PERI-OP CARE

1. PERI-OP CARE ... as an FY1 Frances Balmer frankawm@doctors.org.uk

3. Elective vs Emergency ELECTIVE EMERGENCY • Better outcomes • Co-morbidities identified, assessed and taken into account • Optimisation of pre-op condition • Care pathway organised • Time for patient to prepare psychologically • Pre-op care limited • eg not NBM

4. AsaGradings • American Society of Anaesthetists (ASA) Grading • Predicts risk of morbidity/mortality associated with surgery/anaesthesia I Normally healthy 0.05% II Mild systemic disease Does not limit activity 0.4% III Severe systemic disease Limiting, not incapacitating 4.5% IV Severe systemic disease Life threatening 25% V Moribund 50% VI Dead – organ retrieval -

5. Elective patients: “Clerking in” • History • Operation they are having • Any changes since last reviewed in clinic • Ix prior to surgery (inc MRSA screen) • History / ROS / examination • Ix • All patients: FBC U&Es Clotting BM ECG • Consider: LFTs glu CXR echo • Ix appropriate to surgery: vein mapping • G&S / XM • NICE guidelines: Preoperative tests June 2003 • Kardex and fluids • NBM • Consent/Surgical site form – seniors to complete • Where will they go after surgery? “Are they fit for surgery?”

6. INTRA-OP • Doesn’t really involve the FY1! • fluids given/urine output in theatre • excessive blood loss • any complications (eg arrhythmias/ hypotension) • epidurals left in • But a couple of things to be aware of: • 2008 WHO “Safe Surgery Saves Lives” • “Surgical Safety Checklist” • 2010 National Patient Safety Agency (NPSA) • “Reducing harm in perioperative care

7. NPSA Reducing harm in peri-operative Care

8. Post-Op Care OP NOTE ANALGESIA LMWH INTAKE OUTPUT WOUNDS MOBILISE BOWEL OPENING

9. POST-OP – COMPLICATIONS The timing of complication gives a clue to the underlying pathology

10. ACUTE COMPLICATIONS (< 24 hrs) • 2˚ to GA • haemorrhage / anaemia • hypovolaemia • respiratory compromise • uncontrolled pain • emboli • damage to surrounding stuctures • 54 yr old female – CEA this afternoon. Called to review patient approximately 30 minutes after she returned to the ward as nurses concerned about her breathing. RR 35 SaO2 94%. Tachycardic. Walked into ward and.... • 65 yr old female – aorto-bifemoral bypass this morning. Acute onset abdominal pain and pyrexia, rigidity, raised lactate and metabolic acidosis. Investigation reveals...

11. EARLY COMPLICATIONS (Week 1) SIRS = 2 of : T <36 >38.3 HR > 90 RR > 20 WCC <4 >12 Glu > 7.7 (not diabetic) Acutely altered • delirium • DVT/PE • infection  sepsis • poor wound healing / dehiscence • reperfusion injuries • pressure sores • late haemorrhage • 83 year old gentleman. Left fem-pop bypass 1 day previously. Complaining of increasing pain leg calf. O/E calf is tender to palpation, firm, pain ++ compared to clinical findings, foot neurovascularly intact SIRS + source of infection = SEPSIS O2 Blood cultures Iv Abx Fluid challenge UO Lactate SEPSIS + end organ damage = SEVERE SEPSIS

12. LATE COMPLICATIONS • Damage to local structures  loss of function • Scarring • Chronic pain • Recurrence / failure of surgery • 73 year old gentleman with CEA. Post-op complains of altered voice. Improvement over time but still remains hoarse after several weeks...

13. THANKS FOR LISTENING NHS patient safety first – peri-op care www.patientsafetyfirst.nhs.uk survive sepsis www.survivesepsis.org NICE guidelines preoperative investigation www.nice.org.uk/CG3 NICE guidelines thromboprophylaxis http://guidance.nice.org.uk/CG92 Frances Balmer frankawm@doctors.org.uk