How long before surgery should patient fast for ?
- > 2hrs clear fluids
- > 6hrs solids
When should thromboprophylaxis be started before surgery ?
- 2hrs before
- graduated compression stockings (not in PVD)
- LMWH e.g. Enoxaparin
Complications of post op wound infection ?
- haemorrhage
- sepsis
- wound dehiscence
What antibiotics should be added to pre op prophylaxis in high risk MRSA patients ?
Teicoplanin or vancomycin
When should IV prophylactic antibiotics be administered before surgery ?
30 mins
What is the role of post op surgical drains ?
- vacuum to protect against collection, haematoma and seroma formation
- protect sites where leakage may occur e.g. Bowel anastomoses
- collect RBCs which can be auto transfused (protects against the risks of allotransfusion)
What is a seroma ?
- Pocket of clear serous fluid that sometimes develops in the body after surgery
- occurs when small blood vessels rupture and blood plasma seeps out
- inflammation caused by dying injured cells also contributes to the fluid
*in breast can cause necrosis of overlying tissue
What should be explained to the patient before giving anaesthetics?
- where they will wake up (or ITU will be frightening)
- that they may feel ill on wakening
- risks
What are the premedications given before surgery ? (6a)
- anxiolytics (anti anxiety): benzodiazepines e.g. Lorazepam
- analgesics: pre emptive analgesia not often used- children and anxious adults
- anti-emetics: 5ht3 antagonists e.g. Ondansetron or metoclopramide
- antacids: ranitidine/ omeprazole at particular risk of aspiration
- antisialogues: glycopyrronium - sometimes given to decrease secretions that could block small airways
- antibiotics: metronidazole/cefuroxime/gentamicin (usually 2 of these, varies depending on site of surgery)
Complications of surgery and what causes them?
- no pain sensation -> urinary retention, local nerve palsy (e.g. From arm hanging over bed), diathermy burns
- consciousness: lack of = can’t communicate e.g. Wrong leg. retained consciousness-> PTSD
- lack muscle power -> corneal abrasions (must be taped shut), no respiration/cough-> pneumonia/acetelectasis
When and what might be used for local anaesthetic in surgery ?
- unfit or unwilling for general
- local nerve block e.g. Brachial plexus/spinal blocks
- long acting local anaesthetic e.g. Bupivacaine
What is malignant hyperpyrexia ?
- Autosomal dominate condition
- administration of volatile anaesthetic agents (halothane,suxamethonium) results in 1 degree rise in temp every 30 mins, masseter spasm
- treat with dantrolene and active cooling
Triad of anaesthetics ?
- hypnosis e.g. Proprofol
- muscle relaxation- only if surgery can’t be done without paralysis e.g. Open abdo
- analgesia
What are the things to consider with emergency surgery that may complicate it
- patient will have full stomach
- pain and drugs administered may have delayed gastric emptying
What should be checked on pre op examination of patient ?
- CV and resp - HR, BP, pleural effusions etc
- potential problems with the airway e.g. Short neck, impaired TMJ
- mouth and dentition: loose crowns/teeth
- veins for ease of access
What in particular should be checked for in Afro Caribbean patients before surgery if not already documented ?
Sickle cell trait
How is the airway managed when under general anaesthetic
- laryngeal mask airway unless requires enhanced airway protection
- in emergency surgery, due to full stomach, will require intubation with rapid induction and cricoid pressure
Complications of general anaesthesia?
- damage to mouth or pharynx, including teeth
- nausea and vomiting
- CV collapse, resp distress
- malignant hyperpyrexia
Measurements to be recorded during recovery from general anaesthetic ?
- consciousness level
- O2 sats
- BP, RR, HR + rhythm
- pain intensity (verbal scale)
- temp
- urinary output
What are the different types of local anaesthics?
- topical
- infiltrative
- nerve blocks
- IV regional blocks
- plexus blocks
- extradural and spinal
What are the different local anaesthetic agents ?
- lidocaine: 1-2 hrs
- bupivacaine - 3+ hrs
- prilocaine
- EMLA cream (lidocaine and prilocaine)
- duration can be doubled with addition of adrenaline (constrictsits vessels and so reduces absorption)
Why should HRT and contraceptive pill be stopped 4 weeks before surgery ?
Increases risk of DVT/PE
Reasons for fasting before surgery ?
- ## prevent pulmonary aspiration of stomach contents when under general anaesthesia
What is post operative ileus ?
Severe or absolute constipation and intolerance of oral intake (vomiting) due to non mechanical factors that disrupt the normal coordination of propulsive motor activity of GI tract
* certain degree is normal physiological response to surgery
How long after surgery should gut motility reappear ?
2-3 days
Presentation of post operative paralytic ileus
- vague, mild abdo pain and bloating
- nausea, vomiting, anorexia
- constipation
Difference between ileus and intestinal obstruction
- obstruction: pain more severe + cramping (not seen in ileus)
- obstruction = tinkling bowel sounds, ileus = absent
- obstipation more likely in obstruction
When does secondary post operative haemorrhage start ?
1-2 weeks post op
Warning sign of wound dehiscence
Serous pink discharge from wound
What general post op complications may present immediately ? (4)
- primary haemorrhage (starting during surgery or on Post opincreased BP - reactive bleeding)
- acetelectasis (minor lung collapse)
- shock: blood loss, acute MI, PE, septicaemia
- low urine output: inadequate fluid replacement intra or post operative lay
What is usually the cause of secondary post op bleeding ?
Infection
What complications may occur a within days post op ? (Early complications)
- acute confusion: dehydration, sepsis
- nausea and vomiting: analgesia/anaesthetic related or ileus
- fever
- secondary haemorrhage
- pneumonia
- wound dehiscence
- DVT
- acute urinary retention
- UTI
- infection
- bowel obstruction
Late complications of surgery
- bowel obstruction due to fibrous adhesions
- incisional hernia
- keloid formation
What complications are likely to present 3-5 days post op?
- sepsis, wound infection, abscess
- DVT
- bronchopneumonia
Factors affecting healing rate of surgical wounds ?
- poor blood supply
- excess suture tension
- long term steroids
- immunosuppressive therapy
- radiotherapy
- severe rheumatoid disease
- malnutrition
Risk factors for incision hernia ?
- obesity
- poor muscle tone
- wound infection
- multiple use of same incision site
Signs of post op acetelectasis
- usually mild and asymptomatic
- slow recovery from op, poor colour, mild tachypnoea, tachycardia
- may be associate with early post op fever
Signs of acute respiratory distress ?
- Rapid, shallow breathing, severe hypoxaemia with scattered crepitations
- usually 24-48 hrs after surgery
- no cough, chest pain or haemoptysis
What is a post op fever ?
- Mild fever (
When is sepsis, wound infection or abscess formation post surgery likely to present post op?
Day 3-5
What type of surgery do cellulitis and abscesses usually form after ?
Bowel-related surgery
How does acetelectasis occur post surgery ?
Alveolar collapse usually due to bronchial secretions obstructing airway
Management of aspiration pneumonitis
- urgent bronchial suction
- positive pressure ventilation
- prophylactic antibiotics
- IV steroids
Pain on passive dorsiflexion of the foot post op is suggestive of what ?
DVT