Pre-Operative Management Flashcards
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RAPRIOP
Reassurance
Advice
Prescription
Referral
Investigations
Observetations
Patient understanding and follow-up
How long should fasting be before surgery?
Usually 6 hours before
That goes for dairy products including tea and coffee
When should you stop clear fluids before surgery?
2h before
Why is fasting important before surgery?
Stomach will be empty.
This reduces risk of pulmonary aspiration that can lead to aspiration pneumonitis and aspiration pneumonia of gastric contents.
Give examples of commonly stopped drugs prior to surgery
CHOW
Clopidogrel
Hypoglycaemic agents
Oral contraceptive pill or HRT
Warfarin
When is clopidogrel stopped?
7 days prior to surgery due to bleeding risk
Aspirin and other anti-platelets can of be continued.
When is C/OCP or HRT stopped?
4 weeks before surgery due to DVT risk
When is warfarin stopped?
5 days prior to surgery and commenced on therapeutic dose of LMWH instead.
What is the cutoff INR to allow for surgery?
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.
Drugs to alter prior to surgery
Subcut insulin should be switched to IV
Long-term steroids should possible changed to IV if the patient cannot tolerate it orally.
What is the conversion rate of 5mg PO prednisolone to IV hydrocortisone?
5mg PO pred = 20mg IV hydrocortisone
What are people on steroids at risk of during surgery?
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.
Drugs to start pre-op
LMWH
TED stockings
Antibiotic prophylaxis
When should LMWH be commenced?
5 days prior to surgery.
When should LMWH not be commenced?
Any contraindications to it.
Neck or endocrine surgery
Some patients should be discharged with TED stockings and 28 days of prophylactic LMWH.
Which?
Major GI surgery for cancer
This includes oesophageal, gastic, pancreatic, liver and colonic resection
Lower limb joint replacement should also get the same treatment.
All patients should receive TED stockings, except for which?
Vascular surgery patients
Contraindications of TED stocks
Severe peripheral vascular disease
Peripheral neuropathy
Recent skin graft
Severe eczema
When to start abx prophylaxis (which surgeries)?
Orthopaedic
Vascular
GI
Explain the operative management of T1DM
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.
Explain operative management of T2DM if on oral hypoglycaemics.
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.
When is bowel prep needed?
Left hemi-colectomy, sigmoid colectomy, or abdominal-perineal resection
Anterior resection should also have bowel prep.
When is bowel prep not needed?
Upper GI, HPB or small bowel surgery.
Right hemi-colectomy or extended right hemi-colectomy.
Bowel prep for left hemi-colectomy, sigmoid colectomy or abdominal-perineal resection bowel prep.
Phosphate enema on the morning of surgery
Bowel prep for anterior resection.
2 sachets of picolax the day before or phosphate enema on the morning of surgery.
In what surgeries is it essential to have group and save?
Major GI, HPB, vascular, gynaecological or orthopaedic
Other will need cross-matching.
