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Surgery - Incisions and Closures
Body cavity incisions Incisions that allow access to each bodily cavity are referred to in general terms.
• Laparotomy. An incision into the peritoneal cavity or retroperitoneal region. Laparotomies are classified based on their location in the abdomen, the tissues they traverse, or the individual who performed them
• Thoracotomy. Accessing the chest cavity, usually in the pleural space or posterior mediastinum. A median sternotomy is a form of thoracotomy that allows access to the anterior and middle mediastinum
. • Craniotomy. Accessing the skull's chambers. Incision closures Incisions are closed using certain basic ideas. • Fascial layers are ideal for supporting apposition and forming the primary abdominal closure. Heavy, non-permanent sutures are commonly used to close wounds. • When performing a craniotomy, bone flaws should be minimized to prevent movement. • Replace defects in fascial or bony structures with transposed or inserted tissues, such as skin, muscle, or polypropylene mesh. • Avoid large cavities and crevices between tissues to prevent infection-causing fluid accumulation.
Body cavity incisions Incisions that allow access to each bodily cavity are referred to in general terms.
• Laparotomy. An incision into the peritoneal cavity or retroperitoneal region. Laparotomies are classified based on their location in the abdomen, the tissues they traverse, or the individual who performed them
• Thoracotomy. Accessing the chest cavity, usually in the pleural space or posterior mediastinum. A median sternotomy is a form of thoracotomy that allows access to the anterior and middle mediastinum
. • Craniotomy. Accessing the skull's chambers. Incision closures Incisions are closed using certain basic ideas. • Fascial layers are ideal for supporting apposition and forming the primary abdominal closure. Heavy, non-permanent sutures are commonly used to close wounds. • When performing a craniotomy, bone flaws should be minimized to prevent movement. • Replace defects in fascial or bony structures with transposed or inserted tissues, such as skin, muscle, or polypropylene mesh. • Avoid large cavities and crevices between tissues to prevent infection-causing fluid accumulation.
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Surgery - Surgical Instruments
'Sharps' • Scalps. There are two sizes of handles (4 and 6). Blade types and usage include no. 11 (stab incisions), no. 10 (most skin incisions), no. 15 (fine incisions), and no. 22 (adhesiolysis). • Scissors. It could be dissection or stitch cutting. Dissecting scissors can be straight or curved, such as Mayo, McIndoe, Metzenbaum, and Nelson's.
Forceps • Non-toothed. DeBakey and Adson's forceps are fine, non-toothed instruments used to handle delicate tissues like arteries and bowels. This heavy, non-toothed tool is ideal for general handling, including specimens and sutures. • Toothed. Fine-toothed forceps, such as Gillies' and McIndoe's, are commonly used to handle skin and fascia, as well as to grip delicate tissues precisely. thick-toothed forceps, such as Lane's, are used to grip thick tissues like fascia and scars. • Ring-tipped and microforceps. Used for vascular anastomoses.
Clips and Clamps • Artery clips, such as Spencer-Wells, Robert's (big), and Dunhill's, Mosquito (little), feature serrated jaws. Suitable for vascular clamps, tissue/suture holding. • Tissue clamps, including the Lahey clamp. Clamp with curved tip is commonly used for dissecting vessels. • • Doyen bowel clamp. Non-crushing atraumatic. Babcock/Duval clamp. This non-toothed, semi-atraumatic tissue-holding clamp is commonly employed for holding the bowel. • Use Lane's, Allis, or 'Littlewood' clamps. Tissue clamps with heavy teeth for traumatic use.
Retractors • Self-retaining retractor: • Examples of large retractors include the Goligher retractor for abdominal incisions and the Finichetto retractor for thoracic procedures. • Travers (superficial) and Norfolk and Norwich (deeper) retractors are suitable for minor cutaneous and abdominal incisions. • • • Large handheld retractors, such as Deaver, Kelly, and Morris. Small (e.g. Langenbeck, Kilner/'Catspaw').
'Sharps' • Scalps. There are two sizes of handles (4 and 6). Blade types and usage include no. 11 (stab incisions), no. 10 (most skin incisions), no. 15 (fine incisions), and no. 22 (adhesiolysis). • Scissors. It could be dissection or stitch cutting. Dissecting scissors can be straight or curved, such as Mayo, McIndoe, Metzenbaum, and Nelson's.
Forceps • Non-toothed. DeBakey and Adson's forceps are fine, non-toothed instruments used to handle delicate tissues like arteries and bowels. This heavy, non-toothed tool is ideal for general handling, including specimens and sutures. • Toothed. Fine-toothed forceps, such as Gillies' and McIndoe's, are commonly used to handle skin and fascia, as well as to grip delicate tissues precisely. thick-toothed forceps, such as Lane's, are used to grip thick tissues like fascia and scars. • Ring-tipped and microforceps. Used for vascular anastomoses.
Clips and Clamps • Artery clips, such as Spencer-Wells, Robert's (big), and Dunhill's, Mosquito (little), feature serrated jaws. Suitable for vascular clamps, tissue/suture holding. • Tissue clamps, including the Lahey clamp. Clamp with curved tip is commonly used for dissecting vessels. • • Doyen bowel clamp. Non-crushing atraumatic. Babcock/Duval clamp. This non-toothed, semi-atraumatic tissue-holding clamp is commonly employed for holding the bowel. • Use Lane's, Allis, or 'Littlewood' clamps. Tissue clamps with heavy teeth for traumatic use.
Retractors • Self-retaining retractor: • Examples of large retractors include the Goligher retractor for abdominal incisions and the Finichetto retractor for thoracic procedures. • Travers (superficial) and Norfolk and Norwich (deeper) retractors are suitable for minor cutaneous and abdominal incisions. • • • Large handheld retractors, such as Deaver, Kelly, and Morris. Small (e.g. Langenbeck, Kilner/'Catspaw').
Clamps
Scapel
Forceps
Retractor
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Surgery – Scrubbing up
Scrubbing up helps lessen the chance of infection from the surgeon to the patient. Using bactericidal soaps can lower the amount of organisms that can be cultured from skin swabs, but sterilizing the skin (especially sweat glands and hair follicles) is impossible. Surgical gloves can cause considerable bacterial development within 2 hours due to moisture and heat, even with contemporary cleaning solutions. Bactericidal soaps include chlorhexidine and povidone-iodine.
Protocol
When entering the theatre for the first time, introduce yourself to the senior scrub nurses. It is respectful and safe. It's important to understand the purpose and identity of those in the theatre.
How To Scrub
• Wet your hands and arms first. • Apply disinfecting soap and wash well. • Scrub under nails and excessively filthy areas with a sterile brush and disinfecting soap. Scrubbing too forcefully might cause irritation and have little bactericidal effect. • Use soap to thoroughly clean between fingers, back of hands, beneath fingernails, and base of thumbs. • Rinse well to eliminate soap and prevent skin irritation. • Rinse off, ensuring water runs off elbows. Dry your hands well before moving on to your arms.
How to Gown and Glove
: • Open the gown without touching the exterior 'face'. Do not put your hands through the cuffs. Pick up the right glove with your right hand still in the gown's cuff—palm side down, fingers pointing up towards your forearm. • Fold the other side of the glove's edge 'over' your right hand. • Insert your right hand into the glove. • Grab the left glove by the edge and pull it over the left hand's cuff. • Slide your left hand into the glove and adjust its position. Wearing eye protection and two pairs of gloves is a standard practice to prevent exposure to infectious pathogens. % Infection control strategies include hand hygiene and personal protective equipment (PPE).
Scrubbing up helps lessen the chance of infection from the surgeon to the patient. Using bactericidal soaps can lower the amount of organisms that can be cultured from skin swabs, but sterilizing the skin (especially sweat glands and hair follicles) is impossible. Surgical gloves can cause considerable bacterial development within 2 hours due to moisture and heat, even with contemporary cleaning solutions. Bactericidal soaps include chlorhexidine and povidone-iodine.
Protocol
When entering the theatre for the first time, introduce yourself to the senior scrub nurses. It is respectful and safe. It's important to understand the purpose and identity of those in the theatre.
How To Scrub
• Wet your hands and arms first. • Apply disinfecting soap and wash well. • Scrub under nails and excessively filthy areas with a sterile brush and disinfecting soap. Scrubbing too forcefully might cause irritation and have little bactericidal effect. • Use soap to thoroughly clean between fingers, back of hands, beneath fingernails, and base of thumbs. • Rinse well to eliminate soap and prevent skin irritation. • Rinse off, ensuring water runs off elbows. Dry your hands well before moving on to your arms.
How to Gown and Glove
: • Open the gown without touching the exterior 'face'. Do not put your hands through the cuffs. Pick up the right glove with your right hand still in the gown's cuff—palm side down, fingers pointing up towards your forearm. • Fold the other side of the glove's edge 'over' your right hand. • Insert your right hand into the glove. • Grab the left glove by the edge and pull it over the left hand's cuff. • Slide your left hand into the glove and adjust its position. Wearing eye protection and two pairs of gloves is a standard practice to prevent exposure to infectious pathogens. % Infection control strategies include hand hygiene and personal protective equipment (PPE).
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Surgery – Surgery in Neurological Disease
Surgery for neurological illness.
Cerebrovascular accidents (strokes) Anaesthetic drugs can disrupt cerebrovascular autoregulation, increasing the risk of re-infarction or infarction extension during ischemic episodes. Autoregulation is restored after around 6 weeks. • Haemorrhagic infarctions have a low risk of continued bleeding, especially with thromboprophylaxis. Strategies for reducing risk • Postpone all non-essential surgeries for 6 weeks after infarctions, particularly ischemic ones. • Patients with recent hemorrhagic events may not require thromboprophylaxis. • Control blood pressure throughout perioperative period to prevent hypotension and hypertension and stabilize cerebral blood flow. • Avoid placing the patient's head down on the operating table, as this can increase cerebral venous pressure.
Epilepsy
Paroxysmal neuronal discharge in different parts of the brain can disrupt awareness, movement, and sensory perception. Cerebral space-occupying lesions, uraemia, cerebral oedema, medication toxicity, and hypercalcaemia can all elicit symptoms similar to epilepsy. For patients with known epilepsy, the following measures are recommended. • Determine normal seizure frequency, severity, and prodrome characteristics. • Continue anticonvulsant medication during NBM and immediately after surgery. • If not possible, consult with an anesthetist or neurologist to determine the best bridging regime. • 0 Phenytoin interacts with several medicines used during the perioperative period. • Increase elimination of prednisone, warfarin, and lidocaine. Increase Phenytoin absoption orally through amiodarone, fluconazole, omeprazole, and paroxetine but reduced through antacids with magnesium, calcium, and aluminum and enteral feeding.
Myasthenia gravis
This autoimmune disease causes muscle weakness due to inadequate acetylcholine (ACh) receptors. The disease typically affects young adults and causes symptoms such as ptosis and diplopia, as well as weakness in the neck, limbs, and trunk. Patients may seek thymectomy as a treatment or as an unplanned procedure. Management involves the following: • Continue regular medication. Consider elective post-operative breathing for significant thoracic or upper abdominal surgery, or if the patient has a vital capacity of less than 2L. Consult with an anaesthetist and the ICU. If ventilation is extended after surgery, a tracheostomy may be necessary. Discuss this with the patient during the consent process. • Monitor for respiratory failure after surgery, which could be caused by muscle weakness. Precipitants include hypokalemia, infection, over- or under-treatment, and emotional or physical exertion.
Surgery for neurological illness.
Cerebrovascular accidents (strokes) Anaesthetic drugs can disrupt cerebrovascular autoregulation, increasing the risk of re-infarction or infarction extension during ischemic episodes. Autoregulation is restored after around 6 weeks. • Haemorrhagic infarctions have a low risk of continued bleeding, especially with thromboprophylaxis. Strategies for reducing risk • Postpone all non-essential surgeries for 6 weeks after infarctions, particularly ischemic ones. • Patients with recent hemorrhagic events may not require thromboprophylaxis. • Control blood pressure throughout perioperative period to prevent hypotension and hypertension and stabilize cerebral blood flow. • Avoid placing the patient's head down on the operating table, as this can increase cerebral venous pressure.
Epilepsy
Paroxysmal neuronal discharge in different parts of the brain can disrupt awareness, movement, and sensory perception. Cerebral space-occupying lesions, uraemia, cerebral oedema, medication toxicity, and hypercalcaemia can all elicit symptoms similar to epilepsy. For patients with known epilepsy, the following measures are recommended. • Determine normal seizure frequency, severity, and prodrome characteristics. • Continue anticonvulsant medication during NBM and immediately after surgery. • If not possible, consult with an anesthetist or neurologist to determine the best bridging regime. • 0 Phenytoin interacts with several medicines used during the perioperative period. • Increase elimination of prednisone, warfarin, and lidocaine. Increase Phenytoin absoption orally through amiodarone, fluconazole, omeprazole, and paroxetine but reduced through antacids with magnesium, calcium, and aluminum and enteral feeding.
Myasthenia gravis
This autoimmune disease causes muscle weakness due to inadequate acetylcholine (ACh) receptors. The disease typically affects young adults and causes symptoms such as ptosis and diplopia, as well as weakness in the neck, limbs, and trunk. Patients may seek thymectomy as a treatment or as an unplanned procedure. Management involves the following: • Continue regular medication. Consider elective post-operative breathing for significant thoracic or upper abdominal surgery, or if the patient has a vital capacity of less than 2L. Consult with an anaesthetist and the ICU. If ventilation is extended after surgery, a tracheostomy may be necessary. Discuss this with the patient during the consent process. • Monitor for respiratory failure after surgery, which could be caused by muscle weakness. Precipitants include hypokalemia, infection, over- or under-treatment, and emotional or physical exertion.
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Surgery -Fluid Optimization
Identifying Patients in Need of Fluid Optimization
Preoperative fluid resuscitation can benefit any patient, although certain groups are more likely to require it. Consider less obvious situations of fluid depletion. More patients could benefit from fluid optimization than currently receive it. • Sudden vomiting or diarrhea, maybe due to intestinal blockage, biliary colic, or gastroenteritis.
• Patients who have been immobile or debilitated for a period of time, resulting in reduced fluid intake, such as pancreatitis, chest infections, acute-on-chronic vascular insufficiency, or prolonged sepsis with pyrexia.
• Elderly patients with reduced renal reserve, making fluid balance control less effective.
• Drugs that inhibit renal reactions to fluid fluctuations, such as diuretics. Patients with low body weight and smaller total body fluid volume experience larger effects from similar reductions.
• Children are particularly vulnerable to fluid deprivation and may not exhibit visible physical symptoms. Fluids utilized for optimization. Fluid optimization relies on employing the appropriate volumes and rates. In most cases, isotonic crystalloids are the preferred fluid for balancing out imbalances
• The most often utilized fluid is 0.9% isotonic saline ('normal'). When renal function is adequate, isotonic saline minimizes rapid fluid changes during rehydration and excretes excess sodium (Na+) through the kidneys. Add potassium (K+) only if d K+ is present or probable (e.g., prolonged vomiting, pancreatic or small bowel fistula). Glucose (4%), Hartmann's solution, and Ringer's lactate solution are examples of crystalloids. While Ringer's lactate solution has a fluid composition similar to serum, its theoretical benefits are restricted in practice. Hypertonic (1.8%) and hypotonic (0.45%) saline should be used with caution as they might produce fluid changes in and out of cells, potentially causing harm, especially to neurons. Patients with substantial Na+ balance disorders may require non-isotonic fluid adjustment in HDU. How to Give the Fluids Before administering liquids, it is necessary to determine the volume of depletion. Estimates of losses due to vomiting or diarrhea are typically erroneous. Useful calculations include the following:
• Use a recent correct body weight from normal health for admission, as acute weight loss is primarily water-based.
• If a recent haematocrit from normal health is available, admission haematocrit can be used to determine the degree of haemoconcentration caused by fluid loss. The approximate calculation is: fluid depletion (L) = (PCV1 - PCV2)/PCV1) times 0.7 × weight (kg). (PCV1 = normal haematocrit, PCV2 = current haematocrit.)
• Dehydration, renal disease, GI bleeds, and acute proteolysis raise serum urea more than serum Cr. • Signs of ECF depletion (lax skin tone, reduced sweating, dry mucosae) can be misleading and influenced by age and underlying diseases, such as pyrexia and tachypnea. • Signs of intravascular volume depletion, such as hypotension and tachycardia, can be inaccurate and often occur after losing 10-15% of body water. Once the volume of fluid required has been determined, it can be administered. There are several broad guidelines for administering fluid resuscitation. • Young, fit patients with normal renal and cardiac function can receive up to 15% of body fluid volume via fast infusion.
A common treatment involves infusing 1000mL of 0.9% saline over 2 hours, followed by additional 1000mL infusions over 4 hours until corrected. Elderly patients and those with renal or cardiac impairment should have slower infusions to avoid severe intravascular volume overload. A common treatment involves administering 1000mL of 0.9% saline over 4 hours, followed by a 500mL infusion of 0.9% saline over 3-4 hours. Vital signs, including chest auscultation, should be monitored regularly. Complex patients or those who do not react to initial treatment should be discussed with elders and/or other specialists as they may require monitoring in critical care. Monitoring fluid optimization.
Fluid optimization progress can be assessed using the following methods: • Optimized skin turgor and mucosal hydration are unreliable guides due to gradual changes. • Measuring urine output every hour can provide insight into renal blood flow, which in turn affects intravascular fluid volume and cardiac output. It is a reliable indicator of sufficient blood volume replenishment. Although urine flow is adequate, it is not a reliable measure of total body water due to potential intra- and extracellular depletion. A usual minimum is 0.5mL/kg/h. • Monitoring serum urea can offer an approximate guideline if renal function is adequate and there is no acute GI bleeding or proteolysis. In emergency situations, fast fluid infusions may be necessary for patients requiring surgery and fluid optimization before anesthesia. This can be monitored on HDU.
Identifying Patients in Need of Fluid Optimization
Preoperative fluid resuscitation can benefit any patient, although certain groups are more likely to require it. Consider less obvious situations of fluid depletion. More patients could benefit from fluid optimization than currently receive it. • Sudden vomiting or diarrhea, maybe due to intestinal blockage, biliary colic, or gastroenteritis.
• Patients who have been immobile or debilitated for a period of time, resulting in reduced fluid intake, such as pancreatitis, chest infections, acute-on-chronic vascular insufficiency, or prolonged sepsis with pyrexia.
• Elderly patients with reduced renal reserve, making fluid balance control less effective.
• Drugs that inhibit renal reactions to fluid fluctuations, such as diuretics. Patients with low body weight and smaller total body fluid volume experience larger effects from similar reductions.
• Children are particularly vulnerable to fluid deprivation and may not exhibit visible physical symptoms. Fluids utilized for optimization. Fluid optimization relies on employing the appropriate volumes and rates. In most cases, isotonic crystalloids are the preferred fluid for balancing out imbalances
• The most often utilized fluid is 0.9% isotonic saline ('normal'). When renal function is adequate, isotonic saline minimizes rapid fluid changes during rehydration and excretes excess sodium (Na+) through the kidneys. Add potassium (K+) only if d K+ is present or probable (e.g., prolonged vomiting, pancreatic or small bowel fistula). Glucose (4%), Hartmann's solution, and Ringer's lactate solution are examples of crystalloids. While Ringer's lactate solution has a fluid composition similar to serum, its theoretical benefits are restricted in practice. Hypertonic (1.8%) and hypotonic (0.45%) saline should be used with caution as they might produce fluid changes in and out of cells, potentially causing harm, especially to neurons. Patients with substantial Na+ balance disorders may require non-isotonic fluid adjustment in HDU. How to Give the Fluids Before administering liquids, it is necessary to determine the volume of depletion. Estimates of losses due to vomiting or diarrhea are typically erroneous. Useful calculations include the following:
• Use a recent correct body weight from normal health for admission, as acute weight loss is primarily water-based.
• If a recent haematocrit from normal health is available, admission haematocrit can be used to determine the degree of haemoconcentration caused by fluid loss. The approximate calculation is: fluid depletion (L) = (PCV1 - PCV2)/PCV1) times 0.7 × weight (kg). (PCV1 = normal haematocrit, PCV2 = current haematocrit.)
• Dehydration, renal disease, GI bleeds, and acute proteolysis raise serum urea more than serum Cr. • Signs of ECF depletion (lax skin tone, reduced sweating, dry mucosae) can be misleading and influenced by age and underlying diseases, such as pyrexia and tachypnea. • Signs of intravascular volume depletion, such as hypotension and tachycardia, can be inaccurate and often occur after losing 10-15% of body water. Once the volume of fluid required has been determined, it can be administered. There are several broad guidelines for administering fluid resuscitation. • Young, fit patients with normal renal and cardiac function can receive up to 15% of body fluid volume via fast infusion.
A common treatment involves infusing 1000mL of 0.9% saline over 2 hours, followed by additional 1000mL infusions over 4 hours until corrected. Elderly patients and those with renal or cardiac impairment should have slower infusions to avoid severe intravascular volume overload. A common treatment involves administering 1000mL of 0.9% saline over 4 hours, followed by a 500mL infusion of 0.9% saline over 3-4 hours. Vital signs, including chest auscultation, should be monitored regularly. Complex patients or those who do not react to initial treatment should be discussed with elders and/or other specialists as they may require monitoring in critical care. Monitoring fluid optimization.
Fluid optimization progress can be assessed using the following methods: • Optimized skin turgor and mucosal hydration are unreliable guides due to gradual changes. • Measuring urine output every hour can provide insight into renal blood flow, which in turn affects intravascular fluid volume and cardiac output. It is a reliable indicator of sufficient blood volume replenishment. Although urine flow is adequate, it is not a reliable measure of total body water due to potential intra- and extracellular depletion. A usual minimum is 0.5mL/kg/h. • Monitoring serum urea can offer an approximate guideline if renal function is adequate and there is no acute GI bleeding or proteolysis. In emergency situations, fast fluid infusions may be necessary for patients requiring surgery and fluid optimization before anesthesia. This can be monitored on HDU.
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Surgery - Sterilization, disinfection, and antiseptic
Definitions • Sterilization involves removing all living germs, vegetative organisms, and spores.
• Disinfection removes dividing vegetative germs.
• Antisepsis reduces the danger of medical cross-infection from germs. Sterilization
Heat: • Dry heat (e.g. incineration, blazing, red hot) is effective but rarely useful. Dry heat necessitates temperatures of 160°C for at least 60 minutes. • Moist heat, such as autoclave heating with pressurized steam at 121°C and 15lb/in2 for 15 minutes, is effective and useful for operating theaters.
Irradiation involves gamma radiation. Effective with inorganic materials. Ultrafine membrane filters can disinfect air and fluids, although they are not commonly used in hospitals.
Disinfection methods include using acids or alkalis, such as bleach. Effective for non-human contact applications. Examples of alcohols and phenols include ethyl alcohol for skin swabs, alcohol solutions for hand disinfection, carbolic chloroxylenols, and phenol (Clearsol®). • Oxidizers include povidone-iodine for skin disinfection and surgical washing, hydrogen peroxide (H2O2) for superficial wound cleansing, and aldehydes for surgical tools like endoscopes. •
Cationic solutions, such as chlorhexidine, can be used for antiseptic wash. • Organic dyes, such as Proflavine.
Antisepsis
Antisepsis concepts include: • Remove gross contamination first with plain soap. • Use high-potency acid/alkali disinfectants on inert surfaces. • Apply less corrosive oxidizers to fragile inert materials. • Use weak alcohols and oxidizers to cleanse the skin.
Definitions • Sterilization involves removing all living germs, vegetative organisms, and spores.
• Disinfection removes dividing vegetative germs.
• Antisepsis reduces the danger of medical cross-infection from germs. Sterilization
Heat: • Dry heat (e.g. incineration, blazing, red hot) is effective but rarely useful. Dry heat necessitates temperatures of 160°C for at least 60 minutes. • Moist heat, such as autoclave heating with pressurized steam at 121°C and 15lb/in2 for 15 minutes, is effective and useful for operating theaters.
Irradiation involves gamma radiation. Effective with inorganic materials. Ultrafine membrane filters can disinfect air and fluids, although they are not commonly used in hospitals.
Disinfection methods include using acids or alkalis, such as bleach. Effective for non-human contact applications. Examples of alcohols and phenols include ethyl alcohol for skin swabs, alcohol solutions for hand disinfection, carbolic chloroxylenols, and phenol (Clearsol®). • Oxidizers include povidone-iodine for skin disinfection and surgical washing, hydrogen peroxide (H2O2) for superficial wound cleansing, and aldehydes for surgical tools like endoscopes. •
Cationic solutions, such as chlorhexidine, can be used for antiseptic wash. • Organic dyes, such as Proflavine.
Antisepsis
Antisepsis concepts include: • Remove gross contamination first with plain soap. • Use high-potency acid/alkali disinfectants on inert surfaces. • Apply less corrosive oxidizers to fragile inert materials. • Use weak alcohols and oxidizers to cleanse the skin.
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Surgery - Preoperative management of anemia
Definition: Hb <13g />L for both sexes.
Classification Traditionally, MCV and MCH are used to determine potential causes. Current guidelines for diagnosis Iron and haematinic deficiency, as well as blood loss, are common and treatable issues that require proper investigation.
Postpone major elective surgery (with estimated blood loss >500mL) until correctable causes of anaemia are identified and addressed. Current guidelines Serum ferritin levels below 30 micrograms/L are the most sensitive and specific test for determining absolute iron deficient anaemia. In cases of inflammation (CRP >5 and TSAT <20%), a serum ferritin level of <100 micrograms /> indicates iron deficiency anemia. The prevalence and effects of perioperative anemia Large multicenter studies and worldwide registry databases show that perioperative anemia is widespread in surgical patients (30-35% prevalence) and related with morbidity and mortality, regardless of severity. When paired with additional perioperative risk factors, results worsen by a ratio of 3.5–7.
Assessment and management of anemia
Patients should expect to wait up to 2 months for elective surgery, giving them enough time to check and rectify anemia. If there is a >10% chance of transfusion or >500mL of blood loss, lab tests should be performed immediately to check haematinics. • If Hb is <13g />L, identify possible causes and correctable factors. Examine both visible and hidden indications of blood loss. Some patients may require additional testing, such as radiographic imaging or endoscopic evaluation. • If ferritin is <20 micrograms /> and there is no inflammation (CRP/TSAT normal), or if ferritin is <100 micrograms /> with CRP >5 and/or TSAT <20%, start preoperative iron replacement treatment.< />pan>
• If iron replacement therapy is started, non-urgent surgeries should be postponed until the goal Hb is reached.
Treatment Options for Correcting Anaemia
Preoperative anemia. • B12 and folate deficiencies can be rectified with IM or PO supplements for 2-3 weeks in 712% of patients undergoing surgery. • Iron deficiency anaemia can frequently coexist. The severity, expected malabsorption, and convenience of administration will determine whether to use PO or IM supplements for each patient. 2 To treat iron deficiency anaemia, administer 400-600mg/day of PO ferrous sulfate for 6-8 weeks.
• IV iron therapy is highly effective for urgent surgery and has no ill effects when compared to PO therapy or placebo. Administering 1000- 1500mg IV over an hour can result in a peak rise in Hb over 1-3 weeks. • Patients with iron deficiency (ferritin >100 micrograms/L) who are still anaemic can get subcutaneous (SC) erythropoietin (EPO) at a dose of 300-600mg once weekly for 4 weeks. 2 Many hospitals have perioperative clinics administered by surgical, anesthetic, and critical care teams. Local perioperative anaemia routes are a helpful resource. Post-operative anemia • Check patients' post-operative hemoglobin levels with HemoCue® during recovery or upon return to the ward. Formal FBC can typically be performed on the first day following surgery. • If a patient experiences moderate to substantial blood loss during surgery and is predicted to bleed post-operatively due to coagulopathy or surgical causes, they should be observed in a suitable setting by a senior clinician. Early detection of clinical deterioration by the National Early Warning Score (NEWS) is crucial for effective patient care.
• According to NICE guidelines, most patients should have a transfusion threshold of <7g />L for post-operative anemia, with a Hb target of 7-9g/dL after transfusion, except for extensive hemorrhage and acute coronary syndrome (target 8-10g/dL). • Regular transfusions are required due to chronic anemia. Patients having persistent post-operative blood loss should be evaluated periodically and promptly. The senior surgeon should be informed. Critical care outreach teams can provide crucial assistance.
Mean Cell Volume -Microcytic
Causes - iron deficiency anemia,Thalassemia, chronic Disease
Mean Cell Hemoglobin – Hypochromic
Mean Cell Volume – Normocytic
Causes - Acute blood loss and chronic Disease
Mean Cell Hemoglobin – Normochromic
Mean Cell Volume – Macrocytic
Causes – alcohol dependence, B12/folate deficiency, hypothyroidism, pregnancy, hemolysis
Mean Cell Hemoglobin - Normochromic
Definition: Hb <13g />L for both sexes.
Classification Traditionally, MCV and MCH are used to determine potential causes. Current guidelines for diagnosis Iron and haematinic deficiency, as well as blood loss, are common and treatable issues that require proper investigation.
Postpone major elective surgery (with estimated blood loss >500mL) until correctable causes of anaemia are identified and addressed. Current guidelines Serum ferritin levels below 30 micrograms/L are the most sensitive and specific test for determining absolute iron deficient anaemia. In cases of inflammation (CRP >5 and TSAT <20%), a serum ferritin level of <100 micrograms /> indicates iron deficiency anemia. The prevalence and effects of perioperative anemia Large multicenter studies and worldwide registry databases show that perioperative anemia is widespread in surgical patients (30-35% prevalence) and related with morbidity and mortality, regardless of severity. When paired with additional perioperative risk factors, results worsen by a ratio of 3.5–7.
Assessment and management of anemia
Patients should expect to wait up to 2 months for elective surgery, giving them enough time to check and rectify anemia. If there is a >10% chance of transfusion or >500mL of blood loss, lab tests should be performed immediately to check haematinics. • If Hb is <13g />L, identify possible causes and correctable factors. Examine both visible and hidden indications of blood loss. Some patients may require additional testing, such as radiographic imaging or endoscopic evaluation. • If ferritin is <20 micrograms /> and there is no inflammation (CRP/TSAT normal), or if ferritin is <100 micrograms /> with CRP >5 and/or TSAT <20%, start preoperative iron replacement treatment.< />pan>
• If iron replacement therapy is started, non-urgent surgeries should be postponed until the goal Hb is reached.
Treatment Options for Correcting Anaemia
Preoperative anemia. • B12 and folate deficiencies can be rectified with IM or PO supplements for 2-3 weeks in 712% of patients undergoing surgery. • Iron deficiency anaemia can frequently coexist. The severity, expected malabsorption, and convenience of administration will determine whether to use PO or IM supplements for each patient. 2 To treat iron deficiency anaemia, administer 400-600mg/day of PO ferrous sulfate for 6-8 weeks.
• IV iron therapy is highly effective for urgent surgery and has no ill effects when compared to PO therapy or placebo. Administering 1000- 1500mg IV over an hour can result in a peak rise in Hb over 1-3 weeks. • Patients with iron deficiency (ferritin >100 micrograms/L) who are still anaemic can get subcutaneous (SC) erythropoietin (EPO) at a dose of 300-600mg once weekly for 4 weeks. 2 Many hospitals have perioperative clinics administered by surgical, anesthetic, and critical care teams. Local perioperative anaemia routes are a helpful resource. Post-operative anemia • Check patients' post-operative hemoglobin levels with HemoCue® during recovery or upon return to the ward. Formal FBC can typically be performed on the first day following surgery. • If a patient experiences moderate to substantial blood loss during surgery and is predicted to bleed post-operatively due to coagulopathy or surgical causes, they should be observed in a suitable setting by a senior clinician. Early detection of clinical deterioration by the National Early Warning Score (NEWS) is crucial for effective patient care.
• According to NICE guidelines, most patients should have a transfusion threshold of <7g />L for post-operative anemia, with a Hb target of 7-9g/dL after transfusion, except for extensive hemorrhage and acute coronary syndrome (target 8-10g/dL). • Regular transfusions are required due to chronic anemia. Patients having persistent post-operative blood loss should be evaluated periodically and promptly. The senior surgeon should be informed. Critical care outreach teams can provide crucial assistance.
Mean Cell Volume -Microcytic
Causes - iron deficiency anemia,Thalassemia, chronic Disease
Mean Cell Hemoglobin – Hypochromic
Mean Cell Volume – Normocytic
Causes - Acute blood loss and chronic Disease
Mean Cell Hemoglobin – Normochromic
Mean Cell Volume – Macrocytic
Causes – alcohol dependence, B12/folate deficiency, hypothyroidism, pregnancy, hemolysis
Mean Cell Hemoglobin - Normochromic
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Surgery - Nutrition for surgery patients
Nutrition is crucial to the health of surgery patients. Providing timely nutritional support can minimize acute catabolism and skeletal muscle weakness caused by metabolic loads. This is a prevalent element that impacts the outcome of surgery patients. The incidence of pre-existing malnutrition is high and increases with age. Patients with high nutritional needs, such as those with severe burns, sepsis, intestinal fistulae, advanced cancer, or immunosuppression, may require additional support to prevent excessive acute catabolism due to metabolic demands. Assessment of nutritional status.
All patients should be evaluated for nutritional status. Various methods can be used: • BMI (weight/height in kg/m²). Relatively insensitive to all but major malnutrition. A BMI of 18-25 is considered normal, while <18 indicates underweight and>30 indicates obesity.
• Thickness of the triceps skinfolds. This test is simple and effective for measuring body fat, which can indicate chronic nutritional condition. • Strong grip. Simple, repeatable index of lean skeletal muscle. Serum albumin. Poor predictor of acute nutritional status. Responds slowly to dietary supplementation and is influenced by several circumstances.
• Serum transferrin. A reliable indicator of acute state and response to treatment. Not widely used. Effects of protein-calorie deficiency.
Decreased neutrophil and lymphocyte function. Albumin production is impaired. Impaired wound healing and collagen deposition. Skeletal muscle weakness, known as 'critical illness myopathy,' can lead to respiratory and gastrointestinal problems.
• Micronutrient deficits can cause particular clinical symptoms.
Types of Nutritional Support
• Oral supplements. Examples of high-calorie, high-protein supplements are Fortisip®, Calshakes®, and Ensures®/Enlives®. For nutritional supplementation, oral administration is always the preferable method. It promotes healthy GI flora and reduces the chance of problems following surgery. • Nasogastric (NG) or nasojejunal feeding. Often used in conjunction with oral supplements. Sometimes administered overnight to reduce appetite suppression during the day.
• Surgically implanted feeding tube (gastrostomy or jejunostomy). Not commonly used. This is reserved for people who have a functioning GI tract but cannot take via the oropharyngeal route.
• \tParenteral nutrition. It may be central or peripheral.
Nutrition is crucial to the health of surgery patients. Providing timely nutritional support can minimize acute catabolism and skeletal muscle weakness caused by metabolic loads. This is a prevalent element that impacts the outcome of surgery patients. The incidence of pre-existing malnutrition is high and increases with age. Patients with high nutritional needs, such as those with severe burns, sepsis, intestinal fistulae, advanced cancer, or immunosuppression, may require additional support to prevent excessive acute catabolism due to metabolic demands. Assessment of nutritional status.
All patients should be evaluated for nutritional status. Various methods can be used: • BMI (weight/height in kg/m²). Relatively insensitive to all but major malnutrition. A BMI of 18-25 is considered normal, while <18 indicates underweight and>30 indicates obesity.
• Thickness of the triceps skinfolds. This test is simple and effective for measuring body fat, which can indicate chronic nutritional condition. • Strong grip. Simple, repeatable index of lean skeletal muscle. Serum albumin. Poor predictor of acute nutritional status. Responds slowly to dietary supplementation and is influenced by several circumstances.
• Serum transferrin. A reliable indicator of acute state and response to treatment. Not widely used. Effects of protein-calorie deficiency.
Decreased neutrophil and lymphocyte function. Albumin production is impaired. Impaired wound healing and collagen deposition. Skeletal muscle weakness, known as 'critical illness myopathy,' can lead to respiratory and gastrointestinal problems.
• Micronutrient deficits can cause particular clinical symptoms.
Types of Nutritional Support
• Oral supplements. Examples of high-calorie, high-protein supplements are Fortisip®, Calshakes®, and Ensures®/Enlives®. For nutritional supplementation, oral administration is always the preferable method. It promotes healthy GI flora and reduces the chance of problems following surgery. • Nasogastric (NG) or nasojejunal feeding. Often used in conjunction with oral supplements. Sometimes administered overnight to reduce appetite suppression during the day.
• Surgically implanted feeding tube (gastrostomy or jejunostomy). Not commonly used. This is reserved for people who have a functioning GI tract but cannot take via the oropharyngeal route.
• \tParenteral nutrition. It may be central or peripheral.
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Surgery - Improved recuperation after surgery
Enhanced recovery after surgery (ERAS) aims to minimize perioperative physiological and stress responses, optimize recovery pace, and limit complications. It is typically used for healthy patients who do not require specific preoperative corrections.
The following are the important areas to consider.
Nutrition • Oral carbohydrate loading 24 hours before surgery, including up to 4 hours before anesthesia, is believed to minimize the early catabolic reaction to major surgery.
• Early reintroduction of full nutrition, including carbohydrate-rich drinks from 6 hours post-surgery, nutritional supplements, and a light food from 48 hours post-surgery, to promote immediate GI tract function. Anaesthetic Technique • Avoiding opiate use, such as morphine in PCA and epidurals, to minimize nausea and reduced GI motility.
• Avoiding epidurals to facilitate early mobilization and minimize the effects of autonomic spinal blocking on the heart, lungs, and gastrointestinal system. • Using regional LA-based treatments, such as transversus abdominis plane (TAP) block, regional LA infiltration, or infusional catheters, can reduce central nociceptor input and improve systemic stress response during surgery.
Surgical method
• Minimally invasive procedures, such as laparoscopic surgery, aim to lessen metabolic reaction, improve early mobilization, and minimize GI tract exposure during abdominal surgery. Avoiding bowel preparation during abdominal surgery minimizes the risk of fluid and electrolyte imbalances, disrupts GI tract flora, and leads to fewer GI problems (e.g., anastomotic leaks). Physiotherapy involves early mobilization with particular exercises, sitting out within 12 hours, and walking within 48 hours of surgery.
Perioperative respiratory exercises. Nursing:
• Intensive patient preparation, including preoperative teaching on expected outcomes. Intensive perioperative and post-operative nursing include promoting early re-establishment of food, movement, and self-care. Although intense and demanding, ERAS-type treatments are equally successful in the elderly and young. They are not recommended for insulin-dependent diabetics, people with pre-existing nutritional issues, or those with cognitive impairment.
Enhanced recovery after surgery (ERAS) aims to minimize perioperative physiological and stress responses, optimize recovery pace, and limit complications. It is typically used for healthy patients who do not require specific preoperative corrections.
The following are the important areas to consider.
Nutrition • Oral carbohydrate loading 24 hours before surgery, including up to 4 hours before anesthesia, is believed to minimize the early catabolic reaction to major surgery.
• Early reintroduction of full nutrition, including carbohydrate-rich drinks from 6 hours post-surgery, nutritional supplements, and a light food from 48 hours post-surgery, to promote immediate GI tract function. Anaesthetic Technique • Avoiding opiate use, such as morphine in PCA and epidurals, to minimize nausea and reduced GI motility.
• Avoiding epidurals to facilitate early mobilization and minimize the effects of autonomic spinal blocking on the heart, lungs, and gastrointestinal system. • Using regional LA-based treatments, such as transversus abdominis plane (TAP) block, regional LA infiltration, or infusional catheters, can reduce central nociceptor input and improve systemic stress response during surgery.
Surgical method
• Minimally invasive procedures, such as laparoscopic surgery, aim to lessen metabolic reaction, improve early mobilization, and minimize GI tract exposure during abdominal surgery. Avoiding bowel preparation during abdominal surgery minimizes the risk of fluid and electrolyte imbalances, disrupts GI tract flora, and leads to fewer GI problems (e.g., anastomotic leaks). Physiotherapy involves early mobilization with particular exercises, sitting out within 12 hours, and walking within 48 hours of surgery.
Perioperative respiratory exercises. Nursing:
• Intensive patient preparation, including preoperative teaching on expected outcomes. Intensive perioperative and post-operative nursing include promoting early re-establishment of food, movement, and self-care. Although intense and demanding, ERAS-type treatments are equally successful in the elderly and young. They are not recommended for insulin-dependent diabetics, people with pre-existing nutritional issues, or those with cognitive impairment.
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Pathology - Prophylaxis: antibiotics and thromboprophylaxis.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
