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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.
Surgery - In-theater preparation
Poor preparation and checking in the operating room can lead to risks for patients, such as wrong side surgery (e.g., removing a healthy kidney), incorrect site surgery (e.g., inguinal, not femoral, hernia repaired), allergic reactions to medication, insufficient vital materials (e.g., blood), insufficient equipment (e.g., image intensifier, specialist joint replacement jig), and retained swabs or instruments. Strict adherence to a checklist can reduce the probability of 'never occurrences' in high-risk industries, such as aviation. The WHO suggests a standardized checklist approach.
WHO Checklist
The WHO checklist is a customizable form with four essential checkpoints that can be tailored to specific organizations.
Before the start of the operational list.
• Ensure surgical, anaesthetic, and nursing teams are present and identifiable. • Confirm patient list, procedure order, and address any unique issues
. • Verify that anesthetic equipment, medicine, and monitoring are in working order
. • Confirm imaging and equipment requirements for the list. Before inducing anesthesia, ensure patient identity and permission are valid. Check the site and side markers, if applicable. Check that the anesthetic needs are correct and functional. Check for allergies and predicted blood loss. Before skin incision, ensure all team members are present and known. Check the procedure that will be conducted. Confirm any surgical, anesthetic, or nursing concerns. Confirm that critical imaging/equipment are available. Before leaving the theatre, ensure the correct name for the procedure conducted is known and recorded.
• Verify the swab and instrument counts are accurate. Confirm that any surgical specimens were properly collected and labeled. Confirm any specific postoperative instructions.
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.
Surgery - In-theater preparation
Poor preparation and checking in the operating room can lead to risks for patients, such as wrong side surgery (e.g., removing a healthy kidney), incorrect site surgery (e.g., inguinal, not femoral, hernia repaired), allergic reactions to medication, insufficient vital materials (e.g., blood), insufficient equipment (e.g., image intensifier, specialist joint replacement jig), and retained swabs or instruments. Strict adherence to a checklist can reduce the probability of 'never occurrences' in high-risk industries, such as aviation. The WHO suggests a standardized checklist approach.
WHO Checklist
The WHO checklist is a customizable form with four essential checkpoints that can be tailored to specific organizations.
Before the start of the operational list.
• Ensure surgical, anaesthetic, and nursing teams are present and identifiable. • Confirm patient list, procedure order, and address any unique issues
. • Verify that anesthetic equipment, medicine, and monitoring are in working order
. • Confirm imaging and equipment requirements for the list. Before inducing anesthesia, ensure patient identity and permission are valid. Check the site and side markers, if applicable. Check that the anesthetic needs are correct and functional. Check for allergies and predicted blood loss. Before skin incision, ensure all team members are present and known. Check the procedure that will be conducted. Confirm any surgical, anesthetic, or nursing concerns. Confirm that critical imaging/equipment are available. Before leaving the theatre, ensure the correct name for the procedure conducted is known and recorded.
• Verify the swab and instrument counts are accurate. Confirm that any surgical specimens were properly collected and labeled. Confirm any specific postoperative instructions.
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