fwd: bambury tutorial on preop assessment
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---------- Forwarded message ---------- From: Henning L. Stokmo Date: 2009/2/12 Subject: Bambury tutorial on preop assessment To: [email protected]TRANSCRIPT
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Preoperative care
Ms. Niamh Bambury
05/02/09
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Overview Nutrition Fluids and electrolytes Anaesthetic review Preoperative care Analgesic ladder Blood products Antibiotic prophylaxis Classification of wounds
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Nutrition Essential for
Wound healing Immunological shield Maintaining normal functioning of organs
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The fasting state After 12 hours of fasting the nutrients
provided have been utilised. Plasma insulin levels fall Glucagon levels rise
Glycogen is stored in the liver, muscle The liver converts glycogen into glucose Muscle glycogen is broken down into lactate,
exported to the liver and converted into glucose
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The fasting state After 24 hours glycogen stores are
depleted and gluconeogenesis occurs mostly in the liver
Protein is broken into amino acids which undergo gng to form glucose
Fat is broken down into Glycerol-glucose Fatty acids-ketone bodies in the liver
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Requirementsin the healthy person CHO and lipids are the mainstay of
energy intake 20-25kcal/kg/day Vitamins
metabolic co-enzymes co-factors in wound healing antooxidants
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Requirementsin the healthy person Trace elements
Eg zinc, copper, iron cofactors for metabolic processes components of body tissues
Nitrogen-approx 12g/day- normally provided by protein
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Changes in calorific needs Postoperatively-35kcal/kg/day Increases 10% per degree increase in
temperature Sepsis- 40-45kcal/kg/day Hypercatabolic states (burns, severe
pancreatitis)-60kcal/kg
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Assessing nutritional status
Body Weight and anthropometric techniques
Clinical Laboratory techniques
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Body Weight and anthropometric techniques Body weight (loss of 10% of BW in preceding 6
months is an indicator of poor clinical outcome) Triceps skin fold thickness(body fat mass) Mid-arm muscle circumference(muscle mass) Body mass index
BW in kg Height in m2• 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
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Clinical assessment Clinical history- weight change, dietary intake Physical examination- muscle wasting, loss of
subcutaneous fat, oedema, alopecia Hand grip strength and respiratory function
assess functional impairment which is associated with undernourishment.
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Laboratory techniques Serum albumin can be an indicator of
nutritional status However it is affected in the acute
phase response and by inflammation
(where it falls rapidly and therefore is of little use in assessing nutrition)
• U&E-Ca, Mg, PO4, Na, K
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Feeding options Oral Enteral Parenteral
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Enteral Feeding Requires GIT to be intact. Can be given NG, NJ, PEG, PEJ Indications
Dysphagia (esp for solid food) Major trauma/Surgery- when fasting will be
prolonged IBD(Short gut syndrome,Crohn’s,Pancreatitis) Distal low output enterocutaneous fistulae Oesophagogastric surgery.
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Enteral feeding Monitoring of patients on enteral feeding
Clinical assessment Daily weights Fluid balance Twice weekly electrolytes and trace
elements
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Enteral Feeding Complications
Malposition of the tube itself Aspiration Fistula formation Peritonitis Tube blockage Feed intolerance Hyperglycaemia Enteric infection
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Parenteral Feeding Definition; the delivery of essential
nutritional requirements intravenously usually through a central venous catheter or PICC.
Used in intestinal failure where there is an inability of the GIT to absorb nutrients.
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Parenteral Feeding Indications
Proximal intestinal fistulae Massive intestinal resecton especially
<100cm of bowel left. Severe pancreatitis Prolonged ileus
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Parenteral Feeding Contents of TPN
>50% CHO 40% fat emulsions 1-2g/kg of fat/day H2O 35ml/kg/day Electrolytes-Na, K, Cl, Ca, Mg, PO4 Nitrogen Vitamins ADEK B&C
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Parenteral Feeding Monitoring patients on TPN
Weight U&Es, FBC, LFTs Glucose Temperature and Vitals(signs of sepsis) Daily inspection of line Trace elements
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Parenteral Feeding Complications
Line insertion Sepsis Pneumo/haemothorax Arterial damage/thrombosis Malposition of catheter Cardiac arrythmias
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Parenteral Feeding Complications cont’d
Feed itself Metabolic derangement
TPN jaundice Hyper/Hypoglycaemia
Electrolyte disturbances Vitamin/Trace element deficiency
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Anaesthetic review Suitability for surgery
Cardiac Respiratory
Need for blood products Type of anaesthetic GA versus spinal Post op analgesia required
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Assessment of cardiac function
Non-invasive Chest x-ray ECG Echocardiography Exercise test
Invasive Coronary angiography Thallium scanning
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Assessment of cardiac function Chest x-ray
indicated in the presence of cardiorespiratory symptoms or signs
Increased cardiac morbidity associated with Cardiomegaly Pulmonary oedema
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Assessment of cardiac function ECG
features of ischaemia or previous infarction(LBBB) may be present
Stress test- if there are symptoms of IHD such as chest pain, SOB
on exertion 24-hour monitoring is useful in the detection and
assessment of arrhythmias
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Assessment of cardiac function
Echocardiography Percutaneous Transoesophageal(TOE)
Allows assessment of Muscle mass Ventricular function / ejection fraction End-diastolic and end-systolic volumes Valvular function Segmental defects
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Assessment of cardiac function
Nuclear medicine Myocardial scintigraphy allows assessment of
myocardial perfusion Radiolabelled thallium is commonest isotope used Areas of ischaemia or infarction appear as 'cold' spots
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Assessing respiratory function Lung function tests
predict the type and severity of lung disease predict risk of complications and postoperative
mortality Arterial blood gases Radiological investigations
chest x-ray high-resolution thoracic CT
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Lung Function Tests
Allow assessment of :1)Lung volumes2)Airway calibre3)Gas transfer
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1)Lung Volumes
Assessed with spirometry Volumes measured include:
IC IRV TV VC FRC RV ERV TLC
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2) Airway calibre
Assessed by Peak flow rates Flow rates measured
FVC = Forced vital capacity FEV1 = Forced expiratory volume in one
second Absolute values depend on height, weight, age,
sex and race FEV1 / FVC ratio is important
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2) Airway calibre Lung function can be classified as:
Normal Restrictive Obstructive
Restrictive lung disease FVC is reduced but FEV1/FVC is normal
Obstructive lung disease FVC is normal or reduced and FEV1/FVC is
reduced
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3)Gas transfer Measured by arterial blood gases (ABG) Also allow assessment of ventilation / perfusion mismatch Important parameters to measure are
pH Partial pressure of oxygen Partial pressure of carbon dioxide
Pulse oximetry gives an indirect estimate of gas transfer Technique is unreliable in the presence of other medical
problems (e.g. anaemia)
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Assessment of Renal function Glomerular filtration rate is the gold standard test of
renal function Can be calculated by measuring creatinine clearance rate Requires 24-hour urine collection
Serum creatinine allows a good estimate of renal function may be inaccurate in patients with:
Obesity Oedema Pregnancy Ascites
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Anaesthetic preview Medical co-morbidity increases the risks
already associated with anaesthesia and surgery.
American Society of Anesthesiologists devised a grading system to accurately predict morbidity and mortality
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ASA Grade
Definition Mortality
1 Healthy individual 0.05
2 Mild systemic disease that does not limit activity
0.4
3 Severe systemic disease that limits activity but isn’t incapacitating
4.5
4 Incapacitating disease which is always life-threatening
25
5 Moribound 50
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ASA grading
Cardiovascular disease- Angina, Hypertension, Diabetes. Grade 2-3
Respiratory disease- COPD, Asthma. Grade 2-3
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Planning postoperative pain management. Postoperative pain management is
essential for a number of reasons Improved mobility Patient comfort Enhanced breathing Prevention of gut immobility
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Analgesic Ladder Paracetamol NSAIDS Codeine phosphate Morphine Local anaesthesia
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Analgesic ladder Paracetamol
inhibits COX3 useful for simple operations
NSAIDS used for moderate pain as an adjuvant with opiates in severe pain nonspecific COX inhibition leads to its side effects
especially loss of platelet function renal haemostasis and gastric cytoprotection
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Analgesic ladder Codeine phosphate
does not have a significant respiratory effect
useful in intracranial surgery
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Analgesic ladder Stronger analgesics IM morphine PCA
IV or via epidural catheter Patient controlled lock out time predetermined
Local analgesics continuous epidural anaesthesia with opiates or
local anaesthetics Spinal opiates
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Fluid and electrolytes Managing fluids pre and postoperatively
essential
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Fluid and electrolyte balanceDaily requirementsFor the ‘average’ 70 Kg man
Total body water is 42 L (~60% of body weight) 24L is in the intracellular and 14 L in the extracellular compartments The plasma volume is 3 L The extravascular volume is 11 L
Composition of crystalloids
Hartmann’s Solution
Normal Saline Dextrose Saline Sodium (mmol/l) 131 150 30 Chloride (mmol/l) 111 150 30 Potassium (mmol/l) 5 Nil Nil Bicarbonate (mmol/l) 29 Nil Nil Calcium (mmol/l) 2 Nil Nil
* Clinical history and observations – Pulse, blood pressure, skin turgor * Urine output – oliguria < 0.5 ml/kg/hr * CVP or pulmonary capillary wedge pressure * Response of urine output or CVP to fluid challenge * A fluid challenge should be regarded as a 200-250 ml bolus of colloid * This should be administered as quickly as possible * A response in the CVP or urine output should be seen within minutes * The size and duration of the CVP response rather the actual values recorded is more important
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Fluid replacement 3 factors to consider
Maintenance requirements Abnormal losses Pre-existing deficits in fluids and
electrolytes
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Fluid replacement Maintenance requirements Adults require approx 30-40mls/kg/day Children require considerably more
0-10 kg -100 ml/kg 10-20 kg -1000 ml + 50 ml/kg for each kg > 10 >20 kg -1500 ml + 25 ml/kg for each kg > 20
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Fluid replacement Daily requirements
Sodium and potassium requirements are approx 1mmol/kg/day
Note that there is always a loss of potassium from faeces and urine so patients with diarrhoea can rapidly become hypokalaemic
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Insensible losses
Faeces approx 100 ml/ day Lungs approx 400 ml/ day Skin approx 600 ml/ day Urine approx 1,500mls/day
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Fluid replacement Abnormal losses
Nasogastric aspirate-rich in Na and K Vomit, diarrhoea Stoma, drains, fistula etc
Pre-existing fluid and electrolyte deficit Specific diseases- acute pancreatitis and SBO -
massive consumption of electrolytes and fluid
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Assessing Fluid balance Vital signs-pulse,BP Urine output Dry mucosal surfaces Skin turgor Mental status Capillary return
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Composition of crystalloids Hartmann’s Solution
Sodium 131 mmol/l Chloride 111 mmol/l Potassium 5 mmol/l
Normal Saline Sodium 150mmol/l Chloride 150 mmol/l Potassium 0 mmol/l
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Sodium 131 mmol/l Chloride 111 mmol/l Potassium 5 mmol/l
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Preoperative blood testing FBC U&E Coag screen Group and Hold
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Coagulation tests Prothrombin time (PT)
extrinsic and common pathways measures factors II, V, VII, X and fibrinogen PT is expressed as International Normalised Ratio
(INR) Prolonged in:
Warfarin treatment Liver disease Vitamin K deficiency Disseminated intravascular coagulation
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Coagulation tests Activated partial thromboplastin time (APPT)
Tests intrinsic pathways Prolonged in:
Heparin treatment Haemophilia and factor deficiencies Liver disease Disseminated intravascular coagulation Massive transfusion Lupus anticoagulant
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Transfusion Medicine Choose patients who need to have their
blood type identified pre-operatively
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Transfusion Medicine ABO system
Consists of three allelles - A, B and O antibodies are found in the serum of those lacking the
corresponding antigen. ABO blood group system
Blood group O = universal donor Blood group AB = universal recipient
Rhesus system Rhesus antibodies are immune antibodies requiring
exposure during transfusion or pregnancy 85% population are rhesus positive
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Transfusion Medicine Cross Matching
Patients red cells grouped for ABO and Rhesus antigens
Serum tested to confirm patients ABO group Antibody screening to detect red cell antibodies in
patient’s serum Tests donor red cells against patients serum
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Blood products Whole blood Packed red cells Platelet concentrates Human plasma - fresh frozen plasma Human albumin 25% Cryoprecipitate Clotting factors - Factor VIII / IX Immunoglobulins
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Cryoprecipitate prepared from plasma contains factor 8, and fibrinogen.vWF Factor 13, and
ffibronectin. given as ABO compatible Indications for giving cryoprecipitate
Haemophilia - Used for emergency back up when factor concentrates are not available.
Von Willebrands Disease - As with other forms of haemophilia, factor concentrates are the therapy of choice.
low fibrinogen levels as can occur with massive transfusions Bleeding from excessive anticoagulation- FFP preferable Massive haemorrhage DIC
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Fresh frozen plasma the fluid portion of one unit of human blood Contains components of the coagulation, fibrinolytic and
complement systems Indications for use
Reversal of warfarin effect deficient in the vit K dependent coagulation factors II, VII, IX,
and X, as well as proteins C and S. can be reversed by the administration of vitamin K but
immediate reversal with FFP for patients undergoing emergency surgery
Massive blood transfusion (>1 blood volume within several hours)
FFP is efficacious for treatment of deficiencies of factors II, V, VII, IX, X, and XI when specific component therapy isn’t available
Antithrombin 3 deficiency
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Complications of blood transfusion Early Haemolytic reactions (immediate or delayed) Bacterial infections from contamination Allergic reactions to white cells or platelets Air embolism Hyperkalaemia Clotting abnormalities Late Infection - cytomegalovirus / hepatitis Immune sensitisation Iron overload
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Disseminated intravascular coagulation Results in
activation of clotting cascade Bleeding due to consumption of clotting factors
May present with Bruising purpura Oozing (may be noticed during surgery)
Caused by Severe infection (meningococcal) metastatic adenocarcinoma shock Burns Transfusion reactions
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DIC cont’d Investigation
Increased APTT and PT Reduced serum fibrinogen levels (<1 mg / ml) Thrombocytopenia
Management Treat underlying cause Supportive treatment with fluid and blood products
including platelets, cryo and FFP
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Goals of antibiotic administration Reduce the incidence of surgical site
infection Minimise the effect of antibiotics on the
host’s normal flora Minimise damage to the Host’s immune
system Minimise adverse effects
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Benefits of antibiotic prophylaxis Reduce morbidity and mortality Reduce length of hospital stay as a
result Avoidance of infection in surgical
wounds associated with faster return to normal activity
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Risks of prophylaxis Anaphylactic reaction Antibiotic related diarrhoea Clostridium difficile infection more
common in Elderly GI surgery Use of broad spectrum antibiotics in
particular 3rd generation cephalosporins
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Risks of prophylaxis cont’d Antibiotic resistance
Due to the amount of patients in a population receiving antibiotics and the length of time they are on them
Therefore prophylactic antibiotics should be a single dose unless otherwise indicated
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Risks of prophylaxis cont’d Multiple resistance
NB patients undergoing elective surgery (eg hip replacement, valve replacement, CABG) should undergo screening for carriage of MRSA prior to hospital stay
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Indications for antibiotic prophylaxis Intracranial surgery Upper GI surgery
Oesophageal, stomach and duodenal surgery
Hepatobiliary Lower GI
esp. colorectal and appendicectomy
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Antibiotic prophylaxis Not indicated for Clean abdominal
operations Hernia repair OGD Mesh repairs
Antibiotics should however be considered in High risk patients
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How do the specific type of antibiotics translate into the need for antibiotics?
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Predisposal to infection Patient factors
Extremes of age Poor nutritional status Obesity Diabetes Co-existing infections Immunosuppressants
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Predisposal to infection Operative factors
Length of operation Shaving/skin prep Sterility of instrument/theatre ventilation Drain insertion Haemostasis Type of operation and adequate
antimicrobial coverage
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Classification of wounds Clean Clean contaminated Contaminated Dirty
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Classification of wounds Clean
No inflammation encountered Viscera not entered No break in aseptic technique Eg hernia repair
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Classification of wounds Clean contaminated
emergency surgery Viscus opened but no spillage of gut
content Minor break in aseptic technique right hemicolectomy and cholecystectomy Infection rate usually <10%
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Classification of wounds Contaminated
Wounds left open Penetrating trauma less than 4 hours old Viscus opened with inflammation or spillage of
contents Major break in sterile technique appendicectomy and stab wound Infection rate 15-20%
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Classification of wounds Dirty
Presence of pus Intraperitoneal abscess formation or
visceral perforation Penetrating trauma more than 4 hours old perforated abdominal viscera Infection rate 40%
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Overview