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Surgery and Surgical Specialties > Pre Operative Care > Flashcards

Pre Operative Care Flashcards

1
Q

Fluid Requirements

A

20 – 30ml/kg/day water, 1mmol/kg/day Na, 1mmol/kg/day K, 50-100g/day Glucose.

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2
Q

At Risk Patients of Fluid Imbalance

A

Acute presentation of diarrhoea and vomiting, reduced fluid intake, Elderly
patients and patients with reduced renal reserve, Drugs that impair renal responses to fluid changes (e.g. Diuretics), Patients with low body weight/Children (↓Overall total body fluid)

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3
Q

Isotonic Saline

A

(0.9%) prevents rapid cellular shifts during rehydration and excess sodium
excreted by the kidneys; Potassium (e.g. Sando-K) added if loss expected e.g. Vomiting,
Pancreatic or Small Bowel fistula

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4
Q

Dextrose

A

useful in energy supplementation as well as raising intracellular volume (Glucose influx into cells, glucose metabolism produces water)

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5
Q

Hartmann’s Solution

A

Lower sodium than Isotonic, contains Potassium, Lactate and Calcium

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6
Q

Fluid Depletion

A

Fluid Depletion = %PCV from normal × 0.7 × Patient weight (kg)

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7
Q

Signs of Fluid Depletion

A

Body weight on admission can also provide estimate of loss; Acute loss ≈ Water loss
o Serum Urea is raised disproportionally from Creatinine (UCR)

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8
Q

How to rehydrate

A

Young, fit patients can receive 15% Body fluid volume by rapid infusion; Slower for elderly to
prevent acute overload
o NB: Body fluid volume = 60% Body weight
o Monitoring of Fluid optimisation – 1-hourly urine output; commonly used 0.5ml/kg/hr

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9
Q

Vomiting

A

Postoperative Nausea and Vomiting related to general anaesthetic use; Therapy aims to replace Sodium, Potassium and Water loss via use of anti-emetics (e.g. Ondansetron, Metoclopramide) although not as monotherapy as there is no single effective drug),
avoidance of general anaesthetic
• Avoidance of Emetogenic drugs e.g. Nitrous Oxide, Opioids or use of less emetogenic anaesthetics e.g. Propofol

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10
Q

Shock

A

Inadequate End-organ perfusion and tissue oxygenation; ↓BP, ↑HR,
Pallor/Cold/Clammy, Confusion, ↓Pulse pressure (SBP – DBP), ↓Urine output

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11
Q

Approaching Shock

A

Airway and Breathing, Check Carotid/Femoral pulse, start 500ml IV crystalloids rapidly and recheck BP (Fluid challenge) and identify cause of shock
o Hypovolaemic – Lie flat, start high flow oxygen, repeat 500ml IV, Take FBC (Purple
tube), U&E (Orange tube), Clotting (Blue tube) and Cross-match, Arterial Blood Gases
and treat if Hyperkalaemia present (Insulin ± Dextrose)

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12
Q

Managing Hypovolemia

A

Lie flat, start high flow oxygen, repeat 500ml IV, Take FBC (Purple
tube), U&E (Orange tube), Clotting (Blue tube) and Cross-match, Arterial Blood Gases and treat if Hyperkalaemia present (Insulin ± Dextrose)

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13
Q

Managing Anaphylaxis

A

1:1000 Adrenaline IM, 100mg Hydrocortisone IV, 10mg
Chlorpheniramine IV; Repeat 5-10 minutes again if no improvement
▪ If Wheezy 5ml Salbutamol Nebs
▪ IV Adrenaline (1:10000) only for experienced clinician use

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14
Q

Managing Septic Shock

A

Sepsis Six, Escalate ITU/CCOT; Inotropic Support (E.g. Noradrenaline)

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15
Q

Managing Cardiogenic Shock

A

Morphine, ECG, Anti-arrhythmic, GTN, Aspirin if appropriate; Send ABG, FBC, U&E, Clotting, Troponin
▪ Fluid overload – CXR and Diuretics (e.g. IV Furosemide 40mg)

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16
Q

Reasons for Fluid Overload

A

Seen because of Heart Failure, excessive IV therapy, massive transfusion (i.e. Transfusion Associated Circulatory Overload = TACO), high sodium intake (most drugs)

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17
Q

Presentation of Fluid Overload

A

Presents with increased weight, Fluid in the third space (Peripheral and Pulmonary Oedema,
Ascites), Paroxysmal Nocturnal Dyspnoea and raised JVP

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18
Q

Management of Fluid Overload

A

Managed by stopping excessive Intravenous therapy, Diuretics, Treatment of underlying cause (e.g. Heart failure, AKI), Fluid restriction (1L/day + Urine output)

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19
Q

Uses for blood transfusion

A

Used in the treatment of symptomatic anaemia (Pallor, Fatigue, Hypotension,
Tachypnoea); Higher threshold if not actively
bleeding or about to undergo procedure

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20
Q

Blood

A

One unit increases Hb by 1g/dL in

70kg adult, 1 unit = 350ml of Pack Red cells

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21
Q

Autologous Transfusion

A

2 units drawn

preoperatively and stored up to 6 weeks

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22
Q

Cell Salvage

A

Collection of shed blood,

heparinised, spun with saline and repackaged

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23
Q

Avoiding Transfusion

A

o Transfusion may be avoided by treating Anaemia and Coagulopathy preoperatively, stopping factors which increase bleeding, Procoagulants, Erythropoietin
o Antifibrinolytic Procoagulants (e.g. Tranexamic acid) – Inhibition of Plasminogen and
Plasmin reduces clot breakdown

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24
Q

Platelets

A

One unit increases count by 30-60 x 109/L in 70kg adult, should be ABO compatible

and Rh matched in females of child-bearing age

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25
Q

Fresh Frozen Plasma

A

Contains all coagulation factors except platelets; Will raise clotting factors by 1% in 70kg adult, 5-10ml/kg given, should be ABO compatible and Rh matched in
females of child-bearing age

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26
Q

Cryoprecipitate

A

Fibrinogen, FVII and FVIII; ABO and Rh not relevant

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27
Q

Nutrition for Surgery

A

Anticipate patients have higher than normal nutritional requirements (e.g. Severe Burns, Sepsis, Fistulas, Malignancy, Immunosuppression)

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28
Q

Nutrition for Surgery: Assessment

A

Assessed by BMI, Triceps Skinfold Thickness, Grip Strength, Serum Albumin and Transferrin

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29
Q

Effects of Malnutrition

A

Malnutrition leads to Poor Immunity, Albumin production, Wound healing, Skeletal Muscle Weakness (‘Critical Illness Myopathy’), and specific deficiency syndromes

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30
Q

How can nutrition be supplemented

A

Nutrition can be supplemented by Oral, NG/NJ feeds, RIG/PEG Tube, or Parenteral Feed
o TPN – Limited by Osmolality (If Peripheral) or Volume (if Central); Risks include Osmolality, lack of Glycaemic Control, Micronutrient Deficiencies, Liver Dysfunction, Cholestasis, Pancreatic Atrophy, Volume Overload
o TPN patients require regular U/Es, Glucose, LFTs, Micronutrients (+ Mg, PO4, Mn, Cu)

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31
Q

TPN

A

TPN is typically reserved for patients with Prolonged Post-Op Ileus, Acute Abdominal Sepsis,
or any reason where the GI tract is unable to absorb nutrition (e.g. Extensive resection,
Extensive RT damage, Extensive Crohn’s disease)

32
Q

Antibiotic Prophylaxis

A

Reduce risk of SSI, usually short course (1 – 3
doses); Important to have high circulating
concentration at time of potential tissue contamination (hence given at Anaesthetic), clean
wounds do not require Abx, High risk patients
require extended course or specific Abx
o E.G. Neutropaenic, Immunocompromised,
Severely Malnourished

33
Q

Thromboprophylaxis

A

• Risk factors: Prolonged Anaesthetic time, LL or Pelvic Surgery, Immobility, Malignancy, Age,
Dehydration, Obesity, DM, CVS disease, Inflammatory pathology, Oestrogen, PMH
• Mechanical Thromboprophylaxis – TEDs, Flowtrons, or Pharmacological – Heparin or LMWH

34
Q

Surgical Drains

A

• Removal of existing collections, Prevent build-up of fluids, Prevention of life-threatening conditions
(E.g. Neck drains after Thyroid Surgery)
• Risks – Damage during insertion, Infection route,
Pressure injury if suctioned, Failure to drain causing
false sense of security

35
Q

Acid Base Balance

A

• Normal blood pH is 7.35 – 7.45; Must be seen with PaCO2 and Base Excess to determine cause
• Base Excess = mmol/L of acid needed to titrate blood back to 7.4 if paCO2 was normal
o Excess >2mmol/L =? Metabolic alkalosis, Deficit

36
Q

Anion Gap

A

Anion Gap = Na+ + K + − (Cl− + HCO3−)
Anion Gap should be 8 -16mmol/L – Increased gap =? Metabolic acidosis; Can be used to differentiate between types of Metabolic Acidosis

37
Q

Normal Gap (↓HCO3-/↑Cl-) Metabolic Acidosis

A

Renal Tubular Acidosis (Loss of Bicarbonate)
Diarrhoea/High output Ileostomy
Pancreatic Fistula
Excessive Saline therapy (Hyperchloraemic)

38
Q

High Gap (↑H+) Metabolic Acidosis

A

Lactic Acidosis (Hypoperfusion, Sepsis, Hepatic)
Uraemia (Renal Failure)
Ketones (DKA, ETOH)
Drugs/Toxins (Aspirin, SNP)

39
Q

Metabolic Alkalosis Causes

A

Loss of H+ from Renal (Diuretics) and GI Tract (Vomiting, NG tube),
↑HCO3- reabsorption (Hypochloraemia), Administration of bases

40
Q

Respiratory Acidosis

A

Respiratory Failure/ Hypoventilation, Increased CO2 production (e.g. Sepsis, Malignant Hyperpyrexia), Rebreathing of CO2

41
Q

Respiratory Alkalosis

A

Hyperventilation of any cause; Stroke, Anxiety, Pulmonary Embolism,
Pneumonia, Asthma, etc

42
Q

Analgesia

A

• Non-Opioid Analgesia – NSAIDs (e.g. Aspirin, Ibuprofen, Diclofenac), Paracetamol
• Weak Opioids – Codeine, Dihydrocodeine, Tramadol
• Strong Opioids – Morphine, Diamorphine
• Adjuvants may be added as part of pain ladder –
Antidepressants (e.g. SSRIs), Anti-convulsant, Muscle
relaxants, Sedatives

43
Q

IV Administration

A

100% bioavailability but shortest half-life if bolus

44
Q

IM Administration

A

Provides localised effect, but might be inconvenient or painful; Reduced
muscle bulk or variable blood flow might affect absorption and distribution

45
Q

Oral Administration

A

Might come in formulations for Modified Release to reduce number of
doses a day; Might have interactions with food, affected by GI malabsorption

46
Q

Other forms of administration

A

Continuous Wound Infiltration, Topical (poor

absorption), Intrathecal (into CSF in the spinal cord), Rectal (useful in children)

47
Q

Routine Postoperative Care

A

• Routine Blood – FBC, U/Es to look for Anaemia (slow bleed or haemodilution), Leukocytosis (Infection); Monitor INR/Clotting if anticoagulated; Check Electrolytes for fluid management and AKI, especially if Renal disease, Cardiac or Major Vascular surgery, Nephrotoxic drugs
• ECG rarely used routinely outside Post-cardiac surgery; Look for Ischaemia or Arrhythmia
• CXR – Daily if Chest drains present on suction, after Drain Removal, or to check Positioning of
newly placed lines

48
Q

Complications of Surgery in Pregnancy First Trimester

A

Teratogenic drugs avoided (E.g. Carbamazepine, Valporate, Tetracycline, Warfarin, ACE Inhibitors); Reduced LOS tone, risk of GOR/Aspiration

49
Q

Complications of Surgery in Pregnancy Second Trimester

A

Drugs may have adverse effects on foetal development and

metabolism; Increased susceptibility to UTI (Especially ascending)

50
Q

Complications of Surgery in Pregnancy Third Trimester

A

Drugs might induce labour; Displacement of abdominal viscera superiorly and posterior of gravid uterus; Appendix comes to lie into RUQ; Risk of Hypotension due to IVC compression (Avoid by positioning in slight lateral decubitus

51
Q

Risk of Miscarriage

A

Highest in first trimester; Can be induced by GA

52
Q

Oestrogen-containing Contraceptives

A

Increased risk of Thromboembolic disease; Risk related to existing comorbidities and extent of surgery
o Low risk (e.g. Dental, Day Case, Minor Laparoscopic) – Continue
o Medium risk (e.g. Abdominal, Orthopaedic, Major Breast) – Discontinue for at least
1/12 prior to Elective surgery; If Emergency, Full Thrombo`prophylaxis
o High risk (e.g. Pelvic, LL Orthopaedic, Cancer) – Discontinue 1/12 prior to Elective; Extended Full Thromboprophylaxis if Emergency

53
Q

Progesterone-only formulations

A

can be continued – Little to no risk

54
Q

Anticoagulants

A

Warfarin to be stopped 5 days prior, Clopidogrel stopped 5-7 days prior

55
Q

Diabetes Mellitus

A

Susceptibility to Infection, Poor Wound Healing, Skin Pressure Necrosis,
Associated complications of DM (Renal impairment, CVS disease)
o Should be first on operating list where possible; Ketoacidosis in perioperative period
is associated with very poor outcomes; Avoid at all costs

56
Q

Diabetes Mellitus

o Minor Surgery

A

Stop Preop Insulin if IDDM; Monitor sugar 4hrly, Restart when oral
diet re-established

57
Q

Diabetes Mellitus

Major Surgery

A

Omit long acting Hypoglycaemics; Monitor sugar 4hrly, if >15mmol/L
start IV Insulin regimen; If IDDM, Commence on IV Insulin S/S once NBM, and
continue until normal diet; Restart insulin at half dose initially once oral diet

58
Q

Diabetes Mellitus Emergency Surgery

A

Postpone surgery to <20mmol/L unless emergent

59
Q

Previous MI

A

Non-urgent surgery should be delayed for 6/12 following acute MI where
possible; Ensure normal CVS medication continued through surgery

60
Q

Previous CVA

A

Non-urgent surgery should be delayed 6/52 after infarcts; Omit
Thromboprophylaxis if previous Haemorrhagic event, Avoid head-down positioning

61
Q

Smokers

A

Ensure well hydration; Thromboprophylaxis; Preoperative Chest Physio; Early mobilisation; Consider regional anaesthesia to assist in PT; Ensure post-op PT effective

62
Q

Renal Impairment

A

Avoid Hypovolaemia, Hypotension, Nephrotoxicity; Lower dose of drugs
with Renal Elimination (E.g. Morphine, LMWH)
o If on Dialysis – Dialysis on day before surgery; U/Es twice daily after major surgery

63
Q

Post-Operative Pyrexia

A

Defined as >38oc on 2 consecutive days or >39oc on any postoperative day

64
Q

5Ws of Postoperative Pyrexia

A

Respiratory = Wind (Postop 1-2), UTI = Water (Postop 3-5),
VTE = Walking (Postop 4-6), Site infection = Wound (Postop 5-7), Iatrogenic/Drugs = “What
did we do?” (Postop 7+)
o Most common cause 48 hours post-op is Pyretic Response to surgery
o Other causes – Abscesses, Foreign body, C diff colitis, Haematoma, Osteomyelitis
o Investigations are 48 hours – FBC, CXR, MC&S, Blood and wound cultures

65
Q

Malignant Hyperpyrexia

A

Associated with halogenated anaesthetic and paralytics
(particularly succinylcholine); Linked to Ryanodine Receptor (RYR) gene
o Treated with Dantrolene; Depression of excitation-contraction coupling of skeletal muscle by binding to RYR
o Also associated with Non-haemolytic transfusion reactions and TRALI

66
Q

Sepsis

A

=Life Threatening Organ Dysfunction due to dysregulated Host Response to Infection
o Defined as increase in 2 points or more in SOFA score; Every increase adds 10%
mortality; QSOFA is 2 or more of Hypotension, Altered Mental and Tachypnoea
o Septic Shock – Underlying Circulatory and Cellular/Metabolic Abnormalities profound
enough to cause increased mortality
▪ Persistent Hypotension requiring Vasopressors to achieve MAP>65 and
Lactate >2mmol/L; Mortality in excess of 40%

67
Q

Sepsis presentation

A

Pyrexia, Rigors, Hypothermia, Nausea, Vomiting, Vasodilation, Warm
peripheries; Bounding Pulse, Rapid Capillary Refill, Hypotension (Septic Shock)

68
Q

Sepsis Six

A

Maintenance of oxygen delivery, Blood cultures, IV Empirical antibiotics, Test for
Serum Lactate and FBC, Volume resuscitation (±Hypervolaemia), Urine output measurement

69
Q

Sepsis Additional Management

A

Inotropic (+Vasodilatory) support, Organ support – Renal, Hepatic, Enteral support

70
Q

Acute Lung Injury (ALI)

A

• ALI – Acute onset, PaO2/FiO2 <300, CXR with bilateral infiltrates, PAWP <18mmHg, no
evidence of raised left atrial pressures (not due to Heart failure)
• May progress to ARDS – PaO2/FiO2 <200
• Management by prone ventilation, aggressive diuresis, early ultrafiltration

71
Q

Wound Infection

A

Most wound infections are due to commensal organisms e.g. S. aureus, S epidermidis; or GI
tract organisms e.g. E coli, Pseudomonas from the biliary tree
o Treat as septic shock; Investigate any pus/discharge for MC&S, Blood cultures, FBC
o If no pre-existing infections – Treat with anti-staphylococcus antibiotics (e.g.
Flucloxacillin), if immunocompromised use broad spectrum with anaerobic cover (e.g.
Metronidazole and Cefuroxime); consider Vancomycin if MRSA is suspected, with
drug plasma monitoring

72
Q

Wound Dehiscence

A

Breaking open of the incision along its suture; May be superficial (Skin
and subcutaneous) or full thickness (Fascia or bone), may cause protrusion (Evisceration)
o Most secondary to wound infection
o associated with immunosuppression, malnutrition, steroid use, poor surgical
technique or previous surgery, or intracavity pathology
o If superficial, ensure wound is open and drain any pus, pack with absorbent dressing
o If deep, cover exposed viscera with saline soaked dressing initially
▪ Resuturing or closure if appropriate; inappropriate in the presence of
infection, immunocompromise, instability or intracavity pathology
▪ Closure by secondary intention ± Vacuum closure devices

73
Q

Post-Operative Haemorrhage

A

More commonly venous bleeding due to opening of venous channels or damage to liver/spleen – Non-pulsatile, low pressure and darker in colour but significant amount

74
Q

Primary Haemorrhage

A

Usually due to unsecured blood vessels; occurs immediately after surgery or continuation of intraoperative bleeding

75
Q

Reactionary Haemorrhage

A

First 24hrs; Might be due to improved post-operative

circulation and fluid volume

76
Q

Secondary Haemorrhage

A

Infection of wound leading to clot disintegration

77
Q

Post-Operative Haemorrhage management

A

• Managed with IV crystalloid replacement, direct compression (NB: Do not use tourniquets on limb wounds), emergency crossmatch for a minimum of 2 units
o If bleeding is severe reoperation might be necessary for diagnosis
o If reoperation is highly undesirable conservative management can be considered –
Radiologically guided embolism, FFP infusions, Permissive Hypotension and ITU
o Haematoma formation after vascular/flap/limb/neck surgery needs to be explored
and evacuated to avoid ischaemia, compartment syndrome, flap failure etc

Surgery and Surgical Specialties (10 decks)

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