Pre-, Peri- and Post-Operative Care

Question 1

Pre-operative considerations

Answer 1

History:
Presenting complaint
Comorbidities
Medications and allergies
Past surgical history
Exercise tolerance
Fit for GA - is spinal or LA an option?
Exam

Question 2

Pre-operative investigations

Answer 2

Observations
Urine
Bloods
Imaging

Question 3

ASA guidelines

Answer 3

ASA I: a normal, healthy patient
ASA II: a patient with mild systemic disease
ASA III: a patient with severe systemic disease
ASA IV: a patient with severe systemic disease that is a consistent threat to life
ASA V: a morbid patient who is not expected to survive without the operation
ASA VI: brain dead, organ harvesting

Question 4

Consent factors for surgery

Answer 4

Risks, benefits, alternate options

Surgeon must be experienced in condition and procedure

Patient must be competent to consent
(understand, weigh up info, make a decision and communicate it)

Question 5

DVT prophylaxis

Answer 5

LMWH is routine for DVT prophylaxis

Virchow’s triad:
Stasis of blood flow
Endothelial injury
Hypercoagulablity

Question 6

Assessing fluid requirements

observations, examination, bloods

Answer 6

Obs: pulse, BP, UO, stool chart

Exam: mucous membranes, cap refil, pulse, resp rate/oxygen, JVP

Blood: renal function

Question 7

Normal urine output

Answer 7

0.5ml/kg/hr

Question 8

Nutrition in surgical patients

Answer 8

Surgical patients are metabolically stressed and have increased energy requirements

Question 9

Surgical consequences of malnutrition

Answer 9

Increased infection rates
Slower healing
Wound breakdown/dehiscence
Poor mobility
Death

Question 10

Analgesia pain ladder

Answer 10

Paracetamol
NSAIDs
Codeine
Tramadol
Morphine (mode of delivery)

Question 11

Safe administration of analgesia

Answer 11

Weight of patient
Max safe dose for each LA
Concentration
Is it affecting an end artery
Signs of overdose/toxicity

Question 12

Immediate post-operative complications

Answer 12

Bleeding
Ischaemia
Pain
Aspiration
Structure-related damage
Fluid balance

Question 13

Early post-operative complications

Answer 13

Infection
Wound related
DV/PE
MI
Electrolyte abnormalities
Ileus
Pressure sores

Question 14

Late post-operative complications

Answer 14

Collections
Wound dehiscence
DVT/PE
MI/HF
Scar-related
Nutrition-related

Question 15

What is the aim of antibiotic prophylaxis?

Answer 15

Prevention of surgical site infections

Question 16

Surgery that requires antibiotic prophylaxis

Answer 16

Clean surgery involving the placement of a prosthesis or implant

Clean-contaminated surgery

Contaminated surgery

Surgery on a dirty or infected wound (requires antibiotic treatment in addition to prophylaxis)

Question 17

Surgical site infection epidemiology

Answer 17

~20% of elective surgery

~60% of emergency surgery

Question 18

Principles of antibiotic prophylaxis in surgery

Answer 18

Time administration correctly (e.g. IV prophylaxis 30 min before knife to skin to maximise skin concentration, metro PR 2hrs before)

Use antibiotics which will kill anaerobes and coliforms

Practise strictly sterile technique