(1) CARDIAC SURGERY
1. ADMISSION OF PATIENTS AND PREOPERATIVE WORK-UP
i. Chest X-ray - at least a new PA film. Most patients will have fairly recent films including a penetrated PA to show cardiac chamber size. These films need not be repeated. A lateral film is essential in anyone who has had a previous bypass operation to show the amount of space behind the sternum and the number of wires. For coronary artery cases a PA film is sufficient.
ii. ECG. iii. Respiratory Function Tests - FEV1, Vital Capacity, PEFR. If these tests are poor, arterial blood gases breathing air are a useful baseline for postoperative care.
iv. Blood tests: Full Blood Count, Urea, Electrolytes, Liver Function Tests, Glucose, Creatinine, Coagulation Studies, Hepatitis B & C Screening, Cross Matching (Usually 2- 6 Units). If significant chest disease ABG’s. v. Doppler ultrasound of carotids (if previous history of stroke, TIAs or carotid bruits or age over 65 years) vi. Bacteriology: Nose and throat swabs for St. Aureus, MSU, sputum if appropriate. (Performed by nursing staff.)
All patients are given Bactroban to use at home and once admitted pre operatively.
vii. Chest physiotherapy before operation in patients with known chest disease, eg. chronic airways disease. Sputum culture is particularly important in this group.
viii. Old notes, including cardiac catheter data are essential and should be obtained. (If the cardiac catheter is more than 12 - 18 months old then may require repeating, particularly if the previous disease was single or two vessel)
ix. Transthoracic Echocardiography (TTE): Left Ventricular assessment and Valves assessment.
x. Consent for operation. (Including documentation of the major risks.)
xi. height (cm) and weight (kg) to calculate surface area and body mass index.
2) PREOPERATIVE MODIFICATION OF TREATMENT
i) Anticoagulants - These are tailed off over a few days prior to operation. Patients should have a coagulation screen measured on the preoperative day to confirm a virtually normal clotting status on the day of operation. If the coagulation has not normalised then consider the use of FFP. Vit K is very rarely used (If the operation is postponed then anticoagulants should be temporarily restarted - this is particularly important with a history of previous strokes).
ii) Aspirin and Clopidogrel- This has a significant effect in diminishing platelet function and can lead to increased postoperative blood loss. Ideally it should be stopped 7-10 days before surgery, if not, should be stopped on the day of admission of the patient - unless there is unstable angina.
iii) Digoxin - Continued until the day before operation.
iv) Diuretics and Potassium Supplements - Continued until the day before operation.
v) Beta Blockers, Calcium Antagonists, Long Acting Nitrates - Patients with coronary artery disease will frequently be taking a combination of these drugs. It is important not to interfere with these drugs in any way but to continue them until the day before operation.
vi) Antihypertensives - Maintain until operation.
vii) Monoamine Oxidase Inhibitors - Must be discontinued at least three weeks preoperatively.
viii) Anti-diabetic Agents and Steroids - Should be noted and the appropriate perioperative management will be decided by the Anaesthetist and appropriate physician. Discuss with the anaesthetist whether sliding scale insulin is required.
3. ARRANGEMENTS FOR OPERATION
The definitive operating list must be submitted to the Theatre the day before surgery. In the event of changes to the operating list it is important that Blood Bank should be informed as early as possible.
In the event of an emergency operation out of hours, all key groups must be informed. These are:
i. Theatre ii. Consultant Anaesthetist and Duty Anaesthetic SR iii. Perfusion Technician. iv. Blood Bank. v. CITU Staff. To confirm the availability of a bed on CITU for the postoperative care of the patient. vi.Involvement in all these tasks makes it easy to forget the patient and the anxious relatives. Clearly they must be kept informed of plans and prospects.
4. OPERATING THEATRE
i. The SHO on theatre duty must be present at the scheduled starting time for anaesthesia (usually 8.30 am), prior to theatre the theatre SHO’s should attend the ITU/HDU ward round.
ii. Male patient should be catheterised by the SHO but the anaesthetic / theatre nurse will catheterise female patients unless an emergency or no female staff are available.
iii. Current X-rays and hard copies of the Angiogram if available should be put on the viewing box.
iv. Ensure that patient has been shaved properly. If not, shavers are available in the anaesthetic room to remove additional hair.
v. Patients having re do surgery require external defibrillation pads to be attached to the chest wall and the SHO must connect them once in theatre to the defibrillator
vi. Prophylactic antibiotics are given in the anaesthetic room by anaesthetist 40-60 minutes before knife to skin.
Alterations to antibiotics may be required for example, in patients undergoing surgery for endocarditis. These will have been discussed preoperatively with Bacteriology and appropriate therapy chosen.
Current Antibiotic Prophylaxis Regime
All patients (unless beta-lactam allergic) should receive:
• Cefuroxime 1.5 g @ induction
• 750 mg 8 hourly for 48 hours
High Risk patients should also receive in addition to Cefuroxime:
• Teicoplanin 800 mg @ induction
• Then three further doses of 800 mg 12 hrly
High risk category includes any of the following:
• “Pool” patients or patients from another hospital unless recent negative MRSA screen (< one week)
• Patients received from any critical area
• Patients with no MRSA screen result available
• Redo operations
• Obese patients (BMI > 30)
• Diabetic patients
• Intra cardiac procedures (Valve repair / replacements)
• Bilateral internal mammary artery grafts
Cefuroxime (beta-lactam) allergic patients should receive:
• Teicoplanin 800 mg and Ciprofloxacin 400 mg @ induction
• Then three further doses of Teicoplanin 800 mg and Ciprofloxacin 400 mg
All antibiotic dosages and times should be clearly recorded on the patient’s drug chart
(2) THORACIC SURGERY
To download Thoracic clerking book: http://www.ctss.org.uk/4.html
Pre-operative Care of Thoracic Surgical Patients
Pre Operativ1.Admission and Pre operative work up
Most of thoracic surgical patients are referred due to bronchial or pleural malignancy for primary operative treatment, others are referred with bullous lung disease, empyema or for diagnostic biopsy of lung, mediastinal tissue or pleura.
Thoracic patients need thorough assessment prior to surgical intervention as they are often elderly, have multiple co morbidities and are very frequently smokers. The patients are often admitted two or three days prior to surgery.
The patients should be clerked once admited. The following investigations should be arranged:
1 Chest X ray – An up to date CXR is required, both to reassess the pulmonary pathology and assess heart size. A note should be made of any significant changes in the size of any lesions and the presence of any new pathology e.g. pleural effusion, pleural thickening etc.
3 Pulmonary function tests – Obtained on the ward by the ECG technicians
4 Blood Tests - FBC, Coagulation screen, ESR
• U & E’s, Creat, LFT’s, Calcium, CRP
• Group and Save
• ABG’s on air – If significant SOB / Low O2 Saturation
5 Bacteriology – Nose/Throat swabs for MRSA screening. Urine and sputum as necessary
6 Chest Physiotherapy – This is particularly important as many thoracic surgical patients have significant lung disease
7 Old Notes / Referring Hospital Notes/X rays – These are extremely important as they will have details of investigations so far including details of histology and cytology. They provide the necessary information to allow pre operative planning of surgery.
8 Assessment of Cardiovascular function – Any patients with significant history or risk factors for ischaemic heart disease should undergo Echocardiography and Exercise Tolerance testing (ETT with the Standard Bruce Protocol). If a thoracic surgery patient undergoes ETT then one of the Cardiothoracic SHO’s on the ward will be asked to supervise the test in the Cardiology Out patients department.
9 Consent – This should be completed once the procedure has been finalized with the appropriate Consultant Cardiothoracic Surgeon.
Consent – The major risks of thoracic surgery including, mortality, DVT, PE, Infection, Pneumonia, MI, Angina and the possibility of inoperability should be discussed. The patients should also be informed of the fact that they will have venous lines, arterial lines, central lines, urinary catheter and epidural after most thoracotomies whether they have Lobectomy, Pneumonectomy, pleuropneumonectomy or decortication.
THE SIDE OF THE OPERATION SHOULD BE MARKED ON THE PATIENTS CHEST WITH AN ARROW IN PERMANENT MARKER PRIOR TO SURGERY
2. Pre operative modification of treatment
This is very similar to the advice give in the Cardiac Surgical patient; the majority of medication should be left unchanged.
Anticoagulants - should be stopped so that the INR is less than 1.4 ideally pre operatively. If necessary iv unfractionated heparin should be started in their place. If the coagulation has not normalized pre operatively, then discuss with the appropriate SpR about the use of FFP. (Vitamin K is almost never used, as it makes re anticoagulation extremely difficult) If the operation is delayed then anticoagulation must be temporarily restarted.
Aspirin – This should be withheld at for ideally 2 weeks preop, however if this is not possible then it should be stopped on admission and restarted immediately post op.
Monoamine oxidase inhibitors – Stop 3 weeks prior to surgery.
Anti diabetic agents / Steroids - Discuss with the anaesthetist re. The timing of stopping of anti diabetic agents, the use on insulin sliding scale pre operatively and the use of iv steroids to cover the necessary stress response of major surgery in those on long term oral steroids.
All other medications should continue unhindered
Of special note as pre-operative prophylaxix is the use of digoxin in thoracic surgical patients: -
Digoxin 500mcg PO at 22.00hrs the night before surgery
Digoxin 500mcg PO at 07.00hrs the morning of surgery
l All patients will have been seen by an anaesthetist and a pre med will also have been
3. Arrangements for Surgery
These follow similar principles to the preparation of an operation list for Cardiac surgery, i.e. all results should be in the notes, the pre operative bronchoscopy report and histology/cytology if performed should be in the notes, as should the reports of any Echo / ETT tests. The most recent CXR and any CT scans must be available to go to theatre with the patient.
a) Prior to any major pleural / lung resection every patient undergoes rigid bronchoscopy and this should be noted on the operating list and the patient should be consented for “Rigid Brochoscopy +/- Biopsy”.
b) Those patients undergoing diagnostic bronchoscopy or mediastinoscopy should always be consented for biopsy also.
The typical routine request for blood products pre operatively are as follows: -
Pleuropneunonectomy 4 – 6 units
Pneumonectomy 2-4 units
Lobectomy 2-4 units
Decortication 4 units
Pleural/ Lung Biopsy 2 units
(Open / VATS)
Bronchoscopy +/- Biopsy G & S
4. Operating theatre
Thoracic operating days are typically the responsibilities of the resident doctor (SHO) are similar to the cardiac patients. Once in the anaesthetic room, the patients X rays should be put up on the x ray box in theatre, in male patients the urinary catheter should be placed once the anaesthetist is happy for you to do this and the operation site should be inspected to ensure it has been adequately shaved on the ward. If not there are safety razors in the anaesthetic room to complete the shave. When the patient is asleep and all the lines are in situ you should assist in positioning the patient on the operating table prior to surgery. When entering Cardiothoracic theatres the wearing of masks is mandatory.