Preoperative care Flashcards
FBC
Emergency preop
elective preop >60yrs
elective Females
significant blood loss likely
U/E
Preop >65
Urinanalysis positive
Cardiopulmonary/renal disease
Contraindications to day surgery
ASA>II obese BMI>35 >1hr op operation/pathology >1 hour distance from hospital No one to look after at home No suitable home to return to
Preoperative steroid care
Minor use: 50mg hydrocortisone IM/IV
Intermediate use: 50mg hydrocortisone IM/IV with pre-med and 50mg Hydrocrotisone every 6hrs for 24hrs
Major use: 100mg hydrocortisone IM/IV with pre-med and 100mg hydrocortisone every 6hrs for 72 hrs after surgery
Warfarin
vit ki reverese 10mg IV
stop 3-5 das before surgery and replace with heparin
INR <1.5 for invasive surgery
Heparin
unfract
fractionated (LMWH)-only inhibits FXa
reverse by protamine
Antiplatelet agents (aspirin, dipyridamole, clopidogrel, abciximab)
stop 7-14 days before surgery
Fibrinolytics
Streptokinase and alteplase
acts by converting plasminogen to plasmin
What patient require perioperative steroid cover?
Patients on >7.5mg for >1 week before surgery
Had a course of steroids within 6month
Cardiac effects of GA
Systemic vascular resistance is reduced (induction reduces arterial pressure)
Intubation reduces blood pressure
Myocardial depression (>inhaled cf IV)
Increased cardiac irritability due to released catecholamines
Hypertension before surgery
Diastolic >110mmHg review before surgery
Preop antihypertensives should continue
AS
assess with echo
13% perioperative death
50mmHg gradient indicates critical AS
MS
Predisposes to pulmonary hypertension
Right cardiac failure
Must be given prophylactic antibiotics
AF
Always use bipolar diathermy if possible
COPD
FEV1/FVC <50% risk of post op resp failure is increased
Give preop nebulisers
regional anaesthesia in lower extremity surgery
NO can rupture bullae-use opioids without resp depression
Effect of anaesthetic agents
Increase ventilatory dead space
Reduce functional residual capacity
increase airway resistance and lung compliance
Atelectasis
HbA1c
8 poor control
NIDDM control
Continue normal oral hypoglycaemic agents until the morning of surgery apart from metformin nad chlorpropamide (may need to reduce or stop 48hrs before due to lactic acidosis)
Postop sliding scale
IDDM
Admit night before
Sliding scale morning of surgery
restart regular insulin once patient is eating and drinking
Preoperative jaundice
Attempt to treat beforehand
Hydration
PT time and give vit k 10mg daily (max effect achieved after 3 doses) or FFP within 2 hours post surgery
If surgery involved biliary tree prophylactic antibiotics to prevent cholangitis
Upper GI surgery feeding
Feeding jejunostomy
water contrast study on day 10 of high risk anastomoses before oral feeding
Maxillofacial and pharyngeal surgery
Gastrostomy tube