Pre & Post Op

Question 1

What is the ASA classification?

Answer 1

A tool to assess fitness of patients prior to surgery

Question 2

What are the pre-operative considerations?

Answer 2

1. 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

Question 3

Pre-operative investigations

Answer 3

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

Question 4

Indications & contraindications to NGT

Answer 4

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

Question 5

How can you prevent complications during the post-operative period?

Answer 5

1. 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

Question 6

5 Ws of post-oeprative fever

Answer 6

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)

Question 7

SIRS criteria

Answer 7

≥ 2 meets SIRS of following: 1. Temp >38°C or 90 3. Respiratory Rate > 20 or PaCO2 12,000/mm3, 10% bands

Question 8

Sepsis Criteria

Answer 8

1. SIRS (temp, HR, RR, WBC) + 2. Suspected or present source of infection

Question 9

Severe Sepsis Criteria

Answer 9

Sepsis + evidence of organ dysfunction, hypotension, or hypoperfusion 1. Lactic acidosis 2. SBP 40mmHg of normal

Question 10

Septic Shock Criteria

Answer 10

Severe sepsis (see other cards for full criteria) with hypotension despite adequate fluid resuscitation

Question 11

What medications may blunt a post-op fever?

Answer 11

Chemotherapy, glucocorticoids or immunosuppression

Question 12

What may cause a fever hours after surgery?

Answer 12

• SIRS/inflammatory response to trauma from surgery - Reaction to blood products received during surgery - Malignant hyperthermia (GA gases or neuromuscular blocking agents)

Question 13

What causes a fever day 1-2 post op? (acute)

Answer 13

• 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

Question 14

What causes a fever day 3-7 post op? (subacute)

Answer 14

INFECTION - UTI - Surgical site (wound) infection - IV site/line infection - Septic thrombophlebitis - Leakage at bowel anastomosis

Question 15

What causes a delayed fever day 8+ post op?

Answer 15

• 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)

Question 16

Clinical features of wound dehiscence

Answer 16

POD 1-3 Serosanguinous or salmon colored drainage from wound

Question 17

Risk factors for wound dehiscence

Answer 17

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.

Question 18

What is evisceration?

Answer 18

Protrusion of abdominal contents through abdominal wall - “burst abdomen”. Surgical emergency as carries a mortality rate up to 45%

Question 19

Risk factors for wound haematoma

Answer 19

Anticoagulant therapy, coagulopathies, thrombocytopenia, DIC, severe liver disease, myeloproliferative disorders, severe arterial HPTN, severe cough

Question 20

Prophylaxis against wound infection

Answer 20

Pre-op antibiotics (cephazolin + metronidazole), normothermia, hyperoxygenation, chlorhexidine-alcohol wash, protect skin edges, hair removal only if necessary (clip>shaving)

Question 21

Most common cause of oliguria/anuria post operatively

Answer 21

Prerenal +/- ischemic acute tubular necrosis