Pre-operative Care Flashcards
How do we manage oral hypoglycaemics before surgery?
Stop on day of surgery to prevent Intra-operative hypo
How do we manage clopidogrel before surgery?
Stop 7 days before surgery and consider a platelet transfusion
How do we deal with warfarin before surgery
Stop five days before and give heparin cover, monitor INR to prevent bleeding
What do we do with people on the OCP or HRT and having surgery?
Stop 4 weeks before and for 2 weeks after due to risk of DVT
Your patient is taking herbal medicines for their gallstones. What advice do you give?
They need a laparoscopic cholecystectomy so need to stop herbal meds for 2 weeks before surgery
Describe the nil by mouth protocol before surgery
No foods or non-clear for at least 6 hours
No clear fluids (water, squash, not fizzy) for 2 hours
Continue medication as normal unless likely to cause intraop complications
In Neonates: no milk for 4 hours, no formula for 6 hours
Name some drugs we may prescribe before surgery
Low molecular weight heparin sub cut to reduce DVT risk- 5000 units dalteparin
Prophylactic antibiotics
- co-anoxiclav 600mg (max fax, ENT) or 1.2g (most)
- metronidazole 500mg (GI)
- gentamicin 120mg(GI, urinary)
Benzodiazepine eg midazolam- anxiolytic
Anti-analgesic eg opiate, NSAID, paracetamol
Antacid if risk of acid aspiration
Antiemetic- cyclizine, ondansetron
Amnesic- lorazepam+hyoscine
How do we arrange bloods in preparation for surgery?
Group and save Cross match if likely to need transfusion Arrange cell salvage Get clotting studies for anaesthetists Monitor biochemistry
When does the pre operative assessment occur in elective surgery? How about urgent and emergency?
4-6 weeks before, to allow time to reduce risk eg stop ocp/hrt, stop smoking
Urgent:12-24 hrs before
Emergency: often not done, ask as many key questions as you can!
What do we need to ask in a pre-operative history?
Establish reason for the op and the correct site and side
Presenting complaint
Past surgery- procedure, anaesthetic reaction, complications
PMH- diabetes, obese, thyroid disease, asthma, COPD, sleep apnoea, restrictive disease, recent chest infection, hypertension, IHD, heart failure, valve disease, pacemaker, epilepsy, TIA, stroke, renal disease, dental: caps, crowns, loose teeth.
Family history: malignant hyperthermia
Drugs and allergies
Social
- smoking -last cig, type smoked, abstinence an issue?
- alcohol -withdrawal
- drugs -withdrawal
- religion - heparin in Muslims, transfusion in Jehovah witnesses
Cvs and resp systems review -functional capacity, can they climb two flights of stairs unaided
Assess mental state and capacity
How do we examine patients pre-operatively?
General: anaemia, cyanosis, clubbing, jaundice, oedema, lymphadenopathy
Airway: neck, face, maxilla, mandible, movement of neck and jaw, teeth, tongue, recent chest and neck x rays
Cvs: murmurs, heart rate, BP, JVP, heart sounds
Resp: tracheal position, resp rate, chest expansion, percuss, auscultate
Specific examination of relevant system
Describe the ASA classification of patients
I: normal healthy patient
II: mild systemic disease
III: severe systemic disease
IV: severe systemic disease which is a constant threat to life
v: moribund patient not expected to survive without surgery
VI: brain dead patient needing organ donation
E=emergency surgery
Describe the investigations to be done on a patient before surgery
FBC- if major surgery, or anaemia is suspected
LFTs
U&Es- if over 60, major surgery, on diuretics, or have known or suspected renal disease
Coagulation screen- if history of bleeding tendency, self or family history, or major surgery
Sickle cell test- if afrocarribean
Pregnancy test
ECG to look for disease and to compare post op to look for new MI
Chest X-ray: in acute or recent worsening of cardiac or chest disease, or suspect TB
Group and save or cross match
Why are obese patients high risk in surgery?
Difficult airway due to short fat neck
Imaging often unclear
Manual handling difficult
Might be too big for CT or operating table
A lot of fat to cut through in surgery
Hard to get IV access
Slow recovery due to redistribution of anaesthetic from fat
Why are the elderly high risk in surgery
Multiple comorbidities Polypharmacy Reduced functional capacity Mental decline Reduced immune response and healing Malnutrition Pressure sores
