7 Surgery - Management of post-op issues Flashcards Preview

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Flashcards in 7 Surgery - Management of post-op issues Deck (34):
1

Patients factors increasing VTE risk (5)

Age
Obesity
Varicose Veins
History of DVT/PE
Clotting disorders

2

Surgical factors increasing VTE risk (3)

Immobility – bed rest or reduced mobility
Dehydration
Trauma or surgery - increased risk with:
(↑ duration, Type of surgery ↑ risk with pelvis or abdo surgery for cancer, Major limb amputation, Major trauma or orthopaedic surgery)

3

Medical factors associated with increase VTE risk

(6)

Malignancy
Oestrogen therapy
Pregnancy or post partum
Co-morbidity
Severe infection
Lower limb paralysis

4

All patients must have VTE assessment with .................... of admission.

Reassed every ....................

24H

72H

5

Non-pharma ways to reduce risk of VTE (3)

Hydrate
Mobilise ASAP
Stop meds that increase risk if possible

6

3 mechanical propylaxis of VTE methods

Compression stockings
Intermittent pneumatic compression
Foot impulse devices

7

If low risk of VTE what should be done for prophylaxis?

Early mobilisation and copression stockings (if not contrqaindicated)

8

If high risk consider

LMWH/NOAC
intermittent pneumatic compression during suregery

9

Assess bleed vs VTE risk with

Active bleeding
Recent surgery
Recent stroke
Spinal intervention
Concurrent use of anticoagulants
Uncontrolled systolic hypertension

10

When do you stop VTE prophylaxis?

Continue until mobilized
(Extend regime required for some procedures such as cancer/ #NOF/ lower limb cast)

11

NOACs licenced for what surgery VTE prophylaxis?

Total hip/total knee replacement

Caution errors of duplication

12

NOACs licenced for what surgery VTE prophylaxis?

Total hip/total knee replacement

Caution errors of duplication

13

If pain is poorly managed...

↓ Recovery & ↑ length of stay
↓ Mobility & ↑ VTE risk
↓ wound healing
↑ BP & Pulse
↑ Anxiety & disturb sleep

14

e.g. of procedure specific pain relief

gabapentin/oxycodone with total knee replacement

15

PONV affects ....% of pt

30

16

What is the cause of PONV
(6)

- Anaesthetic agents
- Opioid analgesia
- Bowel surgery
- Antibiotics
- U&E disturbances
- Bowel obstruction

17

Problems with poorly managed PONV (4)

1. ↑ length of stay
2. Cause dehydration & electrolyte disturbance
3. Disrupt wounds
4. Reduce medicines absorption

18

Apfel scoring for PONV

1 point for:
female
History of motion sickness/PONV
Non-smoker
Opiate use

0 = 10% 1 = 20% 2 = 40%
3 = 60% 4 = 80%

19

What meds are usually used for PONVL (4)

ondansetron, cyclizine, dexamethasone or prochlorperazine
- number prescribe depends on risk factors

metoclopriamide is not v effective

20

why is their high bleed risk for spinal injurys

subdural epidural bleeds are catastrophic

21

How much does one antiemetic reduce PONV risk?

25%
- use this to work out how many to prescribe

22

When to administer anti emetics?

20-30mins before planned end of surgery.

Except dexamethasone which is given at induction

23

Vomiting centre has what receptors? What does each antiemetic target?

Cyclizine (antihistamine)‏
Ondansetron (serotonin antagonist)‏
Dopamine Antagonists:
Metoclopramide Domperidone
Prochlorperazine

24

~Infection risk depends on: (4)

-degree of contamination during surgery
- patient factors
- operation length
- surgeon skill

25

Types of procedures with infection risk

Clean:
No break in sterile technique, site not inflamed or infected eg breast surgery
Clean-contaminated:
Respiratory, gut or genito-urinary tract entered but no contamination encountered eg appendectomy
Contaminated:
Major break in sterile technique, spillage from GI tract or acute inflammation encountered
Dirty:
Acute inflammation with pus encountered / GI tract perforation / old dirty wounds

26

e.g. of surgery and antibiotic prophylaxis - CLEAN

No break in sterile technique, site not inflamed or infected eg breast surgery

None (unless implanting)

27

e.g. of surgery and antibiotic prophylaxis - CLEAN-CONTAMINATED

Respiratory, gut or genito-urinary tract entered but no contamination encountered eg appendectomy

At induction and 24h post op

28

e.g. of surgery and antibiotic prophylaxis - DIRTY

Contaminated:
Major break in sterile technique, spillage from GI tract or acute inflammation encountered
Dirty:
Acute inflammation with pus encountered / GI tract perforation / old dirty wounds

Contaminated or Dirty – at induction and treatment course for 5-7 days post op

29

Why should er try to avoid antibiotics?

They carry their own risk
c diff, resistance,
s/e

30

Choice of antibiotic regime depends on

Locally agreed policies
Microbiologists & Pharmacist

Choice depends on:
- Likely organism encountered – local resistance patterns
- Cost-effectiveness
- Pharmacokinetics – tissue concentration

31

What route is preferred for antibiotic prophy

High tissue concentration at time of incision
iv preferred route
Dose / infusion completed just before incision if iv
Re-administer if long surgery

32

Info on NBM post op

Following most surgical procedures, patients can eat and drink that evening
Post GI surgery may be NBM for several days / weeks or have impaired absorption
Regular medicines for underlying disease
- essential to be continued?
Consider alternative routes:
- parenteral - iv/im/sc
- transdermal
- rectal
- via feeding tube
- sub-lingual

33

Info on NBM post op

Following most surgical procedures, patients can eat and drink that evening
Post GI surgery may be NBM for several days / weeks or have impaired absorption
Regular medicines for underlying disease
- essential to be continued?
Consider alternative routes:
- parenteral - iv/im/sc
- transdermal
- rectal
- via feeding tube
- sub-lingual

34

4 things to consider post op

vTE propylaxis
Antibiotic prophylaxis
PONV
pain