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Clinical Pharmacy PH2506 > Surgery > Flashcards

Surgery Flashcards

1
Q

Why is this important

A
  • Hospital pharmacy= medical + surgical wards
  • Post surgery enquires from patients
  • Normal medications + painkillers
  • Cut out the problem= ? cut out some medication- some medications need to be stopped once the surgery has been completed
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2
Q

Emergency surgury

A

-Sudden need
-Circumstances force the decision
-Limited pre-assessment
-Patient not mentally
prepared
e.g. small bowel resection, colonoscopy, or appendectomy, fistual removal, accident

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3
Q

Elective surgery

A
  • Planned
  • Decision made about patient suitability
  • Pre-assessment
  • Patient prepared
  • Might be only option or other options previously failed
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4
Q

Pre-assessment

A

-Baseline parameter taken: height, weight, BP, HR, bloods
+MRSA swab (nose, back of throat, groin)
+Medical and drug history
-Surgical options available
+Explanation of the procedure= pros and cons
+Provision of literature (examples on BB)
-Signing of consent forms- patient needs to agree consent
+Listing of surgery

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5
Q

Surgical considerations

A

1) Drug therapy in the peri-operative (at or around time of operation and post operative release to community) period
+And the drugs in relation to surgery
+dependant on co-morbidities, type of surgery age
+Pain relief, anti-emetic agents, aneasthetics, maintain sedation, maintain body function
+NBM
2)Antibiotic prophylaxis
3)Thrombo prophylaxis (or VTE prophylaxis)
4)Pain control
5) Post-operative Nausea and Vomiting (PONV)

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6
Q

Nill by mouth (NBM)

A
  • Most patients will be nill by mouth (NBM)
  • this will stop the contents of the stomach being aspirised and damaging the lungs (due to acidic nature),
  • This can also lead to lung infection
  • Patients will often feel nausea after surgery due to sedatives and opiates giving prior to surgery therefore having an empty stomach will reduce vomiting
  • Food is witheld for 6 hours pre-op and fluids 2 hours before anaesthesia
  • Ingestion of fluids 2 hours before op has no effect on acidiity or gastric conents
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7
Q

NMB period v need for mediations

A

NMBP
-Risk of aspiration
+Pneumonia and lung dmaage
-Compounded by nausea, disease states and opitate use
NEED FOR MEDICATIONS
-To precent relapse of chronic conditions
-Avoid effects of drug withdrawal
CONSIDERATIONS
-Are all medications needed
-Are there other routes of administration
-How long is the NMB period- the period may encompass more than 1 drug time
-Would the drug pose a risk given the surgery

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8
Q

Drug which are an issue for surgical patients

A

1) Anticoagulants (e.g. warfarin and apixiban)
+Bleeding risk, may require bridging therapy with short acting agent e.g. heparin or enoxaparin, depending on risk/ indication and surgery
2)Anti-platlets: (Aspirin and clopidogrel)- bleeding risk, may have to stop a few days before the surgury
3)NSAIDs- bleeding risk, omit the morning of surgery
4)Contraceptive pill/ HRT- VTE risk, to stop 4-6 weeks pre-op, risk benefit to be discussed with patient
5)MAOI- interact with drugs used in surgery, to create management plan with psychiatrist and anaesthetist
6)Lithium- Stop 24 hrs before major surgery, monitor fluids and electrolytes closely
7)ACEI/ARB- may cause severe hypotension with anaesthetics, stop 24 hours before

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9
Q

Changes to medication: stress

A

surgery=STRESS=metabolic changes
1)Diabetic
-Increased risk of peri-operative complications as unable to compensate for hyperglycaemic response to stress
+Mortality increase; delayed wound healing; increased risk of post-operative problems including metabolic problems)
+People normal produce insulin to conteract hyperglycaemic response to stress but diabetics cannot do this
-Risk of diabetic ketoacidosis (type 1) or non-ketotic hyperosmolar state (type 2)
-Maintain optimal blood glucose control to reduce this
-SLiding scale/Alberti insulin regimen and close monitoring (BMs and K+)- prevent hypo’s and hyper’s
2) CORTISOL SECRETION (30mg -> 50mg)
-Stress of surgery–> increased cortisol release 150mg after minor surgery, 300mg major surgery
-Adrenal insufficiency and long term steroid use e.g. >5mg prednisolone OD will require; high conc inhaled steroids as well additional supplementation- hypocortiocrisis–> Shock
-Give IV hydrocortisone (25-100mg) dependant on type of surgery, how suppressed HPA is
NB- High dose steroids may impair wound healing and increase infection risk

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10
Q

Changes to medication- Thyroidectomy

A

Total thyroidectomy ( cancer, graves disease)

  • Stop anti-thyroid medicine (carbimazole)
  • Start levothyroxine replacement (TSH, T4 measures)- if they have a partial removal may not need hormone exogenous, this is why we measure
  • Ca supplements- A complication of total thyroidectomy is damage to the parathyroid gland, this controls Ca homeostasis, give supplement to prevent hypocalcaemia NB give Vit D supplement
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11
Q

Changes to medication: surgery specific

Ileostomy

A

The is the removal of bowel and an opening created (stoma) in which waste can enter a bag
-Drug absorption effected- modified release preps may not be effective because of quick transition time due to reduced bowel and exit into the bag whole- bag must be check
+Loperamide and codeine can reduce motility
-Fluid and electrolyte loss-
-Review immunosuppressant- Chrons disease or UC area of diease may be removed so must assess whether we need immunosuppresants

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12
Q

Changes to medication: surgery specific

BKA (below knee amputation)

A
  • Diabetic control- this may be reason for BKA- must control via HbA1c to get good glucose control; Consider other conditions: HTN: smoking; anti-platelet
  • Phantom pain- this is when patient experiences pain in limb that was removed: gabapentin and pregabalin can both be used via titration
  • Drug kinetics- reduction is volume of the patient means that the kinetics of the drugs are different (i.e. more concentred know) therefore may need to reduce other medications
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13
Q

2) Anti-biotic prophylaxis

A

-Surgical site of infection (SSI) is a common but potentially avoidable complication of ANY surgical procedure
RISK FACTORS
-Operative (surgeon skill) and environment factors: theatre cleanliness
-Type of operation (risk, site, duration, implants)
-No. of microbes
-Paitent risk factor: age, smoke, obese, malnutrition, immunosuppression therapy, other diseases including steroids and diabetes

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14
Q

2) antibiotic prophylaxis

Managing the risk

A
  • MRSA screening- patients are screened before then can undergo decolonisation therapy before entering hospital
  • Surgical site decontamination- antiseptic prior to skin incision
  • Prophylactic Abs
  • Hospital policies- chlorhexidine was to decontaminate skin
  • Theatre cleaning regimen
  • Sterilised equipment
  • Infection control training
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15
Q

Classification of operation

A

1) CLEAN: No inflammation is encountered and th respiratory alimentary or genitourinary tracts are not entered. There is no break in aseptic operating theatre techniques E.g. hernia repair
2) CLEAN-CONTAMINATED: Respiratory, alimentary or genitourinary tracts are entered but without significant spillage E.g. Caesarean section
3) CONTIMINATED: Acute inflammation (without pus) is encountered, or where there is visible contamination of the wound. Examples include gross spliage from hollow viscus during operation or compound/open injuries operated on within 4 hours E.g. all Colorectal
4) DIRTY: Operations in the presence of pus, where there is a previously perforated hollow viscus or compound/open injuries for more than 4 hours E.g. Perforated duodenal ulcers or abscess

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16
Q

Classification of prophylaxis more detail

A
  • They are classified on degree of microbial risk during procedure
  • Clean procedure dont need antibacterial prophylaxis unless there are implants going in
  • ALL others will
  • Dirty operations or established infection will need treatment antibiotics not just prophylaxis
17
Q

When an anti-biotic is indicated

A

Appropriate choice

  • Effective against the likely agents
  • Decreased aantibiotic resistance
  • Decrease C.difficle infection (can be deadly and has increased in prevalence since hospital stays have increased)
  • Decrease incidence of post-op SSI
  • Decreased morbidity associated with SSI
  • Decrease mortality as a result of SSI –> sepsis
  • Decrease hospital stay
  • Anti-biotics reduce the adherence of bacteria to prosthetic implants and so reduce infection BUT increase antibiotic rassistance and predisposition to C.difficle
  • Must have adequate tissue levels- e.g. IV has 100% bioavailability but wont penetrate to skin very well
  • Expense and side effects must also be covered
18
Q

Example of trust guidance

A

Antibiotic must be relevant for the bacteria that we expect to occur in that site
COLORECTAL SURGERY
-We expect anarobes: E.coli and streptococcus: we will therefore give metronidazole with gentamicin or co-amoxiclav
+NB most trusts will avoid cephlasporins due to broad spec activity (C.difficle resistance)
Orthopaedic surgery
-Bacteria on the skin is most common cause of infection- flucloxacillin is the drug of choice

19
Q

Thromboprophylaxis (VTE prophylaxis

A
  • VTE form of clot in a vein which can be either DVT= clot in the limbs, PE= the clot dislodges and enters in the lungs
  • 25,000-32,000 people died from this post op
  • DVT most likely occurs deep in the calf, known as distal DVT
  • femoral (inside of leg-groin) and Popliteal (back of the knee)- known as proximal DVT
  • Normally start in distal calf then move to proximal veins
  • Distal DVT may be silent with no complications - they become more clinically significant if they enter the proximal veins or into the lungs
  • Pain, redness and swelling in limbs are the main signs of DVT
  • PE: short of breath cough and new onset AF
  • The death rate of undiagnosed PE is 30% when diagnosed this drops to 3%
20
Q

Risk factors for VTE

A
  • Hydration
  • Anaesthetic choice (epidural (regional anaesthetic) reduces chance of VTE compared to systemic because systemic anaesthetics cause immobility leading to stasis leading to coagulation, when coupled with potential vessel trauma further increases risk)
  • Positioning during operation
  • Length of operation
  • Immobility post-op (and discharge)
  • Drugs- OCP/HRT
  • Obesity
  • Previous history of DVT/PE
  • Other medical conditions
21
Q

Risk factors for VTE

Virchows triad

A
  • Trauma (surgery)
  • Stasis flow- Heart valves (static blood clots)
  • Hypercoagulability- genetic conditions which increase the likely hood of VTE
22
Q

How much of a risk is there

A

IF we didn’t give any prophylaxis
-20% major general surgery
-40% major orthopaedic
-44% elective hip surgery
-(10-20% medical patients) would have VTE
-Need to consider both patient risk factors and surgical risk to decide of appropriate thromboprophylaxis
+Patient variability using a risk assessment score will encompass patient variability and different risks of different surgeries

23
Q

Managing VTE risk

A

1) Mechanical prophylaxis
- Graduated elastic compression stockings (GECS)
- Reduce venous stasis
- Can be used on most patients except: established peripheral arterial disease; diabetic neuropathy or severe skin condition
- Thigh length stockings are better but if they dont fit or problem with compliance use knee length
- Patient should wear from admission to the point of normal mobility- reduce risk of VTE
2) Pharmacological prophylaxis
- Injections- LMWH (enoxiparin- clexane, daltiparin), fondaparinux (bleeding is a problem)
- New oral agents- rivaroxabon, dabigatran and apixaban
- Decrease DVT, PE and mortality
3) Other strategies
- Mobilisation and leg exercise
- Hydration

24
Q

4) pain

A

-Post operative pain is one of the main concerns of patient about to undergo surgury
-Normally acute
SURGICAL FACTORS THAT INFLUENCE PAIN
-Intra-operative pain management (opiates)
-Nature and duration of surgery
-Site and size of incision
-Extent of surgical trauma
-Patient factors: mental preparation; previous experience
NB- pain assessment is central to effective management of pain
-Pain should be measured at movement and rest using an appropriate scale- should be regular based on amount of pain

25
Q

Which analgesic

A
  • Analgesic ladder: start at the top of ladder and move down; for chronic pain you move up
  • Patient factors: pre-existing condition, opiate tolerance NB must prescribe anti-emetics
  • Types of surgery
  • Minor surgery e.g. hernia repair = paracetamol/NSAID/Weak opiates
  • Moderate surgery e.g. hip replacement= paracetamol/NSAID+ PCA
  • Major surgery e.g. major abdominal= paracetamol/NSAID + PCA/epidural
26
Q

PCA- patient controlled aanalgesia

A

-IV opiate e.g. morphine infusion pump
-Patient titrates analgesia according to need
-Limites set for dose and lockout
-Can set continuous background if needed
-Records 24hr opiate use
-Step down to oral as patient improves
-Anti-emetics, with O2 becayse of respiratory depression
MONITOR: opitate toxicity; pain score

27
Q

Epidural analgesia

A

-Local anaesthetic: opiate in the space outside the dura e.g. bupivacaine + fentanyl (Opiate will block transmission; local anesthetics block nerve transmission- synergism)
-Using opiate means we can use less local anaesthetic meaning that there are less side effects including leg weakness which limits mobility and increases risk of DVT
-Factors effecting spread in epidural space: volume injected gravity; conc of drug; site of injection and rate of injection
-Drugs inserted can selectively block sensation without shutting off motor funcion entirely
-Level of analgesia dependant of where the catheter is inserted
-Bolus with a continuous background or as a PCA
-Side effects as per individual drugs, in particular
+Hypotension
+Bradycardia
-Haematoma risk with heparins- note timing

28
Q

Epidural- actual injection

A
  • Catheter
  • Extent of analgesia is determined by level at which it is inserted; volume and gravity
  • This is a blind procedure and there is a risk that it can puncture a small blood vessel or dura; or cerebral spinal fluid
  • Test can be given to check the response and correct placement
  • Must check that the epidural doesn’t move into a dangerous position- They chack CV parameters, respiratory rate, area of sensation loss and leg power
  • This will also cause loss of sympathetic tone- leading to hypotension and reduced vascular tone- if hypotension occurs wemust rule out more possible dangerous causes
29
Q

5) PONV

A

-Reported incidence of 20-30%
-Distressing for patient and can lead to a fear of further surgery
-Takes up nurse time
-Many patient would prefer better PONV as opposed to pain management
CONSEQUENCES OF PONV
-Potential for aspiration of vomit
-Delayed administration of opiates
-Wound disruption after abdominal surgery
-Dehydration/electrolyte disturbances
-Delay in mobilisation and recovery
-Patient discomft, distress and fear

30
Q

Risk factors for PONV

A

MULTI FACTORAL

1) Patient: Sex; age; previous history; anxiety; obesity; complied with NBM
2) Surgery type: GI; ENT: orthopaedic and longer surgery 3)Anaesthetic: general has more risk than local; agents including etomide have more potential than propofol
4) Post OP: level of pain; level of opiate use; weather the patient can eat quickly ; level of movement
- Aim to intervene early because it is difficult to treat once nauseus- treat prophylactically
- cost effect

Clinical Pharmacy PH2506 (20 decks)

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