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Enhancing Perioperative Care: Elective vs Emergency Surgery Insights

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This comprehensive overview of perioperative care emphasizes the crucial differences between elective and emergency surgeries. It highlights the benefits of preoperative assessments, appropriate management of comorbidities, and optimized care pathways which lead to better surgical outcomes. Key points discussed include the importance of ASA grading, the preoperative testing algorithm, intraoperative considerations, and common postoperative complications. Emphasis is placed on the need for careful monitoring and adherence to national guidelines to ensure patient safety and minimize risks.

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Enhancing Perioperative Care: Elective vs Emergency Surgery Insights

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

  2. 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

  3. 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 -

  4. 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?”

  5. 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

  6. NPSA Reducing harm in peri-operative Care

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

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

  9. 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...

  10. 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

  11. 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...

  12. 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

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