Specific Pre-Operative Complications

Question 1

Why are patients with diabetes at increased risk of post-operative complications?

Answer 1

Surgery produces stress hormones, which antagonise insulin and therefore further raise blood sugar levels, with impairs healing and increases the risk of infection
Patients with diabetes are also more likely to have IHD and PVD

Question 2

Why are patients with diabetes at risk of hypoglycaemia pre-operatively?

Answer 2

They are NBM

Question 3

What investigations should be done pre-operatively in a patient with diabetes?

Answer 3

Urine dipstick to look for proteinuria
Venous glucose
U&Es

Question 4

What should be considered regarding the list order in patients with diabetes?

Answer 4

Insulin dependant diabetes should be put on the list first

Question 5

Who needs to be informed that an insulin dependant diabetic is on the surgical list?

Answer 5

The surgeon and the anaesthetist

Question 6

What is used in insulin-dependant surgical patients?

Answer 6

Insulin sliding scale

Question 7

What is preferred to an insulin sliding scale in some centres?

Answer 7

GKI infusions (glucose, potassium, insulin)

Question 8

When might an insulin sliding scale not be necessary?

Answer 8

In minor ops

Question 9

Should insulin be stopped before surgery?

Answer 9

You may or may not stop long-acting insulin the night before, and should stop morning insulin if the surgery is in the morning

Question 10

How is an insulin sliding scale given pre-operatively?

Answer 10

Give 5% dex with 20mmol KCl at 125mmol/hr. Then, start infusion pump with 50u actrapid. You should then check CPG hourly, and adjust insulin rate

Question 11

How often should glucose be checked peri-operatively?

Answer 11

Hourly

Question 12

What glucose should be aimed for pre- and peri-operatively?

Answer 12

7-11mM

Question 13

What should be done in an insulin dependant diabetic post-operatively?

Answer 13

Continue sliding-scale into tolerating food

Switch to SC regimen around a meal

Question 14

How should a surgical diabetic patient be managed if their glucose control is poor (fasting >10mm)?

Answer 14

Treat as if they were insulin dependant

Question 15

Should oral hypoglycaemics be omitted pre-operatively in non-insulin dependant diabetics?

Answer 15

Yes, in the morning of surgery

Question 16

When should oral hypoglycaemics be resumed post-operatively if the patient is eating post-op?

Answer 16

With a meal

Question 17

How should a non-insulin dependant diabetic be managed post-operatively if they are not eating?

Answer 17

You should check fasting glucose on the morning of surgery, and start an insulin sliding scale. You should then consult a specialist team regarding restarting oral anti-hyperglycaemics

Question 18

How should a surgical diet-controlled diabetic patient be managed?

Answer 18

Usually no problem, but the patient may be briefly insulin-dependant post-op, in which case you should monitor CPG

Question 19

What is the problem with steroids in surgical patients?

Answer 19

They can cause poor wound healing, infection, and adrenal crisis

Question 20

How are surgical patients on steroids managed?

Answer 20

Need to increase the steroid dose to cope with

Question 21

When should you consider steroid cover in surgical patients?

Answer 21

If they have had high-dose steroids within the last year

Question 22

What steroid cover is given in major surgery?

Answer 22

Hydrocortisone 50-100mg IV pre-med, and then 6-8 hourly for 3 days

Question 23

What steroid cover is given in minor surgery?

Answer 23

Hydrocortisone 50-100mg IV pre-med, and then 6-8 hourly for 24 hours

Question 24

What is important to consider when thinking about operating on a jaundiced patient?

Answer 24

It is best to avoid operating in jaundiced patients, and if possible use ERCP instead

Question 25

Why is it best to avoid operating in jaundiced patients?

Answer 25

Patients with obstructive jaundice have a high risk of post-op renal failure Increased risk of coagulopathy Increased infection risk, which may lead to cholangitis

Question 26

What is the result of the high risk of post-op renal failure in jaundiced patients?

Answer 26

In these patients, you need to maintain a good urine output

Question 27

What should be avoided in the pre-medication for patients with jaundice?

Answer 27

Morphine

Question 28

What should be done pre-operatively in surgical patients with jaundice?

Answer 28

Check clotting, consider pre-op vit K Give 1L normal saline pre-op Urinary catheter to monitor urine output Antibiotic prophyalxis

Question 29

When should you not give 1L normal saline to jaundiced patient pre-operatively?

Answer 29

In congestive cardiac failure

Question 30

What is the purpose of giving saline pre-op in jaundiced patients?

Answer 30

Produce moderate diuresis

Question 31

What antibiotic prophylaxis should be given pre-operatively in jaundiced patients?

Answer 31

Cef + met

Question 32

How are patients with jaundice managed intra-operatively?

Answer 32

Hourly urine output monitoring, with normal saline titrated to output

Question 33

How are patients with jaundice managed post-operatively?

Answer 33

Intensive monitoring of fluid status

Question 34

How should patients with jaundice be managed post-operatively if they have poor urine output despite normal saline?

Answer 34

Consider CVP and furosmide

Question 35

What needs to be balanced in anti-coagulated surgical patients?

Answer 35

The risk of haemorrhage vs the risk of thrombosis

Question 36

Who should be consulted when considering anti-coagulated surgical patients?

Answer 36

Surgeon Anaesthetist Haematologist

Question 37

Can any surgery be untaken without stopping warfarin?

Answer 37

Very minor surgery may be undertaken without stopping warfarin if INR <3.5

Question 38

What should be avoided in anti-coagulated patients?

Answer 38

Epidural, spinal, and regional blocks

Question 39

Should aspirin/clopidogrel be stopped before surgery?

Answer 39

In general, continue until 7 days before surgery, unless risk of bleeding is high then stop earlier

Question 40

How should surgical patients with low thromboembolic risk, e.g. AF, be managed?

Answer 40

Stop warfarin 5 days pre-op | Restart next day

Question 41

What INR is required to operate on surgical patients with low thromboembolic risk?

Answer 41

<1.5

Question 42

How should surgical patients with high thromboembolic risk, e.g. prosthetic valves, recurrent VTE, be managed?

Answer 42

Stop warfarin 5 days pre-op, and start LMWH. Stop LMWH 12-18 hours pre-op, and restart 6 hours post-op. Restart warfarin next day, and stop LMWH when INR >2

Question 43

How should anti-coagulated patients who require emergency surgery be managed?

Answer 43

Discontinue warfarin, and give vit K 0.5mg slow IV. Request FFP or PCC to cover surgery

Question 44

What are the risks of surgery in COPD patients?

Answer 44

Basal atelectasis Aspiration Chest infection

Question 45

What investigations should be done pre-operatively in COPD patients?

Answer 45

CXR | PFTs

Question 46

How are the risks of surgery in COPD patients minimised?

Answer 46

Pre-operative physio for breathing exercises | Stop smoking at least 4 weeks prior to surgery