Post Op Care of Surgical Patient

Question 1

What is pre-operative care?

Answer 1

The preparation and assessment, physical and psychological of a patient before surgery

Question 2

Why do we ask patients to stop smoking before an operation?

Answer 2

wound healing
chest infections
herpes

Question 3

Why would you ask someone to reduce their alcohol intake before an operation?

Answer 3

Alcohol damages the liver

As a result less clotting factors and less vitamin K so clotting is impaired

Question 4

What are some things important for wound healing?

Answer 4

Proteins/Albumin
Zinc (collagen synthesis)
Vitamin C (collagen synthesis)
Magnesium

Question 5

What are some high-risk patients for surgery?

Answer 5

Children
Elderly
Immunosuppressed
Obese
Liver Impairment
Clotting disorders
Renal Impairment

Question 6

What is the ASA (american society of anaesthesiologists) classification?

Answer 6

A scoring classification that predicts the morbidity and mortality of a patient going into surgery.
ASA 1 Healthy
ASA 2 Mild systemic disease, no functional limitation
ASA 3 Moderate systemic disease, definite functional limitation
ASA 4 Severe systemic disease that is a constant threat to life
ASA 5 Moribund patient. unlikely to survive 24 hours.
postscript E indicates emergency surgery

Question 7

Give an example of an ASA 4/5 patient

Answer 7

Abdominal Aortic Aneurysm Rupture

Question 8

Where is death almost certain with AAA?

Answer 8

If it’s a anterior bleed. Posterior bleed presents as renal colic and a pulsatile mass on palpation of the abdomen.

Question 9

What is the grade of surgery?

Answer 9

Grade 1: Minor procedures e.g diagnostic endoscopy, breast biopsy
Grade 2: Inguinal hernia repair, varicose veins adenotonsillectomy, knee arthroscopy
Grade 3: Total abdominal hysterectomy, TURP, lumbar discectomy, thyroidectomy
Grade 4: Major procedures, e.g. total joint, artery reconstruction, colonic resection, radical neck dissection

Question 10

According to ASA guidelines: Would you do a full blood count for all patients going into surgery?

Answer 10

Yes (as long as the national & local guidelines agree and it makes sense for the surgery). You would definitely do it if the patient looks anaemic.

Question 11

According to ASA guidelines: Would you do a clotting screen (haemostasis)?

Answer 11

Not routinely for ASA 1 or 2, but consider in people with chronic liver disease in ASA 3 or 4.

Question 12

In what patients would you perform a clotting screen pre-surgery?

Answer 12

Liver Impaired
Clotting disorders
Patients on anticoagulant

Question 13

According to ASA guidelines: Would you assess kidney function for all patients going into surgery?

Answer 13

Yes for ASA 2, 3 or 4. Consider in people at risk of AKI for ASA 1.

Question 14

According to ASA guidelines: Would you do an ECG for all patients going into surgery?

Answer 14

Yes for ASA 2, 3 or 4. Consider in 65+ if no ECG results available from past 12 months.

Question 15

According to ASA guidelines: Would you do lung function tests for all patients going into surgery?

Answer 15

Not routinely for ASA 1 or 2. Consider in ASA 3 or 4 with known suspected respiratory disease.

Question 16

What are the basic fasting guidelines for children and adults before surgery?

Answer 16

No eating for 6-8 hours before.
No fluids for up to 2 hours before.
only clear fluids allowed
i.e. coffee or juice not allowed

Question 17

What are some associated medical conditions that affect surgery?

Answer 17

Difficult airway, obesity, cardiac disease, respiratory disease, gastrointestinal disease,
Renal failure,
Diabetes,
Haematological disorders - anaemia, sickle cell anaemia,
Allergic reactions, and those rendering patients at high risk
Additional investigations for specific illnesses – such as cardiopulmonary exercise testing to evaluate both cardiac and pulmonary function

Question 18

When would you consider performing a G&S (group & save) investigation?

Answer 18

In higher grade surgeries and higher stage surgeries.

Surgeries where blood loss is a factor e.g. trauma, emergency surgery, ASA 5

Question 19

What should you be thinking about in post-op care?

Answer 19

Analgesia
Op Note
Intake Output
Mobilise
LMWH? (if can't mobilise)
Wounds
Bowel Opening? (opiates may affect this)

Question 20

How to perform fluid status assessment

Answer 20

Remind yourself of patient’s medical history, either past or ongoing.
Examine the patient and look at the observations, urine output, and fluid balance chart.
Assess the fluid status looking at lying and standing blood pressure, heart rate, jugular venous pressure, and mucous membranes.
Ensure you auscultate the chest and look at the peripheries for oedema.
Scan the drug chart to see if any drugs may be affecting fluid balance and whether any changes can be made. e.g. U&Es
Check the patient’s electrolytes—does any action need to be taken, or do these point to specific fluids to use?
Does the patient have any ongoing fluid and electrolyte losses that need to be taken into account?
Can fluids be taken orally instead of intravenously?

Question 21

Which patients are in need of fluid optimisation

Answer 21

diarrhoea and vomiting
where the patient has been immobile / debilitated for a prolonged period prior to admission (which has decreased fluid intake)
elderly patients with reduced renal function that makes fluid balance maintenance more challenging
drugs that lower renal fluid exchange functions
low BMI patients in whom ‘normal’ fluid loss volumes will be more significant.

Question 22

How to perform fluid optimisation

Answer 22

Recognise the different types of fluid used for optimisation, especially Hartmann’s, Normal 0.9% Saline and Dextrose.
Determine the correct volume and rate of administration.
Assess the volume of body fluid depletion, and how to administer fluid resuscitation to patients especially according to them being elderly / unfit / with impaired cardiac and/or renal function.
Monitor the progression of fluid optimisation

Question 23

What are some of the different types of thromboprophylaxis?

Answer 23

mechanical
drugs (heparin /LMWH + doses)
antiplatelet or indirectly acting medications.

Question 24

What are some of the types of patients that are indicated for thromboprophylaxis?

Answer 24

immobilised patients
elderly patients
etc.. add to this one

Question 25

How many deaths a year occur in the UK every year after surgery?

Answer 25

20,000 to 25,000

80% occur in high risk patients which comprise 10% of the surgical inpatient population.

Question 26

What is the timing classification of post-op complications?

Answer 26

Acute <24 hours
Early <1 week
Late >1 week

Question 27

What often cause acute post-op complications?

Answer 27

2ry to GA
Haemorrhage or anaemia
Hypovolaemia
Respiratory compromise
Uncontrolled pain
Emboli
Damage to surrounding structures

Question 28

65yr old aorto-bifemoral bypass in the morning develops acute onset abdominal pain and pyrexia, rigidity, raised lactate and metabolic acidosis

How would you manage this case?

Answer 28

Assessment of the patient’s airway patency (openness of the airway), vital signs , and level of consciousness. The following is a list of other assessment categories:
surgical site (intact dressings with no signs of overt bleeding)
patency (proper opening) of drainage tubes/drains
body temperature (hypothermia/hyperthermia)
patency/rate of intravenous (IV) fluids
circulation/sensation in extremities after vascular or orthopedic surgery
level of sensation after regional anesthesia
pain status
nausea/vomiting

Question 29

65yr old aorto-bifemoral bypass in the morning develops acute onset abdominal pain and pyrexia, rigidity, raised lactate and metabolic acidosis

What could cause this?

Answer 29

Sepsis
Haemorrhage
Emboli
etc.

Question 30

The first 24 hours after surgery, you must monitor vital signs. What else should you monitor?

Answer 30

respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours.
Body temperature must be monitored, since patients are often hypothermic after surgery, and may need a warming blanket or warmed IV fluids.
Fluid intake and urine output should be monitored every 1-2hours.
If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate.
If the patient had a vascular or neurological procedure performed, circulatory status or neurological status should be assessed as ordered by the surgeon, usually every one to two hours.
The patient may require medication for nausea or vomiting, as well as pain.
Patients with a patient-controlled analgesia pump may need to be reminded how to use it.
Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.
Movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear; they will be much more likely to perform these tasks.

Question 31

What are some early post-op complications?

Answer 31

Delirium
DVT/PE
Infection/Sepsis
Poor wound healing/Dehiscence
Reperfusion injuries
Pressure sores
Late haemorrhage

Question 32

What happens if you have a post-operative ileus?

Answer 32

You can hear tinkling bowel sounds. Also an accent?

There is no point of feeding the patient if they have ileus.

Question 33

What are some late post-op complications?

Answer 33

Damage to local structures - loss of function
Scarring
Chronic pain
Recurrence/Failure of surgery

Question 34

What are the signs and symptoms of early sepsis?

Answer 34

Respiratory acidosis
Decreased cardiac output
Hypoglycemia
Increased arteriovenous oxygen difference
Cutaneous vasodilation

Question 35

Your F2 colleague has asked you to chase the bloods for a colorectal patient. It is now day 6 and the ileus has resolved. He was ready for discharge today but has suddenly spiked a temp of 38. His abdomen has become peritonitic.
Bloods: WCC:23 CRP:300 Creat :200 Urea:9

How would you manage this patient?

Answer 35

Seems like early sepsis. Elevated WCC, CRP, Creatinine.

Full patient assessment

Decide and plan:
stable?
unstable? get investigatoins
definitive care? surgery

Question 36

All of the following are contraindications to passing a nasogastric tube EXCEPT
(A) suspected perforation of the oesophagus
(B) confirmed perforation of the oesophagus
(C) history of oesophageal varices
(D) nearly complete obstruction of the oesophagusdue to benign or malignant strictures
(E) presence of an oesophageal foreign body

Answer 36

(C) history of oesophageal varices

oeseophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus

Question 37

Laparoscopic cholecystectomy is indicated for symptomatic gallstones in which of the following conditions?

Cirrhosis
Prior upper abdominal surgery
Suspected carcinoma of the gallbladder
Morbid obesity 
Coagulopathy

Answer 37

Morbid obesity

The other conditions would require more investigations

Question 38

A 60-year-old male presents with an inguinal hernia of recent onset. Which of the following
statements are TRUE?

(A) The hernia is more likely to be direct than indirect.

(B) Presents through the posterior wall of the inguinal canal, lateral to the deep inguinal ring.

(C) Is covered anteriorly by the transversalis fascia.

(D) Is more likely than a femoral hernia to strangulate.

(E) The sac is congenital.

Answer 38

(A) The hernia is more likely to be direct than indirect.

As this is an older patient

Question 39

48 year old woman presented with right abdominal pain, nausea & vomiting. On examination she had tenderness in the right hypochondrial area. Investigations showed high WBC count, high alkaline phosphatase & high bilirubin level. The most likely diagnosis is

a) Acute cholecystitis
b) Acute appendicitis
c) Perforated peptic ulcer
d) Acute pancreatitis

Answer 39

a) Acute cholecystitis

Question 40

A 67-year-old male presents with complaints of itching, dark urine, and epigastric pain. Physical examination reveals jaundice. Initial laboratory tests show total bilirubin of 6.5 mg/dL, alkaline phosphatase elevated at 3 the upper limit of normal, and mild elevations in serum transaminases. Appropriate management includes which diagnostic test next?

a. Abdominal ultrasonography
b. Computed tomography of the abdomen
c. Magnetic resonance imaging of the abdomen
d. Endoscopic retrograde cholangiography

Answer 40

a. Abdominal ultrasonography

better than CT in this case as gall stones suspected, so less will be in the way in an USS than CT