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Surgery > PreOp Mx > Flashcards

PreOp Mx Flashcards

1
Q

Info Regarding OCP/HRT for surgery?

A

Stop 4wks before major / leg surgery

Restart 2wks post-op if mobile

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2
Q

Prophylactic abx for surgery?

A

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

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3
Q

DVT prophylaxis after surgery?

A

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)

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4
Q

Risk of surgical complications due to pts on long term steroids?

A

Poor wound healing

Infection

Adrenal crisis

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5
Q

Mx of pts on long term steroids needing to undergo surgery?

A

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

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6
Q

Why are diabetics at increased risk of post op complications?

A

Surgery → stress hormones → antagonise insulin

Pts. are NBM

↑ risk of infection

IHD and PVD

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7
Q

What to do about insulin for patients with insulin dependent DM about to undergo surgery?

A

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

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8
Q

Mx of diet controlled DM pts about to undergo surgery?

A

Usually no problem

Pt. may be briefly insulin-dependent post-op

-> Monitor CPG

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9
Q

Mx of Non insulin dependent DM patient about to undergo surgery?

A

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
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10
Q

if patients with high thromboembolic risk (ie. mechanical valves, recurrent VTE) need to undergo surgery, what to do about their anticoagulant medications?

A

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

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11
Q

if pt w low thromboembolic risk e.g. AF needs to undergo surgery, what to do about their current anticoag medication?

A

Stop warfarin 5d pre-op: need INR <1.5

Restart next day

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12
Q

if risk of bleeding in surgery is high and need to stop antiplatelet therapy e.g. aspirin/ clopi? when to stop

A

7 days before surgery

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13
Q

what kind of analgesia should be avoided if pt is anticoagulated?

A

epidural, spinal and regional blocks

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14
Q

if anticoagulated pt needs to undergo emergency surgery?

A

discontinue warfarin

Vit K 5mg slow IV

request FFP or PCC to cover surgery

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15
Q

Risks of operating in Jaundiced patients?

A

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

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16
Q

pre-op measures to reduce risk of complications in surgery for jaundiced pt?

A

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

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17
Q

risks of operating in pt with COPD?

A

Basal atelectasis

Aspiration

Chest infection

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18
Q

preop measures to reduce risk of complications of surgery in COPD pts?

A

CXR
PFTs
Physio for breathing exercises
Quit smoking (at least 4wks prior to surgery)

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19
Q

e.g. if induction anaesthetic?

A

IV propofol

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20
Q

e.g.s of muscle relaxation anaesthetics?

A

depolarising: suxamethonium

non-depolarising: vecuronium, atracurium

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21
Q

e.g. of maintenance anaesthesia?

A

halothane/ enflurane

22
Q

how to reverse paralysis of anaesthesia?

A

neostigmine, atropine

23
Q

when is regional anaesthesia used?

A

for minor procedures or if unsuitable for GA
nerve or spinal blocks

e.g. bupivacaine

24
Q

mx of malignant hyperpyrexia?

A

ppted by halothane or suxamethonium

dantrolene + cooling

25
Q

why is analgesia important post op?

A

pain -> autonomic activation → arteriolar constriction → ↓ wound perfusion → impaired wound healing
Pain → ↓ mobilisation → ↑ VTE and ↓ function

Pain → ↓ respiratory excursion and ↓ cough → atelectasis and pneumonia

26
Q

what pain meds are available on step 1?

A

Paracetamol

NSAIDs

  • Ibuprofen: 400mg/6h PO max
  • Diclofenac: 50mg PO / 75mg IM
27
Q

2nd step for pain ladder e.g.?

A

Codeine
Dihydrocodeine

Tramadol

28
Q

pain ladder 3rd step e.g.s?

A

Morphine: 5-10mg/2h max

Oxycodone

Fentanyl

29
Q

immediate surgical complications?

<24h

A

intubation-> oropharyngeal trauma

surgical trauma to local structures

primary or reactive haemorrhage

30
Q

early surgical complications?

A

secondary haemorrhage

VTE

urinary retention

atelectasis and pneumonia

wound infection and dehiscence

antibx assoc colitis

31
Q

late surgical complications?

A

Scarring
Neuropathy

Failure or recurrence

32
Q

complications of cholecystectomy?

A

Conversion to open: 5%

CBD injury: 0.3%

Bile leak

Retained stones (needing ERCP)

Fat intolerance / loose stools

33
Q

complications of appendicectomy?

A

Abscess formation

Fallopian tube trauma

Right hemicolectomy (e.g. for carcinoid, caecal necrosis)

34
Q

complications of inguinal hernia repair?

A

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%

35
Q

complications of colonic surgery?

A

Early

Ileus

AAC

Anastomotic leak

Enterocutaneous fistulae

Abdominal or pelvic abscess

Late

Adhesions → obstruction

Incisional hernia

36
Q

complications of anorectal surgery?

A

Anal incontinence

Stenosis

Anal fissure

37
Q

complications of small bowel surgery?

A

Short gut syndrome (≤250cm)

38
Q

complications of splenectomy?

A

Gastric dilatation (2O gastric ileus)

-> Prevent w NGT

Thrombocytosis → VTE

Infection: encapsulated organisms

39
Q

complications of cardiothoracic surgery?

A

Pneumo-/haemo-thorax
Infection: mediastinitis, empyema

40
Q

complications of tracheostomy?

A

Stenosis
Mediastinitis
Surgical emphysema

41
Q

Complications of arterial surgery?

A

Thrombosis and embolization

Anastomotic leak

Graft infection

42
Q

Complications of aortic surgery?

A

Gut ischaemia

Renal failure

Aorto-enteric fistula

Anterior spinal syndrome (paraplegia)

Emboli → distal ischaemia (trash foot)

43
Q

complications of breast surgery?

A

Arm lymphoedema

Skin necrosis
Seroma

44
Q

Complications of prostatectomy?

A

Urinary incontinence

Erectile dysfunction

Retrograde ejaculation

Prostatitis

45
Q

Ix of post op febrile pt?

A

Urine: dip + MCS

Blood: FBC, CRP, cultures ± LFTs

Cultures: wound swabs, CVP tip for culture

CXR

46
Q

what type of diabetic pt will require a variable rate IV insulin infusion?

A

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%)

47
Q

what is the aim of the variable rate IV insulin infusion?

A

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

48
Q

What to do about patient’s regular insulin when going for surgery + going to start a variable rate insulin infusion?

A

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;

49
Q

When to stop the variable rate IV insulin infusion + IV fluids after surgery?

A

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

50
Q

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?

A

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

51
Q

Mx of non-insulin dependent diabetic pts if undergoing elective minor surgical procedures only requiring 1 missed meal?

A

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

Surgery (17 decks)

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