PreOp Mx Flashcards by Shanxi Jen

Info Regarding OCP/HRT for surgery?

Stop 4wks before major / leg surgery

Restart 2wks post-op if mobile

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Prophylactic abx for surgery?

Give 15-60 min before surgery

Biliary: cef n met

Colorectal/ appendix: cef n met

Vascular: co-amoxiclav

MRSA +Ve: Vancomycin

used for GI surgery, joint replacement

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DVT prophylaxis after surgery?

Stratify pts according to patient factors and type of surgery.

Low risk: early mobilisation

Med: early mobilisation + TEDS + 20mg enoxaparin

High: early mobilisation + TEDS + 40mg enoxaparin + intermittent compression boots perioperatively.

Prophylaxis started @ 1800 post-op

May continue medical prophylaxis at home (up to 1mo)

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Risk of surgical complications due to pts on long term steroids?

Poor wound healing

Infection

Adrenal crisis

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Mx of pts on long term steroids needing to undergo surgery?

Need to ↑ steroid to cope w stress

Consider cover if high-dose steroids w/i last yr

Major surgery: hydrocortisone 50-100mg IV w pre-med then 6-8hrly for 3d.

Minor surgery: Hydrocortisone 50-100mg IV for 24h

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Why are diabetics at increased risk of post op complications?

Surgery → stress hormones → antagonise insulin

Pts. are NBM

↑ risk of infection

IHD and PVD

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What to do about insulin for patients with insulin dependent DM about to undergo surgery?

put pt first on list

stop long-acting insulin the night before

Omit AM insulin if surgery is in the morning

Start sliding scale

5% Dex w 20mmol KCl 125ml/hr
Infusion pump w 50u actrapid
Check CPG hrly and adjust insulin rate

Check glucose hrly: aim for 7-11mM

Post-op

Continue sliding-scale until tolerating food

Switch to SC regimen around a meal

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Mx of diet controlled DM pts about to undergo surgery?

Usually no problem

Pt. may be briefly insulin-dependent post-op

-> Monitor CPG

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Mx of Non insulin dependent DM patient about to undergo surgery?

If glucose control poor (fasting >10mM): treat as IDDM (Sliding scale)

Omit oral hypoglycaemics on the AM of surgery

Eating post-op: resume oral hypoglycaemics w meal

if No eating post-op:

Check fasting glucose on AM of surgery
Start insulin sliding scale
Consult specialist team ore. restarting PO Rx

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if patients with high thromboembolic risk (ie. mechanical valves, recurrent VTE) need to undergo surgery, what to do about their anticoagulant medications?

Need bridging w LMWH

Stop warfarin 5d pre-op and start LMWH

Stop LMWH 12-18h pre-op
Restart LMWH 6h post-op
Restart warfarin next day

Stop LMWH when INR >2

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if pt w low thromboembolic risk e.g. AF needs to undergo surgery, what to do about their current anticoag medication?

Stop warfarin 5d pre-op: need INR <1.5

Restart next day

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if risk of bleeding in surgery is high and need to stop antiplatelet therapy e.g. aspirin/ clopi? when to stop

7 days before surgery

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what kind of analgesia should be avoided if pt is anticoagulated?

epidural, spinal and regional blocks

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if anticoagulated pt needs to undergo emergency surgery?

discontinue warfarin

Vit K 5mg slow IV

request FFP or PCC to cover surgery

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Risks of operating in Jaundiced patients?

best to avoid

use ERCP instead

Pts w obstructive jaundice have ↑ risk of post-op renal failure -> need to maintain good UO.

Coagulopathy
↑ infection risk: may → cholangitis

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pre-op measures to reduce risk of complications in surgery for jaundiced pt?

Avoid morphine in pre-med
Check clotting and consider pre-op vitamin K
Give 1L NS pre-op (unless CCF) → moderate diuresis

Urinary catheter to monitor UPO
Abx prophylaxis: e.g. cef+met

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risks of operating in pt with COPD?

Basal atelectasis

Aspiration

Chest infection

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preop measures to reduce risk of complications of surgery in COPD pts?

CXR
PFTs
Physio for breathing exercises
Quit smoking (at least 4wks prior to surgery)

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e.g. if induction anaesthetic?

IV propofol

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e.g.s of muscle relaxation anaesthetics?

depolarising: suxamethonium

non-depolarising: vecuronium, atracurium

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e.g. of maintenance anaesthesia?

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halothane/ enflurane

how to reverse paralysis of anaesthesia?

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neostigmine, atropine

when is regional anaesthesia used?

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for minor procedures or if unsuitable for GA
nerve or spinal blocks

e.g. bupivacaine

mx of malignant hyperpyrexia?

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ppted by halothane or suxamethonium

dantrolene + cooling

why is analgesia important post op?

pain -\> autonomic activation → arteriolar constriction → ↓ wound perfusion → **impaired wound healing** Pain → ↓ mobilisation → **↑ VTE and ↓ function** ## Footnote Pain → ↓ respiratory excursion and ↓ cough → **atelectasis and pneumonia**

what pain meds are available on step 1?

Paracetamol NSAIDs - Ibuprofen: 400mg/6h PO max - Diclofenac: 50mg PO / 75mg IM

2nd step for pain ladder e.g.?

Codeine Dihydrocodeine Tramadol

pain ladder 3rd step e.g.s?

Morphine: 5-10mg/2h max Oxycodone Fentanyl

immediate surgical complications? \<24h

intubation-\> oropharyngeal trauma surgical trauma to local structures primary or reactive haemorrhage

early surgical complications?

secondary haemorrhage VTE urinary retention atelectasis and pneumonia wound infection and dehiscence antibx assoc colitis

late surgical complications?

Scarring Neuropathy Failure or recurrence

complications of cholecystectomy?

Conversion to open: 5% CBD injury: 0.3% Bile leak Retained stones (needing ERCP) Fat intolerance / loose stools

complications of appendicectomy?

Abscess formation Fallopian tube trauma Right hemicolectomy (e.g. for carcinoid, caecal necrosis)

complications of inguinal hernia repair?

**Early** Haematoma / seroma formation: 10% Intra-abdominal injury (lap) Infection: 1% Urinary retention **Late** Recurrence (\<2%) Ischaemic orchitis: 0.l5% Chronic groin pain / paraesthesia: 5%

complications of colonic surgery?

**Early** Ileus AAC Anastomotic leak Enterocutaneous fistulae Abdominal or pelvic abscess **Late** Adhesions → obstruction Incisional hernia

complications of anorectal surgery?

Anal incontinence Stenosis Anal fissure

complications of small bowel surgery?

Short gut syndrome (≤250cm)

complications of splenectomy?

Gastric dilatation (2^O gastric ileus) -\> Prevent w NGT Thrombocytosis → VTE Infection: encapsulated organisms

complications of cardiothoracic surgery?

Pneumo-/haemo-thorax Infection: mediastinitis, empyema

complications of tracheostomy?

Stenosis Mediastinitis Surgical emphysema

Complications of arterial surgery?

Thrombosis and embolization ## Footnote Anastomotic leak Graft infection

Complications of aortic surgery?

Gut ischaemia Renal failure Aorto-enteric fistula Anterior spinal syndrome (paraplegia) Emboli → distal ischaemia (trash foot)

complications of breast surgery?

Arm lymphoedema Skin necrosis Seroma

Complications of prostatectomy?

Urinary incontinence Erectile dysfunction Retrograde ejaculation Prostatitis

Ix of post op febrile pt?

Urine: dip + MCS Blood: FBC, CRP, cultures ± LFTs Cultures: wound swabs, CVP tip for culture CXR

what type of diabetic pt will require a variable rate IV insulin infusion?

Pts usually treated with insulin + undergoing major procedures (surgery requiring a long fasting period of \>1 missed meal) OR whose diabetes is poorly controlled (HbA1c \>69 or 8.5%)

what is the aim of the variable rate IV insulin infusion?

achieve and maintain [Glucose] within 6-10 mmol/L (up to 12 acceptable) by infusing a constant rate of glucose-containing fluid as a substrate, while also infusing insulin at a variable rate

What to do about patient's regular insulin when going for surgery + going to start a variable rate insulin infusion?

Day before surgery: any once-daily long-acting insulin analogue given @ 80% normal dose, other insulin given at normal dose On day of surgery and throughout intra-op period: once daily long-acting insulin analogues should be continued at 80 % usual dose; all other insulin should be stopped until the patient is eating and drinking again after surgery;

When to stop the variable rate IV insulin infusion + IV fluids after surgery?

stop 30-60 mins after the first meal time short acting insulin dose any long-acting insulin should have been continued throughout the operative period @ 80% normal dose

Mx of patients undergoing elective surgery but are undergoing minor procedures and have good glycaemic control (HbA1c \< 69 mmol or 8.5%) and treated w insulin?

Day before surgery: pt's usual insulin given as normal, other than once daily long-acting insulin analogues, which should be given at 80% normal dose

Mx of non-insulin dependent diabetic pts if undergoing elective minor surgical procedures only requiring 1 missed meal?

Omit: acarbose, nateglinide, repaglinide morning of surgery if fasting Pioglitazone, DDP4 (gliptins) and GLP1R agonists can be taken as normal during whole periop period Omit Sulfonylureas until pt eating and drinking again Omit Sodium glucose co-transporter 2 inhibitors til pt is stable. Metformin can be continued if only one meal will be missed

PreOp Mx Flashcards

(51 cards)