Pre & Post Op Flashcards
What is the ASA classification?
A tool to assess fitness of patients prior to surgery
What are the pre-operative considerations?
- Last meal - NBM >6 hours 2. Routine vitals 3. IV fluids (reduces risk of cardioresp complications) 4. Review regular medications - particular note to oral hypoglycaemics and insulin, steroids, anti-coagulants 5. Chart prophylactic surgical antibiotics 6. DVT prophylaxis 7. Smoking cessation (preferably 6-8 weeks prior to surgery) 8. Treat remote infection and delay elective surgery until infection controlled 9. Consider NGT and IDC
Pre-operative investigations
Blood group and hold and cross match, coags (INR/PT, PTT), FBC, UEC, LFTs, ABGs + PFTs (if resp insufficiency), CXR, ECG, B-hCG testing in all women of reproductive age
Indications & contraindications to NGT
Indications: gastric decompression, analysis of gastric contents, irrigation/dilution of gastric contents, to test anastomosis for leak, feeding (aspiration risk) Contraindications: basal skull fracture, obstruction of nasal passages due to trauma
How can you prevent complications during the post-operative period?
- Frequent examination of he patient and their wound 2. Remove surgical tubes ASAP 3. Early ambulation 4. Monitor fluid balance and electrolytes 5. Analgesia 6. Skillful nursing care
5 Ws of post-oeprative fever
WIND: POD #1-2 (pulmonary- atelectasis, pneumonia) WATER: POD #3-5 (urine-UTI) WOUND: POD #5-8 (any early = streptococcal or clostridial infection) WALK: POD #8+ (thrombosis = DVT/PE) WONDER DRUGS: POD #1+ (drug)
SIRS criteria
≥ 2 meets SIRS of following: 1. Temp >38°C or 90 3. Respiratory Rate > 20 or PaCO2 12,000/mm3, 10% bands
Sepsis Criteria
- SIRS (temp, HR, RR, WBC) + 2. Suspected or present source of infection
Severe Sepsis Criteria
Sepsis + evidence of organ dysfunction, hypotension, or hypoperfusion 1. Lactic acidosis 2. SBP 40mmHg of normal
Septic Shock Criteria
Severe sepsis (see other cards for full criteria) with hypotension despite adequate fluid resuscitation
What medications may blunt a post-op fever?
Chemotherapy, glucocorticoids or immunosuppression
What may cause a fever hours after surgery?
- SIRS/inflammatory response to trauma from surgery - Reaction to blood products received during surgery - Malignant hyperthermia (GA gases or neuromuscular blocking agents)
What causes a fever day 1-2 post op? (acute)
- Atelectasis - Early wound infection - clostridium, GAS - feel for crepitus and look for “dishwater” drainage (necrotising fasciitis) - Aspiration pneumonitis - Other: Addisonian crisis, thyroid storm, transfusion reaction
What causes a fever day 3-7 post op? (subacute)
INFECTION - UTI - Surgical site (wound) infection - IV site/line infection - Septic thrombophlebitis - Leakage at bowel anastomosis
What causes a delayed fever day 8+ post op?
- Intra-abdominal abscess - DVT/PE (most commonly POD 8-10 but can be anytime post-op) - Other: cholecystitis, peri-rectal abscess, URTI, infected seroma/biloma/haematoma, parotitis, C. difficile colitis, endocarditis, sinusitis (NGT)
Clinical features of wound dehiscence
POD 1-3 Serosanguinous or salmon colored drainage from wound
Risk factors for wound dehiscence
Local: technical failure of closure; increased intraabdominal pressure (COPD, ileus, bowel obstruction); haematoma, infection, poor blood supply, radiation, patient not fully paralyzed while closing, transverse incision Systemic: smoking, malnutrition (hypoalbuminaemia, vitamin C deficiency), connective tissue diseases, immunosuppressive, pulmonary disease, ascites, poor nutrition, steroids, chemotherapy, obesity, other - age, sepsis, uraemia.
What is evisceration?
Protrusion of abdominal contents through abdominal wall - “burst abdomen”. Surgical emergency as carries a mortality rate up to 45%
Risk factors for wound haematoma
Anticoagulant therapy, coagulopathies, thrombocytopenia, DIC, severe liver disease, myeloproliferative disorders, severe arterial HPTN, severe cough
Prophylaxis against wound infection
Pre-op antibiotics (cephazolin + metronidazole), normothermia, hyperoxygenation, chlorhexidine-alcohol wash, protect skin edges, hair removal only if necessary (clip>shaving)
Most common cause of oliguria/anuria post operatively
Prerenal +/- ischemic acute tubular necrosis
