Pre-Operative Management Flashcards
General principles for pre-op management?
RAPRIOP Reassurance Advice Prescriptions Referral Investigations Observations Patient Understanding and follow up
What advice would you give pre-op patients? Why?
Fasting:
- stop eating 6 hours before
Stop dairy - 6 hours before
Stop clear fluids 2 hours before
This ensures that stomach is empty, reducing the risk of pulmonary aspiration leading to aspiration pneumonitis/pneumonia
How would you manage a patiets prescription pre-op?
Drugs to stop
Drugs to alter
Drugs to start
What drugs are stopped pre-op? When? Why?
CHOW
Clopidogrel - stopped 7 days prior to surgery due to bleeding risk, aspirin and other anti-platelets can be continued
Hypoglycaemics
OCP/HRY - stopped 4 weeks prior to surgery due to DVT risk - alternative contraception in this time
Warfarin - 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose of LMWH.
What must the INR be for surgery to go ahead? How can this be achieved?
INR<1.5
Use PO vitamin K to reverse warfarinisation
What drugs will be altered pre-op?
Subcut insulin - switched to IV variable rate insulin infusion
Long term steroids - must be continued - switch to IV if patient cannot take orally
(5mg PO prednisone = 20mg IV hydrocortisone
What drugs should be commenced pre-op?
Low molecular weight heparin
- VTE risk assessment
Patients undergoing major GI cancer surgery or lower limb joint replacement discharged with TEDs and 28 days of prophylactic LMWH
TED stockings - all patients receive below knee TED stocking
Contraindications - PVD, peripheral neuropathy, recent skin graft, eczema
Antibiotic prophylaxis
Note: blood products must be prescribed
How should insulin be altered in type 1 Diabetics?
Night before surgery - reduce submit basal insulin dose by 1/3rd
Omit morning insulin and commence an IV variable rate insulin infusion pump (sliding scale)
Whilst patient is nil by mouth, prescribe infusion of 5% dextrose, given at 125ml/hr Check BM every 2 hours and alter infusion rate accordingly
Continue until patient is able to eat and drink.
Overalp IV variable rate insulin infusion stopping and normal SC insulin regimens starting
How should oral hypoglycaemic be altered in T2DMs?
Stop metformin on the morning of the surgery
All pottery oral hypoglycaemic stopped 24 hours before operation
Patients put on IV VRIII with 5% dextrose and managed as if type 1
What is bowel preparation?
Laxatives or enemas to clean colon pre-operatively
Bowel preparation is used less frequently as the fluid shifts can be harmful to patients.
What should be considered for referral?
HDU/ITU bed
