Perioperative Complications Flashcards
(23 cards)
Perioperative medications to stop
-ACE inhibitors (morning of surgery due to risk of AKI)
-COCP (4 weeks prior to surgery due to VTE risk)
-Apixaban should be stopped at least 24 hours prior to interventions with a low risk of bleeding
-Apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of bleeding
-If thromboprophylaxis is indicated, LMWH should be commenced at prophylactic doses, and the first dose given at least 24 hours after the last dose of apixaban
-If it is an emergency situation and you can’t wait, regional anaesthesia is contra-indicated (haematoma in spine)
-Once post-operative haemostasis is secure, apixaban can be restarted 24 hours after the last dose of LMWH
-Stop warfarin if low thrombosis risk (omit 5 doses prior to theatre) no pre-op LMWH required
-Stop if high risk (enoxaparin day 3, 2, 1)
-Diabetic mediation withheld or altered according to local protocol (variable rate insulin infusion)
Perioperative medications that can continue
-Aspirin (low dose)
-Beta blockers
Complications in the immediate post-operative period
-Pain
-Inadequate analagesia
-Haematoma
-Nerve irritation (neurostenalgia)
-Compartment syndrome
Complications in the 3 days post-operative period
-Infection
=Cellulitis
=Metalwork / implant infection
=Abscess
-Metalwork failure
Review of pain management in post-operative pain
- Anaesthetic methods of post-operative analgesia, such as a regional block or a epidural.* When was it sited? Is it still working?
- Surgical methods of post-operative analgesia, such as elevation, orthoses, and casts* Are they being correctly implemented?
- Medications* Background: drug, dose, route, frequency? When was it last administered?* Breakthrough analgesia
Describe the pain ladder
- Mild pain
=Non-opioid with or without adjuvant therapy - Mild to moderate pain
=Weak opioid or multimodal fixed-dose opioids +/- nonopioid +/- adjuvant therapy - Moderate to severe pain
=String opioid +/- nonopioid +/- adjuvant therapy
Causes of fever in immediate postoperative period
-Reaction to anaesthetic
-Reaction to intra-operative blood products
-Pre-existing infection
Causes of fever in day 3 post-operative period
-Atelectasis
-Infection
=Many possible sites!
=Wound
=Lines
=Metal /implants
=Chest
=Urine
=Others.
Causes of fever day 5-7 post operative
-DVT/PE
-Infection
Anaesthetic causes of post-operative confusion (delirium)
-Anaesthetic medications (inc. opioids and sedatives)
-Hypothermia
-Hypoxia
-Hypotension
Surgical causes of delirium
-Pain
-Anaemia
-Infection
-Ileus
Medical causes of delirium
-Electrolyte abnormalities (K+, Na+, Mg2+, Ca2+,PO43-)
-Low BM
-AKI
-Constipation
-Infection
-Acute urinary retention
-EtOH withdrawal
Rare causes of delirium
-Intra-cranial event
-Malignant hyperthermia
-Others
Investigation of post-operative delirium
-Medication review (sedatives, analgesia, steroids, anti-Parkinson)
-Bloods:
=Electrolytes, inc. Na+, K+, Mg2+,Ca2+, PO43-
=Glucose
-Others, as required
Management of post-operative delirium
-Re-orientate
-Correct reversible causes (i.e., electrolyte abnormalities or infection)
-Treat
=Pain
=Constipation
=Dehydration
-Medication: Haloperidol (rarely needed)
Risk factors for post-operative nausea and vomiting
20-30% patients
- Patient (Apfel score)
-Female
-Non-smoker-Motion sickness or previous PONV
-Post-operative opioid use - Anaesthetic
-Inhaled anaesthetic agents
-Prolonged anaesthetic
-Intra-op opioid use - Surgical
-Abdominal, gynaecological, intra-cranial and ear sugery
-Prolonged operation
Differentials for post-operative N&V
-Gastrointestinal
=Ileus
=Obstruction
= GI infections etc.
-Acidosis:
=Sepsis
=Uraemia (AKI)
=DKA
=Others
-CNS
=Raised ICP
-Aural (i.e., labyrinthitis)
Management of post-operative N&V
-Multimodal analgesia, avoiding opioids where possible
-Ondansetron as the first-line anti-emetic
-Furthermore, the anaesthetic team will generally take prophylactic steps to reduce the risk of PONV becoming established
Types of post-operative haemorrhage
-Primary: managed intra-operatively
-Secondary: 7-10 days, infection eroding vessel walls
-Reactive: 24 hours, due to failure of the intra-operative haemostatic methods
What structures could be bleeding?
-Capillary beds
-Arterial
-Venous
Factors in haemorrhagic shock classification
-Blood loss
-Pulse
-BP
-Pulse pressure
-CRT
-RR
-UO
-Mental status
Tennis scores (1-4)
Blood investigations in haemorrhage
-VBG (quick Hb result)
-FBC (definitive Hb result)
-Coag (?coagulopathic)
-Lactate (?shock
- X-match (for blood transfusion)
Management of haemorrhage
-Escalate
-?Activate major haemorrhage protocol
-Prescribe:
=IV fluids
=Blood products
=+/– Tranexamic acid
-Definitive:
=Depends on the aetiology
