General surgery principals

General Surgery Principals

• Informed consent in surgery requires outlining the procedure, indications, contraindications, risks (anesthetic, intra-op, early/late post-op, long-term), alternative options and expectations for recovery.

Surgical Presentation Approach

• ABC IM FINE is a surgical presentation mnemonic
• Airway management requires assessment, breathing, circulation, IV access, medications, Foley catheter, imaging, NBM/NGT and extra help.

ERAS Principles

• Enhanced Recovery After Surgery (ERAS) minimizes stress and improves organ function.
• ERAS leads to reduced length of stay, fewer post-op complications, and lower in-hospital expenses.
• Pre-operative measures include patient education, multimodal non-opioid analgesics, and PONV prophylaxis.
• Intra-operative involves minimally invasive techniques, minimizing drains/tubes, temperature control, fluid balance and regional analgesia.
• Post-operative includes early drain/tube removal, early diet, mobilization, non-opioid pain management, and follow-up.

Pain Management

• Pain is a warning, requires knowledge of condition and operation. Special considerations are important. Assess adequate and administered medication for PCA/epidural and regional blocks.

WHO Ladder of Analgesia

• Paracetamol should be considered first for analgesia

• 15mg/kg (1g for most adults) every 4-6 hours. Max dose 90mg/kg in first 24h, then 60mg/kg per day

• NSAIDs should only be considered if safe for kidneys or GI system

• Ibuprofen 10 mg/kg every 6-8 hours, up to 3 times daily (400mg TDS)

• Ketorolac 10-30mg IM every 6 hours, max 5 days

• Opiates such as morphine and fentanyl work as mu and kappa agonists. Effects sedation, respiratory depression, N/V, itch, constipation, allergy, rashes and serotonin syndrome

• Fentanyl bolus dose 0.25-0.5 mcg/kg IV, repeat as necessary every 3-5 min, nasal/SC and IM are other possible routes of administration, fast onset but wearing off by 30-60 min

• IV morphine: divide dose into smaller increments and administer every 5-10 min, lasts about 3 hours. Reduce dose and interval in CKD

• Some opioid analgesics are oxycodone, tramadol and tapentadol

• Oxycodone is immediate-release IR. Oxycontin is slow-release SR. Better oral absorption and longer action than morphine. IV, IM, SC, and PO possible to administer.

• Tramadol/tapentadol has agonistic effects on the opioid (mainly µ-opioid) and gammaaminobutyric acid (GABA) receptors and inhibits the reuptake of serotonin (SRI) and norepinephrine (NRI). PO 50-100mg 4-6hourly to a maximum 400mg/day, can use IM/IV

PONV Management

• The 'Apfel Score' identifies patients at high risk for Postoperative Nausea & Vomiting (PONV), assessing for Female sex, Non-smoker, History of PONV, and Post-operative opioids
• Ondansetron (5HT3 antagonist) is used to treat PONV, chemo, radio, and opiate-induced N&V. Can cause headache, diarrhea/constipation, dry mouth, tachycardia and long QTc
• Metoclopramide works on GIT (pro-kinetic) → dopamine and 5HT3 receptors
• Side effects of Metoclopramide are dyskinesia and long QTc. Can be treated with benztropine for oculogyric crisis, lockjaw, or opisthotonus
• Dexamethasone and Droperidol are other antiemetic options
• Antihistamines in order from least to most sedative are cyclizine → prochlorperazine → promethazine

Fluid Management Parameters

• Fluid therapy to maintain S - Septic (anaphylaxis, neurogenic) and H - Hypovolaemic (haemorrhagic, fluid loss) and O - Obstructive shock (3Ts: Tamponade, Tension Ptx, Thromboembolism/PE) and C- Cardiogenic (Structural or Rhythm) and K- Dissociative shock
• Use Foley to monitor catheter output, ABC IM FINE for surgical interventions

Shock General Principles

• Septic shock requires FOCCALS management
• Haemorrhagic shock treatment requires recognizing and stopping the bleeding, then replacing the blood loss through direct compression, or a splint or surgery. Bleeding sites are skin, chest, abdomen, long bones, pelvis and retroperitoneum
• Damage control resuscitation includes damage control surgery (stop the bleeding), haemostatic resuscitation (whole blood products) and permissive hypotension (lower BP targeting a pulse and GCS>14)
• Obstructive shock requires thrombolysis or anticoagulants (heparin, oral)
• Cardiogenic shock managed by defibrillation, CPR, intubation, adrenaline infusion targeting MAP>65, urgent cath lab
• Neurogenic shock requires early intubation, protect airway, adequate oxygenation, vasopressors targeting MAP>65, neurosurg referral, avoid hypothermia
• Anaphylactic shock treatment SOFAH approach → steroids + salbutamol, O2, fluids, adrenaline, histamine blocker

Massive Transfusion Complications and Management

• Large volume resuscitation can cause coagulopathy, acidosis, and hypothermia, requiring early control of bleeding and blood products with clotting factors

Pelvic Binder Application

• Apply major bleeding from pelvic injury is often venous
• Pelvic binders limit pelvic volume, increase interstitial pressure and controls bleeding
• Can worsen some injuries, usually applied field and requires repeat imaging after

Fluid Spaces

• First space is plasma. Second space is intracellular. Third space is interstitial
• Fluid requirements are for defecit + maintenance + ongoing loss

Fluid Parameters

• Deficit (hypovolaemia, dehydration) requires 20mL/kg in 0.5-1 hour for Shock (haemorrhage, sepsis) 2-4mL/kg x BSA x weight for Burns and consideration for Cardiac failure
• Maintenance: Balance water intake and output, insensible losses Water from metabolism = loss in faces (100-200ml) and total about 3000mL/day
• Ongoing losses are Vomiting, diarrhoea, urine → NG, IDC drainage and surgery
• Minor surgery → 4ml/kg/hr
• Moderate surgery → 6ml/kg/hr
• Major surgery → 8ml/kg/hr

Types of IV Fluids

• Crystalloid (3:1 replacement for blood loss) such as 5% dextrose, Normal saline (NS) and Hartmanns
• Hartmanns solution is sophisticated ECF Na 131, CI 111, K 5.4, Ca 1.8, HCO3 28 (sophisticated ECF) .
• 4/2/1 Rule requires 4ml/kg/hr for the first 10kg, 2ml/kg/hr for the next 10kg, 1ml/kg/hr for the remaining weight >20kg
• Colloid (1:1 replacement for blood loss) such as Haemaccel, FFP, albumin
• Fluid Challenge usually 5-10ml/kg or 250-500ml and Monitor response through pulse, BP, RR, UO and CVP line

Fluid Overload

• Signs include hypertension, tachycardia, raised JVP/gallop rhythm, oedema, pleural effusions, pulmonary oedema and ascites

Fluid Depletion

• Volume depletion signs include postural hypotension, tachycardia, absent JVP at 45 degrees, decreased skin turgor, dry mucosae, supine hypotension oliguria, organ failure

Burns

• Parkland formula = 4mL x (% of total body SA sustaining non-superficial burns) x (persons weight in kg)
• Half of calculated solution should be given in the first 8 hours from time of burn, and remainder half in next 16 hours. Add maintenance on top and use Hartmanns

Nutrition in Surgical Patients

• Malnutrition increases susceptibility to infection, length of stay, risk of complications such as pressure injuries, overgrowth of bacteria in gut, abnormal nutrient loss through stool, impaired complement production and impaired function of neutrophils
• Nutrition Options are high energy and high protein diets, or oral supplementation with high protein, fibre, low volume, renal, diabetic, wound healing, flavourless, vitamins/minerals
• Enteral (tube): Naso-enteric tube (nasogastric, nasojejunal) inserted through the nose, short term Gastrostomy tube inserted through the abdominal wall, long term Pejunostomy tube placed into small bowel, long term
• Parenteral (IV) is second resort and requires surgical considerations, disease process and clinical decision

Enteral Tube Feed Considerations

• Naso-enteric tube goes short term (4-6 weeks). Good for bolus and continuous feeds, but may lead to dislodgement, clogging, nasal and pharyngeal discomfort, aspiration and diarrhoea
• Gastrostomy tube good for long-term feeding. Good for bolus and continuous feeds. May lead to site leak and breakdown
• Jejunostomy tube for long-term. No bolus. May lead to site leak and breakdown, volvus and clogg

Parenteral Nutrition

• Total Parenteral Nutrition (TPN) Definition: provision of nutrients (dextrose, amino acids, electrolytes, vitamins, minerals) directly into the bloodstream.
• Bypasses normal digestion route and is delivered via a central venous catheter (CVC) or PICC. Impaired absorption, inadequate GI function, enteral feeding cannot be established within 7 days, post-op bowel anastomosis leak. Indications TPN is suitable

Refeeding

• Requires a CVC to enable Infection controls , Blood clot management Pneumothorax management, Air embolism mitigation and to stem potential Bleeding via injury
• Can lead to Metabolic abnormalities Refeeding syndrome in chronic alcoholic patients, and in patients NBM >7 days, Hyperglycemia management, sudden discontinuation can lead to hypoglycaemia, serum electrolyte abnormalities control, Wernicke's encephalopathy and Parenteral associated cholestasis treatments
• Management of TPN Initially monitor electrolyte balance daily; monitor BSL; UECs and fluid balance. Calculate Nitrogen Balance, TPN can be used sole source of fluid. • Refeeding Syndrome Occurs during starvation or periods of significantly reduced oral intake. • Refeeding Risk Derangement serum electrolytes low, Vitamin deficiencies -thiamine, B12, folate- treatment, Sodium retention - oedema. Monitor nutritional intake and ensure adequate nutritional input.

Wounds and Wound Healing

• The principles for wound managements and healing require and understanding of accidental wounds, infections, and how the body heals
• Wound breaches give rise to inflammation, pain and potential for systemic issues. Most surgical infections occur 5 days after anything earlier means there was earlier infection.
• Factors for Infection, increased of, presence of foreign bodies, reduces requirements for cellular healing. Consider Devascularised tissue or Immunodeficency.
• Reduce less bacteria

Wound Managements

• Removal foriegn bodies through Debridement and lavage
• Assessment & Classification
• clean, few any or bacteria
• clean contaminants, Elective surgery. Infection risk 1%, clean first. infection risk 5-50 % proceed accordingly
• Contaminant managements thoguh washing
• dirty, wash and extract waste

Surgical Complications And Management

• The timeframe Complications, depends on specific surgery, as is prevention for technical errors.
• E.g after complications might, haemorrhage, paralytic ileus
• Watch DVT or a Pulmonary embolism

Post Operative Complication

• Respiratory due to Atelectasis that causes a cascading series of complications.
• Atelectasis common with pain etc Requires; optimize medical and patient factors and control pain.

Indications For Perioperative Anticoagulation

• PE and VTE prophylaxis
• Antiplatelets or AF depends, check Cardio valvular systems.
• Parenteral anticoagulants drugs
• LMWH Indirect factor, Heparin immune and Antiplatelets factors -aspirin and clopidogrel-

Complications To Management

• Contraindications for mechanical prophylaxis
• active, skin and Severe pain and PVD. Assess
• stopping treatment and Bridging therapy and check
• LMWH Fixed, weight-based dose and Heparin
• Reassess

Emergency Managemnt

• Surgical removal depends on infection abscess
• Abcess the -Abx, drainage
• Sepsis - Systemic Inflammatory Response
• SIRS, temp and Bp watch
• Quick Qsofa to quickly assess, Bp and rr

Surgical Site Infection

SSI, occur after in 30 days or a year and Prevention through MINDME HAND Hygiene, before after touching patients Skills include sutering Choice suture materials - Absorable Set up through a proper technique Removal through cosmesis

Trauma Response

Management of trauma and Emergency protocols.

• Follow ABcde and stabilise before operating
• Inury to c spine an breathing should be addressed

InterCOSTAL catheter, insert Check A history AMPLE and C Spine

Skeletal

• Follow CHISSEEl to access damages
• check if brain hearniation Traumas and bleeding
• Ensure safe for C spine

Abdominal Rupture

• Inury to the Lap Belt causes and can do pressure

Follow OTTAWA check points and Rules

• Follow Burn treatment through parkland formular
• Understand degrees injuries

The Gallbladder for surgical treatments

• Common, more prevalent in females and older patients. Biliar problems often relate obesity.
• May have extrahepatic or intrahepatic - pain fever .
• Watch for Charcots Triad Aspirations, wash to prevent spreading further.

Breast Surgery

• Anatomy, of glandular tissue,connective tissue and fatty tissue.
• Lymph Node involvement DDx, of Breast lump - include a Benign, cyst or Fat necrosis. Malignancys is another option for concerns.

Test and Imaging

Follow protocols when an abnormality. has detected through mammography

Malfunctions of the Breasts requires different treatments

From DCIS or IDC to surgical interventions- WLE , Rtx and Mastectomy The RISK is if surgery, in areas there is pressure or weakness. Tests and diagnosis include imaging scans