W12 40 peri-operative care Flashcards
What is perioperative medicine?
The practice of patient-centred multidisciplinary and integrated medical care of patients from the moment of contemplation of surgery until full recovery.
What is the purpose of pre operative assessment?
Identify high risk patients
Optimise pre-existing medical problems
Arrange further investigations
Reduce pt anxiety
Plan service provision
Build rapport with the patient
What does perioperative care involve?
Determination of fitness for surgery
Comorbidities
Medication review
Adverse drug reactions (drug interactions)
Investigations - basics like ECG, BP etc
Suitability for day case surgery
Discussion of starvation guidelines
Anaesthetic review
Previous anaesthetics and surgery
What are the ASA grades?
ASA I - normal healthy patients
ASA II - patients with mild systemic disease
ASA III - patients with severe systemic disease that is limiting but not incapacitating
ASA IV - patients with incapacitating disease which is a constant threat to life
ASA V - moribund patients not expected to live more than 24hrs
ASA VI - a declared brain dead patient whose organs are being removed for donor purposes
What are the fasting guidelines?
Time pre-op / what can be consumed:
6hrs - food
4hrs - breast milk
2hrs - clear fluids
What is monitored intra and post-operatively?
Routine monitoring (under any conscious sedation, GA etc) - BP, Sats, ECG
If intubated - ETCO2, temperature
Advanced - ABP, CVP
Where are surgical patients are an increased risk of VTE - main criteria? (and hence require thromboprophylaxis)?
Surgical procedure with a total anaesthetic and surgical time of more than 90mins, or 60mons if the surgery involves the pelvis or lower limb
Acute surgical admission with inflammatory or intra-abdominal condition
Expected significant reduction in mobility
What other patients are at increased risk of VTE, minor criteria?
Active cancer or cancer treatment
Age over 60 years
Critical care admission
Dehydration
Known thombopilias
Obesity
One or more significant medical comorbidities
Person history or first degree relative with history of VTE
Use of hormone replacement therapy
Use of oestrogen-containing contraceptive therapy
Varicose veins with phlebitis
What methods of thromboprophylaxis are there?
Mechanical devices - anti-embolism stockings (thigh or knee high); foot impulse devices; intermittent pneumatic compression devices
Pharmacological - LMWH starting 6-12 hrs after surgery
What is the WHO pain ladder for pain management?
Start on paracetamol, ibuprofen, OTC medications (non-steroidals have an increased risk of bleeding)
Low dose opiates eg codeine
Stronger opiates eg morphine
Multimodal analgesia eg patches of lidocaine
Regional/local anaesthetic eg nerve blocks
Fluid and feeding options
Intravenous
Nasogastric
PEG/JEJ
Oral
What issues can be encountered in recovery?
Airway
Respiratory
Cardiovascular
Neurological
PONV
What airway issues can be encountered and what should be checked?
Make sure patients are spontaneously breading and airway is safe
Check vocal cords and epiglottis
Oedematous can compromise the airways
Potentially due to anaphylaxis, drug reactions, oedema from tube down for a long time
What respiratory issues can be encountered and how are they fixed?
Hypoventilation
Hyperventilation - will reduce CO2 causing tingling, usually from anxiety or pain. Get them enough oxygen!
Bronchospasm - can occur if they aspirate water. Usually in asthmatic patients. Take 10 puffs of blue inhaler. Oxygen.
What cardiovascular issues can be encountered and how are they resolved?
Hypotension - lie pt back and elevate legs. Figure out reason eg vagal episode, loss of blood, drug reaction?
Hypertension - can be caused with pain. Antihypertensives not given preoperatively so might raise after operation etc. Measure to see not above 160.
