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Surgery LO's > Specific Pre-Operative Complications > Flashcards

Specific Pre-Operative Complications Flashcards

1
Q

Why are patients with diabetes at increased risk of post-operative complications?

A

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

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2
Q

Why are patients with diabetes at risk of hypoglycaemia pre-operatively?

A

They are NBM

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3
Q

What investigations should be done pre-operatively in a patient with diabetes?

A

Urine dipstick to look for proteinuria
Venous glucose
U&Es

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4
Q

What should be considered regarding the list order in patients with diabetes?

A

Insulin dependant diabetes should be put on the list first

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5
Q

Who needs to be informed that an insulin dependant diabetic is on the surgical list?

A

The surgeon and the anaesthetist

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6
Q

What is used in insulin-dependant surgical patients?

A

Insulin sliding scale

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7
Q

What is preferred to an insulin sliding scale in some centres?

A

GKI infusions (glucose, potassium, insulin)

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8
Q

When might an insulin sliding scale not be necessary?

A

In minor ops

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9
Q

Should insulin be stopped before surgery?

A

You may or may not stop long-acting insulin the night before, and should stop morning insulin if the surgery is in the morning

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10
Q

How is an insulin sliding scale given pre-operatively?

A

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

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11
Q

How often should glucose be checked peri-operatively?

A

Hourly

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12
Q

What glucose should be aimed for pre- and peri-operatively?

A

7-11mM

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13
Q

What should be done in an insulin dependant diabetic post-operatively?

A

Continue sliding-scale into tolerating food

Switch to SC regimen around a meal

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14
Q

How should a surgical diabetic patient be managed if their glucose control is poor (fasting >10mm)?

A

Treat as if they were insulin dependant

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15
Q

Should oral hypoglycaemics be omitted pre-operatively in non-insulin dependant diabetics?

A

Yes, in the morning of surgery

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16
Q

When should oral hypoglycaemics be resumed post-operatively if the patient is eating post-op?

A

With a meal

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17
Q

How should a non-insulin dependant diabetic be managed post-operatively if they are not eating?

A

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

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18
Q

How should a surgical diet-controlled diabetic patient be managed?

A

Usually no problem, but the patient may be briefly insulin-dependant post-op, in which case you should monitor CPG

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19
Q

What is the problem with steroids in surgical patients?

A

They can cause poor wound healing, infection, and adrenal crisis

20
Q

How are surgical patients on steroids managed?

A

Need to increase the steroid dose to cope with

21
Q

When should you consider steroid cover in surgical patients?

A

If they have had high-dose steroids within the last year

22
Q

What steroid cover is given in major surgery?

A

Hydrocortisone 50-100mg IV pre-med, and then 6-8 hourly for 3 days

23
Q

What steroid cover is given in minor surgery?

A

Hydrocortisone 50-100mg IV pre-med, and then 6-8 hourly for 24 hours

24
Q

What is important to consider when thinking about operating on a jaundiced patient?

A

It is best to avoid operating in jaundiced patients, and if possible use ERCP instead

25
Q

Why is it best to avoid operating in jaundiced patients?

A

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

26
Q

What is the result of the high risk of post-op renal failure in jaundiced patients?

A

In these patients, you need to maintain a good urine output

27
Q

What should be avoided in the pre-medication for patients with jaundice?

A

Morphine

28
Q

What should be done pre-operatively in surgical patients with jaundice?

A

Check clotting, consider pre-op vit K
Give 1L normal saline pre-op
Urinary catheter to monitor urine output
Antibiotic prophyalxis

29
Q

When should you not give 1L normal saline to jaundiced patient pre-operatively?

A

In congestive cardiac failure

30
Q

What is the purpose of giving saline pre-op in jaundiced patients?

A

Produce moderate diuresis

31
Q

What antibiotic prophylaxis should be given pre-operatively in jaundiced patients?

A

Cef + met

32
Q

How are patients with jaundice managed intra-operatively?

A

Hourly urine output monitoring, with normal saline titrated to output

33
Q

How are patients with jaundice managed post-operatively?

A

Intensive monitoring of fluid status

34
Q

How should patients with jaundice be managed post-operatively if they have poor urine output despite normal saline?

A

Consider CVP and furosmide

35
Q

What needs to be balanced in anti-coagulated surgical patients?

A

The risk of haemorrhage vs the risk of thrombosis

36
Q

Who should be consulted when considering anti-coagulated surgical patients?

A

Surgeon
Anaesthetist
Haematologist

37
Q

Can any surgery be untaken without stopping warfarin?

A

Very minor surgery may be undertaken without stopping warfarin if INR <3.5

38
Q

What should be avoided in anti-coagulated patients?

A

Epidural, spinal, and regional blocks

39
Q

Should aspirin/clopidogrel be stopped before surgery?

A

In general, continue until 7 days before surgery, unless risk of bleeding is high then stop earlier

40
Q

How should surgical patients with low thromboembolic risk, e.g. AF, be managed?

A

Stop warfarin 5 days pre-op

Restart next day

41
Q

What INR is required to operate on surgical patients with low thromboembolic risk?

A

<1.5

42
Q

How should surgical patients with high thromboembolic risk, e.g. prosthetic valves, recurrent VTE, be managed?

A

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

43
Q

How should anti-coagulated patients who require emergency surgery be managed?

A

Discontinue warfarin, and give vit K 0.5mg slow IV. Request FFP or PCC to cover surgery

44
Q

What are the risks of surgery in COPD patients?

A

Basal atelectasis
Aspiration
Chest infection

45
Q

What investigations should be done pre-operatively in COPD patients?

A

CXR

PFTs

46
Q

How are the risks of surgery in COPD patients minimised?

A

Pre-operative physio for breathing exercises

Stop smoking at least 4 weeks prior to surgery

Surgery LO's (10 decks)

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