Preoperative care Ms. Niamh Bambury 05/02/09
Overview <ul><li>Nutrition </li></ul><ul><li>Fluids and electrolytes </li></ul><ul><li>Anaesthetic review </li></ul><ul><l...
Nutrition <ul><li>Essential for  </li></ul><ul><ul><li>Wound healing </li></ul></ul><ul><ul><li>Immunological shield </li>...
The fasting state <ul><li>After 12 hours of fasting the nutrients provided have been utilised. </li></ul><ul><ul><li>Plasm...
The fasting state <ul><li>After 24 hours glycogen stores are depleted and  gluconeogenesis  occurs mostly in the liver </l...
Requirements in the healthy person <ul><li>CHO and lipids are the mainstay of energy intake </li></ul><ul><li>20-25kcal/kg...
Requirements in the healthy person <ul><li>Trace elements </li></ul><ul><ul><li>Eg zinc, copper, iron </li></ul></ul><ul><...
Changes in calorific needs <ul><li>Postoperatively-35kcal/kg/day </li></ul><ul><li>Increases 10% per degree increase in te...
Assessing nutritional status <ul><li>Body Weight and anthropometric techniques </li></ul><ul><li>Clinical </li></ul><ul><l...
Body Weight and anthropometric techniques <ul><li>Body weight (loss of 10% of BW in preceding 6 months is an indicator of ...
Clinical assessment <ul><li>Clinical history- weight change, dietary intake </li></ul><ul><li>Physical examination- muscle...
Laboratory techniques <ul><li>Serum albumin can be an indicator of nutritional status </li></ul><ul><li>However it is affe...
Feeding options <ul><li>Oral </li></ul><ul><li>Enteral </li></ul><ul><li>Parenteral </li></ul>
Enteral Feeding <ul><li>Requires GIT to be intact. </li></ul><ul><li>Can be given NG, NJ, PEG, PEJ </li></ul><ul><li>Indic...
Enteral feeding <ul><li>Monitoring of patients on enteral feeding </li></ul><ul><ul><li>Clinical assessment </li></ul></ul...
Enteral Feeding <ul><li>Complications </li></ul><ul><ul><li>Malposition of the tube itself </li></ul></ul><ul><ul><li>Aspi...
Parenteral Feeding <ul><li>Definition; the delivery of essential nutritional requirements intravenously usually through a ...
Parenteral Feeding <ul><li>Indications </li></ul><ul><ul><li>Proximal intestinal fistulae </li></ul></ul><ul><ul><li>Massi...
Parenteral Feeding <ul><li>Contents of TPN </li></ul><ul><ul><li>>50% CHO </li></ul></ul><ul><ul><li>40% fat emulsions </l...
Parenteral Feeding <ul><li>Monitoring patients on TPN </li></ul><ul><ul><li>Weight </li></ul></ul><ul><ul><li>U&Es, FBC, L...
Parenteral Feeding <ul><li>Complications </li></ul><ul><ul><li>Line insertion </li></ul></ul><ul><ul><ul><li>Sepsis </li><...
Parenteral Feeding <ul><li>Complications cont’d </li></ul><ul><ul><li>Feed itself </li></ul></ul><ul><ul><ul><li>Metabolic...
Anaesthetic review <ul><li>Suitability for surgery </li></ul><ul><ul><li>Cardiac </li></ul></ul><ul><ul><li>Respiratory </...
Assessment of cardiac function <ul><li>Non-invasive </li></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>ECG </li>...
<ul><li>Assessment of cardiac function </li></ul><ul><li>Chest x-ray </li></ul><ul><ul><li>indicated in the presence of ca...
<ul><li>Assessment of cardiac function </li></ul><ul><li>ECG </li></ul><ul><ul><li>features of ischaemia or previous infar...
Assessment of cardiac function <ul><li>Echocardiography </li></ul><ul><ul><li>Percutaneous </li></ul></ul><ul><ul><li>Tran...
Assessment of cardiac function <ul><li>Nuclear medicine </li></ul><ul><ul><li>Myocardial scintigraphy allows assessment of...
Assessing respiratory function <ul><li>Lung function tests </li></ul><ul><ul><li>predict the type and severity of lung dis...
Lung Function Tests <ul><li>Allow assessment of : </li></ul><ul><li>1)Lung volumes </li></ul><ul><li>2)Airway calibre </li...
1)Lung Volumes <ul><li>Assessed with spirometry </li></ul><ul><li>Volumes measured include: </li></ul><ul><ul><li>IC </li>...
2) Airway calibre <ul><li>Assessed by  Peak flow rates </li></ul><ul><li>Flow rates measured  </li></ul><ul><ul><li>FVC = ...
2) Airway calibre <ul><li>Lung function can be classified as: </li></ul><ul><ul><li>Normal </li></ul></ul><ul><ul><li>Rest...
3)Gas transfer <ul><li>Measured by arterial blood gases (ABG) </li></ul><ul><li>Also allow assessment of ventilation / per...
Assessment of Renal function <ul><li>Glomerular filtration rate is the gold standard test of renal function </li></ul><ul>...
Anaesthetic preview <ul><li>Medical co-morbidity increases the risks already associated with anaesthesia and surgery. </li...
50 Moribound 5 25 Incapacitating disease which is always life-threatening 4 4.5 Severe systemic disease that limits activi...
ASA grading <ul><li>Cardiovascular disease- Angina, Hypertension, Diabetes. Grade 2-3 </li></ul><ul><li>Respiratory diseas...
Planning postoperative pain management. <ul><li>Postoperative pain management is essential for a number of reasons </li></...
Analgesic Ladder <ul><li>Paracetamol </li></ul><ul><li>NSAIDS </li></ul><ul><li>Codeine phosphate </li></ul><ul><li>Morphi...
Analgesic ladder <ul><li>Paracetamol </li></ul><ul><ul><li>inhibits COX3 </li></ul></ul><ul><ul><li>useful for simple oper...
Analgesic ladder <ul><li>Codeine phosphate </li></ul><ul><ul><li>does not have a significant respiratory effect  </li></ul...
Analgesic ladder <ul><li>Stronger analgesics </li></ul><ul><li>IM morphine </li></ul><ul><li>PCA </li></ul><ul><ul><li>IV ...
Fluid and electrolytes <ul><li>Managing fluids pre and postoperatively essential </li></ul>
 
 
 
 
 
 
 
 
Fluid and electrolyte balance <ul><li>Daily requirements </li></ul><ul><li>For the ‘average’ 70 Kg man </li></ul><ul><ul><...
Fluid replacement <ul><li>3 factors to consider </li></ul><ul><ul><li>Maintenance requirements </li></ul></ul><ul><ul><li>...
Fluid replacement <ul><li>Maintenance requirements </li></ul><ul><li>Adults require approx 30-40mls/kg/day </li></ul><ul><...
Fluid replacement <ul><li>Daily requirements  </li></ul><ul><ul><li>Sodium and potassium requirements are approx 1mmol/kg/...
Insensible losses <ul><li>Faeces approx 100 ml/ day </li></ul><ul><li>Lungs approx 400 ml/ day </li></ul><ul><li>Skin appr...
Fluid replacement <ul><li>Abnormal losses </li></ul><ul><ul><li>Nasogastric aspirate-rich in Na and K </li></ul></ul><ul><...
Assessing Fluid balance <ul><li>Vital signs-pulse,BP </li></ul><ul><li>Urine output </li></ul><ul><li>Dry mucosal surfaces...
Composition of crystalloids <ul><li>Hartmann’s Solution </li></ul><ul><ul><li>Sodium  131 mmol/l  </li></ul></ul><ul><ul><...
<ul><ul><li>Sodium  131 mmol/l  </li></ul></ul><ul><ul><li>Chloride 111 mmol/l  </li></ul></ul><ul><ul><li>Potassium 5 mmo...
Preoperative blood testing <ul><li>FBC </li></ul><ul><li>U&E </li></ul><ul><li>Coag screen </li></ul><ul><li>Group and Hol...
Coagulation tests <ul><li>Prothrombin time (PT) </li></ul><ul><ul><li>extrinsic and common pathways </li></ul></ul><ul><ul...
Coagulation tests <ul><li>Activated partial thromboplastin time (APPT) </li></ul><ul><ul><li>Tests intrinsic pathways </li...
Transfusion Medicine <ul><li>Choose patients who need to have their blood type identified pre-operatively </li></ul>
Transfusion Medicine <ul><li>ABO system </li></ul><ul><ul><li>Consists of three allelles - A, B and O  </li></ul></ul><ul>...
Transfusion Medicine <ul><li>Cross Matching </li></ul><ul><ul><li>Patients red cells grouped for ABO and Rhesus antigens  ...
Blood products <ul><li>Whole blood  </li></ul><ul><li>Packed red cells  </li></ul><ul><li>Platelet concentrates  </li></ul...
Cryoprecipitate <ul><li>prepared from plasma </li></ul><ul><li>contains factor 8, and fibrinogen.vWF Factor 13, and ffibro...
Fresh frozen plasma <ul><li>the fluid portion of one unit of human blood </li></ul><ul><li>Contains components of the coag...
Complications of blood transfusion <ul><li>Early </li></ul><ul><li>Haemolytic reactions (immediate or delayed)  </li></ul>...
Disseminated intravascular coagulation <ul><li>Results in  </li></ul><ul><ul><li>activation of clotting cascade </li></ul>...
DIC cont’d <ul><li>Investigation </li></ul><ul><ul><li>Increased APTT and PT </li></ul></ul><ul><ul><li>Reduced serum fibr...
Goals of antibiotic administration <ul><li>Reduce the incidence of surgical site infection </li></ul><ul><li>Minimise the ...
Benefits of antibiotic prophylaxis <ul><li>Reduce morbidity and mortality </li></ul><ul><li>Reduce length of hospital stay...
Risks of prophylaxis <ul><li>Anaphylactic reaction </li></ul><ul><li>Antibiotic related diarrhoea </li></ul><ul><li>Clostr...
Risks of prophylaxis cont’d <ul><li>Antibiotic resistance </li></ul><ul><ul><li>Due to the amount of patients in a populat...
Risks of prophylaxis cont’d <ul><li>Multiple resistance </li></ul><ul><ul><li>NB patients undergoing elective surgery (eg ...
Indications for antibiotic prophylaxis <ul><li>Intracranial surgery </li></ul><ul><li>Upper GI surgery </li></ul><ul><ul><...
Antibiotic prophylaxis <ul><li>Not indicated for Clean abdominal  operations  </li></ul><ul><ul><li>Hernia repair </li></u...
How do the specific type of antibiotics translate into the need for antibiotics?
Predisposal to infection <ul><li>Patient factors </li></ul><ul><ul><li>Extremes of age </li></ul></ul><ul><ul><li>Poor nut...
Predisposal to infection <ul><li>Operative factors </li></ul><ul><ul><li>Length of operation </li></ul></ul><ul><ul><li>Sh...
Classification of wounds <ul><li>Clean </li></ul><ul><li>Clean contaminated </li></ul><ul><li>Contaminated </li></ul><ul><...
Classification of wounds <ul><li>Clean </li></ul><ul><ul><li>No inflammation encountered </li></ul></ul><ul><ul><li>Viscer...
Classification of wounds <ul><li>Clean contaminated  </li></ul><ul><ul><li>emergency surgery </li></ul></ul><ul><ul><li>Vi...
Classification of wounds <ul><li>Contaminated </li></ul><ul><ul><li>Wounds left open </li></ul></ul><ul><ul><li>Penetratin...
Classification of wounds <ul><li>Dirty </li></ul><ul><ul><li>Presence of pus </li></ul></ul><ul><ul><li>Intraperitoneal ab...
 
 
 
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Fwd: Bambury tutorial on preop assessment

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From: Henning L. Stokmo <helangen@gmail.com&gt;
Date: 2009/2/12
Subject: Bambury tutorial on preop assessment
To: ucdgrad09@gmail.com

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Fwd: Bambury tutorial on preop assessment

  1. 1. Preoperative care Ms. Niamh Bambury 05/02/09
  2. 2. Overview <ul><li>Nutrition </li></ul><ul><li>Fluids and electrolytes </li></ul><ul><li>Anaesthetic review </li></ul><ul><li>Preoperative care </li></ul><ul><li>Analgesic ladder </li></ul><ul><li>Blood products </li></ul><ul><li>Antibiotic prophylaxis </li></ul><ul><li>Classification of wounds </li></ul>
  3. 3. Nutrition <ul><li>Essential for </li></ul><ul><ul><li>Wound healing </li></ul></ul><ul><ul><li>Immunological shield </li></ul></ul><ul><ul><li>Maintaining normal functioning of organs </li></ul></ul>
  4. 4. The fasting state <ul><li>After 12 hours of fasting the nutrients provided have been utilised. </li></ul><ul><ul><li>Plasma insulin levels fall </li></ul></ul><ul><ul><li>Glucagon levels rise </li></ul></ul><ul><li>Glycogen is stored in the liver, muscle </li></ul><ul><li>The liver converts glycogen into glucose </li></ul><ul><li>Muscle glycogen is broken down into lactate, exported to the liver and converted into glucose </li></ul>
  5. 5. The fasting state <ul><li>After 24 hours glycogen stores are depleted and gluconeogenesis occurs mostly in the liver </li></ul><ul><li>Protein is broken into amino acids which undergo gng to form glucose </li></ul><ul><li>Fat is broken down into </li></ul><ul><ul><li>Glycerol-glucose </li></ul></ul><ul><ul><li>Fatty acids-ketone bodies in the liver </li></ul></ul>
  6. 6. Requirements in the healthy person <ul><li>CHO and lipids are the mainstay of energy intake </li></ul><ul><li>20-25kcal/kg/day </li></ul><ul><li>Vitamins </li></ul><ul><ul><li>metabolic co-enzymes </li></ul></ul><ul><ul><li>co-factors in wound healing </li></ul></ul><ul><ul><li>antooxidants </li></ul></ul>
  7. 7. Requirements in the healthy person <ul><li>Trace elements </li></ul><ul><ul><li>Eg zinc, copper, iron </li></ul></ul><ul><ul><li>cofactors for metabolic processes </li></ul></ul><ul><ul><li>components of body tissues </li></ul></ul><ul><li>Nitrogen-approx 12g/day- normally provided by protein </li></ul>
  8. 8. Changes in calorific needs <ul><li>Postoperatively-35kcal/kg/day </li></ul><ul><li>Increases 10% per degree increase in temperature </li></ul><ul><li>Sepsis- 40-45kcal/kg/day </li></ul><ul><li>Hypercatabolic states (burns, severe pancreatitis)-60kcal/kg </li></ul>
  9. 9. Assessing nutritional status <ul><li>Body Weight and anthropometric techniques </li></ul><ul><li>Clinical </li></ul><ul><li>Laboratory techniques </li></ul>
  10. 10. Body Weight and anthropometric techniques <ul><li>Body weight (loss of 10% of BW in preceding 6 months is an indicator of poor clinical outcome) </li></ul><ul><li>Triceps skin fold thickness(body fat mass) </li></ul><ul><li>Mid-arm muscle circumference(muscle mass) </li></ul><ul><li>Body mass index </li></ul><ul><ul><li>BW in kg </li></ul></ul><ul><ul><li>Height in m2 </li></ul></ul><ul><ul><li>Note these values can be inaccurate in the presence of oedema which occurs when there are changes in fluid balance in critically ill patients with fluid retention </li></ul></ul>
  11. 11. Clinical assessment <ul><li>Clinical history- weight change, dietary intake </li></ul><ul><li>Physical examination- muscle wasting, loss of subcutaneous fat, oedema, alopecia </li></ul><ul><li>Hand grip strength and respiratory function assess functional impairment which is associated with undernourishment. </li></ul>
  12. 12. Laboratory techniques <ul><li>Serum albumin can be an indicator of nutritional status </li></ul><ul><li>However it is affected in the acute phase response and by inflammation </li></ul><ul><li>(where it falls rapidly and therefore is of little use in assessing nutrition) </li></ul><ul><li>U&E-Ca, Mg, PO4, Na, K </li></ul>
  13. 13. Feeding options <ul><li>Oral </li></ul><ul><li>Enteral </li></ul><ul><li>Parenteral </li></ul>
  14. 14. Enteral Feeding <ul><li>Requires GIT to be intact. </li></ul><ul><li>Can be given NG, NJ, PEG, PEJ </li></ul><ul><li>Indications </li></ul><ul><ul><li>Dysphagia (esp for solid food) </li></ul></ul><ul><ul><li>Major trauma/Surgery- when fasting will be prolonged </li></ul></ul><ul><ul><li>IBD(Short gut syndrome,Crohn’s,Pancreatitis) </li></ul></ul><ul><ul><li>Distal low output enterocutaneous fistulae </li></ul></ul><ul><ul><li>Oesophagogastric surgery. </li></ul></ul>
  15. 15. Enteral feeding <ul><li>Monitoring of patients on enteral feeding </li></ul><ul><ul><li>Clinical assessment </li></ul></ul><ul><ul><li>Daily weights </li></ul></ul><ul><ul><li>Fluid balance </li></ul></ul><ul><ul><li>Twice weekly electrolytes and trace elements </li></ul></ul>
  16. 16. Enteral Feeding <ul><li>Complications </li></ul><ul><ul><li>Malposition of the tube itself </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><ul><li>Fistula formation </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Tube blockage </li></ul></ul><ul><ul><li>Feed intolerance </li></ul></ul><ul><ul><li>Hyperglycaemia </li></ul></ul><ul><ul><li>Enteric infection </li></ul></ul>
  17. 17. Parenteral Feeding <ul><li>Definition; the delivery of essential nutritional requirements intravenously usually through a central venous catheter or PICC. </li></ul><ul><li>Used in intestinal failure where there is an inability of the GIT to absorb nutrients. </li></ul>
  18. 18. Parenteral Feeding <ul><li>Indications </li></ul><ul><ul><li>Proximal intestinal fistulae </li></ul></ul><ul><ul><li>Massive intestinal resecton especially <100cm of bowel left. </li></ul></ul><ul><ul><li>Severe pancreatitis </li></ul></ul><ul><ul><li>Prolonged ileus </li></ul></ul>
  19. 19. Parenteral Feeding <ul><li>Contents of TPN </li></ul><ul><ul><li>>50% CHO </li></ul></ul><ul><ul><li>40% fat emulsions </li></ul></ul><ul><ul><li>1-2g/kg of fat/day </li></ul></ul><ul><ul><li>H2O 35ml/kg/day </li></ul></ul><ul><ul><li>Electrolytes-Na, K, Cl, Ca, Mg, PO4 </li></ul></ul><ul><ul><li>Nitrogen </li></ul></ul><ul><ul><li>Vitamins ADEK B&C </li></ul></ul>
  20. 20. Parenteral Feeding <ul><li>Monitoring patients on TPN </li></ul><ul><ul><li>Weight </li></ul></ul><ul><ul><li>U&Es, FBC, LFTs </li></ul></ul><ul><ul><li>Glucose </li></ul></ul><ul><ul><li>Temperature and Vitals(signs of sepsis) </li></ul></ul><ul><ul><li>Daily inspection of line </li></ul></ul><ul><ul><li>Trace elements </li></ul></ul>
  21. 21. Parenteral Feeding <ul><li>Complications </li></ul><ul><ul><li>Line insertion </li></ul></ul><ul><ul><ul><li>Sepsis </li></ul></ul></ul><ul><ul><ul><li>Pneumo/haemothorax </li></ul></ul></ul><ul><ul><ul><li>Arterial damage/thrombosis </li></ul></ul></ul><ul><ul><ul><li>Malposition of catheter </li></ul></ul></ul><ul><ul><ul><li>Cardiac arrythmias </li></ul></ul></ul>
  22. 22. Parenteral Feeding <ul><li>Complications cont’d </li></ul><ul><ul><li>Feed itself </li></ul></ul><ul><ul><ul><li>Metabolic derangement </li></ul></ul></ul><ul><ul><ul><ul><li>TPN jaundice </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyper/Hypoglycaemia </li></ul></ul></ul></ul><ul><ul><ul><li>Electrolyte disturbances </li></ul></ul></ul><ul><ul><ul><li>Vitamin/Trace element deficiency </li></ul></ul></ul>
  23. 23. Anaesthetic review <ul><li>Suitability for surgery </li></ul><ul><ul><li>Cardiac </li></ul></ul><ul><ul><li>Respiratory </li></ul></ul><ul><li>Need for blood products </li></ul><ul><li>Type of anaesthetic GA versus spinal </li></ul><ul><li>Post op analgesia required </li></ul>
  24. 24. Assessment of cardiac function <ul><li>Non-invasive </li></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Echocardiography </li></ul></ul><ul><ul><li>Exercise test </li></ul></ul><ul><li>Invasive </li></ul><ul><ul><li>Coronary angiography </li></ul></ul><ul><ul><li>Thallium scanning </li></ul></ul>
  25. 25. <ul><li>Assessment of cardiac function </li></ul><ul><li>Chest x-ray </li></ul><ul><ul><li>indicated in the presence of cardiorespiratory symptoms or signs </li></ul></ul><ul><li>Increased cardiac morbidity associated with </li></ul><ul><ul><li>Cardiomegaly </li></ul></ul><ul><ul><li>Pulmonary oedema </li></ul></ul>
  26. 26. <ul><li>Assessment of cardiac function </li></ul><ul><li>ECG </li></ul><ul><ul><li>features of ischaemia or previous infarction(LBBB) may be present </li></ul></ul><ul><li>Stress test- </li></ul><ul><ul><li>if there are symptoms of IHD such as chest pain, SOB on exertion </li></ul></ul><ul><li>24-hour monitoring is useful in the detection and assessment of arrhythmias </li></ul>
  27. 27. Assessment of cardiac function <ul><li>Echocardiography </li></ul><ul><ul><li>Percutaneous </li></ul></ul><ul><ul><li>Transoesophageal(TOE) </li></ul></ul><ul><li>Allows assessment of </li></ul><ul><ul><li>Muscle mass </li></ul></ul><ul><ul><li>Ventricular function / ejection fraction </li></ul></ul><ul><ul><li>End-diastolic and end-systolic volumes </li></ul></ul><ul><ul><li>Valvular function </li></ul></ul><ul><ul><li>Segmental defects </li></ul></ul>
  28. 28. Assessment of cardiac function <ul><li>Nuclear medicine </li></ul><ul><ul><li>Myocardial scintigraphy allows assessment of myocardial perfusion </li></ul></ul><ul><ul><li>Radiolabelled thallium is commonest isotope used </li></ul></ul><ul><ul><li>Areas of ischaemia or infarction appear as 'cold' spots </li></ul></ul>
  29. 29. Assessing respiratory function <ul><li>Lung function tests </li></ul><ul><ul><li>predict the type and severity of lung disease </li></ul></ul><ul><ul><li>predict risk of complications and postoperative mortality </li></ul></ul><ul><li>Arterial blood gases </li></ul><ul><li>Radiological investigations </li></ul><ul><ul><li>chest x-ray </li></ul></ul><ul><ul><li>high-resolution thoracic CT </li></ul></ul>
  30. 30. Lung Function Tests <ul><li>Allow assessment of : </li></ul><ul><li>1)Lung volumes </li></ul><ul><li>2)Airway calibre </li></ul><ul><li>3)Gas transfer </li></ul>
  31. 31. 1)Lung Volumes <ul><li>Assessed with spirometry </li></ul><ul><li>Volumes measured include: </li></ul><ul><ul><li>IC </li></ul></ul><ul><ul><li>IRV </li></ul></ul><ul><ul><li>TV </li></ul></ul><ul><ul><li>VC </li></ul></ul><ul><ul><li>FRC </li></ul></ul><ul><ul><li>RV </li></ul></ul><ul><ul><li>ERV </li></ul></ul><ul><ul><li>TLC </li></ul></ul>
  32. 32. 2) Airway calibre <ul><li>Assessed by Peak flow rates </li></ul><ul><li>Flow rates measured </li></ul><ul><ul><li>FVC = Forced vital capacity </li></ul></ul><ul><ul><li>FEV1 = Forced expiratory volume in one second </li></ul></ul><ul><li>Absolute values depend on height, weight, age, sex and race </li></ul><ul><li>FEV1 / FVC ratio is important </li></ul>
  33. 33. 2) Airway calibre <ul><li>Lung function can be classified as: </li></ul><ul><ul><li>Normal </li></ul></ul><ul><ul><li>Restrictive </li></ul></ul><ul><ul><li>Obstructive </li></ul></ul><ul><li>Restrictive lung disease </li></ul><ul><ul><li>FVC is reduced but FEV1/FVC is normal </li></ul></ul><ul><li>Obstructive lung disease </li></ul><ul><ul><li>FVC is normal or reduced and FEV1/FVC is reduced </li></ul></ul>
  34. 34. 3)Gas transfer <ul><li>Measured by arterial blood gases (ABG) </li></ul><ul><li>Also allow assessment of ventilation / perfusion mismatch </li></ul><ul><li>Important parameters to measure are </li></ul><ul><ul><li>pH </li></ul></ul><ul><ul><li>Partial pressure of oxygen </li></ul></ul><ul><ul><li>Partial pressure of carbon dioxide </li></ul></ul><ul><li>Pulse oximetry gives an indirect estimate of gas transfer </li></ul><ul><li>Technique is unreliable in the presence of other medical problems (e.g. anaemia) </li></ul>
  35. 35. Assessment of Renal function <ul><li>Glomerular filtration rate is the gold standard test of renal function </li></ul><ul><ul><li>Can be calculated by measuring creatinine clearance rate </li></ul></ul><ul><ul><li>Requires 24-hour urine collection </li></ul></ul><ul><li>Serum creatinine allows a good estimate of renal function </li></ul><ul><ul><li>may be inaccurate in patients with: </li></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Oedema </li></ul></ul></ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul><ul><ul><ul><li>Ascites </li></ul></ul></ul>
  36. 36. Anaesthetic preview <ul><li>Medical co-morbidity increases the risks already associated with anaesthesia and surgery. </li></ul><ul><li>American Society of Anesthesiologists devised a grading system to accurately predict morbidity and mortality </li></ul>
  37. 37. 50 Moribound 5 25 Incapacitating disease which is always life-threatening 4 4.5 Severe systemic disease that limits activity but isn’t incapacitating 3 0.4 Mild systemic disease that does not limit activity 2 0.05 Healthy individual 1 Mortality Definition ASA Grade
  38. 38. ASA grading <ul><li>Cardiovascular disease- Angina, Hypertension, Diabetes. Grade 2-3 </li></ul><ul><li>Respiratory disease- COPD, Asthma. Grade 2-3 </li></ul>
  39. 39. Planning postoperative pain management. <ul><li>Postoperative pain management is essential for a number of reasons </li></ul><ul><ul><li>Improved mobility </li></ul></ul><ul><ul><li>Patient comfort </li></ul></ul><ul><ul><li>Enhanced breathing </li></ul></ul><ul><ul><li>Prevention of gut immobility </li></ul></ul>
  40. 40. Analgesic Ladder <ul><li>Paracetamol </li></ul><ul><li>NSAIDS </li></ul><ul><li>Codeine phosphate </li></ul><ul><li>Morphine </li></ul><ul><li>Local anaesthesia </li></ul>
  41. 41. Analgesic ladder <ul><li>Paracetamol </li></ul><ul><ul><li>inhibits COX3 </li></ul></ul><ul><ul><li>useful for simple operations </li></ul></ul><ul><li>NSAIDS </li></ul><ul><ul><li>used for moderate pain </li></ul></ul><ul><ul><li>as an adjuvant with opiates in severe pain </li></ul></ul><ul><ul><li>nonspecific COX inhibition leads to its side effects especially loss of platelet function renal haemostasis and gastric cytoprotection </li></ul></ul>
  42. 42. Analgesic ladder <ul><li>Codeine phosphate </li></ul><ul><ul><li>does not have a significant respiratory effect </li></ul></ul><ul><ul><li>useful in intracranial surgery </li></ul></ul>
  43. 43. Analgesic ladder <ul><li>Stronger analgesics </li></ul><ul><li>IM morphine </li></ul><ul><li>PCA </li></ul><ul><ul><li>IV or via epidural catheter </li></ul></ul><ul><ul><li>Patient controlled lock out time predetermined </li></ul></ul><ul><li>Local analgesics </li></ul><ul><ul><li>continuous epidural anaesthesia with opiates or local anaesthetics </li></ul></ul><ul><li>Spinal opiates </li></ul>
  44. 44. Fluid and electrolytes <ul><li>Managing fluids pre and postoperatively essential </li></ul>
  45. 53. Fluid and electrolyte balance <ul><li>Daily requirements </li></ul><ul><li>For the ‘average’ 70 Kg man </li></ul><ul><ul><li>Total body water is 42 L (~60% of body weight) </li></ul></ul><ul><ul><li>24L is in the intracellular and 14 L in the extracellular compartments </li></ul></ul><ul><ul><li>The plasma volume is 3 L </li></ul></ul><ul><ul><li>The extravascular volume is 11 L </li></ul></ul><ul><li>Composition of crystalloids </li></ul><ul><li>Hartmann’s Solution </li></ul><ul><li>Normal Saline </li></ul><ul><li>Dextrose Saline </li></ul><ul><li>Sodium (mmol/l) 131 150 30 </li></ul><ul><li>Chloride (mmol/l) 111 150 30 </li></ul><ul><li>Potassium (mmol/l) 5 Nil Nil </li></ul><ul><li>Bicarbonate (mmol/l) 29 Nil Nil </li></ul><ul><li>Calcium (mmol/l) 2 Nil Nil </li></ul><ul><li>* Clinical history and observations – Pulse, blood pressure, skin turgor </li></ul><ul><li>* Urine output – oliguria < 0.5 ml/kg/hr </li></ul><ul><li>* CVP or pulmonary capillary wedge pressure </li></ul><ul><li>* Response of urine output or CVP to fluid challenge </li></ul><ul><li>* A fluid challenge should be regarded as a 200-250 ml bolus of colloid </li></ul><ul><li>* This should be administered as quickly as possible </li></ul><ul><li>* A response in the CVP or urine output should be seen within minutes </li></ul><ul><li>* The size and duration of the CVP response rather the actual values recorded is more important </li></ul>
  46. 54. Fluid replacement <ul><li>3 factors to consider </li></ul><ul><ul><li>Maintenance requirements </li></ul></ul><ul><ul><li>Abnormal losses </li></ul></ul><ul><ul><li>Pre-existing deficits in fluids and electrolytes </li></ul></ul>
  47. 55. Fluid replacement <ul><li>Maintenance requirements </li></ul><ul><li>Adults require approx 30-40mls/kg/day </li></ul><ul><li>Children require considerably more </li></ul><ul><ul><li>0-10 kg -100 ml/kg </li></ul></ul><ul><ul><li>10-20 kg -1000 ml + 50 ml/kg for each kg > 10 </li></ul></ul><ul><ul><li>>20 kg -1500 ml + 25 ml/kg for each kg > 20 </li></ul></ul>
  48. 56. Fluid replacement <ul><li>Daily requirements </li></ul><ul><ul><li>Sodium and potassium requirements are approx 1mmol/kg/day </li></ul></ul><ul><ul><li>Note that there is always a loss of potassium from faeces and urine so patients with diarrhoea can rapidly become hypokalaemic </li></ul></ul>
  49. 57. Insensible losses <ul><li>Faeces approx 100 ml/ day </li></ul><ul><li>Lungs approx 400 ml/ day </li></ul><ul><li>Skin approx 600 ml/ day </li></ul><ul><li>Urine approx 1,500mls/day </li></ul>
  50. 58. Fluid replacement <ul><li>Abnormal losses </li></ul><ul><ul><li>Nasogastric aspirate-rich in Na and K </li></ul></ul><ul><ul><li>Vomit, diarrhoea </li></ul></ul><ul><ul><li>Stoma, drains, fistula etc </li></ul></ul><ul><li>Pre-existing fluid and electrolyte deficit </li></ul><ul><ul><li>Specific diseases- acute pancreatitis and SBO -massive consumption of electrolytes and fluid </li></ul></ul>
  51. 59. Assessing Fluid balance <ul><li>Vital signs-pulse,BP </li></ul><ul><li>Urine output </li></ul><ul><li>Dry mucosal surfaces </li></ul><ul><li>Skin turgor </li></ul><ul><li>Mental status </li></ul><ul><li>Capillary return </li></ul>
  52. 60. Composition of crystalloids <ul><li>Hartmann’s Solution </li></ul><ul><ul><li>Sodium 131 mmol/l </li></ul></ul><ul><ul><li>Chloride 111 mmol/l </li></ul></ul><ul><ul><li>Potassium 5 mmol/l </li></ul></ul><ul><li>Normal Saline </li></ul><ul><ul><li>Sodium 150mmol/l </li></ul></ul><ul><ul><li>Chloride 150 mmol/l </li></ul></ul><ul><ul><li>Potassium 0 mmol/l </li></ul></ul>
  53. 61. <ul><ul><li>Sodium 131 mmol/l </li></ul></ul><ul><ul><li>Chloride 111 mmol/l </li></ul></ul><ul><ul><li>Potassium 5 mmol/l </li></ul></ul>
  54. 62. Preoperative blood testing <ul><li>FBC </li></ul><ul><li>U&E </li></ul><ul><li>Coag screen </li></ul><ul><li>Group and Hold </li></ul>
  55. 63. Coagulation tests <ul><li>Prothrombin time (PT) </li></ul><ul><ul><li>extrinsic and common pathways </li></ul></ul><ul><ul><li>measures factors II, V, VII, X and fibrinogen </li></ul></ul><ul><ul><li>PT is expressed as International Normalised Ratio (INR) </li></ul></ul><ul><ul><li>Prolonged in: </li></ul></ul><ul><ul><ul><li>Warfarin treatment </li></ul></ul></ul><ul><ul><ul><li>Liver disease </li></ul></ul></ul><ul><ul><ul><li>Vitamin K deficiency </li></ul></ul></ul><ul><ul><ul><li>Disseminated intravascular coagulation </li></ul></ul></ul>
  56. 64. Coagulation tests <ul><li>Activated partial thromboplastin time (APPT) </li></ul><ul><ul><li>Tests intrinsic pathways </li></ul></ul><ul><ul><li>Prolonged in: </li></ul></ul><ul><ul><ul><li>Heparin treatment </li></ul></ul></ul><ul><ul><ul><li>Haemophilia and factor deficiencies </li></ul></ul></ul><ul><ul><ul><li>Liver disease </li></ul></ul></ul><ul><ul><ul><li>Disseminated intravascular coagulation </li></ul></ul></ul><ul><ul><ul><li>Massive transfusion </li></ul></ul></ul><ul><ul><ul><li>Lupus anticoagulant </li></ul></ul></ul>
  57. 65. Transfusion Medicine <ul><li>Choose patients who need to have their blood type identified pre-operatively </li></ul>
  58. 66. Transfusion Medicine <ul><li>ABO system </li></ul><ul><ul><li>Consists of three allelles - A, B and O </li></ul></ul><ul><ul><li>antibodies are found in the serum of those lacking the corresponding antigen. </li></ul></ul><ul><li>ABO blood group system </li></ul><ul><ul><li>Blood group O = universal donor </li></ul></ul><ul><ul><li>Blood group AB = universal recipient </li></ul></ul><ul><li>Rhesus system </li></ul><ul><ul><li>Rhesus antibodies are immune antibodies requiring exposure during transfusion or pregnancy </li></ul></ul><ul><ul><li>85% population are rhesus positive </li></ul></ul>
  59. 67. Transfusion Medicine <ul><li>Cross Matching </li></ul><ul><ul><li>Patients red cells grouped for ABO and Rhesus antigens </li></ul></ul><ul><ul><li>Serum tested to confirm patients ABO group </li></ul></ul><ul><ul><li>Antibody screening to detect red cell antibodies in patient’s serum </li></ul></ul><ul><ul><li>Tests donor red cells against patients serum </li></ul></ul>
  60. 68. Blood products <ul><li>Whole blood </li></ul><ul><li>Packed red cells </li></ul><ul><li>Platelet concentrates </li></ul><ul><li>Human plasma - fresh frozen plasma </li></ul><ul><li>Human albumin 25% </li></ul><ul><li>Cryoprecipitate </li></ul><ul><li>Clotting factors - Factor VIII / IX </li></ul><ul><li>Immunoglobulins </li></ul>
  61. 69. Cryoprecipitate <ul><li>prepared from plasma </li></ul><ul><li>contains factor 8, and fibrinogen.vWF Factor 13, and ffibronectin. </li></ul><ul><li>given as ABO compatible </li></ul><ul><li>Indications for giving cryoprecipitate </li></ul><ul><ul><li>Haemophilia - Used for emergency back up when factor concentrates are not available. </li></ul></ul><ul><ul><li>Von Willebrands Disease - As with other forms of haemophilia, factor concentrates are the therapy of choice. </li></ul></ul><ul><ul><li>low fibrinogen levels as can occur with massive transfusions </li></ul></ul><ul><ul><li>Bleeding from excessive anticoagulation- FFP preferable </li></ul></ul><ul><ul><li>Massive haemorrhage </li></ul></ul><ul><ul><li>DIC </li></ul></ul>
  62. 70. Fresh frozen plasma <ul><li>the fluid portion of one unit of human blood </li></ul><ul><li>Contains components of the coagulation, fibrinolytic and complement systems </li></ul><ul><li>Indications for use </li></ul><ul><ul><li>Reversal of warfarin effect </li></ul></ul><ul><ul><ul><li>deficient in the vit K dependent coagulation factors II, VII, IX, and X, as well as proteins C and S. </li></ul></ul></ul><ul><ul><ul><li>can be reversed by the administration of vitamin K but immediate reversal with FFP for patients undergoing emergency surgery </li></ul></ul></ul><ul><ul><li>Massive blood transfusion (>1 blood volume within several hours) </li></ul></ul><ul><ul><li>FFP is efficacious for treatment of deficiencies of factors II, V, VII, IX, X, and XI when specific component therapy isn’t available </li></ul></ul><ul><ul><li>Antithrombin 3 deficiency </li></ul></ul>
  63. 71. Complications of blood transfusion <ul><li>Early </li></ul><ul><li>Haemolytic reactions (immediate or delayed) </li></ul><ul><li>Bacterial infections from contamination </li></ul><ul><li>Allergic reactions to white cells or platelets </li></ul><ul><li>Air embolism </li></ul><ul><li>Hyperkalaemia </li></ul><ul><li>Clotting abnormalities </li></ul><ul><li>Late </li></ul><ul><li>Infection - cytomegalovirus / hepatitis </li></ul><ul><li>Immune sensitisation </li></ul><ul><li>Iron overload </li></ul>
  64. 72. Disseminated intravascular coagulation <ul><li>Results in </li></ul><ul><ul><li>activation of clotting cascade </li></ul></ul><ul><ul><li>Bleeding due to consumption of clotting factors </li></ul></ul><ul><li>May present with </li></ul><ul><ul><li>Bruising </li></ul></ul><ul><ul><li>purpura </li></ul></ul><ul><ul><li>Oozing (may be noticed during surgery) </li></ul></ul><ul><li>Caused by </li></ul><ul><ul><li>Severe infection (meningococcal) </li></ul></ul><ul><ul><li>metastatic adenocarcinoma </li></ul></ul><ul><ul><li>shock </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Transfusion reactions </li></ul></ul>
  65. 73. DIC cont’d <ul><li>Investigation </li></ul><ul><ul><li>Increased APTT and PT </li></ul></ul><ul><ul><li>Reduced serum fibrinogen levels (<1 mg / ml) </li></ul></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>Treat underlying cause </li></ul></ul><ul><ul><li>Supportive treatment with fluid and blood products including platelets, cryo and FFP </li></ul></ul>
  66. 74. Goals of antibiotic administration <ul><li>Reduce the incidence of surgical site infection </li></ul><ul><li>Minimise the effect of antibiotics on the host’s normal flora </li></ul><ul><li>Minimise damage to the Host’s immune system </li></ul><ul><li>Minimise adverse effects </li></ul>
  67. 75. Benefits of antibiotic prophylaxis <ul><li>Reduce morbidity and mortality </li></ul><ul><li>Reduce length of hospital stay as a result </li></ul><ul><li>Avoidance of infection in surgical wounds associated with faster return to normal activity </li></ul>
  68. 76. Risks of prophylaxis <ul><li>Anaphylactic reaction </li></ul><ul><li>Antibiotic related diarrhoea </li></ul><ul><li>Clostridium difficile infection more common in </li></ul><ul><ul><li>Elderly </li></ul></ul><ul><ul><li>GI surgery </li></ul></ul><ul><ul><li>Use of broad spectrum antibiotics in particular 3rd generation cephalosporins </li></ul></ul>
  69. 77. Risks of prophylaxis cont’d <ul><li>Antibiotic resistance </li></ul><ul><ul><li>Due to the amount of patients in a population receiving antibiotics and the length of time they are on them </li></ul></ul><ul><ul><li>Therefore prophylactic antibiotics should be a single dose unless otherwise indicated </li></ul></ul>
  70. 78. Risks of prophylaxis cont’d <ul><li>Multiple resistance </li></ul><ul><ul><li>NB patients undergoing elective surgery (eg hip replacement, valve replacement, CABG) should undergo screening for carriage of MRSA prior to hospital stay </li></ul></ul>
  71. 79. Indications for antibiotic prophylaxis <ul><li>Intracranial surgery </li></ul><ul><li>Upper GI surgery </li></ul><ul><ul><li>Oesophageal, stomach and duodenal surgery </li></ul></ul><ul><li>Hepatobiliary </li></ul><ul><li>Lower GI </li></ul><ul><ul><li>esp. colorectal and appendicectomy </li></ul></ul>
  72. 80. Antibiotic prophylaxis <ul><li>Not indicated for Clean abdominal operations </li></ul><ul><ul><li>Hernia repair </li></ul></ul><ul><ul><li>OGD </li></ul></ul><ul><ul><li>Mesh repairs </li></ul></ul><ul><li>Antibiotics should however be considered in High risk patients </li></ul>
  73. 81. How do the specific type of antibiotics translate into the need for antibiotics?
  74. 82. Predisposal to infection <ul><li>Patient factors </li></ul><ul><ul><li>Extremes of age </li></ul></ul><ul><ul><li>Poor nutritional status </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Co-existing infections </li></ul></ul><ul><ul><li>Immunosuppressants </li></ul></ul>
  75. 83. Predisposal to infection <ul><li>Operative factors </li></ul><ul><ul><li>Length of operation </li></ul></ul><ul><ul><li>Shaving/skin prep </li></ul></ul><ul><ul><li>Sterility of instrument/theatre ventilation </li></ul></ul><ul><ul><li>Drain insertion </li></ul></ul><ul><ul><li>Haemostasis </li></ul></ul><ul><ul><li>Type of operation and adequate antimicrobial coverage </li></ul></ul>
  76. 84. Classification of wounds <ul><li>Clean </li></ul><ul><li>Clean contaminated </li></ul><ul><li>Contaminated </li></ul><ul><li>Dirty </li></ul>
  77. 85. Classification of wounds <ul><li>Clean </li></ul><ul><ul><li>No inflammation encountered </li></ul></ul><ul><ul><li>Viscera not entered </li></ul></ul><ul><ul><li>No break in aseptic technique </li></ul></ul><ul><ul><li>Eg hernia repair </li></ul></ul>
  78. 86. Classification of wounds <ul><li>Clean contaminated </li></ul><ul><ul><li>emergency surgery </li></ul></ul><ul><ul><li>Viscus opened but no spillage of gut content </li></ul></ul><ul><ul><li>Minor break in aseptic technique </li></ul></ul><ul><ul><li>right hemicolectomy and cholecystectomy </li></ul></ul><ul><ul><li>Infection rate usually <10% </li></ul></ul>
  79. 87. Classification of wounds <ul><li>Contaminated </li></ul><ul><ul><li>Wounds left open </li></ul></ul><ul><ul><li>Penetrating trauma less than 4 hours old </li></ul></ul><ul><ul><li>Viscus opened with inflammation or spillage of contents </li></ul></ul><ul><ul><li>Major break in sterile technique </li></ul></ul><ul><ul><li>appendicectomy and stab wound </li></ul></ul><ul><ul><li>Infection rate 15-20% </li></ul></ul>
  80. 88. Classification of wounds <ul><li>Dirty </li></ul><ul><ul><li>Presence of pus </li></ul></ul><ul><ul><li>Intraperitoneal abscess formation or visceral perforation </li></ul></ul><ul><ul><li>Penetrating trauma more than 4 hours old </li></ul></ul><ul><ul><li>perforated abdominal viscera </li></ul></ul><ul><ul><li>Infection rate 40% </li></ul></ul>
  81. 92. Overview

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