PreOp Mx Flashcards
Info Regarding OCP/HRT for surgery?
Stop 4wks before major / leg surgery
Restart 2wks post-op if mobile
Prophylactic abx for surgery?
Give 15-60 min before surgery
Biliary: cef n met
Colorectal/ appendix: cef n met
Vascular: co-amoxiclav
MRSA +Ve: Vancomycin
used for GI surgery, joint replacement
DVT prophylaxis after surgery?
Stratify pts according to patient factors and type of surgery.
Low risk: early mobilisation
Med: early mobilisation + TEDS + 20mg enoxaparin
High: early mobilisation + TEDS + 40mg enoxaparin + intermittent compression boots perioperatively.
Prophylaxis started @ 1800 post-op
May continue medical prophylaxis at home (up to 1mo)
Risk of surgical complications due to pts on long term steroids?
Poor wound healing
Infection
Adrenal crisis
Mx of pts on long term steroids needing to undergo surgery?
Need to ↑ steroid to cope w stress
Consider cover if high-dose steroids w/i last yr
Major surgery: hydrocortisone 50-100mg IV w pre-med then 6-8hrly for 3d.
Minor surgery: Hydrocortisone 50-100mg IV for 24h
Why are diabetics at increased risk of post op complications?
Surgery → stress hormones → antagonise insulin
Pts. are NBM
↑ risk of infection
IHD and PVD
What to do about insulin for patients with insulin dependent DM about to undergo surgery?
put pt first on list
stop long-acting insulin the night before
Omit AM insulin if surgery is in the morning
Start sliding scale
5% Dex w 20mmol KCl 125ml/hr
Infusion pump w 50u actrapid
Check CPG hrly and adjust insulin rate
Check glucose hrly: aim for 7-11mM
Post-op
Continue sliding-scale until tolerating food
Switch to SC regimen around a meal
Mx of diet controlled DM pts about to undergo surgery?
Usually no problem
Pt. may be briefly insulin-dependent post-op
-> Monitor CPG
Mx of Non insulin dependent DM patient about to undergo surgery?
If glucose control poor (fasting >10mM): treat as IDDM (Sliding scale)
Omit oral hypoglycaemics on the AM of surgery
Eating post-op: resume oral hypoglycaemics w meal
if No eating post-op:
- Check fasting glucose on AM of surgery
- Start insulin sliding scale
- Consult specialist team ore. restarting PO Rx
if patients with high thromboembolic risk (ie. mechanical valves, recurrent VTE) need to undergo surgery, what to do about their anticoagulant medications?
Need bridging w LMWH
Stop warfarin 5d pre-op and start LMWH
Stop LMWH 12-18h pre-op
Restart LMWH 6h post-op
Restart warfarin next day
Stop LMWH when INR >2
if pt w low thromboembolic risk e.g. AF needs to undergo surgery, what to do about their current anticoag medication?
Stop warfarin 5d pre-op: need INR <1.5
Restart next day
if risk of bleeding in surgery is high and need to stop antiplatelet therapy e.g. aspirin/ clopi? when to stop
7 days before surgery
what kind of analgesia should be avoided if pt is anticoagulated?
epidural, spinal and regional blocks
if anticoagulated pt needs to undergo emergency surgery?
discontinue warfarin
Vit K 5mg slow IV
request FFP or PCC to cover surgery
Risks of operating in Jaundiced patients?
best to avoid
use ERCP instead
Pts w obstructive jaundice have ↑ risk of post-op renal failure -> need to maintain good UO.
Coagulopathy
↑ infection risk: may → cholangitis
pre-op measures to reduce risk of complications in surgery for jaundiced pt?
Avoid morphine in pre-med
Check clotting and consider pre-op vitamin K
Give 1L NS pre-op (unless CCF) → moderate diuresis
Urinary catheter to monitor UPO
Abx prophylaxis: e.g. cef+met
risks of operating in pt with COPD?
Basal atelectasis
Aspiration
Chest infection
preop measures to reduce risk of complications of surgery in COPD pts?
CXR
PFTs
Physio for breathing exercises
Quit smoking (at least 4wks prior to surgery)
e.g. if induction anaesthetic?
IV propofol
e.g.s of muscle relaxation anaesthetics?
depolarising: suxamethonium
non-depolarising: vecuronium, atracurium
e.g. of maintenance anaesthesia?
halothane/ enflurane
how to reverse paralysis of anaesthesia?
neostigmine, atropine
when is regional anaesthesia used?
for minor procedures or if unsuitable for GA
nerve or spinal blocks
e.g. bupivacaine
mx of malignant hyperpyrexia?
ppted by halothane or suxamethonium
dantrolene + cooling
why is analgesia important post op?
pain -> autonomic activation → arteriolar constriction → ↓ wound perfusion → impaired wound healing
Pain → ↓ mobilisation → ↑ VTE and ↓ function
Pain → ↓ respiratory excursion and ↓ cough → atelectasis and pneumonia
what pain meds are available on step 1?
Paracetamol
NSAIDs
- Ibuprofen: 400mg/6h PO max
- Diclofenac: 50mg PO / 75mg IM
2nd step for pain ladder e.g.?
Codeine
Dihydrocodeine
Tramadol
pain ladder 3rd step e.g.s?
Morphine: 5-10mg/2h max
Oxycodone
Fentanyl
immediate surgical complications?
<24h
intubation-> oropharyngeal trauma
surgical trauma to local structures
primary or reactive haemorrhage
early surgical complications?
secondary haemorrhage
VTE
urinary retention
atelectasis and pneumonia
wound infection and dehiscence
antibx assoc colitis
late surgical complications?
Scarring
Neuropathy
Failure or recurrence
complications of cholecystectomy?
Conversion to open: 5%
CBD injury: 0.3%
Bile leak
Retained stones (needing ERCP)
Fat intolerance / loose stools
complications of appendicectomy?
Abscess formation
Fallopian tube trauma
Right hemicolectomy (e.g. for carcinoid, caecal necrosis)
complications of inguinal hernia repair?
Early
Haematoma / seroma formation: 10%
Intra-abdominal injury (lap)
Infection: 1%
Urinary retention
Late
Recurrence (<2%)
Ischaemic orchitis: 0.l5%
Chronic groin pain / paraesthesia: 5%
complications of colonic surgery?
Early
Ileus
AAC
Anastomotic leak
Enterocutaneous fistulae
Abdominal or pelvic abscess
Late
Adhesions → obstruction
Incisional hernia
complications of anorectal surgery?
Anal incontinence
Stenosis
Anal fissure
complications of small bowel surgery?
Short gut syndrome (≤250cm)
complications of splenectomy?
Gastric dilatation (2O gastric ileus)
-> Prevent w NGT
Thrombocytosis → VTE
Infection: encapsulated organisms
complications of cardiothoracic surgery?
Pneumo-/haemo-thorax
Infection: mediastinitis, empyema
complications of tracheostomy?
Stenosis
Mediastinitis
Surgical emphysema
Complications of arterial surgery?
Thrombosis and embolization
Anastomotic leak
Graft infection
Complications of aortic surgery?
Gut ischaemia
Renal failure
Aorto-enteric fistula
Anterior spinal syndrome (paraplegia)
Emboli → distal ischaemia (trash foot)
complications of breast surgery?
Arm lymphoedema
Skin necrosis
Seroma
Complications of prostatectomy?
Urinary incontinence
Erectile dysfunction
Retrograde ejaculation
Prostatitis
Ix of post op febrile pt?
Urine: dip + MCS
Blood: FBC, CRP, cultures ± LFTs
Cultures: wound swabs, CVP tip for culture
CXR
what type of diabetic pt will require a variable rate IV insulin infusion?
Pts usually treated with insulin
+ undergoing major procedures (surgery requiring a long fasting period of >1 missed meal)
OR
whose diabetes is poorly controlled (HbA1c >69 or 8.5%)
what is the aim of the variable rate IV insulin infusion?
achieve and maintain [Glucose] within 6-10 mmol/L (up to 12 acceptable)
by infusing a constant rate of glucose-containing fluid as a substrate, while also infusing insulin at a variable rate
What to do about patient’s regular insulin when going for surgery + going to start a variable rate insulin infusion?
Day before surgery: any once-daily long-acting insulin analogue given @ 80% normal dose, other insulin given at normal dose
On day of surgery and throughout intra-op period: once daily long-acting insulin analogues should be continued at 80 % usual dose; all other insulin should be stopped until the patient is eating and drinking again after surgery;
When to stop the variable rate IV insulin infusion + IV fluids after surgery?
stop 30-60 mins after the first meal time short acting insulin dose
any long-acting insulin should have been continued throughout the operative period @ 80% normal dose
Mx of patients undergoing elective surgery but are undergoing minor procedures and have good glycaemic control (HbA1c < 69 mmol or 8.5%) and treated w insulin?
Day before surgery: pt’s usual insulin given as normal, other than once daily long-acting insulin analogues, which should be given at 80% normal dose
Mx of non-insulin dependent diabetic pts if undergoing elective minor surgical procedures only requiring 1 missed meal?
Omit: acarbose, nateglinide, repaglinide morning of surgery if fasting
Pioglitazone, DDP4 (gliptins) and GLP1R agonists can be taken as normal during whole periop period
Omit Sulfonylureas until pt eating and drinking again
Omit Sodium glucose co-transporter 2 inhibitors til pt is stable.
Metformin can be continued if only one meal will be missed
