Flashcards in Surgical Preparation Deck (22):
What are the 4 signs of peritonism on examination?
1. Rebound tenderness
2. Percussion tenderness
3. Cough tenderness
4. Freely moving
What are the 4 broad categories of patient management?
1. Active management
2. Supportive management
3. Ongoing investigations
4. Safety netting
What 3 things should you consider prior to surgery?
1. Medications - all should continue except for anticoagulants, immunosuppressants, and diabetic medications
2. Food and fluid - NBM - 6hrs prior, clear fluid 2hrs prior
3. Are antibiotics required prior to surgery?
What is the general fluid maintenance rate?
40ml + weight (kg) per hour
*this does not account for losses, just maintenance!
How much K+ is required per day?
For a 70kg person, they need 70mmol per day
Signs of fluid depletion
1. Dry mucous membranes
2. Reduced skin turgor (over sternum)
3. Urine output low (<0.5ml/kg/hr)
4. Complaining of thirst
5. In worsening stages - CRT prolonged, tachycardia, hypotension
Signs of fluid overload
1. Raised JVP
2. Peripheral oedema
3. Pulmonary oedema
4. In worsening stages - tachycardia, tachypnoea +/- hypoxia
- Most commonly used
- Used for acute settings, theatre and fluid maintenance
- Types: 0.9% saline (N/S), Hartmann's, dextrose
- Have high colloid osmotic pressure - were thought to raise intravascular pressure faster (no strong evidence of this)
- Used in resuscitation
- Disadvantages - anaphylactic reactions, coagulopathy, high cost
Difference between 0.9% saline, dextrose and Hartmann's solution?
0.9% saline - Na (154), Cl (154)
Dextrose - glucose (50)
Hartmann's - Na (131), Cl (111), K (5), Ca (2)
Consenting for surgery
- General risks and followup required
- Infection - requiring abx and further treatment
- Bleeding - may require return to the operating room
- Small areas of the lungs collapse -> increases risk of chest infection -> may need abx, chest physio
- Heart attack or stroke
- Blood clot in leg -> lungs
ABCDEF of surgical patient preparation
A - call anaesthetist
B - book patient theatre
C - consent/capacity
D - disposition - where will the patient go post surgery?
E - equipment - is there extra equipment that needs to be organised?
F - NFR - know what the patient's wishes are
SIRS - systemic inflammatory response syndrome
- Temperature >38
- HR >100
- RR >24
- WCC > 12
Must meet 2 criteria
Group and Hold
- Determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies.
- The process takes around 40 minutes and no blood is issued.
- Recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected.
- Involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places.
- If it does not, the donor blood is issued and can be transfused in to the patient. This process also takes ~40 minutes, in addition to the 40 minutes required to G&H the blood (which must be done first).
- A cross-match is done if blood loss is anticipated
Post surgical nausea and vomiting - risk factors
Factors which increase the likelihood of developing postoperative nausea and vomiting in adults include:
<50 years old
history of motion sickness
prior history of postoperative nausea and vomiting
type of anaesthetic medicines used (opioids, volatile anaesthetics and nitrous oxide)
longer duration of surgery and type of surgery.
Patient with Post-operative nausea and pain - what questions should you ask?
- Pain severity - determines type of analgesia required
- Site of pain - is the pain in the region of the surgery, or somewhere else (chest pain)
- What medications has the patient already received?
- Has the patient opened their bowels or passed flatus - absence of BO/flatus -> increases suspicion for postoperative ileus
- Is nausea associated with vomiting?
- Other postoperative symptoms
- Regular medications/allergies
- Current medical conditions
Increased pain following surgery - what conditions should be suspected?
- Compartment syndrome
Respiratory depression is the most dangerous adverse effect of opioid analgesics.
It is almost always preceded by excessive sedation. Monitoring your patient’s sedation score is more effective at detecting early respiratory depression than monitoring the respiratory rate.
Aim for a sedation score of < 2.
A score of 2 indicates early respiratory depression and that intervention is required.
0 – wide awake
1 – easy to rouse
2 – easy to rouse, but cannot stay awake
3 – difficult to rouse
What things should be monitored while a patient is using pharmacological VTE prophylaxis?
3. Signs of bleeding
4. Signs of HIT
5. Renal function
Do patients who receive therapeutic anticoagulation require additional VTE prophylaxis?
Patients already receiving therapeutic anticoagulation (with rivaroxaban, dabigatran, apixaban or warfarin) do not require additional pharmacological VTE prophylaxis. In fact, adding pharmacological VTE prophylaxis increases their risk of bleeding.