Specific Pre-Operative Complications Flashcards
Why are patients with diabetes at increased risk of post-operative complications?
Surgery produces stress hormones, which antagonise insulin and therefore further raise blood sugar levels, with impairs healing and increases the risk of infection
Patients with diabetes are also more likely to have IHD and PVD
Why are patients with diabetes at risk of hypoglycaemia pre-operatively?
They are NBM
What investigations should be done pre-operatively in a patient with diabetes?
Urine dipstick to look for proteinuria
Venous glucose
U&Es
What should be considered regarding the list order in patients with diabetes?
Insulin dependant diabetes should be put on the list first
Who needs to be informed that an insulin dependant diabetic is on the surgical list?
The surgeon and the anaesthetist
What is used in insulin-dependant surgical patients?
Insulin sliding scale
What is preferred to an insulin sliding scale in some centres?
GKI infusions (glucose, potassium, insulin)
When might an insulin sliding scale not be necessary?
In minor ops
Should insulin be stopped before surgery?
You may or may not stop long-acting insulin the night before, and should stop morning insulin if the surgery is in the morning
How is an insulin sliding scale given pre-operatively?
Give 5% dex with 20mmol KCl at 125mmol/hr. Then, start infusion pump with 50u actrapid. You should then check CPG hourly, and adjust insulin rate
How often should glucose be checked peri-operatively?
Hourly
What glucose should be aimed for pre- and peri-operatively?
7-11mM
What should be done in an insulin dependant diabetic post-operatively?
Continue sliding-scale into tolerating food
Switch to SC regimen around a meal
How should a surgical diabetic patient be managed if their glucose control is poor (fasting >10mm)?
Treat as if they were insulin dependant
Should oral hypoglycaemics be omitted pre-operatively in non-insulin dependant diabetics?
Yes, in the morning of surgery
When should oral hypoglycaemics be resumed post-operatively if the patient is eating post-op?
With a meal
How should a non-insulin dependant diabetic be managed post-operatively if they are not eating?
You should check fasting glucose on the morning of surgery, and start an insulin sliding scale. You should then consult a specialist team regarding restarting oral anti-hyperglycaemics
How should a surgical diet-controlled diabetic patient be managed?
Usually no problem, but the patient may be briefly insulin-dependant post-op, in which case you should monitor CPG
What is the problem with steroids in surgical patients?
They can cause poor wound healing, infection, and adrenal crisis
How are surgical patients on steroids managed?
Need to increase the steroid dose to cope with
When should you consider steroid cover in surgical patients?
If they have had high-dose steroids within the last year
What steroid cover is given in major surgery?
Hydrocortisone 50-100mg IV pre-med, and then 6-8 hourly for 3 days
What steroid cover is given in minor surgery?
Hydrocortisone 50-100mg IV pre-med, and then 6-8 hourly for 24 hours
What is important to consider when thinking about operating on a jaundiced patient?
It is best to avoid operating in jaundiced patients, and if possible use ERCP instead
Why is it best to avoid operating in jaundiced patients?
Patients with obstructive jaundice have a high risk of post-op renal failure
Increased risk of coagulopathy
Increased infection risk, which may lead to cholangitis
What is the result of the high risk of post-op renal failure in jaundiced patients?
In these patients, you need to maintain a good urine output
What should be avoided in the pre-medication for patients with jaundice?
Morphine
What should be done pre-operatively in surgical patients with jaundice?
Check clotting, consider pre-op vit K
Give 1L normal saline pre-op
Urinary catheter to monitor urine output
Antibiotic prophyalxis
When should you not give 1L normal saline to jaundiced patient pre-operatively?
In congestive cardiac failure
What is the purpose of giving saline pre-op in jaundiced patients?
Produce moderate diuresis
What antibiotic prophylaxis should be given pre-operatively in jaundiced patients?
Cef + met
How are patients with jaundice managed intra-operatively?
Hourly urine output monitoring, with normal saline titrated to output
How are patients with jaundice managed post-operatively?
Intensive monitoring of fluid status
How should patients with jaundice be managed post-operatively if they have poor urine output despite normal saline?
Consider CVP and furosmide
What needs to be balanced in anti-coagulated surgical patients?
The risk of haemorrhage vs the risk of thrombosis
Who should be consulted when considering anti-coagulated surgical patients?
Surgeon
Anaesthetist
Haematologist
Can any surgery be untaken without stopping warfarin?
Very minor surgery may be undertaken without stopping warfarin if INR <3.5
What should be avoided in anti-coagulated patients?
Epidural, spinal, and regional blocks
Should aspirin/clopidogrel be stopped before surgery?
In general, continue until 7 days before surgery, unless risk of bleeding is high then stop earlier
How should surgical patients with low thromboembolic risk, e.g. AF, be managed?
Stop warfarin 5 days pre-op
Restart next day
What INR is required to operate on surgical patients with low thromboembolic risk?
<1.5
How should surgical patients with high thromboembolic risk, e.g. prosthetic valves, recurrent VTE, be managed?
Stop warfarin 5 days pre-op, and start LMWH. Stop LMWH 12-18 hours pre-op, and restart 6 hours post-op. Restart warfarin next day, and stop LMWH when INR >2
How should anti-coagulated patients who require emergency surgery be managed?
Discontinue warfarin, and give vit K 0.5mg slow IV. Request FFP or PCC to cover surgery
What are the risks of surgery in COPD patients?
Basal atelectasis
Aspiration
Chest infection
What investigations should be done pre-operatively in COPD patients?
CXR
PFTs
How are the risks of surgery in COPD patients minimised?
Pre-operative physio for breathing exercises
Stop smoking at least 4 weeks prior to surgery
