Pre Op management

Question 1

Which drugs need to be stopped before surgery

Answer 1

CHOW
Clopidogrel - stopped 7 days before surgery due to bleeding risk. Aspirin and dipyridamole can be continued
Hypoglycaemics
- metformin morning dose on day of surgery is omitted
- all other hypopglycaemics should be stopped 24hrs before
Oral contraceptive pill/ hormonal replacement therapy - Stopped 4 weeks prior to surgery due to DVT risk, use alternative methods of contraception
Warfarin - usually stopped 5 days before surgery and commenced on LMWH (therapeutic dose)

Question 2

What does a patients INR need to be for surgery to go ahead

Answer 2

<1.5
Warfarin may need to be reversed with octiplex or beriplex or with 1-5mg PO vitamin K if INR is high the night before surgery

Question 3

Which drugs need to be altered prior to surgery

Answer 3

SC insulin - switched to a variable rate IV insulin infusion
Long term steroids - must be continued, risk of Addisonian crisis if stopped
If cannot take steroids orally convert to IV
5mg pred = 20mg IV hydro

Question 4

Which drugs should be started prior to surgery?

Answer 4

LMWH - admitting doctor will complete a VTE assessment and prescribe appropriately
TED Stockings - all patients BUT vascular surgery patients will receive below the knee stockings. Need to be prescribed but checked for contraindications
Abx Prophylaxis - patients having ortho, vascular or GI surgery require abx. Generally prescribed by the anaethetist or surgeon

Question 5

Which patients dont have LMWH before surgery

Answer 5

Patients have neck or endocrine surgery
patients with contraindications
- patientswith known allergies to LMWH or heparin
- patients with history of heparin induced thrombocytopenia
- patients with active major bleed

Question 6

What are contraindications for TED stockings

Answer 6

Peripheral arterial disease
Peripheral neuropathy
Recent skin graft
Severe eczema

Question 7

Where should a patient with T1DM be on the operating list

Answer 7

First

May need admitting the night before

Question 8

How should Diabetics insulin be managed prior to surgery

Answer 8

Night before surgery 
- reduce basal insulin by 1/3 
Morning of surgery 
- omit morning insulin 
- commence an IV variable rate insulin infusion pump - sliding scale. Syringe with 49.5ml of saline and 50 units of actrapid 
Patient is NBM 
- prescribe a 5% dextrose - given at a rate of 125ml/hr 
- BMs to be checked every 2 hours 

Continue until patient is able to eat and drink
- sliding scale and SC insulin regimes must overlap

Question 9

When is bowel preparation needed

Answer 9

In left hemi-colectomy, sigmoid colectomy, abdo-perineal resection - phosphate enema on morning of surgery
Anterior resection - 2 sachets of picolax or phosphate enema

Question 10

What advice do patients need to be given prior to surgery regarding eating and drinking

Answer 10

Stop eating 6 hours before
Stop dairy products 6 hours before
Stop clear fluids 2 hours before

Question 11

Why do patients need to fast prior to surgery

Answer 11

Reduces risk of aspiration and aspiration pneumonitis (inflammation caused by very acidic gastric contents) and aspiration pneumonia (due to secondary infection following pneumonitis)

Question 12

Which investigations are needed prior to surgery

Answer 12

Bedside obs - HR, RR, BP, Sats 
ECG
Bloods 
- FBC
- U+Es
- LFTs
- Clotting 
- Group and save 
- TFTs - if only thyroxine or having thyroid surgery 
- HbA1c - in diabetics 
Imaging 
CXR - only be used when absolutely necessary 
- resp illness who have not had a cxr in the last 12 months 
- new cardioresp symptoms 
- recent travel from areas with endemic TB 
- significant smoking hx