe eczema.
Briefly describe the use of antibiotic prophylaxis in surgery
Patients having orthopaedic, vascular, or gastrointestinal surgery will require prophylactic antibiotics. Generally, these will be prescribed by the anaesthetist or the surgeon but if in any doubt, call your senior to discuss.
Briefly describe the pre-op management of type 1 diabetes mellitus
All patients with Type I DM should be first on the morning list and they may need admitting on the night before the operation (depending on how major the procedure is).
On the night before surgery, reduce their subcutaneous basal insulin dose by 1/3rd. Omit their morning insulin and commence an IV variable rate insulin infusion pump (commonly termed ‘sliding scale’), which is a syringe driver that usually contains 49.5mL of normal saline with 50 units of Actrapid.
Whilst the patient is nil by mouth, you will also need to prescribe an infusion of 5% dextrose, which is usually given at a rate of 125mL/hr. Ask the nurse to check the capillary glucose (‘BM’) every 2 hours and to alter the infusion rate accordingly.
Continue until the patient is able to eat and drink. Once they are doing so, you must overlap their IV variable rate insulin infusion stopping and their normal SC insulin regimens starting. To do this, give their SC rapid acting insulin ~20 minutes before a meal and stop their IV infusion ~30-60 minutes after they’ve eaten.
Briefly describe the pre-op management of type 2 diabetes
Management is dependent on they way that their Type II DM is controlled. If diet controlled, no action is required peri-operatively.
If, however, the patient is controlled by oral hypoglycaemics, metformin should be stopped on the morning of surgery, whilst all others should be stopped ~24 hours before the operation. These patients will then be put on IV variable rate insulin infusion along with 5% dextrose as described above and managed peri-operatively the same as a Type I diabetic.
