Surgery Flashcards
What are the risks associated with poor glycemic control?
significant impact on the risk of postoperative
infection
Give contraindications to use of antiembolism stockings?
Peripheral vascular disease and neuropathy.
Diabetic patients should be well controlled before surgery, what HbA1c value are we aiming for?
<69 mmol/l
T or F - all medication which reduces gastric acid should be given on the day of surgery?
True
T or F - all asthma drugs and inhalers should be given before surgery?
True
How many days before an operation should clopidogrel be stopped?
7 days
If a patient is taking dual antiplatelet therapy and requires surgery, what should we try and do and why?
Try and delay the surgery until it is safe to stop one of the antiplatlets
Should lithium be taken before surgery?
NO- omit 24 hours pre-op unless minor surgery
How long before surgery should the COC be stopped?
4 weeks
What general monitoring is required during and after surgery?
Fluids
Blood pressure
Renal function
Pain control
What non pharmacological advice is very important for patients with Ulcerative colitis?
Stopping smoking!
Should mesalazine be taken the day of surgery?
No should discontinue the day before surgery
How do we ensure patients who are taking long term steroids have adequate glucocorticoid levels to cope with the stress of surgery?
Give IV hydrocortisone 25mg-50mg at induction and afterwards (how long afterwards will depend on surgery)
Dose depends on patients normal daily dose
How can we manage pain in a patient with UC following a colectomy?
Paracetamol
Dihydrocodeine or morphine
Why is codeine not a suitable analgesic in patients with UC?
Risk of toxic megacolon
Why is dihydrocodeine preferred to codeine as a post-op analgesic?
Approx. 20% of patients are unable to metabolise codeine and obtain its analgesic effects
What analgesic should never been given to patients with UC?
NSAIDS
T or F - smoking is protective against PONV?
True - non smokers are more likely to experience PONV
Are men or women more likely to experience PONV?
Female
Which antiemetic is not useful for PONV?
Metoclopramide
When should antiemetics be given to prevent PONV?
30 mins before the end of surgery
Outline the management of patients taking warfarin who have a planned surgery
Need to assess the reason patient is taking warfarin and this will determine there risk of VTE.
Last dose of warfarin needs to be taken 6 days before surgery.
Whether we bridge or not with LMWH or UFH depends on VTE risk
What INR are we aiming for before surgery?
<1.5
If a patient taking warfarin is at low risk of VTE how should we manage this pre-operatively?
No LMWH is required
Stop warfarin, take the last dose 6 days before
Use non-pharmacological methods
If a patient taking warfarin is at moderate risk of VTE how should this be managed pre-operatively?
Stop warfarin 5 days before
Start therapeutic-dose LMWH at 8 am 2 days after stopping warfarin
Take last LMWH dose 24 hours before surgery is planned (i.e. at 8 am the day before surgery)
If a patient taking warfarin is at high risk of VTE how should this be managed pre-operatively?
Stop warfarin 5 days before
Start therapeutic dose of LMWH at 8 am 2 days after stopping warfarin
Take last dose LMWH 24 hours before surgery
Start patient on UFH and this should be stopped 6 days before surgery
Should aspirin for secondary prevention of CVD be omitted before surgery?
Should continue unless very high bleeding risk
What dose of exogenous steroids and within what time period might mean patients require additional glucocorticoids during surgery?
Patients on >10mg/day of prednisolone within 3 months of surgeyr
If patients stop taking COC before surgery what are the risks associated with this?
Pregnancy - also has a vte risk
Should tamoxifen be stopped before surgery?
Patients taking tamoxifen are at increased risk of VTE, but need to discuss with oncologists whether safe to stop. if we can stop then try and stop 3 weeks before.
What are the two main issues associated with MAOIs and surgery?
Potentially fatal drug interactions and with anaesthesia
and risk of hypertensive crisis
What is very important that we ensure in patients taking lithium during surgery where we havent been able to stop the lithium 24 hours before?
Need to ensure hydrated - Li is renally excreted and want to avoid accumulation.
Should monitor fluid balance and Li levels
In terms of VTE prophylaxis post-op how do we classify patients in terms of risk and how does their managemnet vary accordingly?
Either classified as low or high risk. One risk factor puts patient in the high risk category
If low risk - use non pharmacological methods
if high risk - use LMWH or NOACs
Extended VTE prophylaxis is required following surgery on a fractured neck of femur, how long should VTE prophylaxis be continued?
4 weeks
Extended VTE prophylaxis is required following abdominal/pelvic cancer surgery, how long should VTE prophylaxis be continued?
4 weeks
How do we managed pain post-op?
Use the WHO pain ladder in reverse
Outline the Apfel scoring system
Female- 1
History of PONV or motion sickness - 1
Post op use of opioids - 1
Non-smoker - 1
What is meant by a clean surgical procedure? Are antibiotics required prophylatically?
Clean: No break in sterile technique, site not inflamed or infected e.g. breast surgery
Generally no prophylaxis is needed
What is meant by a clean-contaminated procedure? Are antibiotics required prophylatically?
Clean – Contaminated – at induction and up to 24 hours post op
Used at induction and up to 24 hours post op
What is meant by contaminated surgery?
Contaminated: Major break in sterile technique, spillage from GI tract or acute inflammation encountered
What is the preferred route for antibiotic prophylaxis?
IV
What time should antibiotic prophylaxis be given and why?
Dose / infusion completed just before incision if iv – to be effective we want the concentration of antibiotic to be highest at the time of incision.
should atorvastain be taken the morning of surgery?
Yes
