Surgery L1 - Pre & Post Op Flashcards
(18 cards)
Post-operative considerations – 5
- Antibiotic prophylaxis
- VTE prophylaxis
- Post-operative pain, nausea & vomiting
- Nutrition, Fluid balance & electrolytes
- Medicines management & chronic conditions post-op
Know your procedure - 3
-ectomy; removal of
Colectomy, cholecystectomy, mastectomy, nephrectomy
-otomy: opening of
Laparotomy, thoracotomy
-ostomy: bringing to the skin surface
Ileostomy, colostomy, nephrostomy
Patient risk factors for prophylactic antibiotic use – 9
- Age
- Poor nutritional state
- Obesity
- Diabetes mellitues
- Smoking
- Coexisting infections at other sites
- Bacterial colonisation
- Immunosuppression
- Prolonged postoperative stay
Considerations for using prophylactic antibiotics – 3
- Type of surgery (not needed for clean)
- Duration of antibiotics
- Likely causative organism (local resistance, cost-effectiveness)
Surgery: Clean – 4
- Non-traumatic
- No inflammation
- No breach in technique
- No breach of respiratory, alimentary or genito-urinary tracts
Surgery: Clean-Contaminated – 2
- Non-traumatic but break in technique or beach of respiratory, alimentary or genito-urinary tract
- No significant spillage
Surgery: Contaminated - 4
- Major break in technique
- Gross spillage from a viscus that may include non-purulent material
- Dirty traumatic wounds, faecal contamination, foreign body, devitalised viscus
- Pus encountered from any source during surgery
Considerations for using prophylactic antibiotics - 4
- Give within 30mins before procedure, ensures high [tissue] at time of incision
- IV preferred route, easier to administer & higher BA
- Dose / infusion completed just before incision if IV
- Re-administer if long surgery or significant blood loss
BLEEDING RISK FACTORS - 7
- Surgery-related
- Recent stroke
- Impaired liver function
- Bleeding disorders
- Hypertension
- Thrombocytopaenia
- Anticoagulants
CLOTTING RISK FACTORS - 13
- Stagnation of blood - Immobility / inactivity
- Vascular Injury e.g. Surgery, Broken bones
- Pregnancy
- Clotting disorders
- Previous / family history
- Some cancers & chemotherapies
- CV or lung diseases
- Inflammatory Disease
- Age >60
- Overweight
- Smoking
- Oestrogens (HRT / COC)
- Dehydration
Methods of VTE prophylaxis - 10
Actions:
1. Mobilize as soon as possible
2. Avoid dehydration
3. Stop meds which increase risk where possible
Mechanical:
4. Anti-embolism stockings (AES)
5. Intermittent Pneumatic Compression devices (IPC)
6. Foot impulse devices
Pharmacological:
7. Low molecular weight heparin (LMWH)
8. Unfractionated heparin
9. Rivaroxaban, Dabigatran, Apixaban
10. Fondaparinux
Prophylactic regimens - 4
Low Risk
1. Early mobilisation & maintain hydration
2. Anti-embolic stockings if not contra-indicated
High Risk:
3. Intermittent pneumatic compression during surgery
4. Pharmacological prophylaxis: LMWH / DOAC:
- Choice based on local practice
- Dose based on weight, renal function
- Duration depends on surgery type
Duration of prophylaxis - 3
- Continue for a minimum of 7 days for most patients
- Extended prophylaxis with LMWH is needed for some procedures e.g. Fractured neck of femur (hip) 4 to 5 weeks
- Patient taught how to give SC injection, but K is monitored for patients at risk of hyperkalaemia
Pain - 6
Epidurals / PCAs often used – avoid duplicate opiates
1. (PCA – Patient controlled analgesia)
2. (Epidurals – infuse into epidural space, high bleed risk)
3. Weak opioids (e.g. Codeine / dihydrocodeine / tramadol)
- Tramadol used as metabolism of codeine can be unpredictable
4. Nerve blocks & local anesthetic infusions
5. Paracetamol
6. NSAIDs where appropriate
Epidurals (spine injection) – 5
- Can provide better pain relief than other methods
- Usually local anesthetic + / - opioid (e.g. Levobupivicaine and Fentanyl)
- Synergistic action with Analgesia localised to chest, pelvis, lower limb depending upon catheter site
- Risks: Motor nerve block, haematoma, infection (abscess), dural puncture
- Risk of epidural Haematoma when inserting or removing epidural catheter in an anticoagulated patient
Post-op nausea & vomiting (PONV) - 7
- Anti-emetics used to decrease risk
Caused by: - Anaesthetic agents
- Opioid analgesia
- Bowel surgery
- Antibiotics
- U&E disturbances
- Bowel obstruction
PONV Risk factors - 6
- Gender – females increase risk
- History of motion sickness
- Previous PONV
- Non-smokers increase risk
- Duration / type of surgery
- Opiate use
Nil by mouth: Post op – 2
- Post major GI surgery may be NBM for several days or have impaired absorption e.g. oesophagectomy, Whipple’s
- Means some medications can’t be taken, so alternate routes may be used e.g. parenteral
