surgical patient journey

Question 1

what does pre operative mean? what are the two types of pre operative period?

Answer 1

the time before surgery
distant pre operative- more than 24 hours before surgery
immediate pre operative surgery- less than 24 hours before surgery

Question 2

tasks to carry out in the pre operative period

Answer 2

• educate patients on what is going to happen
• encourage concordance with surgery and treatment beyond
• pre-operative assessment clinics
• specific investigations
• risk reduction measures

Question 3

important information to know about the patient

Answer 3

• past medical history
• smoking/ alcohol/ other addictions
• past anaesthetic history
• drug history
• social history- who do they live with
• past surgical history (nausea and vomiting history?)

Question 4

important information to know about the surgery

Answer 4

• length of stay
• surgical technique
• specific surgical risk
• anaesthetic technique
• specific anaesthetic risk
• will pts be able to eat or drink after surgery (diabetics)
• they will be immobile- risk of clot developing

Question 5

4 important pre-operatic considerations

Answer 5

• appropriate pre-operative investigations
• starvation
• thromboprophylaxis
• antibiotic prophylaxis

Question 6

3 types of pre operative investigations

Answer 6

• blood tests- FBC, U&E, LFT
• imaging- X-rays, CT, MRI
• specialist- ECG, lung function test, CPET

Question 7

what is the 2-6 rule and who does it apply to

Answer 7

adults- intake of water up to 2 hours before surgery (water encouraged 2 hours before). a minimum of pre-operative fasting time of 6 hours (inc milk, or milk containing products)

Question 8

why is it important for a patient to have an empty stomach

Answer 8

if you undergo general anaesthetic and you bring food back up it could be aspirated into the lungs

Question 9

what is the 2-4-6 rule and who does it apply to

Answer 9

children- intake of water and other clear fluids up to 2 hours before (again, encouraged). Breast milk up to 4 hours before. Formula milk, cows milk or solids up to 6 hours before

Question 10

does the 2-4-6 and 2-6 rule apply to oral medications?

Answer 10

no- take as normal

Question 11

what are the two types of thromboprophylaxis

Answer 11

pharmacological thromboprophylaxis usually low molecular weight heparins eg enoxaparin
Mechanical means- stocking applied to encourage venous return

Question 12

measures used to reduce infection risk

Answer 12

procedural measures- eg hand hygiene, aseptic measures, pharmacological measures

Question 13

ways in which infection could still occur after surgery

Answer 13

wrong antibiotics prophylaxis given, on antibiotic for too long or too short

Question 14

what are some risks for people with a high BMI when undergoing surgery

Answer 14

• associated medical condition
• temperature regulation
• anaesthetic considerations
• surgcical considerations

Question 15

why does smoking increase risks during surgery

Answer 15

wound healing, intra operative and post operative breathing problems, pneumonia, increased risk of small and large vessel disease, DVT, chest infection, cardiovascular problems

Question 16

what are some risks associated with hypertension during surgery

Answer 16

drugs, co-morbidities, risk of complications

Question 17

how could you overcome anxiety before surgery/ what do you need to consider

Answer 17

benzodiazepines, distraction

you may need to consider a different route of administration for the anaesthesia

Question 18

what are some factors to consider when a diabetic patient undergoes surgery

Answer 18

what insulins is the patient on eg short or long acting. starvation (affects blood glucose). surgical stress response- push blood sugar levels high, other medication

Question 19

what are some things to consider in a patient with renal impairment

Answer 19

changing drug doses, further renal insults (through surgery), high doses of antibiotics could cause further renal function

Question 20

what is the sliding scale regimen

Answer 20

changing from oral diabetic drugs to IV cannula to go on soluble insulin

Question 21

what values need to be looked at to assess renal impairment

Answer 21

urea, creatinine, eGFR, urine output

Question 22

what’s RIFLE

Answer 22

R- risk
I- Injury
F- failure
L- loss
E- end stage

Question 23

what does rifle use to assess function

Answer 23

GFR and urine output

Question 24

what are the consequences of reduce renal function

Answer 24

antibiotics doses

Question 25

benefits of regional anaesthetic

Answer 25

get patients out of hospital quicker, reduce risk of nausea and vomiting

Question 26

what class of drug is associated with risk of regional anaesthetic

Answer 26

anticoagulants- interaction

vital that timing is considered with anticoagulants and anti platelets

Question 27

causes of decrease in oxygen sats

Answer 27

related to BMI, new pathology, pneumothorax, hypotension, PE, equipment problems eg blockage/ oxygen failure

Question 28

immediate post operative problems

Answer 28

• primary haemorrhage
• bottom of lungs get compressed and can’t inflate
• shock
• low urine output
• inadequate intraoperative fluid
• myocardial infarction, blood loss and septicaemia

Question 29

Early post operative problems

Answer 29

• secondary haemorrhage- bleed 24 hours after operation
• pneumonia
• wound or anastomosis dehiscence
• DVT
• acute urinary retention
• paralytic ileus
• wound infection
• nausea and vomiting

Question 30

late post operative complications

Answer 30

• bowel obstruction due to fibrous adhesions which stick in the bowels
• incisional hernia- this could cause bowel obstruction as its in a place it shouldn’t be
• persistent sinus- breach of the skin (small hole that takes a long time to heal)
• recurrence of reason for surgery

Question 31

what factors increase the risk of nausea and vomiting

Answer 31

female, previous history, history of motion sickness, type of surgery eg craniotomy, type of anaesthetic (opioids, nitrous oxide and volatile agents)

Question 32

how do you prevent and treat nausea and vomiting

Answer 32

no smoking, cyclizine, meetoclopramide

Question 33

what is ERAS

Answer 33

Enhanced recovery after surgery
combination of evidence based elements that in combination lead to: better recovery after major surgery, decreased complications, faster time to discharge home