Pre-Op Flashcards by Eilidh Seaton

What can the trauma of surgery lead too

Stress
Fluid shift in body 
Blood loss 
CVS / respiratory / renal failure 
Decreased FRC due to GA so post-op oxygen

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What is pre-op important for

Assess and identify high risk patients and minimise risk
Establish baseline
Establish severity of disease
Exclude any serious issue that will affect analgesia 
Dx unknown or suspected conditions
Inform and support patient decisions
Get consent
Guide management

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What do you want to know in the Hx

Known co-moridities
- Exacerbations / Ax / home oxygen / use of steroid

Unknown co-morbid

Ability to withstand stress

ETT
Cardio / resp disease

Drugs and allergy

Previous surgery and anaesthesia

FH - malignant hyperthermia or cholinesterase

SH - drug / smoke / alcohol

Potential anaeshteitc problems - is neck / jaw immobile / teeth stable

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What increases likelihood of airway issue

Reflux
Obesity
Pregnancy
FH

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What do you want to confirm before op

How have they been in time leading up
Confirm drug and allergies
Fasting

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What happens for an elective operation

Assess CVS system and exercise tolerance
Bloods
- FBC, U+E, LFT, finger tip blood glucose in most
- G+S
- DO clotting in liver / renal / DIC / anti-coagulation
- Blood glucose if DM
Drug levels as appropriate
Urinanalysis
Pregnancy test
Sickle cell if from area
TFT if thyroid disease
Assess for DVT risk
Thromboprophylaxis plan
MRSA screen - decolonize carrier
CXR = not routine - if cardiorespiratory disease
ECG if >65 / DM / renal or poor ETT
Lateral Spine X-ray if RA / Down’s / AS as risk of atlanto-axial instability

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Risk assessment tools

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What are NICE guidelines for risk

ASA grade
Surgery grade
Co-morbid

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ASA 1

Otherwise healthy

No smoking or alcohol

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ASA 2

Mild - mod systemic disturbance
No functional limitation
Current smoker / social alcohol / obesity / well controlled DM or high BP

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ASA 3

Severe systemic disturbance / disease 
Functional limitation
Poor controlled DM / BP 
COPD / asthma / end stage renal
Previous MI

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ASA 4

Life threatening

Recent MI / CVA or severe reduction n EF

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ASA 5

Moribund
Not expected to survive without operaiton
Rupture AAA / ischaemic bowel

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ASA 6

Organ retrieval

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What does cardiac risk index look at

High risk surgery
IHD
CCF
Cerebrovascular
DM
Renal failure

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If cardio procedure what do you get / what other tests can be done

ECG
ETT
ECHO +- stress
May have angio prior
PFT

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If CVS issue what are options

GA = high risk of myocardial depression
Regional - may not cover
Spinal - watch for CI

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If resp procedure what do you get

O2 sats
ABG
CXR or CT chest - not routine 
Peak flow
FVC and gas transfer

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E+D prior to surgery

Foods / solid >6 hours

Clear fluid >2 hours

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What do you do if DM prior to surgery

If diet or tablet controlled = omit and check BG regularly
If poor control or insulin = sliding variable rate IV insulin infusion
Put first on list
May need K supplementation
Treat as hypo if <4

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Pre-op meds

Most continue as normal

esp inhalers / angina / epilpesy

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If on steroids what do you need to do

Supplement with hydrocortisone as surgery will increase stress

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What do you do if on anti-coagulant

VTE risk assessment
Withhold warairn
Use short acting e.g. LMWH
Withold LMWH the evening before and use TEDS

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Anaemia pre-surgery

Blood transfusion to correct
IV iron will take too long
If refuse then can give IV iron
Oral iron is possible but will take 2-4 weeks to work

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Operations with high risk of transfusion needing X-match 4-6 units

``` Total gastrectomy Oophorectomy Oesophagectomy Elective AAA reapir Cystectomy ```

Operations which may need transfusion so X-match 2 units

Salpingectomy for rupture | THR

Operations unlikely to need transfusion so G=S

``` Hysterectomy Appendectomy Thyroid ELective LSCS Lap chole ```

How does paralytic ileus present post surgery

Vomiting Absent bowel CRP raised anyway as post surgical response

What causes and what is associated

``` No peristalsis Chest infection MI Stroke AKI ```

What are nutrition options post surgery

``` Oral - early feeding good NG - If entubated soon NJ Feeding jejunostomy PEG TPN ```

What is CI in head injury

NG as risk of worsening

What is benefits of NJ over NG

Insertion is more complicated but avoids risk of aspiration / food pooling in stomach

What can be used long term

Feeding jejunostomy 1st line in most if longer term Low risk of aspiration

What is main risk

Displacement | Leakage = peritonitis

Risk of PEG

Aspiration

When do you use TPN

If enteral CI

What are SE

Phlebitis Fatty liver Deranged LFT

What are early causes of post op pyrexia

Blood transfusion Infections - Cellulitis / UTI - have low threshold Pulmonary atelectasis - needs prompt physio Physiological

What are later causes

VTE Pneumonia Wound infection Anastomotic leak

How do you avoid surgical complications

WHO checklist Ax DVT risk + prophylaxis

When do you carry out checklist

Prior to induction Incision Patient leaves operation room

What does checklist involve

``` Site marked Confirm identity Confirm procedure Confrim consent Anaesthesia check complete Pulse oximeter on Allergies Airway / aspiration risk >500ml blood loss risk ```

What are complications of surgery

``` Bleeding Haemorrhagic shock Infection Confusion Arrhythmia following cardiac Electrolyte imbalance Ileus Fluid and electrolyte loss Pulmonary oedema Anastomotic leak MI Nerve damage ```

What can cranial surgery cause

SIADH = hyponatraemia

Who is very sensitive to oedema

After pneumonectomy as lose lung volume

What are baseline investigations in any acutely unwell

Bloods- FBC, U+E, LFT,, CRP, Ca, clotting Blood culture ABG ECG +- enzyme Urinanalysis Consider CXR / USS / CT depeniding on finding

What ae specialist test

``` CT for abscess / leak Gastrograffin enema for rectal leak Doppler for DVT CTPA for PE Peritoneal fluid ECHO if effusion ```

What is a CI to thrombolysis

Recent surgery

What is thermoregulation in perioperative period

Temp management 1 hour prior to 24 hours after

When is hypothermia more common

``` If under anaesthesia ASA 2+ Major surgery LBW Large volume of unwarmed infusion Unwarmed blood ```

If temp <36 pre op

Active warming before induction | Do not move to there unless time critical

How do you measure temp intra op

Oesophageal probe | Axillary / sublingual

What should be used if high risk of >30 minutes

Forced air warming device

If fluid >500ml

Warm all

What happens post-op

Document temp every 15 minutes till in ward Do not transfer if <36 May develop hyperthermia due to fever

What are complications of hypothermia

``` Coagulopathy - reduced clotting so increased loss Prolonged recovery Reduced wound healing as constriction Infection Shivering increases metabolic rate ```

What increases risk of VTE

``` Surgery >90 mins or >60 if LL Abdominal inflammation Reduction mobility 3+ days Hip / knee replacement or fracture 60+ Known malignancy Thrombophilia Previous thrombosis BMI >30 HRT / OCP Varicose veins ```

What are general RF

Dehydration Co-morbid Critical care Pregnant or <6 weeks post partum

What is mechanical prophylaxis

Early amputation | Compression stocking

When is compression CI

PAD

What is options for therapeutic

LMWH SC daily Unfractioned heparin IV Dabigatran

Benefits of unfractioned

IV | Rapid onset and decline on stopping infusion

How do you measure

APTT

How do you reverse

Protamine sulphate

When is dabigatan used

Hip and knee | No active monitoring required

If risk of active bleeding

What do you have as prophylaxis if RF

Mechanical and therapeutic

How long

Stat 6-12 hours after op Elective hip = 28 days Elective knee = 14 days Hip fracture = until mobile / 28 day s

If patient N+V post op what should you think

Any mechanical obstruction Ileus ? Emetic drugs - opiates / anaesthesia

What should you consider

AXR | NGT

What should you aim for UO post op

>30ml / hr in adults

If UO decreased what do you look for

Blocked or malted catheter Incorrect fluid replacement Urinary retention AKI

What do you do

``` Review fluid chart Examine fluid status Examine bladder Fluids to establish normovolaemia Cathterise for accurate monitoring Correct issue ```

If dyspnea or hypoxia post op what do you do / what tests

Sit patient up and give O2 Monitor sats Examine for evidence of pnuemonia / collapse / aspiration / LVF / PE Do FBC, ABG, CXR, ECG and enzymes

What can cause LVF post op

MI | Fluid overload

What are risks of surgery in jaundice patient

Coagulopathy - decreased vit K Sepsis Renal failure

What should you do prior

ERCP to relieve

Pre-Op Flashcards

(77 cards)