Pre operative care Flashcards
Preoperative check list
Know Hx and physical findings Check consent Check bloods - all pt having GA need a FBC, Uand E, BSL, LFT's, urine dipstick, B HCG Order antibiotics and DVT prophylaxis CVS check - BP, Pulse, ECG. Medications - stop relative meds Resp check exam, RFT Renal insufficiency - beware of dehydration
Specific intervention prior to surgery
Right patient
Right site
Right operation
Sources of sepsis - oral, urine, chest
Cigarette smoking and alcohol - stop 6 wks before
Obesity - 2wk crash diet meal substitution
Topics to cover in post operative handover
Problems Observations chart Test results and X-rays Fluid balance chart Medication chart
Topic covered in post operative Ward round
End of the bed Nurses report Hx and physical Orders Patient questions death with
Ways to sort out post op problems
First 24 hr - anaesthetic, medical, surgical
1-7 days - Surgical, medical, anaesthetic
7 - 30 days - Medical, surgical, social/domestic
Cause of unresponsive post operative pt in the first 24 hrs
Inadequate reversal
Drug interaction
Opiate overdose
Cause of shock in post operative pt in the first 24 hrs
Bleeding - anaesthetic or surgical
MI
Rare sepsis clostridial/strep epidural
Cause of Hypoxic in post operative pt in the first 24 hrs
Airway obstruction
Collapsed lung
Pneumothorax
Cause of febrile in post operative pt in the first 24 hrs
May be normal, lung collapse
Cause of febrile in post operative pt in the 1-7 days
Chest infection UTI Wound infection IV site Leak
Cause of Febrile and unstable in post operative pt in the 1-7 days
Chest infection UTI Wound infection IV site Leak Severe sepsis Beware complex wound infection
Cause of vomiting/distention in post operative pt in the 1-7 days
Acute Gastric dilatation
Intestinal Obstruction
Ileus
Pseudo-obstruction- OGilvie’s syndrome
Cause of Leg swelling in post operative pt in the 7-30 days
CHF
DVT
Cause of Chest pain in post operative pt in the 7-30 days
Lung collapse
Pneumonia
PE
MI
Cause of sepsis in post operative pt in the 7-30 days
Wound Chest blood stream Prosthesis Urine
Cause of dehydration and or malnutrition in post operative pt in the 7-30 days
Poor slide or food intake
Unable to deal with stoma
M38, post total colectomy for CUcolitis • Steady post-op deterioration. Now 6 hours postop-shocked and hypoxic despite oxygen by mask not responsive to fluids. No blood in drain, abdomen flat. Subclavian CVP low • Hb 8, sats 90 on oxygen, GCS 14 • What investigation is crucial? • What are you going to do?
Ix - Chest Xray
A 75 year old woman has had a sigmoid colectomy. She has been coughing post- operatively, and has a post op ileus.
• You are asked to see her because a large volume of clear, slightly blood stained fluid has been discharged from an opening in the skin wound.
• What should you do, and what do you expect to find? What management?
?
An elderly, frail lady living alone, 3 weeks after laparoscopic cholecystectomy is admitted via A&E, with dehydration, creatinine of 180, confusion and faecal incontinence.
• What do you think is happening?
• What treatments are required?
• How may have this been prevented?
?
F34/Routine admission for LapChole
• Recent mild pain/Dark urine
• Has stopped all meds including OCP • Insists on Keyhole surgery only
LFT’s/ lipase abnormal/ Pregnancy test?/ Urgent US-CBD stone
What are you going to do?
What do you think the surgeons options are?
Are there implications for consent?
?
M78-admit for resection Ca sigmoid
• Decreasing exercise tolerance
• Bilateral leg swelling
• Continuous dribbling urine
• Physical exam- JVP/S3/Basal creps/Pitting odema. Bladder palpable
• Tests-Hb9/creatinine up/ ECG recent change/BSL 18
What are your options?
?
A 58 year old executive, recently divorced, has an incompletely excised BCC on the tip of his nose. The margins were positive on the deep surface and on one edge, and was histologically a micronodular BCC. He presents for re-excision and graft or flap
• Describe the consent process that may be required, and what issues you may need to discuss with the patient.
Re operation on tip of nose leads to conmectic defect. (hole in nose
Things to ask on Hx and Ex for a pre operative patient
Why having the surgery PSHx PMHx/Meds FmHx Ask about Heart, diabetes, Resp, endocrine, DVT, PVD. Allergies Clots Cancer Prothetics/dentures Fluid Assess surgical fitness - exercise tolerance - 2 flights - Prev anaesthetics - MSK disorder - Chronic disease + Mx to optimise Snap - 6wks Wt loss - Nutrient - Stop smoking - Physical activity
Ix for pre operative patient
FBC UEC LFTs Albumin Group and hold ECG, RFT, B12 B HCG Folate and B 12 if needed ECG Imaging if require
