Pre, peri and post op care Flashcards
what are the risk factors for wound dehiscence
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
what factors impair wound healing
reduced blood flow - DM, atherosclerosis
infections
immunosuppression
oedema
smoking
what is a sign of wound dehiscence
pink haemoserous discharge coming from wound
what are the 2 stages of wound healing
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.
what are the 2 types of wound healing
primary intention
secondary intention
what is primary intention wound healing
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.
what is secondary intention wound healing
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.
what is wound dehiscence
wound fails to heal following surgery and often re-opens a few days following surgery
often occurs after abdo surgery
what are the 2 clinical entities of wound dehiscence
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.
what is the most common cause of wound dehiscence
infection
management of superficial dehiscence
washing out wound
simple wound care to prevent infection
management of full thickness dehiscence
analgesia
broad spectrum abx
cover wound in saline soaked gauze
return patient to theatre to close wound with large interrupted sutures
what is a keloid scar
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
management of a wound or laceration
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
what is the VTE assessment
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)
what are the admission related risks included on a VTE assessment
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
if a patient is at a high risk of VTE, what do they receive
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
contraindications for VTE stocking
peripheral artery disease
cautious with LMWH for what patient groups
CKD - renally excreted
what is antibiotic prophylaxis
abx administered before surgery
commonly given before orthapaedic, vascular or GI surgery
GI at georges = metronidazole
what is bowel prep
involves a patient fasting and taking laxatives to ensure the colon is empty
done for colonoscopy to allow for clear surgical view
what is a pre-op assessment
allows for the identification of potential problems - minimise their impact and maximise patient health before surgery
takes place 2-4 weeks before elective procedure
what are the 3 grades of surgery
minor - draining of abscess
intermediate - hernia repair
major/complex - hysterectomy, lung op
how are patients graded and what is the system
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)
what aspects are included in the pre-op assessment
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
tests to do before the op
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
patient on COCP what should she do pre-op
stop COCP 4 weeks before surgery
then restart 2 weeks after
what is the nil by mouth rule
patient should not drink any clear fluids 2 hours before surgery
patient should drink after 6 hours post surgery
reduced risk of pulmonary aspiration
what drugs need to be stopped before surgery (CHOW)
clopidogrel - stp 7 days before
hypoglycaemics
oral CP
warfarin - stop 5 days before
what drugs are often altered for surgery
subcutaneous insulin - changed to IV
long term steroids - continue due to risk of addisonian crisis (patient may need additional steroids during op)
peri-op care - what are surgical patients at risk of
fluid depletion
loss of fluid due to
1) fasting prior to op
2) blood loss during op
3) loss through vomitting and diarrhoea
what is the daily requirement of Na and.K for surgical patients
1-2mmol of Na
0.5-1 mmol of K
what are the post-op complications
pneumonia infection/sepsis haemorrhage N&V pyrexia ARDS atelectasis constipation surgical site infection delirium AKI
why are post-op patients at risk of penumonia
reduced chest ventilation - in bed
debilitation - immunocomprimised
intubation and ventilation
how to treat someone with post op pneumonia
co-amox oral or tazocin IV
what is aspiration pneumonia and pneumonitis
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)
what are the 3 categories of post op haemorrhage
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)
management for post op N&V
prophylaxis - antiemetic therapy, avoid opiates
conservative measures - fluids, analgesia
pharmaceutical measures - anti emetics = metoclopramide, ondansetron, cyclizine
post op pyrexia - causes and source of infection
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
what is acute resp distress syndrome
acute lung injury - severe hypoxaemia with no cardiogenic cause
inflammatory damage to alveoli -> pulmonary oedema and resp failure
causes of ARDS
direct = pneumonia, smoke inhalation, aspiration
indirect = sepsis, acute pancreatitis, major burns
how would someone with ARDS present
worsening SOB
rapid hypoxia
tachypnoea
inspiratory crackles on auscultation
what will a patient with ARDS require
CXR - looks like pulmonary oedema
ventilation - intubation and ITU
poor prognosis
what is post op atelectasis and how is it caused
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
post op constipation management
conservative hydration sufficient dietary fibre early mobilisation laxatives
different types of laxatives
osmotic - lactulose
stimulant - senna (bowel contract)
bulk forming
rectal - phosphate enema
features of surgical site infection
spreading erythema localised pain pus/discharge wound dehiscence persistent pyrexia
post op AKI
present with decreased urine output
must review fluid chart for signs of volume depletion
often caused by urinary retention
