Surgery Flashcards
Routine investigations for all surgeries?
FBC U+E LFT Clotting G+S/X-match TFTs (if on thyroxine) Sickle cell screen (Afro-caribbean)
CXR/ECG
Spirometry/CPX (if lung disease)
When to stop warfarin?
Warfarin - 5 days (bridge with LMWH)
When to stop Aspirin/clopi/dipyrid?
7 days (unless high risk indication)
When to stop insulin?
avoid morning dose and prescribe slidng scale from midnight
When to stop oral hypoglycaemics?
avoid on day of operation and prescribe sliidng scale if not well controlled
When to stop diuretics/ACEi?
avoid on day of op
When to stop OCP/HRT?
4 weeks before
Restart 2 weeks post op if mobile
AEDs in surgery?
Give as usual - post-op give IV or NG if unable to tolerate orally
Beta blockers in surgery?
Continue as normal
How long NBM?
> 2h for clear fluids
6h for solids
“Clear fluids from midnight, NBM from 6am”
Bowel prep?
Needed in left sided ops (not usually in right sided procedures
When do you need prophylactic abx?
GI surgery
Joint replacement
15-60 mins before surgery
What proohylactic abx to give?
SEE LOCAL GUIDLINES
Biliary - Cef 1.5g + Met 500mg IV
Colorectal or appendicetomy - Cef+Met TDS
Vascular - co-amoxiclav 1.2g IV TDS
- MRSA+ve: vancomycin
DVT prophylaxis in surgery?
Stratify according to patient risk and type of surgery
LOW - early mobilisation
MED - early mobilisation + TEDS + 20mg enox
HIGH - early mobilisation + TEDS + 40mg enox + intermittent compression boots pre-op
Prophylaxis started at 1800 post-op
May need medical prophylaxis at home (up to 1 month)
ASA Grades?
- Normally healthy
- Mild systemic disease
- Severe systemic disease that limits activity
- Systemic disease which is a constant threat to life
- Moribund: not expected to survive 24h post-op
Insulin-controlled diabetes in surgery?
Patient needs to be first on the list - sliding scale may not be necessary in minor ops (liaise with diabetes specialist nurse)
Stop short acting insulin night before, omit AM insulin if surgery is in morning.
SLIDING SCALE
Continue post-op until tolerating food, switch to SC when eating and drinking normally.
Non-insulin controlled diabetes in srugery?
If control poor, treat as insulin-dependent.
Omit oral hypoglycaemics on AM of surgery
If eating post-op continue oral hypoglycaemics
If not, check fasting glucose on AM of surgery and start sliding scale and contact specialist team about restarting oral drugs
Anticoagulated patients in surgery?
Avoid epidural, spinal and regional blocks if anticoagulated
Aspirin/clopi stop 7days before
Low risk anticoagulated patients in surgery? (e.g. AF)
Stop warfarin 5 days pre-op (INR needs to be <1.5)
Restart next day
High risk anticoagulated patients in surgery? (e.g. valves, recurrent VTE)
NEED BRIDGING 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
Anticoagulcated patients in emergency surgery?
Discontinue warfarin
Vit K .5mg slow IV
Request FFP or PCC to cover surgery
Pre-op considerations for smokers/COPD?
CXR
PFTs
Physio for breathing exercises
Quit smoking (at least 4wks prior to surgery)
Steroids in surgery?
Need to ↑ steroid to cope c¯ stress
Consider cover if high-dose steroids w/i last yr
Major surgery: hydrocortisone 50-100mg IV c¯ pre-med then 6-8hrly for 3d.
Minor: as for major but hydrocortisone only for 24h
Wound infection Rs?
PRE-OPERATIVE ↑ Age Comorbidities: e.g. DM Pre-existing infection: e.g. appendix perforation Pt. colonisation: e.g. nasal MRSA
OPERATIVE
Op classification and wound infection risk
Duration
Technical: pre-op Abx, asepsis
POST-OPERATIVE
Contamination of wound from staff
Causes of post-op urinary retention?
Drugs: opioids, epidural/spinal, anti-AChM
Pain: sympathetic activation → sphincter contraction
Psychogenic: hospital environment
Management of post-op urinary retention?
CONSERVATIVE Privacy Ambulation Void to running taps or in hot bath Analgesia
Catheterise ± gent 2.5mg/kg IV stat
TWOC = Trial w/o Catheter
If failed, may be sent home with silicone catheter
and urology outpt. f/up.
What is pulmonary atelectasis?
Occurs after every nearly every GA
Mucus plugging + absorption of distal air → collapse
Presentation of atelectasis?
w/i first 48hrs
Mild pyrexia
Dyspnoea
Dull bases with ↓AE
Management of atelectasis?
Good analgesia to aid coughing
Chest physiotherapy
Presentation of wound dehiscence?
Occurs ~10d post-op
Preceded by serosanguinous (pink serous fluid) discharge from wound
RFs for wound dehiscence?
PRE-OPERATIVE FACTORS ↑ age Smoking Obesity, malnutrition, cachexia Comorbs: e.g. BM, uraemia, chronic cough, Ca Drugs: steroids, chemo, radio
OPERATIVE FACTORS
Length and orientation of incision
Closure technique: follow Jenkin’s Rule
Suture material
POST-OPERATIVE FACTORS
↑ IAP: e.g. prolonged ileus → distension
Infection
Haematoma / seroma formation
Management of wound dehiscence?
Replace abdo contents and cover with sterile soaked gauze
IV Abx: cef+met (or cover skin, fluclox)
Opioid analgesia
Call senior and arrange theatre
Repair in theatre
Wash bowel
Debride wound edges
Close with deep non-absorbable sutures (e.g. nylon)
May require VAC dressing or grafting
Management of anastamotic leak? (need to act quickly, high mortality)
Bloods – FBC, CRP, WCC, clotting, cultures, lactate
A-E –> fluids/blood
Abx
?return to theatre
Management of paralytic ileus?
Anti-emetics IV
NG tube + NBM – drip and suck – bowel rest
Fluid balance is key
Self-resolving – may take a few days
Type of retention that doesn’t fix with a normal catheter?
Clot retention (increased risk in urology patients)
Need a 3 way catheter and bladder washout (aim for urine to drain Rosé –> clear)
When to transfuse if bleeding
<70/symptomatic
