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Pre-Operative Nutritional Optimisaation - Coggle Diagram
Pre-Operative Nutritional Optimisaation
Weeks
Risk Assessment
Cardiac
Respiratory
Performance
Pre-Assessment Clinic
Run by anaesthetists
Fitness for surgery
Post op ICU / HDU
DOSA
Medications
Antihypertensives
Anticoag / antiplatelets
Prehabilitation
Run by physiotherapists
Improve CArdioresp
Famiiarise with exercise
Exercise Prehabilitation
The Prehabilitation Concept
All pt undergoing surgery experience a reduction in functional status postop followed by a recovery period
2.Complication may cause slower / incomplete recovery threatening longer term indepence
Pre-habilitated pt are better place to cope
Should a complication occur, prehabilitation might be crucial to safegaurding longer-term fx status and independence
Trial
Pre-HIIT Trial
Assessing impact of HIIT prehabilitation on pre-op fitness, postop recovery and use of healthcare resources
Preliminary finidings - improves al
Checklist 24hr Prior to Major Surgery
FBC - Hb, neuts, platelets
Iron def anaemia - do they need iron infusion preop
Neuts - is there infx
Pla
U&E and Creatinine
Inparticular K+ , creatiniti
Group and cross match
2 at most for majo electives
CXR unless recent CT thorax and ECG
Informed consent
Consultant or S reg
Get to know your pt
VTE Prophylaxis
At risk
Inflammatory response to opperation
Underlying conditions
Immobilisations
Cancer pts
Thrombophlebitis (inflammation of a vein the occurs whena blood clot forms) is s presenting sign of cryptic malignancy
Wards
TEDS
Clexane / Ino hep
In theatre / ICU
SCDs - Sequencial compression devices
Causes of Venous Thrombosis - Virchow's Triad
Blood flow
Haemodynamic changes
Stasis
Turbulence
Tumour pressure on veins (pelvic tumours iliac vessels)
Shock / dehydration
Vessel wall
Endothelial injury from direct or shear stress
Long term vascular access
BEGF
Thrombomodulin
Components of blood
Hypercoagulability
Risk Factors
Hx VTE
Anaesthesia lasting > 2hrs
Bed rest post op > 4 days
Advanced tumour
Age > 60
Wells Score
Extended Prophylaxis After SUrgery
Clexane for month after surgery
LMWH General Rules for Major Sugreyr
Avoid on morning of surgery in patient having epideural
Ideally 12 hr prior to epidural
Continue postoperatively at least until discharge or to 28 days
Approach VTE prophylaxis in combination with preoperative encourage to mobilise, smoking cessation, TEDS, and early mobilisation within ERAS
Infection / Antimicrobial Prophylaxis
Basic Prinicple is to have suffucient antibiotic at high concentration in tissue at time of maximum risk ie during operation
Classification of Operations (Surgical Wounds)
Clean
Clean-contaminated
Contaminated
Dirty (Infected)
Antimicrobial Prophylaxis
MEG
Day of Surgery
Thoracic Epidural is standard of care for complex major
Risk
Hypotension (postural) - may need inotropes
Combined with PCA 1mg morphine/6min lockout
Disadvantage
Poor night pain controol
IV paracetamol 1g q 6hr IV
Best to avoid NSAIDs in long complex operations for the first 48hrs due to renal risk / ulcer risk / risk to anastomotic healing
Use crystalloid fluids intra-op (500ml/H max) and postoperatively (100ml/h) avoid Excess
1 Day Post OP
IV fluids to chart
Medication Issues
VTE
Pulmonary complications
Complications of Surgery
Pain
Haemorrhage
Nutritional Support
Enhanced Recovery
ERAS
Multimodal perioperative care protocol designed to redice surgical stress and support basic bodily functions
