Week 4 - Pre & Post-operative Care Flashcards
How are patients managed pre-operatively with regard to anticoagulants in the elective situations?
- DOACs?
- Warfarin?
- Antiplatelet Agents?
How are patients managed pre-operatively with regard to anticoagulants in emergency situations?
What methods are available for nutritional support in surgical patients? (3)
In surgical patients, various methods of nutritional support are available to ensure adequate nutrient intake during the perioperative period. The choice of method depends on the patient’s clinical condition, anticipated duration of nutritional support, gastrointestinal function, and surgical considerations.
What are 6 causes of post-operative fever occurring in the first four days following an appendicectomy?
How would you approach a patient with a fever who is 4 days post-operative following an appendicectomy? (6 things)
Why do surgeons do ward rounds? (5 things)
How do you assess the state of hydration of a post-surgical patient? (7 things)
What is meant by the term “maintenance fluids” in the post-operative setting?
Give an example of the fluid volume and rate you would use in the first 24 hours in an 18-year-old man recovering from an uncomplicated appendicectomy.
The specific fluid volume and rate for an 18-year-old man recovering from an uncomplicated appendicectomy can vary based on factors such as the patient’s weight, comorbidities, and individual fluid requirements. However, as a general example, a commonly used approach for maintenance fluid calculation is the Holliday-Segar method. This method estimates the daily fluid requirement based on body weight.
Describe the principles involved in obtaining informed consent from a patient. (8)
Define the term ‘material risk’.
List 8 mechanisms to ensure surgery is performed on the correct anatomical site.
Describe 4 methods taken pre-operatively to prevent thrombo-embolic disease.
Describe 3 methods taken intra-operatively to prevent thrombo-embolic disease.
Describe 3 methods taken post-operatively to prevent thrombo-embolic disease.
Describe the broad principles of surgical drains. (7)
Surgical drains are devices used to remove fluid or air from a surgical site or body cavity. They play a crucial role in the management of postoperative fluid collections, prevention of infection, and promotion of wound healing.
What 5 things are involved in the monitoring of post-operative patients?
What supportive measures need to be considered after surgery? (9)
- Vital signs (blood pressure, pulse, oxygen saturation, temperature)
-
Surgical site assessment and focused physical examination based on the type of surgery
Daily input/output monitoring, including: -
Urine output: If output is < 0.5 mL/kg/hour for > 6 hours carry out the following.
- Check catheter patency.
- Consider possible causes of AKI.
4.Surgical drain output
- Fluid volume in 24 hours
- Fluid type (e.g., serous, bloody, purulent, feculent)
5.Stool output
6 Signs and Symptoms of Post-Operative Wound Infections?
Management of Post-Operative Wound Infections? (7)
5 signs, symptoms of post-operative fever? Management? (7)
List the possible post-operative complications:
- 3 General?
- 4 Cardiac?
- 8 Pulmonary?
- 9 Gastrointestinal?
- 3 Renal/Urinary Tract?
- 5 Haematological?
List the possible post-operative complications:
- 2 Neurological?
- 5 Skin & Soft Tissue?
What is the definition of a post-operative fever?
Aetiology of Post-operative fever?
- Immediate?
- Acute?
Temperature > 38°C (100.4°F) in the postoperative period
The most common infectious causes of postoperative fever include surgical site infections (SSIs), pneumonia, catheter-associated UTIs, and primary bloodstream infections. The most common noninfectious causes include febrile drug reactions and venous thromboembolism.
Discuss the Aetiology of perioperative hemorrhage.
What is a Hematoma? What is Seroma?
- 6 Clinical Features?
- Treatment?
Hematoma: a collection of blood due to unsuccessful hemostasis or coagulation
Seroma: a collection of serum, lymphatic fluid, and liquified fat often due to the presence of an empty cavity following surgery
Clinical Features:
1. Most commonly occurs several days after surgery
2. May be asymptomatic
3. Localized swelling
4. Pain or discomfort
5. Drainage of fluid: Hematoma: dark & Seroma: clear
6. Hematoma: purple discoloration
Surgical Site Infections
- Definition?
- Epidemiology?
- Causative pathogens during the first 48–72 hours?
- Causative pathogens 48–72 hours after surgery?
- Causative pathogens > 30 days after surgery?
SSI = An incisional skin and soft tissue infection or organ/space infection located at the site of recent surgery, typically arising within 30 days postoperatively.
- Accounts for ∼ 20% of all health care-associated infections.
- Most common nosocomial infection among patients undergoing surgery.
- Incidence: ∼ 2% of all surgical wounds.
List 9 Patient-related risk factors for surgical site infections and 6 Procedure-related risk factors?
Classify the different types of surgical wounds?
- Wounds can be classified preoperatively and/or postoperatively based on clinical characteristics.
- The classification may be used to predict the risk of developing an SSI and the necessity of perioperative antibiotic prophylaxis.
Diagnostics for Surgical Site Infections
- 3 Routine laboratory studies?
- 2 Microbiological studies?
- Imaging?
General Principles of Treatment for Surgical Site Infections?
- 4 Surgical management options?
Surgical management
1. Suture removal, incision, and drainage.
2. Debridement of necrotic tissue (e.g., necrotizing soft tissue infection).
3. Regular dressing changes and daily wound inspections
4. Delayed closure once the infection has resolved
Which antibiotics are best for empiric antibiotic therapy for Surgical Site Infections?
- Incisional SSI not involving the genital or GI tracts?
- Incisional SSI involving the perineum, axilla, or GI or genital tracts?
- Suspected necrotizing soft tissue infection?
- Choose initial empiric antibiotics based on the location of surgery (e.g., intraabdominal, genital) and presence of complications (e.g., necrotizing infection).
- Antibiotic duration depends on the severity and extent of the infection.
- Necrotizing soft tissue infections are a medical emergency and require immediate surgical consultation and treatment.
List 3 Complications of Surgical Site Infections?
5 Preventive measures for SSIs?
Complications of SSI
1. Wound dehiscence
2. Secondary hemorrhage
3. Bloodstream infection, which may lead to sepsis and septic shock
Risk factors for post-operative nausea and vomitting?
- Differential diagnoses of PONV <1 week after surgery?
- Differential diagnoses of PONV >1 week after surgery?
- < 1 week after surgery: self-limiting gastric or intestinal atony, or a more severe paralytic ileus
- > 1 week after abdominal surgery: early mechanical bowel obstruction
List 4 Complications of Post-operative nausea and vomitting?
- PONV prophylaxis?
Complications of PONV
1. Prolonged hospital stay
2. Increased risk of aspiration pneumonia
3. Secondary hemorrhage due to retching
4. Mallory Weiss syndrome
- 4 Clinical Features of post-operative urinary retention?
- 4 Patient-related risk factors?
- 7 Procedure-related risk factors?
Clinical Features
1. Suprapubic discomfort and/or pain
2. Sensation of bladder fullness
3. Palpable bladder
4. Urinary retention may be asymptomatic in patients with sensory deficits (e.g., due to spinal cord injuries or stroke) or after recent regional anesthesia.
Diagnostics for post-operative urinary retention?
Management for post-operative urinary retention?
Diagnostics
- Primarily a clinical diagnosis
- Consider the following to support the diagnosis as necessary:
- Bladder ultrasound or bladder scanner: preferred methods of assessing bladder volume
- Bladder catheterization
- Further evaluation is usually not necessary in patients with postoperative urinary retention.
Post-operative urinary retention
- Diagnostics?
- 3 Complications?
- Management?
Diagnostics
- Primarily a clinical diagnosis
- Consider the following to support the diagnosis as necessary:
- Bladder ultrasound or bladder scanner: preferred methods of assessing bladder volume
- Bladder catheterization
- Further evaluation is usually not necessary in patients with postoperative urinary retention.
Complications
1. Acute hydronephrosis (postrenal cause of AKI)
2. Urinary tract infection
3. Hospital-acquired infection due to prolonged hospital stay
What is a Postoperative ileus? What is a Prolonged postoperative ileus?
- 6 Risk factors?
Postoperative ileus (physiologic): impaired gastrointestinal motility that occurs following abdominal or pelvic surgery and typically resolves spontaneously within 72 hours; one of the most common causes of paralytic ileus.
Prolonged postoperative ileus: a form of paralytic ileus associated with prolonged impaired gastrointestinal motility for > 72 hours after surgery.
4 Symptoms & 3 Exam Findings of Post-operative ileus?
- 8 Preventive measures for postoperative ileus?
Symptoms
1. Constipation and reduced passage of gas
2. Continuous (non-colicky) abdominal pain or discomfort
3. Nausea, vomiting.
4. Abdominal distention
Examination findings
1. Percussion: diffuse tympany
2. Palpation: usually no tenderness unless peritonitis is present
3. Auscultation: Bowel sounds are absent (silent abdomen) or decreased (early paralytic ileus).
Management of Post-operative Ileus
- General principles?
- 5 Initial measures for all patients?
- Evidence-based recommendations for the management of paralytic ileus are scarce.
- Management is mainly conservative and includes symptomatic treatment, IV fluids, and bowel rest.
- Surgery is typically not indicated unless the underlying cause necessitates surgical intervention (e.g., appendicitis, gallstone pancreatitis).
- The underlying cause should be evaluated for and managed appropriately.
- For postoperative ileus, preventative measures are paramount.
- If there is no suspicion of more severe conditions such as mechanical obstruction or Ogilvie syndrome, the treatment of paralytic ileus is mainly supportive.
Management of Post-operative Ileus
- 4 Further measures?
- Improvement of symptoms and tolerance of enteral feeding are better predictors of the normalization of gastrointestinal motility than successful bowel movements.
- Obtain urgent surgery consult if the patient develops signs of peritonitis.
7 Vascular Risk Factors?
Outline a Vascular History Protocol
- Vascular Diseases?
- Symptoms?
Features of Intermittent Claudication in a patient with vascular disease? (5)
Features of Rest Pain in a patient with vascular disease? (4)
3 Differential diagnoses of calf pain other than Chronic Arterial Insufficiency?
- Differentiate Vascular vs Neurogenic Claudication.
Differential diagnosis - Calf pain due to:
1. Musculoskeletal: knee, ankle, hip pathology
2. Neurological: spinal stenosis
3. Deep vein thrombosis
Differentiate Vascular vs Neurogenic Claudication.
Outline what is involved in the Vascular Examination of the Upper Limb and Chest?
Outline what is involved in the Vascular Examination of the Abdomen and Groins?
Outline what is involved in the Vascular Examination of the Lower Limbs?
What is Buerger’s Test and what does it indicate when positive?
What is the Rutherford Classification of Chronic Limb Ischaemia?
4 Stages of Arterial Insufficiency?
CHRONIC PVD FEATURES - Which vessel?
5 Clinical features/Diagnostic criteria of Critical Limb Ischamia (CLI)?
ABI = Ankle Brachial Index
Clinical features of Chronic CLI Ulcers?
Chronic CLI - Ulcers
1. usually begin as traumatic wounds
2. failure to heal
3. painful
4. pale
5. associated trophic changes
6. occur at sites of increased focal pressure
7. may be mixed arterial/venous disease
8. differentiate from neuropathic ulcers, venous ulcers and vasculitic ulcers
Clinical Features of dry vs. wet gangrene?
Prognosis of:
- Intermittent claudication?
- Critical limb ischaemia?
- Gangrene?
Critical Limb Ischaemia - 6 P’s?
Pathology of CLI?
- Pain
- Pulselessness
- Pallor
- Paresthesias
- Paralysis
- Perishing cold
Management Pathway for Acute Limb Ischaemia?
Compartment Syndrome
- What is it?
- Clinical features in Acute Limb Ischaemia?
- Tx?
Compartment Syndrome
- Elevated pressure due to increased volume within fascial compartment
- Occurs in ischaemia and especially after revascularisation
- Typically in ACUTE ischaemia
- Inflammatory reaction – leaky microcirculation and accumulation of metabolic byproducts
- Oedema of tissues within non-expanding fascia
- Tense muscle belly
- Look for pain on dorsiflexion & plantarflexion of foot
- Can measure compartment pressures with sphygmomanometer and column of fluid: Pressure > 30mmHg abnormal
- Will occur inevitably if revascularising paralysed limb
- Usually warrants fasciotomy at time of revascularisation: splitting of deep fascia of some/all muscle compartments & delayed closure
You are called to see a 77-year-old man with increasing confusion on day three (3) following a right inguinal hernia repair. How would you classify the causes (6) of the confusion and how would you investigate and manage this patient?
Post-Operative Confusion
- Overview?
- 4 Risk Factors?
- Causes: Anaesthetic? Surgical?
- 6 Investigations?
- Management?
OVERVIEW
- Often multi-factorial
- not uncommon
- requires a systematic approach (history, review of notes, examination and review of investigation with simultaneous management)
RISK FACTORS
1. Increased age
2. Polypharmacy
3. Pre-existing confusion, delirium and dementia
4. Pre-existing electrolyte abnormalities
previous brain dysfunction (CVA)
INVESTIGATIONS
1. ABG
2. U+E
3. Glucose
4. FBC
5. CXR
6. ECG
Outline important steps in the peri-operative management of diabetic patients undergoing major surgery (15 points).
List and describe the 6 signs, symptoms, and management of post-operative myocardial infarction.
Post-Operative Atelectasis
- What is it?
- Pathophysiology?
- 7 Risk Factors?
- Clinical features?
Atelectasis refers to a partial collapse of the small airways. The majority of post-operative patients will develop some degree of atelectasis, resulting in abnormal alterations in lung function or compromise to the lung’s immune defences. It is a clinically important condition as it is often a precursor or contributor to other important, and often more severe, post-operative pulmonary complications.
Risk Factors - The main risk factors for developing atelectasis in the surgical patient include:
1. Age
2. Smoking
3. Use of general anaesthesia
4. Duration of surgery
5. Pre-existing lung or neuromuscular disease.
6. Prolonged bed rest (especially with limited position changes).
7. Poor post-operative pain control (resulting in shallow breathing).
Post-Operative Atelectasis
- Investigations?
- Management?
- Prevention?
- 4 Key Points?
Key Points
1. Atelectasis refers to a partial collapse of the small airways, a common post-operative complication.
2. It can present with hypoxia, raised respiratory rate, or even low-grade pyrexia.
3. Diagnosis is typically clinical, occurring within 24 hours post-operatively.
4. Pain control and physiotherapy form the mainstay of management
List and describe the 7 signs, symptoms and management of post-operative atelectasis.
List 7 social and 11 medical complications of obesity.
6 Complications of Bariatric Surgery?
- 6 Signs of Malnutrition?
- 5 Risk factors for Malnutrition?
- 4 Methods to improve nutrition?
Signs of Malnutrition:
1. Unintended weight loss.
2. Muscle wasting or loss of subcutaneous fat.
3. Poor wound healing.
4. Weakness and fatigue.
5. Impaired immune function.
6. Oedema (severe protein-energy malnutrition).
Risk Factors:
1. Chronic illnesses (e.g., cancer, heart failure, COPD).
2. Hospitalization or recent surgery.
3. Advanced age.
4. Social factors (e.g., poverty, isolation).
5. Decreased appetite or difficulty eating.
- 5 Complications of Malnutrition?
- 5 Complications of Enteral Feeding?
- 5 Complications of Parenteral Feeding?
Complications of Enteral Feeding:
1. Aspiration: There is a risk of aspirating (inhaling) tube feedings, leading to pneumonia.
2. Tube Displacement: Tubes can become dislodged or migrate, requiring repositioning or replacement.
3. Gastrointestinal Issues: Enteral feeding may cause diarrhea, constipation, or abdominal discomfort.
4. Tube Site Infection: Infection or irritation at the tube insertion site can occur.
5. Metabolic Abnormalities: Electrolyte imbalances, hyperglycemia, or refeeding syndrome may develop.
