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Surgery - Getting the patient to theatre
Organizing and following a routine are crucial when preparing patients for surgical procedures. Inadequate preparedness can lead to serious implications for patients. Background papers Prepare the theatre or endoscopic list ahead of time to ensure accuracy. The list should include the patient's name, hospital number, location, surgery information, surgeon, and anesthesiologist. Patient paperwork
• Ensure current medical notes are available for this admission, including a complete history and examination.
• \tMonitor blood results for specific conditions, such as K+ in renal failure, clotting function in anticoagulated patients, and calcium (Ca2+) in parathyroidectomy patients.
• Ensure patients have access to blood and blood products from the transfusion department. (Most hospitals have protocols for determining the appropriate quantity of units of blood.)
• Ensure necessary imaging results are available. Ensure the consent form is completed and included in the medical notes.
• Complete the medication chart.
Patient preparation • Ensure the patient's procedure side/site is clearly indicated (if applicable). This should be done with the patient awake and validated by nursing staff. Check if the patient has been marked by any relevant professionals, such as a stoma care provider or a prosthetist for amputees.
• Determine any necessary preparations, such as bowel preparation, ahead of time. Bowel preparation This device is used to empty the big bowel prior to surgery. Preparation options include a stimulant mechanical bowel preparation, such as sodium picosulfate, which should be given with plenty of drink at least 8 hours before surgery. Avoid any potential obstructions.
• Use an osmotic mechanical bowel preparation, such as magnesium citrate or Klean Prep®, with 2-4 sachets diluted in water up to 8 hours before operation. Suitable for bowel preparation during colonic surgeries, including colonoscopy and CT colonography.
• Stimulant left colon preparation, such as phosphate enema. Suitable for rectum/anus surgery or flexible sigmoidoscopy procedures.
• Mechanical bowel preparation is now less common than it was previously. Bowel surgery may increase the risk of septic complications and has known adverse effects such as electrolyte imbalances, hypovolaemia in the elderly, and nausea and vomiting (especially with large-volume osmotic preparations). Getting The Patient to Theatre 97 Anaesthetic premedication. Reduces anxiety during anaesthesia preparation and reduces the need for anesthetic agents during induction. Benzodiazepines, such as diazepam (PO) or midazolam (5mg IV), are commonly utilized as preoperative agents. Hyoscine butylbromide is occasionally used to reduce upper aerodigestive tract secretions.
Organizing and following a routine are crucial when preparing patients for surgical procedures. Inadequate preparedness can lead to serious implications for patients. Background papers Prepare the theatre or endoscopic list ahead of time to ensure accuracy. The list should include the patient's name, hospital number, location, surgery information, surgeon, and anesthesiologist. Patient paperwork
• Ensure current medical notes are available for this admission, including a complete history and examination.
• \tMonitor blood results for specific conditions, such as K+ in renal failure, clotting function in anticoagulated patients, and calcium (Ca2+) in parathyroidectomy patients.
• Ensure patients have access to blood and blood products from the transfusion department. (Most hospitals have protocols for determining the appropriate quantity of units of blood.)
• Ensure necessary imaging results are available. Ensure the consent form is completed and included in the medical notes.
• Complete the medication chart.
Patient preparation • Ensure the patient's procedure side/site is clearly indicated (if applicable). This should be done with the patient awake and validated by nursing staff. Check if the patient has been marked by any relevant professionals, such as a stoma care provider or a prosthetist for amputees.
• Determine any necessary preparations, such as bowel preparation, ahead of time. Bowel preparation This device is used to empty the big bowel prior to surgery. Preparation options include a stimulant mechanical bowel preparation, such as sodium picosulfate, which should be given with plenty of drink at least 8 hours before surgery. Avoid any potential obstructions.
• Use an osmotic mechanical bowel preparation, such as magnesium citrate or Klean Prep®, with 2-4 sachets diluted in water up to 8 hours before operation. Suitable for bowel preparation during colonic surgeries, including colonoscopy and CT colonography.
• Stimulant left colon preparation, such as phosphate enema. Suitable for rectum/anus surgery or flexible sigmoidoscopy procedures.
• Mechanical bowel preparation is now less common than it was previously. Bowel surgery may increase the risk of septic complications and has known adverse effects such as electrolyte imbalances, hypovolaemia in the elderly, and nausea and vomiting (especially with large-volume osmotic preparations). Getting The Patient to Theatre 97 Anaesthetic premedication. Reduces anxiety during anaesthesia preparation and reduces the need for anesthetic agents during induction. Benzodiazepines, such as diazepam (PO) or midazolam (5mg IV), are commonly utilized as preoperative agents. Hyoscine butylbromide is occasionally used to reduce upper aerodigestive tract secretions.
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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.
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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Surgery - Positioning the Patient
Getting the patient to the surgical table • The surgical team plays a role in ensuring patient safety during and after surgery. Ensure compliance with basic safety guidelines.
• The anaesthetist is responsible for maintaining the patient's airway by coordinating all movements. • Avoid dislodging IV cannulae, epidural sites, or existing drains. • Use approved manual handling techniques, such as a 'Patslide' or comparable device, instead of lifting patients. • Take special precautions with prosthetic joints that may dislocate during relaxation, unstable fractures, Rheumatoid arthritis related instability, ulcers, or skin sores.
Once in position. • Prevent diathermy exit point burns by ensuring no patient points come into contact with the operating table's metal surface. • Properly pad bony prominences and thin skin areas, such as the neck of the fibula in leg stirrups. • Ensure diathermy pads are properly applied and not impacted by skin preparations. • Provide adequate patient support, especially if the table is likely to shift, tilt, or rotate throughout the procedure (e.g., arm, thoracic, and abdominal supports for lateral positions, shoulder bolsters for head down positions). • When doing procedures that need access to the perineum, ensure sufficient pelvic support while exposing the perineum over the end of the operating table.
• Plan the placement of ancillary equipment. For instance, where will video stacks be located? Is more than one energy source needed, and where will the generators be located? Is there access to mobile imaging equipment or on-table radiography? Position all equipment to offer the surgical team enough access to the patient.
Getting the patient to the surgical table • The surgical team plays a role in ensuring patient safety during and after surgery. Ensure compliance with basic safety guidelines.
• The anaesthetist is responsible for maintaining the patient's airway by coordinating all movements. • Avoid dislodging IV cannulae, epidural sites, or existing drains. • Use approved manual handling techniques, such as a 'Patslide' or comparable device, instead of lifting patients. • Take special precautions with prosthetic joints that may dislocate during relaxation, unstable fractures, Rheumatoid arthritis related instability, ulcers, or skin sores.
Once in position. • Prevent diathermy exit point burns by ensuring no patient points come into contact with the operating table's metal surface. • Properly pad bony prominences and thin skin areas, such as the neck of the fibula in leg stirrups. • Ensure diathermy pads are properly applied and not impacted by skin preparations. • Provide adequate patient support, especially if the table is likely to shift, tilt, or rotate throughout the procedure (e.g., arm, thoracic, and abdominal supports for lateral positions, shoulder bolsters for head down positions). • When doing procedures that need access to the perineum, ensure sufficient pelvic support while exposing the perineum over the end of the operating table.
• Plan the placement of ancillary equipment. For instance, where will video stacks be located? Is more than one energy source needed, and where will the generators be located? Is there access to mobile imaging equipment or on-table radiography? Position all equipment to offer the surgical team enough access to the patient.
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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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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.
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Surgery - Operative procedures in renal and hepatic disorders
Renal dysfunction
Renal impairment encompasses a continuum, from individuals with subclinical dysfunction (normal serum creatinine and urea levels, although borderline creatinine clearance) to those with end-stage renal failure. It is beneficial to categorize these patients into two primary groups: those with chronic renal impairment and those who are dialysis-dependent.
Chronic kidney dysfunction
Surgery may induce acute renal failure in patients with chronic renal insufficiency. Avoid hypovolemia and hypotension. Ensure that these patients obtain sufficient intravenous hydration if they are to remain nil by mouth for an extended duration. Avoid nephrotoxic agents wherever feasible, including non-steroidal anti-inflammatory medications (NSAIDs), aminoglycosides, ACE inhibitors, and radiographic contrast media. Decrease dosages of medications eliminated by the kidneys, such as morphine, low-molecular-weight heparin (LMWH), and digoxin, and regularly seek relevant levels.
Patients with diagnosed renal insufficiency undergoing dialysis
For patients undergoing major surgery, consult with the anesthesiologist and ICU regarding their post-operative management at the earliest opportunity. Dialysis must be conducted the day before to surgery. Patients are required to undergo a complete blood count (FBC) and urea and electrolytes (U&Es) upon admission, as well as pre- and post-dialysis assessments. Additionally, U&Es should be conducted twice day following major surgery until the patient is stabilized on their standard dialysis regimen.
Decrease dosages of medications eliminated by the kidneys, such as morphine, low molecular weight heparin (LMWH), and digoxin, and regularly seek relevant serum values. If the patient is typically anuric, the insertion of a urine catheter is unwarranted, as it poses an unnecessary risk of infection.
Identify the locations of arteriovenous fistulae. Avoid utilizing them for phlebotomy or cannulation, and refrain from applying blood pressure cuffs on that side.
These patients are susceptible to several complications:
Hyperkalemia, acidosis, and pulmonary edema are potential life-threatening situations (% Renal complications, pp. 136–8). Infection. Anemia with coagulopathy. Disruptions in fluid and electrolyte balance.
Metabolic acidosis. Systemic hypertension, pericarditis.
Hepatic dysfunction
The risk associated with liver disease in patients undergoing general surgery was assessed by Child and Turcotte (refer to Box 2.3). Child grade C correlates with elevated perioperative mortality. Liver failure results in the subsequent complications: Hypoglycemia; hepatic encephalopathy; coagulopathy (international normalized ratio); ascites; and infection.
Multiple variables can precipitate abrupt decompensation of mild hepatic impairment and should be avoided or managed vigorously in this population: • Infection, particularly bacterial peritonitis; drowsiness; diuretics; constipation; electrolyte imbalance; dehydration; and hypotension.
• Preoperatively: assess hepatitis serology, order liver ultrasound for newly detected hepatic impairment; consult with haematology on additional blood product requests; confer with a specialist about normal drug dosages. Jaundice Patients with obstructive jaundice are susceptible to post-operative renal failure (hepatorenal syndrome). This is believed to result from the nephrotoxic impact of toxins typically excreted by the liver, along with alterations in circulation. • Maintain sufficient hydrated. For a patient who is NBM, administer IV normal saline 1L over a duration of 6 to 8 hours. • Insert a urine catheter and initiate an hourly fluid balance chart. • Conduct daily assessments of urea and electrolytes (U&E) and liver function tests (LFTs). Coagulopathy in chronic cholestatic jaundice may be ameliorated with 1 mg of intravenous vitamin K—consult with hematology. Avoid or minimize the dosages of hepatotoxic medications and those eliminated by the liver.
Renal dysfunction
Renal impairment encompasses a continuum, from individuals with subclinical dysfunction (normal serum creatinine and urea levels, although borderline creatinine clearance) to those with end-stage renal failure. It is beneficial to categorize these patients into two primary groups: those with chronic renal impairment and those who are dialysis-dependent.
Chronic kidney dysfunction
Surgery may induce acute renal failure in patients with chronic renal insufficiency. Avoid hypovolemia and hypotension. Ensure that these patients obtain sufficient intravenous hydration if they are to remain nil by mouth for an extended duration. Avoid nephrotoxic agents wherever feasible, including non-steroidal anti-inflammatory medications (NSAIDs), aminoglycosides, ACE inhibitors, and radiographic contrast media. Decrease dosages of medications eliminated by the kidneys, such as morphine, low-molecular-weight heparin (LMWH), and digoxin, and regularly seek relevant levels.
Patients with diagnosed renal insufficiency undergoing dialysis
For patients undergoing major surgery, consult with the anesthesiologist and ICU regarding their post-operative management at the earliest opportunity. Dialysis must be conducted the day before to surgery. Patients are required to undergo a complete blood count (FBC) and urea and electrolytes (U&Es) upon admission, as well as pre- and post-dialysis assessments. Additionally, U&Es should be conducted twice day following major surgery until the patient is stabilized on their standard dialysis regimen.
Decrease dosages of medications eliminated by the kidneys, such as morphine, low molecular weight heparin (LMWH), and digoxin, and regularly seek relevant serum values. If the patient is typically anuric, the insertion of a urine catheter is unwarranted, as it poses an unnecessary risk of infection.
Identify the locations of arteriovenous fistulae. Avoid utilizing them for phlebotomy or cannulation, and refrain from applying blood pressure cuffs on that side.
These patients are susceptible to several complications:
Hyperkalemia, acidosis, and pulmonary edema are potential life-threatening situations (% Renal complications, pp. 136–8). Infection. Anemia with coagulopathy. Disruptions in fluid and electrolyte balance.
Metabolic acidosis. Systemic hypertension, pericarditis.
Hepatic dysfunction
The risk associated with liver disease in patients undergoing general surgery was assessed by Child and Turcotte (refer to Box 2.3). Child grade C correlates with elevated perioperative mortality. Liver failure results in the subsequent complications: Hypoglycemia; hepatic encephalopathy; coagulopathy (international normalized ratio); ascites; and infection.
Multiple variables can precipitate abrupt decompensation of mild hepatic impairment and should be avoided or managed vigorously in this population: • Infection, particularly bacterial peritonitis; drowsiness; diuretics; constipation; electrolyte imbalance; dehydration; and hypotension.
• Preoperatively: assess hepatitis serology, order liver ultrasound for newly detected hepatic impairment; consult with haematology on additional blood product requests; confer with a specialist about normal drug dosages. Jaundice Patients with obstructive jaundice are susceptible to post-operative renal failure (hepatorenal syndrome). This is believed to result from the nephrotoxic impact of toxins typically excreted by the liver, along with alterations in circulation. • Maintain sufficient hydrated. For a patient who is NBM, administer IV normal saline 1L over a duration of 6 to 8 hours. • Insert a urine catheter and initiate an hourly fluid balance chart. • Conduct daily assessments of urea and electrolytes (U&E) and liver function tests (LFTs). Coagulopathy in chronic cholestatic jaundice may be ameliorated with 1 mg of intravenous vitamin K—consult with hematology. Avoid or minimize the dosages of hepatotoxic medications and those eliminated by the liver.
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Surgery - Operative procedures during gestation
Pregnancy testing: Urinary dipstick for β-human chorionic gonadotrophin (HCG) exhibits a sensitivity of 91%, which is notably lower for women conducting self-tests. Specificity varies from 61% to 100% when assessed from the initial day of the first missed menstrual cycle, which occurs two weeks post-ovulation. Blood β-HCG exhibits nearly 100% sensitivity and specificity, capable of detecting pregnancy 6 to 8 days post-ovulation. False negatives and positives primarily result from user error. Alterations in anatomical and physiological structures Pregnancy induces several alterations pertinent to surgical procedures.
First trimester: Drugs may have teratogenic effects Decreased lower oesophageal sphincter (LOS) tone elevates the risk of gastro-oesophageal reflux and aspiration in the supine position.
Second trimester: • Pharmacological agents may adversely impact fetal growth or metabolism without resulting in overt malformations. • Increased vulnerability to urinary tract infections (UTIs), especially ascending kidney infections and pyelonephritis. The risk of venous thromboembolism (VTE) increases throughout the second trimester and is consistently elevated in the third trimester. • Increased susceptibility to superficial infections.
Third trimester: Drugs may initiate labor. Superior and posterior displacement of the movable abdominal viscera due to the expanding uterus. The appendix is positioned higher in the right upper quadrant (RUQ).
• The risk of hypotension in the supine position arises from inferior vena cava compression by the gravid uterus; this can be mitigated by placing the drugged or unconscious patient in a mild lateral decubitus position. Potential risks of miscarriage The risk of miscarriage associated with surgical pathology and surgery fluctuates by trimester. It is at its peak in the initial instance. The likelihood of viable premature labor increases during the third trimester. The risk of miscarriage associated with GA is consistently weighed against the danger of sepsis resulting from untreated surgical conditions, especially acute appendicitis. This is a prevalent problem in surgical practice. Ultrasound imaging may be ineffective due to inadequate visualization, and CT scanning is contraindicated because of radiation exposure. MRI is frequently utilized post-first trimester. Diagnostic laparoscopy is contraindicated because of the impact of pneumoperitoneum on pregnancy. The sole method for obtaining a diagnosis may necessitate surgery when significant differential diagnoses have been ruled out.
Common differential diagnoses of appendicitis during pregnancy include ectopic pregnancy problems. Pyelonephritis. Imminent miscarriage/placental abruption.
Pharmaceutical prescription during gestation
Screening pharmaceuticals for detrimental effects on the human embryo is unequivocally immoral; hence, numerous novel and frequently utilized medications have not been administered during pregnancy. Certain older medications have been utilized during pregnancy and are considered 'safe' due to the lack of data indicating fetal harm. An essential equilibrium must be preserved between addressing the mother's significant sickness and mitigating any danger to the fetus. In general, refrain from providing medications whenever feasible. Be aware of the pregnant stage; numerous medications are sanctioned only during specific trimesters. Two Verify any medication you prescribe in the BNF (or its equivalent). • If uncertain, see a professional for guidance. • Significant teratogens comprise: • Thalidomide (an antiemetic). • Carbamazepine with sodium valproate. • Isotretinoin. Tetracycline. • Warfarin. • Angiotensin-converting enzyme (ACE) inhibitors. Lithium. • Methotrexate, cyclophosphamide
Pregnancy testing: Urinary dipstick for β-human chorionic gonadotrophin (HCG) exhibits a sensitivity of 91%, which is notably lower for women conducting self-tests. Specificity varies from 61% to 100% when assessed from the initial day of the first missed menstrual cycle, which occurs two weeks post-ovulation. Blood β-HCG exhibits nearly 100% sensitivity and specificity, capable of detecting pregnancy 6 to 8 days post-ovulation. False negatives and positives primarily result from user error. Alterations in anatomical and physiological structures Pregnancy induces several alterations pertinent to surgical procedures.
First trimester: Drugs may have teratogenic effects Decreased lower oesophageal sphincter (LOS) tone elevates the risk of gastro-oesophageal reflux and aspiration in the supine position.
Second trimester: • Pharmacological agents may adversely impact fetal growth or metabolism without resulting in overt malformations. • Increased vulnerability to urinary tract infections (UTIs), especially ascending kidney infections and pyelonephritis. The risk of venous thromboembolism (VTE) increases throughout the second trimester and is consistently elevated in the third trimester. • Increased susceptibility to superficial infections.
Third trimester: Drugs may initiate labor. Superior and posterior displacement of the movable abdominal viscera due to the expanding uterus. The appendix is positioned higher in the right upper quadrant (RUQ).
• The risk of hypotension in the supine position arises from inferior vena cava compression by the gravid uterus; this can be mitigated by placing the drugged or unconscious patient in a mild lateral decubitus position. Potential risks of miscarriage The risk of miscarriage associated with surgical pathology and surgery fluctuates by trimester. It is at its peak in the initial instance. The likelihood of viable premature labor increases during the third trimester. The risk of miscarriage associated with GA is consistently weighed against the danger of sepsis resulting from untreated surgical conditions, especially acute appendicitis. This is a prevalent problem in surgical practice. Ultrasound imaging may be ineffective due to inadequate visualization, and CT scanning is contraindicated because of radiation exposure. MRI is frequently utilized post-first trimester. Diagnostic laparoscopy is contraindicated because of the impact of pneumoperitoneum on pregnancy. The sole method for obtaining a diagnosis may necessitate surgery when significant differential diagnoses have been ruled out.
Common differential diagnoses of appendicitis during pregnancy include ectopic pregnancy problems. Pyelonephritis. Imminent miscarriage/placental abruption.
Pharmaceutical prescription during gestation
Screening pharmaceuticals for detrimental effects on the human embryo is unequivocally immoral; hence, numerous novel and frequently utilized medications have not been administered during pregnancy. Certain older medications have been utilized during pregnancy and are considered 'safe' due to the lack of data indicating fetal harm. An essential equilibrium must be preserved between addressing the mother's significant sickness and mitigating any danger to the fetus. In general, refrain from providing medications whenever feasible. Be aware of the pregnant stage; numerous medications are sanctioned only during specific trimesters. Two Verify any medication you prescribe in the BNF (or its equivalent). • If uncertain, see a professional for guidance. • Significant teratogens comprise: • Thalidomide (an antiemetic). • Carbamazepine with sodium valproate. • Isotretinoin. Tetracycline. • Warfarin. • Angiotensin-converting enzyme (ACE) inhibitors. Lithium. • Methotrexate, cyclophosphamide
