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Periop For TI
Periop For TI
patient
management – practical tips
and tricks
Arnold – Registrar, General Surgery
Acute surgical patients can be scary
• Sick people with surgical problems
• Controlled trauma
• Massive inflammatory event
• Friendly anesthetist…while in PACU
• On return to ward, the patient is yours
• Aim of this talk ‐ Clear and practical steps to get you through
• Things not covered:
• Reviewing sick/deteriorating patients (later lecture)
• Detailed fluid management (later lecture)
Textbooks…kinda help
Key basics for HO
• Have solid foundations to fall back
on
• Maintain relationship with your
registrar and boss…and other HOs
• Keep it simple
• Escalate, debrief
• Perioperative medicine is fun and a
great training ground
Pre‐operative management
• When do you meet
these patients?
• Do we always know
what’s wrong?
• NO
• Then how can we prep
them for theatre???
Basic pre‐operative principles
• These apply to all patients
• Resuscitate
• Fluids
• Antibiotics
• Meds
• Nutrition
• DVT
• Symptom management
• Scans/seniors will figure out the surgical plan
Fluids
• Is your patient in shock/volume deficient?
• Tachycardia, hypotension
• AKI
• Types of shock
• Most common in surgery are septic and hypovolemic
• The first key step? –> give a bolus of IV fluids
• If young/fit/healthy –> start with one litre
• If dodgy heart/fluid balance problem ‐> start with 500ml
• In unwell pre‐op patients, electrolytes/weight‐based calculations are
less important – obviously replace if clear deficit!
Post‐op fluids
• 4 main reasons for IV fluids
• Correcting volume deficit – not uncommon after major operations with blood loss
• ‘Maintenance’ fluids – replace losses (sweat/urine/vomiting/diarrhea/NG/stoma)
• Replacing specific electrolytes
• Vessel for other treatment (ABs, PCA, TPN etc)
• Have a therapeutic range – too little and your patient is dry, too much and
patient is overloaded
• Dry = increased risk MI/stroke, kidney injury, prolonged recovery
• Overload = risk of oedema, breathing difficulty, prolonged recovery
• Wider ‘therapeutic range’ for less traumatic operations ‐ more room
for error
• How do I know how much maintenance fluid to give?
• Historically target UO of 30‐50ml/hr, and fluid provided to achieve this
• Normal physiological UO is 0.5‐1ml/kg/hr
• However surgical patients are different – controlled trauma
• Large ADH release, fluid retention – survival adaptation
• Therefore don’t chase urine output for 24‐48 post‐op
For generic recovering patient:
• Assess the fluid balance – total in/out since admission
• Consider oral replacement ‐ do they need any IV fluid?
• Check patient weight – key part of fluid review that is often overlooked
• Maintenance IV to top‐up
Antibiotics
• Problem‐dependent – empiric recommendations change based on
site of infection
• 3 things to think about – charting antibiotics, cultures, surgical control
• Knee joint SA? Cover Staph/strep ‐> Flucloxacillin
• Appendicitis? Cover bowel bugs ‐> Cefuroxime/metronidazole
• But…how do we know we’re covering the right bug?
• Check cultures/aspirates daily – lab usually calls if anything interesting
Medications
• Complex ++
• Aiming just to cover basic rules for key meds
• Antihypertensives:
• Withhold ACE I, ARB, NSAIDs, Frusemide day of surgery
• Continue others including metoprolol (more rate control), CCBs etc
• Corticosteroids
• HPA axis suppression
• Think about before stopping steroids, consider stress dose
• Likely if low‐dose >3w or high dose >5 days (quicker in old/frail)
• What is a stress dose?
• Basically double normal dose
• Give while unwell (then 2‐4 days post‐op)
• Diabetes
• Patient is generally NBM awaiting theatre, high
steroid levels – screws with blood sugars
• Sliding scale (50 units actrapid in 50ml normal
saline) – continuous infusion
• Cease post‐op if able to eat, and re‐introduce
insulin
• If unable to eat, continue infusion
• Metformin + SGLT2 inhibitors (eg
dapagliflozin), ‐ Ideally stop 3 days pre‐op,
restart day 2‐3 post‐op
• Asked to review for high BSL? Stat novorapid,
can chart PRN
DVT prevention
• Why are DVT bad?
• Periop period = increased risk
• Virchows triad
• Not indicated if anticoagulated
• TEDs, SCDs, prophylactic clex
• Usually 40mg SC OD
• If CrCl <30ml/hr or <45kg =
20mg SC OD
Anticoagulants
• Generally – withhold on admission
• Warfarin
• Reverse with Vit K/prothrombinex
• Recheck INR, target <1.5
• Dabigatran
• Reverse with Praxbind
• Recheck TCT (most sensitive for dabi)
• Rivaroxiban
• Reduce effect with prothrombinex and FFP
• Repeat INR, target <1.3
• Can restart all 24 hours post‐op unless high bleeding risk
Bridging clexane
• Used after anticoag reversed and subtherapeutic, in patients who are
at risk off anticoagulation
• Eg – recent DVT/PE, mechanical heart valve
• Who needs it?
• Low risk – uncomplicated AF, normal mobility ‐> TEDS
• Medium risk ‐ >1 month since thrombosis ‐> prophylactic clex
• High risk ‐ <1 month since thrombosis, TIA/stroke, mechanical valve ‐>
bridging/therapeutic clexane
Nutrition
•Pre‐op = NBM
• Clear fluids 0200, NBM 0600
• Return to eating
• Generally let patients eat when they feel like it
• Exceptions are bowel surgery – anastomosis/ileus/obstruction – be guided by
surgical team, wait for the next ward round
• TPN – as per dietician! May need PICC line
Time for a few cases!
• All real
• Duty shifts
• Confidential
• Apply principles discussed
• 52 year old
• 3/7 worsening
right knee pain,
fevers
• T2 diabetic,
Otherwise well
• Sent up to Ortho
ward without
note from
registrar
‐> text page from nurse at 8pm, ‘please admit’
• On review:
• HR 110
• BP 90/65
• Febrile 38.1
• Knee ‘bloody sore’
• Feels nauseated
• Angry
• How do you initiate management?
• Resuscitate (Fluids, Abx)
• Symptom management
• Feeling a bit better
• Now what…are they ready for theatre?
• Not quite
• Meds, DVT, Nutrition
• Be a human as well as a doctor
• Practical thinking
• 84 year female with
RUQ, fevers, jaundice
• Background heart
failure, COPD, CKD, T2
diabetes
• Anticoag on warfarin
• Literally 20 meds
• Registrar is busy, will see
in 2‐3 hours, and has
advised – Cefuroxime,
metronidazole, notify if
concerns
• Appears crook
• Nauseated, vomiting
• HR 100
• BP 80/50
• Febrile 39.0
• On multiple meds:
• Antihypertensives
• Warfarin
• Metformin
• Diagnosis ideas?
• Anything beyond cef + met?
• Asked to fluid review a 60 year
old man post‐op laparoscopic
cholecystectomy
• Day 5 post‐op, asked to review
as patient slow to start drinking
• Feeling pretty well
• What do you want to know?
• Asked to fluid review a 60 year
old man post‐op laparoscopic
cholecystectomy
• Day 5 post‐op, asked to review
as patient slow to start drinking
• Feeling pretty well Fluid balance – total in/out is
balanced with slow IVF
• What do you want to know? Urine output – 10ml/hr
Weight ‐ normal
Symptoms of overload
‐ feeling a little SOB
‐ RR 28, sats 88% RA
Next step?
• ECG – NSR
• CXR:
Plan?
• ECG – NSR
• CXR:
Plan?
IV Augmentin
O2
Bloods
Inform registrar
Culture the bug
Final tips for your last few months
• Turn up to SARA/go to ED with your registrar
• See patients first, before your House Officer
• No cutting corners, do everything you can to make the best possible plan
• You will never be fully supervised again!