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Year 3 perioperative management > Pre-Operative assessment > Flashcards

Pre-Operative assessment Flashcards

1
Q

Aims of preoperative assessment

A

Informed consent
Assess risks vs benefits
Optimise fitness of pt
Anaesthesia and analgesia optimisation

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2
Q

Pre - op checks

OP CHEC

A

Operative fitness - cardiorespiratory comorbidities
Pills - medication - especially anticoagulants and insulin
Consent
History - previous anaphylaxis or DVT
Ease of intubation
Clexane - DVT prophylaxis
Site - correct and marked

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3
Q

OCP/HRT

A

Stop 4 wks before major surgery or any leg surgery

Restart 2 wks post op if mobile

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4
Q

Nill by mouth

A

Stop solids at least 6 hours before surgery

Stop clear fluids at least 2 hours before surgery

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5
Q

Bowel prep

A

Normally needed in left sided operations

  • Picolax - laxative
  • Klean prep - macrogol flush
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6
Q

S/E of bowel prep

A

Liquid bowel contents spillage
Dehydration
Electrolyte disturbance
Increased rate of post-op anastomotic leak

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7
Q

Prophylactic abx

A

Given 15 - 60 mins before surgery

Biliary - Ceftriaxone + metronidazole IV

CR or appendicetomy - Ceftriaxone + metronidazole TDS
Vascular - Co-amoxiclav IV
MRSA +ve - vancomycin

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8
Q

DVT prophylaxis

A

Low risk - early mobilisation

Medium risk - early mobilisation, TEDS +dalteparin subcut 7 days or until mobilised

High - early mobilisation, TEDS + dalteparin subcut (28 days) + intermittent compression boots

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9
Q

Routine pre - op investigations

A 
Routine: 
- Bloods - FBC, U+E, G+S, clotting, glucose
- Cross-match
Gastrectomy: 4units
AAA: 6units
-  MRSA swabs
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10
Q

ASA grades

A

I - Normally healthy
II- Mild systemic disease
III- Severe systemic disease that limits activity - not constantly life-threatening
IV - Systemic disease which is a constant threat to life
V- Moribund: not expected to survive 24h even with op

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11
Q

How does surgery affect a diabetic pt

A 
Increased rsk of post-op complications
• Surgery causes release of stress hormones i.e. adrenaline and glucocorticoids → antagonise insulin
• Pts. are NBM
• Increased risk of infection
• IHD and PVD
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12
Q

Pre op investigation of diabetic pt

A
  • Dipstick: proteinuria
  • Venous glucose
  • U+E: K+
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13
Q

How to mx insulin dependent DM pt

A

• Put pt. first on list and inform surgeon and
anaesthetist

• Sliding scale may not be necessary for minor ops - liaise with diabetes specialist nurse

Insulin
• stop long-acting insulin the night before
• Omit AM insulin if surgery is in the morning
• Start sliding scale
- 5% Dex with KCl
- actrapid infusion pump
- Check CPG 2 hrly and adjust insulin rate
- Check glucose hrly: aim for 7-11mM

Post-op:

  • Continue sliding-scale until tolerating food
  • Switch to subcutanoeus insulin
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14
Q

Non-insulin dependent DM pts

A

If glucose control poor (fasting >10mM): treat as
IDDM
• Omit oral hypoglycaemics on the morning of surgery
• Resume oral hypoglycaemics with meal post op

• If not eating post-op:

  • Check fasting glucose on morning of surgery
  • Start insulin sliding scale
  • Consult specialist team restarting oral medication

Diet Controlled
• Pt. may be briefly insulin-dependent post-op
- Monitor CPG

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15
Q

Risks of surgery for steroid pt

A

Poor wound healing
Infection
Adrenal crisis

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16
Q

Mx of steroid pt

A
  • ↑ steroid to cope with stress response
  • Major surgery: - Hydrocortisone IV with premedication and then 6-8hrly for 3 days
  • Minor: hydrocortisone only for 24h
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17
Q

Jaundice pt

A
  • Avoid operating in jaundiced pts

- Use ERCP instead

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18
Q

Risk of surgery in jaundice pt

A

• Obstructive jaundice have ↑ risk of post-op renal
failure - need to maintain good urine output
• Coagulopathy
• ↑ infection risk: may cause cholangitis

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19
Q

Jaundice pt mx

A

Pre-op:
• Avoid morphine in pre-med
• Check clotting and consider pre-op vitamin K
• Give 1L saline pre-op (unless congested HF) → moderate diuresis
• Urinary catheter to monitor urine output
• Abx prophylaxis: cef+met

Intra-op:
• Hrly urine output monitoring
• Normal saline titrated to output

Post-op:
• Monitor fluid status
• Consider CVP + furosemide if poor output despite saline

20
Q

Antocoagulated pts

A

• Consult surgeon, anaesthetist and haematologist
• Very minor surgery may be undertaken w/o stopping
warfarin if INR <3.5.
• Avoid epidural, spinal and regional blocks if
anticoagulated
• Continue aspirin/clopidogrel unless risk of bleeding is high – then stop 7d before surgery

21
Q

AF pt

A
  • Stop warfarin 5d pre-op: need INR <1.5

* Restart next day

22
Q

High thromboembolic risk

A

If prosthetic valves or recurrent VTE

23
Q

High thromboembolic risk mx

A

• bridging with treatment dose LMWH

  • Stop warfarin 5d pre-op and start LMWH if INR > 1.5
  • Stop LMWH 12-18h pre-op
  • Restart LMWH 6h post-op
  • Restart warfarin next day
  • Stop LMWH when INR >2
24
Q

Emergency surgery thromboembolic risk precautions

A
  • Discontinue warfarin
  • Vit K slow IV
  • Request FFP or PCC to cover surgery
25
FFP and PCC
Fresh frozen plasma (FFP) Prothrombin complex concentrate (PCC)
26
Risks of smoking and COPD during surgery
* Basal atelectasis * Aspiration * Chest infection
27
Pre-op management of smoking or COPD pt
- CXR • Pulmonary function tests • Physio for breathing exercises • Quit smoking (at least 4wks prior to surgery)
28
Pre-op: optimisation
• Aggressive physiological optimisation - Hydration - BP control - Anaemia control - DMcontrol - Co-morbidities mx * Smoking cessation: ≥4wks before surgery * Admission on day of surgery, avoidance of prolonged fast * Carb loading prior to surgery: e.g. carb drinks
29
How to decrease intra - operative physical stress
* Short-acting anaesthetic agents * Epidural use * Minimally invasive techniques * Avoid drains and NGTs where possible
30
Group + save and cross match
Group and save - determines blood group and screens for atypical antibodies Cross match - physically mix patients blood with donor blood to check immune reaction
31
MRSA swab
All patients get swabbed
32
Anaesthetist assessment
Degree of mouth opening Teeth or dentures Oropharynx - mallampati classification Neck movements
33
Drugs to stop (CHOW)
Clopidogrel - stopped 7 days before surgery Hypoglycaemics Oral contraceptives/HRT - 4 weeks before Warfarin - 5 days prior to surgery, use LMWH ACEi - stop on day of surgery K+ sparring diuretics
34
INR
INR < 1.5 - reverse warfarin effects by vitamin K
35
Drugs to alter
Subcut insulin - switched to IV insulin Long term steroids - switch to IV if nill by mouth as cannot stop
36
Drugs to start
LMWH - reduce VTE risk TED stockings Antibiotic prophylaxis
37
Specific pre op investigations
Specific: - LFTs: liver disease, EtOH, jaundice - TFT: thyroid disease - CXR: cardiorespiratory disease/symptoms, >65yrs - Echo: poor LV function, Ix murmurs - ECG: HTN, Hx of cardiac disease, >55yrs - Cardiopulmonary Exercise Testing - Pulmonary function tests: pulmonary disease or obesity
38
Contraindication for LMWH prophylaxis
Chronic venous insufficiency | Neck or endocrine surgery
39
Pre-Operative ERAS Protocol
Patient education -regarding the surgery and the expected post-operative course Ensuring the patient is as healthy as possible Optimising medical management including smoking and alcohol cessation Optimal pre-operative fasting guidelines
40
Intra-Operative ERAS Protocol
Use of opioid-sparing analgesia - including regional anaesthesia and continuous wound infusion where possible Avoidance of short-acting benzodiazepines in the elderly Postoperative nausea and vomiting prophylaxis Minimally invasive surgery Goal-directed fluid therapy regime
41
Post-Operative ERAS Protocol
Ensure adequate pain control Early oral intake Multi-disciplinary post-operative patient follow-up
42
If rapid sequence induction is required in emergencies what precautions are made ?
Do not use a bag mask ventilation | Cricoid pressure used - occludes oesophagus
43
Contraindications for anti embolic stockings
``` Lower limb neuropathic ulcer Severe eczema Peripheral vascular disease Peripheral neuropathy - DM Gangrene ```
44
If eGFR < 30 with dalteparin
Unfractionated heparin used
45
High risk VTE pt
Cancer pt | Lower limb joint surgery
46
Parkinson’s anti - emetic
Do not use metoclopramide as dopamine antagonist and crosses the blood brain barrier
47
Which pts do need prophylactic abx
``` GI surgery Cardiac surgery Insertion of artificial prosthetics MSK surgery Wide local excisions ```

Year 3 perioperative management (23 decks)

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