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Revision > Pre, peri and post op care > Flashcards

Pre, peri and post op care Flashcards

1
Q

what are the risk factors for wound dehiscence

A

patient factors

  • increasing age
  • male gender
  • co-morbidities - DM
  • steroids
  • smoking
  • obesity

intra-operative factors

  • emergency surgery
  • abdo surgery
  • length of op
  • wound infection
  • poor surgical technique

post-op factors

  • prolonged ventilation
  • post op blood transfusion
  • poor tissue perfusion
  • excessive coughing
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2
Q

what factors impair wound healing

A

reduced blood flow - DM, atherosclerosis

infections

immunosuppression

oedema

smoking

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3
Q

what is a sign of wound dehiscence

A

pink haemoserous discharge coming from wound

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4
Q

what are the 2 stages of wound healing

A

Tissue Regeneration involves the complete regeneration of a tissue with a normal function and structure.

Tissue Repair involves connective tissue formation, leading to the development of a scar.

This occurs as a result of an inflammatory process causing dead cells to be cleared and the release of growth factors for repair.

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5
Q

what are the 2 types of wound healing

A

primary intention

secondary intention

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6
Q

what is primary intention wound healing

A

This is where an injury is limited to an epithelial layer and is repaired by tissue regeneration.

This occurs when the edges of a wound are brought together, such as when a wound margin is sutured together.

This will lead to minimal scarring.

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7
Q

what is secondary intention wound healing

A

This is where there is more extensive tissue losses and leads to repair by regeneration and scarring as the healing must occur from the bottom of the wound upwards.

This occurs when wound edges are too far from each other, which can occur as a result of significant tissue loss.

This can lead to significant scarring and restricted function.

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8
Q

what is wound dehiscence

A

wound fails to heal following surgery and often re-opens a few days following surgery

often occurs after abdo surgery

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9
Q

what are the 2 clinical entities of wound dehiscence

A

superficial dehiscence

  • skin wound fails to heal but the rectus sheath remains intact
  • This often occurs as a result of a secondary local infection, poorly controlled diabetes mellitus or poor nutritional status

full thickness dehiscence

  • This is where the rectus sheath fails to heal and bursts, with protrusion of abdominal contents, often termed a burst abdomen
  • This can occur secondarily to a raised intra-abdominal pressure, poor surgical technique, or if the patient is critically unwell.
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10
Q

what is the most common cause of wound dehiscence

A

infection

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11
Q

management of superficial dehiscence

A

washing out wound

simple wound care to prevent infection

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12
Q

management of full thickness dehiscence

A

analgesia
broad spectrum abx

cover wound in saline soaked gauze
return patient to theatre to close wound with large interrupted sutures

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13
Q

what is a keloid scar

A

during the healing process, there is excessive collagen deposition
leads to a raised scar which grows beyond the margins of the original wound
more common for afro-carribean ethnicity

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14
Q

management of a wound or laceration

A

haemostasis - injury pressure, tourniquet, elevation, suturing

cleaning wound - disinfecting, debriding, irrigating, abx

analgesia

skin closure - bringing edges together allows healing via primary intention (reduces size of scar), using adhesive strips, sutures, staples

dressing and follow up advice - correct dressing, keep wound dry, avoid heavy lifting

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15
Q

what is the VTE assessment

A

includes qs for thrombosis risk and bleeding risk

weighs up the two to see if prophylactic VTE medication is required

thrombosis risk

  • cancer or cancer treatment
  • > 60
  • thrombophilia
  • dehydration
  • obesity
  • 1 or more significant co-morbidities
  • hx of past VTE
  • HRT
  • COCP
  • varicose veins with phlebitis
  • pregnancy
  • 6 weeks post partum

bleeding risk

  • active bleeding
  • acquired bleeding disorder
  • use of anticoagulants
  • acute stroke
  • thrombocytopenia
  • unctrolled systolic hypertension
  • inherited bleeding disorder (untreated)
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16
Q

what are the admission related risks included on a VTE assessment

A

thrombosis risk

  • reduced motility for 3+ days
  • hip or knee replacement
  • hip fracture
  • surgery time >90 mins
  • surgery involving pelvis or lower limb and >60 mins
  • critical care admission

bleeding risk

  • neurosurgery, spinal surgery, eye surgery
  • lumbar puncture/spinal anaesthesia within next 12 hours or previous 4 hours
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17
Q

if a patient is at a high risk of VTE, what do they receive

A

VTE stockings - reduce risk of thrombus by increasing venous blood flow

intermittent pneumatic compression devices - mechanically compress calves to reduce stasis and reduce risk of thrombus forming

LMWH (enoxaparin) - limits clotting

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18
Q

contraindications for VTE stocking

A

peripheral artery disease

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19
Q

cautious with LMWH for what patient groups

A

CKD - renally excreted

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20
Q

what is antibiotic prophylaxis

A

abx administered before surgery

commonly given before orthapaedic, vascular or GI surgery

GI at georges = metronidazole

21
Q

what is bowel prep

A

involves a patient fasting and taking laxatives to ensure the colon is empty

done for colonoscopy to allow for clear surgical view

22
Q

what is a pre-op assessment

A

allows for the identification of potential problems - minimise their impact and maximise patient health before surgery

takes place 2-4 weeks before elective procedure

23
Q

what are the 3 grades of surgery

A

minor - draining of abscess

intermediate - hernia repair

major/complex - hysterectomy, lung op

24
Q

how are patients graded and what is the system

A

ASA (american society of anesthesioogists)

ASA 1 - normal healthy patient

ASA 2 - patient with mild systemic disease (well controlled asthma, DM, smoker)

ASA 3 - patient with severe systemic disease (poorly controlled diabetes)

ASA 4 - patient with severe systemic disease which is a constant threat to life (cardiac ischaemia, severe valve dysfunction)

ASA 5 - patient not expected to survive without op (ruptured AA, massive trauma)

ASA 6 - declared brain dead patient (organs being removed for donor purposes)

25
Q

what aspects are included in the pre-op assessment

A

comprehensive hx

  • ask about MI, diabetes, asthma, hypertension, epilepsy, jaundice, COPD
  • pregnancy
  • smoking and alcohol intake
  • drug allergies
  • previous surgeries

examination

  • look for CVS, resp, abdo signs
  • airway examination to determine if they will be difficult to intubate - Mallampati classifiction
26
Q

tests to do before the op

A

bedside

  • pregnancy test
  • blood glucose
  • ECG (if >55)
  • urinalysis

Bloods

FBC - anaemia, thrombocytopenia, infection
U&Es - baseline renal function for post op fluids
LFTs - baseline liver function = jaundice, malignancy, alcohol abuse
coagulation screen - risk of bleeding during surgery = liver/renal disease
crossmatch - identify blood group and unit allocated = anticipated blood loss
group and save - identify blood group but blood only dispensed if required
TFTs - for thyroid disease
sickle cell test -afro carribbean

imaging

CXR
echocardiogram
lateral cervical spine XR

special

spirometry - baseline lung function
MRSA swab

27
Q

patient on COCP what should she do pre-op

A

stop COCP 4 weeks before surgery

then restart 2 weeks after

28
Q

what is the nil by mouth rule

A

patient should not drink any clear fluids 2 hours before surgery
patient should drink after 6 hours post surgery

reduced risk of pulmonary aspiration

29
Q

what drugs need to be stopped before surgery (CHOW)

A

clopidogrel - stp 7 days before

hypoglycaemics

oral CP

warfarin - stop 5 days before

30
Q

what drugs are often altered for surgery

A

subcutaneous insulin - changed to IV

long term steroids - continue due to risk of addisonian crisis (patient may need additional steroids during op)

31
Q

peri-op care - what are surgical patients at risk of

A

fluid depletion

loss of fluid due to

1) fasting prior to op
2) blood loss during op
3) loss through vomitting and diarrhoea

32
Q

what is the daily requirement of Na and.K for surgical patients

A

1-2mmol of Na

0.5-1 mmol of K

33
Q

what are the post-op complications

A 
pneumonia 
infection/sepsis 
haemorrhage 
N&V
pyrexia
ARDS
atelectasis 
constipation 
surgical site infection 
delirium
AKI
34
Q

why are post-op patients at risk of penumonia

A

reduced chest ventilation - in bed
debilitation - immunocomprimised
intubation and ventilation

35
Q

how to treat someone with post op pneumonia

A

co-amox oral or tazocin IV

36
Q

what is aspiration pneumonia and pneumonitis

A

aspiration of stomach contents into lungs = affects right middle and lower lobes

pneumonia = gastric contents cause infection of lungs

pneumonitis = gastric contents cause damage and inflamm (supportive management)

37
Q

what are the 3 categories of post op haemorrhage

A

primary bleeding - occurs within intra-op period

reactive bleeding - within 24 hours of op

secondary bleeding - 7-10 days post op (erosion of blood vessel)

38
Q

management for post op N&V

A

prophylaxis - antiemetic therapy, avoid opiates

conservative measures - fluids, analgesia

pharmaceutical measures - anti emetics = metoclopramide, ondansetron, cyclizine

39
Q

post op pyrexia - causes and source of infection

A

due to infection

day1-2 = resp
day 3-5 = UT source
day 5-7 = surgical site collection

any day post op = infected central lines of IV lines

40
Q

what is acute resp distress syndrome

A

acute lung injury - severe hypoxaemia with no cardiogenic cause

inflammatory damage to alveoli -> pulmonary oedema and resp failure

41
Q

causes of ARDS

A

direct = pneumonia, smoke inhalation, aspiration

indirect = sepsis, acute pancreatitis, major burns

42
Q

how would someone with ARDS present

A

worsening SOB
rapid hypoxia
tachypnoea
inspiratory crackles on auscultation

43
Q

what will a patient with ARDS require

A

CXR - looks like pulmonary oedema

ventilation - intubation and ITU

poor prognosis

44
Q

what is post op atelectasis and how is it caused

A

partial collapse of small airways

due to a combination of airway compression and impairment of surfactant production

predisposes patients to developing more severe pulmonary complications such as hypoxaemia, reduced lung compliance, pulmonary infections and acute respiratory failure

45
Q

post op constipation management

A 
conservative 
hydration 
sufficient dietary fibre 
early mobilisation 
laxatives
46
Q

different types of laxatives

A

osmotic - lactulose
stimulant - senna (bowel contract)
bulk forming
rectal - phosphate enema

47
Q

features of surgical site infection

A 
spreading erythema 
localised pain 
pus/discharge 
wound dehiscence 
persistent pyrexia
48
Q

post op AKI

A

present with decreased urine output

must review fluid chart for signs of volume depletion

often caused by urinary retention

Revision (20 decks)

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