Page 409 - TNFlipTest

Toronto Notes 2019 Pre-Operative Preparations Pre-Operative Preparations
Considerations
• informedconsent(seeEthical,Legal,andOrganizationalMedicine,ELOM7)
• screeningquestionnairetodetermineriskfactorse.g.age,exercisecapacity,medicationuse,allergies • considerpre-operativeanesthesia,medicineconsultasindicatedtooptimizepatientstatus
• NPOaccordingtofastingguidelines(seeAnesthesiaandPerioperativeMedicine,A6)
• IV–balancedcrystalloidatmaintenancerate(4:2:1rule→roughly100-125cc/h):normalsaline
or Ringer’s lactate; bolus to catch up on estimated losses including losses from bowel prep
■ appropriate use of fluids perioperatively decreases risk of cardiorespiratory complications
• patient’sregularmedicationsincludedwiththeexceptionofhypoglycemicagents,diureticsandACEI • patientsonsteroidsmayrequirestressdosecoverage,anticoagulation/antiplateletmedicationmustbe managed to decrease surgical bleeding but not put patient at risk for increased thrombotic events (e.g.
switching from warfarin to LMWH)
• prophylacticantibioticsdependingonwoundclass(within1hpriortoincision):usuallycefazolin
(Ancef®) ± metronidazole (Flagyl®)
• RoleofMBP:CurrentevidencesuggeststhatuseofMBPpre-operativelyhasnoimpactonpost-
operative complications and therefore routine use of MBP for non-LAR elective colorectal surgery is not recommended
■ MBP is still frequently used for left-sided colonic surgery (i.e. sigmoid and rectum) to facilitate bowel manipulation and colorectal anastomoses
• consider VTE prophylaxis for all inpatient surgery (LMWH or heparin)
• onlyholdVTEprophylaxisifepiduralisexpected
• smokingcessationandweightlosspre-operativecansignificantlydecreasepost-operativecomplications • infection:delayelectivesurgeryuntilinfectioncontrolled,includingrespiratoryinfection(particularly
in asthma patients)
Investigations
• seeAnesthesiaandPerioperativeMedicine,A2
• routinepre-operativelaboratoryinvestigationsforelectiveproceduresshouldbeselective
■ only ASA class and surgical risk have been found to independently predict post-operative adverse effects
• bloodcomponents:groupandscreenorcrossandtypedependingonprocedure • CBC, electrolytes, creatinine
• INR/PT, PTT
• CXR(PAandlateral)forpatientswithhistoryofcardiacorpulmonarydisease
• ECGasindicatedbyhistoryorif>69yrandnoriskfactors • β-hCGtestinginallwomenofreproductiveage
Drains
• NGT
■ indications: gastric decompression, analysis of gastric contents, irrigation/dilution of gastric
contents, feeding, if necessary
■ contraindications: suspected basal skull fracture, obstruction of nasal passages, esophageal stricture,
esophageal varices
• Foley catheter with urometer
■ indications: to accurately monitor urine output, decompression of bladder, relieve obstruction, rapidly expanding suprapubic mass
■ contraindications: suspected urethral injury, and difficult insertion of catheter
Surgical Complications
• general principles in preventing complications during the post-operative period include: ■ frequent examination of the patient (daily or more) and their wound
■ removal of surgical tubes as soon as possible (e.g. Foley catheters and surgical drains) ■ early ambulation
■ monitor fluid balance and electrolytes
■ analgesia - enough to adequately address pain, but not excessive ■ skillful nursing care
Post-Operative Fever
• feverdoesnotnecessarilyimplyinfectionparticularlyinthefirst24-48hpost-operative
• fevermaynotbepresentorisbluntedifpatientisreceivingchemotherapy,glucocorticoids,or
immunosuppression
• timingoffevermayhelpidentifycause
■ hours after surgery – POD #1
◆ inflammatory reaction in response to trauma from surgery; unlikely to be infectious ◆ reaction to blood products received during surgery
◆ malignant hyperthermia
Serum Bilirubin
Indirect
Direct
Urine
  N N  
General Surgery and Thoracic Surgery GS7
Bilirubin Levels
Prehepatic Intrahepatic Posthepatic
Urobilinogen   –
Bilirubin – + +
Fecal
Urobilinogen   –
In patients with liver disease and an acute abdomen, spontaneous bacterial peritonitis must be ruled out
Surgical Emergencies: Take an AMPLE History
Allergies
Medications
Past medical/surgical history (including anesthesia and bleeding disorders) Last meal
Events (HPI)
Best Practice in General Surgery (BPIGS)
http://www.bpigs.ca/
BPIGS is a University of Toronto initiative with the goal of standardizing care in general surgery. This link contains EBM based guidelines which have been implemented by consensus within all Toronto teaching hospitals. This is a highly recommended source for the most up-to-date pre-operative and general treatment guidelines
Mechanical Bowel Preparation Strategies: A Clinical Practice Guideline developed by the University of Toronto’s Best Practice in Surgery
Informed by: Can J Surg 2010;53:385–395. 14 RCTs (5,071 participants), 8 meta-analyses 1. Allopen/laparoscopiccolorectal
procedures (excluding LARs ± diverting stoma)
• No MBP
• No dietary restrictions before NPO • Fleet enema for left colon
anastomoses with transrectal stapling 2. Open/laparoscopicLAR±divertingstoma
• MBP
• No dietary restrictions before MBP;
clear fluids after MBP complete
Drain Size
Measured by the unit French: French = diameter (mm) x 3