Care of Surgical Patients

Question 1

Pre-op assessment

MRSA status management

Answer 1

Accurate DH
Check MRSA status - need decolonisation treatment 5 days before using chlorhexidine. Suppression treatment if carrier

Question 2

Planning for Patients on Steroids

Considerations

Answer 2

Steroids in PMH and on replacement therapy
Receiving or have received repeated course of >10mg prednisolone within 3 months of surgery or 5mg prednisolone for >5 days 2 weeks before surgery

Question 3

Planning for Patients on Steroids

Steroids given depending on the severity of operation

Answer 3

Minor op - usual oral corticosteroid dose OM of the operation or hydrocortisone IV at induction
Moderate and major op - usual oral corticosteroid dose OM of the operation + hydrocortisone IV at induction.

Question 4

NIL by mouth: Medicines to be stopped

Answer 4

Bleeding risk - NSAIDS, antiplatelets, anticoagulants
VTE risk - contraceptives, COC
Antidiabetics / Insulin
Antihypertensives - ACE, ARB, diuretics
Herbal and homeopathic prep

Question 5

Bridging

what to give

Answer 5

Stopping long term oral anticoag / NOAC but needs treatment to continue via non-oral route
Heparin - give treatment dose. Continue until oral treatment restarts and is at therapeutic level
For high VTE risk patients

Question 6

Bridging: when should it be used

Answer 6

Moderate to high thromboembolic risk
Where anticoag has prolonged interruption

Question 7

Anticoagulant bridging for warfarin patients

steps, what to give

Answer 7

Stop warfarin 5 days before surgery
Use LMWH to cover INR below desired range
High risk VTE - need bridging with LMWH treatment dose
Stop LMWH at least 24hr pre-op
Phytomenadione - antidote for warfarin. Give day before if INR is still >1.5

Question 8

Post-op pharmaceutical care

4As

Answer 8

Anticoagulants
Analgesia
Antiemetics
Antibiotics

Question 9

Anticoagulants: VTE risk

For surgical patients

Answer 9

Dalteparin 5000units + anti-embolism stockings + pneumatic compression + early mobilisation

Question 10

Anticoagulants: Extended prophylaxis

Management options

Answer 10

LMWH 10/7 then aspirin 75mg or 150mg for further 28/7
or
LMWH 28/7 + anti-embolism stockings - until discharge
or
Option for VTE prevention - DOACs e.g. apixaban, rivaroxaban, dabigatran

Question 11

Analgesia: Post-op pain

what to use

Answer 11

WHO pain ladder
Patient controlled analgesia after surger - use strong opioids e.g. morphine, oxycodone, fentanyl
Adjuvants analgesics - enhances analgesic action e.g amitriptyline, gabapentin, pregabalin, carbamazepine, lidocaine patch, ketamine

Question 12

Analgesia: Managing Opioid S/E

Answer 12

Constipation - proactive laxative use e.g. senna, macrogol
N+V - anti-emetics e.g. cyclizine / ondansetron
Itch / Rash - antihistamine e.g. chlophenamine
Dry mouth - increase fluid intake
Drowsiness / Sedation - dose adjustment / opioid rotation
Respiratory depression - naloxone

Question 13

Anti-emetics: Post-op N+V (PONV)

what to give

Answer 13

High risk patient - give anti-emetics pre-op and regularly post-op
5HT3-receptor antagonists - ondansetron
H2 receptor antagonists - cyclizine
Centrally acting Dopamine antagonists - prochlorperazine, metoclopramide

Question 14

Antibiotics prophylaxis

Answer 14

Only give if there is a clear evidence of benefit for the surgery type - e.g. open surgery to abdomen or known infections are present
Single dose within 30mins before incision
Can give extra dose - if surgery is longer
MRSA colonisation - Vancomycin