List the pre-op considerations
- history including SHx and whether patient fit for GA
- examine patient
- organise investigations
- ASA score (1-6)
- gain consent - give patient the benefits, risks, alternative options (ensure they are competent)
- prophylaxis - VTE and abx
What is ASA grading?
shorthand to communicate the broad level of systemic function for a patient
grading can help to decide which pre-op investigations are useful
ASA grading between 1-6
1 = healthy patient, 6 = declared brain dead and the organs are being removed for donor purposes
If you smoke, but are otherwise completely healthy, what is your ASA grade?
smoking automatically puts the ASA grade up by 1 so ASA 2
What is the 2-level DVT Wells score?
If patient is suspected to have a DVT we use his scoring system to assess
If score >= 2 DVT is likely therefore organise proximal leg US within 4 hours
What are the clinical features listed in the Wells score?
- active cancer
- Paralysis, paresis or recent plaster immobilisation of the lower extremities
- bedridden for 3 days or major surgery within 12 weeks
- entire leg swollen
- calf swelling >= 3cm larger than symptomatic side
- pitting oedema in symptomatic leg only
- collateral superficial veins
- previous DVT
What are the risk factors for DVT?
- active cancer/chemotherapy
- aged over 60
- known blood clotting disorder (e.g. thrombophilia)
- BMI over 35
- dehydration
- one or more significant medical comorbidities (e.g. heart disease; metabolic/endocrine pathologies; respiratory disease; acute infectious disease and inflammatory conditions)
- critical care admission
- use of hormone replacement therapy (HRT)
- use of the combined oral contraceptive pill
- varicose veins
- pregnant or less than 6 weeks post-partum
What happens in a VTE risk assessment?
All patients admitted to hospital are assesssed for individual risk factors for VTE development and bleeding risk
Decision can be made whether to start VTE prophylaxis or not - start ASAP
What are the mechanical VTE prophylaxis types?
- compression stockings
- flowtron boots (intermittent pneumatic compression device)
What are the pharmacological VTE prophylaxis types?
- LMWH (enoxaparin) - caution in renal patients
- fondaparinux sodium (SC)
- patients with CKD are offered unfractionated heparin (rather than LMWH)
What surgical procedures require VTE prophylaxis for all patients?
hip and knee replacement post surgery
What is Virchow’s triad (factors that contribute to thrombosis)?
endothelial injury
hypercoaguable state
blood stasis
How much of the human body is made of fluids?
60%
When we administer fluids, which compartment are we influencing?
intravascular fluid (plasma) of the extracellular compartment
How much K+ and Na+ do we need everyday?
K+ 0.5 mmol/kg/day
Na+ 1-2 mmol/kg/day
What factors affect fluid prescription?
- pre-existing = renal failure, BP, congestive CF (pulmonary oedema), liver failure, age and fragility
- post-op = NBM, blood loss, V&D, obstruction, ileus
- end organ damage = AKI, pulmonary oedema, sepsis
How can fluid status be assessed?
- OBS - pulse, BP, RR, O2 sats, stool chart
- daily weights
- exam = JVP, cap refill, skin turgor, tongue, mucus membranes
- investigations - blood tests (renal function - U&Es)
- imaging
What is the normal urine output?
0.5 ml/kg/hr
What is a fluid challenge?
bolus of 500ml crystalloid (0.9% saline) over less than 15 minutes
What are the different types of fluids?
-5% dextrose
-crystalloids - 0.9% NaCl + Hartmann’s solution
(Can add K+ into bags)
If someone is acutely bleeding what fluids do we give them?
blood products - packed red cells, FFP (clotting factors), platelets, factor concentrates
On admission, what routine bloods are required?
G&S and clotting screen
Why is nutrition so important in surgical patients?
these patients are metabolically stressed and have increased energy requirements
malnutrition leads to infections, decreased healing, wound breakdown, death
What is the difference between enteral and paraenteral feeding?
enteral = refers to delivery of food via the GIT
paraenteral = refers to the delivery of calories and nutrients into a vein (bypasses GIT)/venous system via PIC or central line
What are the different types of enteral nutrition tubes?
- nasogastric
- nasoduodenal
- gastrostomy
- jujunostomy
- nasojejunal
