Pre-op Management Flashcards
What acronym can be used for management of any patient?
RAPRIOP
What does the first R stand for in RAPRIOP?
Reassurance
What does A stand for in RAPRIOP?
Advice
What does the first P stand for in RAPRIOP?
Prescription
What does the second R stand for in RAPRIOP?
Referral
What does I stand for in RAPRIOP?
Investigations
What does O stand for in RAPRIOP?
Observations
What does the second P stand for in RAPRIOP?
Patient understanding and follow up
Why is reassurance important?
A few kind words can help settle patient anxiety
What advice should be given regarding eating food before an operation?
Stop 6 hours before the operation
What advice should be given regarding drinking dairy products (INCLUDING tea and coffee)?
Stop 6 hours before
What advice should be given with regards to drinking clear fluids e.g. water before surgery?
Stop 2 hours before
Can patients use water to take medications before operation?
Only small sips if <2 hours before
Why is it important to fast before surgery?
To reduce the risk of aspiration pneumonitis and aspiration and pneumonia
What mnemonic can be used to remember medications to stop before surgery?
CHOW
What does CHOW stand for?
Clopidogrel
Hypoglycaemics
Oral contraceptive pill and HRT
Warfarin
When should clopidogrel be stopped?
7 days before surgery
Why should clopidogrel be stopped?
Increases bleeding risk
Should normal does aspirin be stopped?
No - only higher treatment doses
When should metformin be stopped?
Morning of surgery
When should all other oral hypoglycaemics (not metformin) be stopped?
24 hours before surgery
What happens to Type 2 diabetics once they stop their medications?
They will likely need to be put on VRIII and 5% dextrose
When should the OCP and HRT be stopped?
4 weeks before surgery
Why must OCP and HRT be stopped?
Due to risk of DVT
What advise should be given when telling a patient to stop OCP?
Use other means of contraception
When should warfarin be stopped?
5 days before surgery
What INR should be aimed for before undertaking surgery?
<1.5
When a patient stops their warfarin what should they be given?
Cover with SC LMWH
If the INR is high the evening before what should the patient be given?
PO vitamin K to reverse the warfarin
What drugs should be altered before surgery?
SC insulin
Long-term steroids
What happens to SC insulin before surgery?
Should be switched to VRIII
Where should all Type 1 DM patients be placed on the surgical list?
First in the morning
When might T1DM patients need admitting?
Night before surgery
What should happen on the night before surgery in T1DM patients?
Reduce basal insulin dose by 1/3
What should happen to morning insulin dose on day of surgery in T1DM patient?
Omit it
What happens to a T1DM patient on the morning of surgery?
They are put on a VRIII (sliding scale)
What is a VRIII?
A syringe driver with 49.5ml saline with 50 units of actrapid
What is usually given alongside VRIII?
5% dextrose at 125ml/hour
How often should CBG be checked when on a VRIII?
Every 2 hours
What should be done based on 2 hourly CBG measurements?
Adjust infusion rate
When should a VRIII be continued until?
Until the patient can eat and drink
How should a VRIII be stopped?
Give SC rapid acting 30 mins before meal then stop VRIII 30-60 mins after eating
Why must long-term steroids be continued?
To avoid an Addisonian crisis
Why might continuing oral steroids be difficult?
If a patient cannot take them orally
If a patient cannot take long-term steroids orally what should be done?
Switch to IV
How can oral steroids be converted to IV?
5mg PO prednisolone = 20mg IV hydrocortisone
Which drugs should be started (if necessary) before surgery?
LMWH
TED stockings
Anitbiotic prophylaxis
What decides if a patient needs LMWH?
VTE risk assessment
Who will not receive LMWH?
Those with contraindications/having neck or endocrine surgery
Which patients should receive post-op LMWH and TED stockings?
Major GI surgery for cancer/lower limb joint replacement/fracture repair
How long should post-op VTE prophylaxis be given if needed?
28 days
Who should be given TED stockings?
Everyone*
*Who is the exception to ‘everyone should have TED stockings’?
Vascular surgery patients
Can you just give a patient TED stockings?
No - they need to be prescribed
What are the contraindications for TED stockings?
Severe PVD
Peripheral neuropathy
Recent skin graft
Severe eczema
Who needs antibiotic prophylaxis?
Patients having orthopaedic, vascular, or GI surgery
What are the forms of bowel preparation?
Laxatives
Enemas
Are bowel preparations always used?
No
Why are bowel preparations being used less and less?
Because they’ve been shown to prolong recovery time and cause fluid shifts
What broad class of surgery may require bowel preparation?
Colorectal
Is bowel prep needed in upper GI, HPB or small bowel surgery?
No
Is bowel prep needed in right hemi-colectomy or extended right hemi-colectomy?
No
Is bowel prep needed in left hemi-colectomy, sigmoid colectomy, or abdo-peroneal resection?
Yes
What bowel prep is needed in left hemi-colectomy, sigmoid colectomy, or abdo-peroneal resection?
Phosphate enema
When is a phosphate enema given for left hemi-colectomy, sigmoid colectomy, or abdo-peroneal resection?
Morning of surgery
Is bowel prep needed in anterior resection?
Yes
What bowel prep is needed in anterior resection?
2 sachets of picolax or phosphate enema
What should all patients receiving major GI, HPB, vascular, gynae or orthopaedic surgery have as a minimum?
G&S
What colour blood bottle is used for G&S (vacutainer)?
Pink
What may some patients require before major GI, HPB, vascular, gynae or orthopaedic surgery?
Cross matching
When might a patient need a referral before surgery?
When they may require a HDU or ITU bed
What investigations may a patient need before surgery?
FBC Kidney function testing ECG Haemostasis Lung function/ABG Pregnancy testing Sickle cell testing HbA1c MSU for MCS Echo
