Pre-Operative Management

Question 1

c

Answer 1

RAPRIOP

Reassurance

Advice

Prescription

Referral

Investigations

Observetations

Patient understanding and follow-up

Question 2

How long should fasting be before surgery?

Answer 2

Usually 6 hours before

That goes for dairy products including tea and coffee

Question 3

When should you stop clear fluids before surgery?

Answer 3

2h before

Question 4

Why is fasting important before surgery?

Answer 4

Stomach will be empty.

This reduces risk of pulmonary aspiration that can lead to aspiration pneumonitis and aspiration pneumonia of gastric contents.

Question 5

Give examples of commonly stopped drugs prior to surgery

Answer 5

CHOW

Clopidogrel

Hypoglycaemic agents

Oral contraceptive pill or HRT

Warfarin

Question 6

When is clopidogrel stopped?

Answer 6

7 days prior to surgery due to bleeding risk

Aspirin and other anti-platelets can of be continued.

Question 7

When is C/OCP or HRT stopped?

Answer 7

4 weeks before surgery due to DVT risk

Question 8

When is warfarin stopped?

Answer 8

5 days prior to surgery and commenced on therapeutic dose of LMWH instead.

Question 9

What is the cutoff INR to allow for surgery?

Answer 9

Surgery often only goes ahead if INR <1.5

This means that PO vitamin K might have to be given the evening before if INR remains high.

Question 10

Drugs to alter prior to surgery

Answer 10

Subcut insulin should be switched to IV

Long-term steroids should possible changed to IV if the patient cannot tolerate it orally.

Question 11

What is the conversion rate of 5mg PO prednisolone to IV hydrocortisone?

Answer 11

5mg PO pred = 20mg IV hydrocortisone

Question 12

What are people on steroids at risk of during surgery?

Answer 12

Acute adrenal insufficiency peri-operatively as they might not be able to mount a sufficient endogenous steroid response.

This means that they might need peri-operative corticosteroid therapy.

Question 13

Drugs to start pre-op

Answer 13

LMWH

TED stockings

Antibiotic prophylaxis

Question 14

When should LMWH be commenced?

Answer 14

5 days prior to surgery.

Question 15

When should LMWH not be commenced?

Answer 15

Any contraindications to it.

Neck or endocrine surgery

Question 16

Some patients should be discharged with TED stockings and 28 days of prophylactic LMWH.

Which?

Answer 16

Major GI surgery for cancer

This includes oesophageal, gastic, pancreatic, liver and colonic resection

Lower limb joint replacement should also get the same treatment.

Question 17

All patients should receive TED stockings, except for which?

Answer 17

Vascular surgery patients

Question 18

Contraindications of TED stocks

Answer 18

Severe peripheral vascular disease

Peripheral neuropathy

Recent skin graft

Severe eczema

Question 19

When to start abx prophylaxis (which surgeries)?

Answer 19

Orthopaedic

Vascular

GI

Question 20

Explain the operative management of T1DM

Answer 20

Night before surgery -> Reduce subcut basal insulin by 1/3rd.
Omit morning insulin
Commence IV variable rate insulin infusion pump (sliding scale) (49.5ml of normal saline and 50 units of Actrapid)

When the patient is NBM prescribe 5% dextrose at 125ml/hr.
Nurse should do capillary glucose every 2hrs
This should be continued until they are able to eat and drink.

Once able to eat and drink overlap IV insulin sliding scale stopping and starting of subcut.
Give subcut rapid acting insulin 20min before meal and stop their IV infusion 30-60 min after they have eaten.

Question 21

Explain operative management of T2DM if on oral hypoglycaemics.

Answer 21

Metformin should be stopped on the morning of surgery.

If they are on any other oral hypoglycaemics, they should be stopped 24hrs before.

Patients are then put on IV insulin sliding scale with 5% dextrose as described above and managed peri-op the same as a type 1 diabetic.

Question 22

When is bowel prep needed?

Answer 22

Left hemi-colectomy, sigmoid colectomy, or abdominal-perineal resection

Anterior resection should also have bowel prep.

Question 23

When is bowel prep not needed?

Answer 23

Upper GI, HPB or small bowel surgery.

Right hemi-colectomy or extended right hemi-colectomy.

Question 24

Bowel prep for left hemi-colectomy, sigmoid colectomy or abdominal-perineal resection bowel prep.

Answer 24

Phosphate enema on the morning of surgery

Question 25

Bowel prep for anterior resection.

Answer 25

2 sachets of picolax the day before or phosphate enema on the morning of surgery.

Question 26

In what surgeries is it essential to have group and save?

Answer 26

Major GI, HPB, vascular, gynaecological or orthopaedic

Other will need cross-matching.