Surgery Workshop Flashcards
What are the risk factors for negative surgical outcomes? [5]
- Increasing age
- Complexity of surgical procedure
- Duration of anaesthesia
- Co-existing pathology: diabetes, cerebovascular disease; cardiovascular, renal or hepatic disease.
- Obestiy, clotting disorders, concurrent medication and alcohol use.
The stress-inducing effects of surgery lead to the release of catabolic hormones such as
Cortisol and catecholamines and local cytokines.
Patients taking long-term corticosteroids should be assumed to have some degree of hypothalmic-pituitary-adrenocortical axis (HPA) suppression and should receieve corticosteroid replacement according to
Magnitude of the srugery.
Generally switching to IV prep immediately prior to surgery and for up to 72 hours post surgery dependent on stress.
Medicines which increase the risk of surgical morbidity due to interaction with thermo-regulation and/or anaesthetics include:
Antipsychotics: lithium and MAOs.
A full medication history prior to surgery is especially important in identifying herbal remedies such as
St Johns Wort
Garlic/ginseng: affect clotting.
Patients with what disease require a special surgical care plan, which can be found in the BNF and each local trusts guidelines.
Diabetes
Insulin should never be stopped in people with ______ diabetes because this will lead to ketoacidosis
Type 1
Surgery is frequently associated by a period of starvation, which induces a catabolic state. How can this be attenutated in diabetes by
An Infusion of insulin and glucose (180g/day)
When can a patient with diabetes be managed without the need for insulin/glucose infusion?
If the starvation period is short: hypoglycaemia will stimulate secretion of counter-regulatory hormones and exacerbate the catabolic effect of surgery.
Prior to surgery we should aim for an HbA1c of less than __mmol/mol (___%)
Optimise the diabetes management, in
particular aiming for an HbA1c of less
than 69mmol/mol (8.5%) prior to
surgery, where it is appropriate to do so
safely, and identification of other comorbidities.
If opiates are prescribed for pain control there may be associated ________, _______ and _______ which may require additional prescribing.
Remember that if opiates are to be prescribed there may be associated constipation, nausea and vomiting which may require further prescribing.
Frequency of DVT is __-__% in those undergoing surgery and __-__% in patients having total hip replacements.
frequency of DVT is 25-33% in those undergoing general surgery and 45-70% in patients having total hip replacements
On day of surgery: Cardiac or blood pressure medication, give or miss?
Give all all cardiac and blood pressure medication except: ACEi and AT2 antagonists and diuretics.
Give all all cardiac and blood pressure medications on the day of surgery other than:
ACEi and AT2 antagonists and diuretics.
On day of surgery: Lithium, give or miss?
Lithium is usually omitted 24 hours pre-operatively unless a minor procedure.
Clopidogrel, dipyridamole, warfarin, rivaroxaban, dabigatran. Give on day of surgery or omit?
You must be familiar with the individual requirements of your surgical team, but it is usual practice to stop clopidogrel 7 days pre-operatively, dipyridamole 24 hours pre-operatively if used in combination with another antiplatelet (if used alone it may be continued), and warfarin and NOAC’s several days pre-operatively to allow for reduction in their anticoagulant effect and in the case of warfarin reduction in the INR. However patients who are prescribed dual antiplatelet therapy of aspirin and clopidogrel post coronary stent or acute coronary syndrome (ACS) are at particular risk of thrombosis and if possible surgery should be delayed until it is safe to stop the clopidogrel (usually between 3 – 12 months). Where a delay is not possible, advice should be sought from a cardiologist.
COC/HRT. Give or omit on day of surgery?
If possible should be stopped 4 weeks before elective surgery. If not possible, or desirable: ensure anti-embolism stockings and prophylactic LMWH is used.
Anticholinesterases for dementia: galantamine/rivastigmine. Give or omit wrt surgery?
Should be stopped 24 hours pre-operatively as they prolong the action of muscle relaxants used in anaethesia. Donepezil is not normally stopped pre-operatively as due to its long half-life it would need to be stopped 2-3 weeks pre-op which would cause too great a decline in the patients cognitive function.
