MRCS iSense Notes

By Dr Reda Harby

Dr Reda Harby MRCS Part A iSense Note Book

Perioperative

https://www.facebook.com/MRCSMECourses/
General preoperative assessment

General preoperative assessment

1. Obtain surgical consent.

2. Obtain a thorough medical history and perform a physical examination.

3. Specific diagnostics

• Laboratory tests if indicated (see table below)

• Preoperative cardiac assessment

• Preoperative pulmonary assessment

• Preoperative nutritional status assessment

Laboratory test Indication

• * Liver disease
Hemoglobin or hematocrit
• * Procedures in which severe blood loss is anticipated

• * Extremes of age

• * Clinical features of anemia

• * Clinical features or history of bleeding

and/or hematopoietic disorders

Blood grouping and crossmatching • * Procedures in which severe blood loss is anticipated

Random blood glucose • * Risk factors, clinical features, and/or history of diabetes mellitus

• * Use of hyperglycemic medications (e.g., systemic glucocorticoids)

Electrolytes and creatinine • * > 40 years

• * History of hypertension, diabetes mellitus, congestive heart

failure, chronic kidney disease, and/or liver disease

• * Use of certain medications (e.g., diuretics, digoxin, ACE

inhibitors, ARBs, chronic NSAID use)

Perioperative Reda Harby Notes 1

 Coagulation studies • * Clinical features and/or a history of bleeding disorders

• * Family history of bleeding disorders

• * Patients on anticoagulant or antiplatelet medications

• Systemic disorders associated with increased bleeding

(e.g., liver disease, hematopoietic stem cell disorders, renal

dysfunction)

• Procedures in which severe blood loss is anticipated

Urine analysis • Implantation of foreign bodies during surgery (e.g., metal implants,

artificial heart valves)

• Invasive urological surgery

• Clinical features of urinary tract disease

Pregnancy test • Women of childbearing age if pregnancy would potentially alter

management

Preoperative tests should be ordered only if they are indicated!

If a known healthy adult > no preoperative investigations are required

Preoperative hepatic assessment

• Indications for preoperative LFTs

• Symptoms of liver disease (e.g., jaundice, hepatomegaly)

• In asymptomatic individuals, if the patient has chronic liver disease

• Risk assessment

• Patients with acute hepatitis: Elective surgery is contraindicated until LFTs improve.

• Chronic liver disease

• Child class B and A, or a MELD score < 15: Surgery may be performed after treating

encephalopathy, coagulopathy, and ascites.

• Child class C or MELD score > 15: Elective surgery is contraindicated until the Child or MELD score improves.

Discontinuation of medication prior to surgery

Preoperative preparation

• Discontinue certain medications (see discontinuation of medication prior to surgery above).

• Fasting
• 8 hours before surgery: no meat or fried, fatty food
• 6 hours before surgery: no milk or solid food

Perioperative Reda Harby Notes 2

 • Breast-fed infants: no breast milk 4 hours before surgery
• 2 hours before surgery: nil per os (NPO)

The preoperative fasting recommendations can be remembered with the “2, 4, 6, 8 rule”!

• Anesthesia (see general anesthesia and regional anesthesia)

• Perioperative antibiotic prophylaxis
• Aim: to reduce the incidence of postoperative surgical site infections
• Antibiotic of choice
• First-line: intravenous cefazolin
• In patients with beta-lactam allergy: clindamycin or vancomycin
• Add intravenous metronidazole for:
• Patient with small intestinal obstruction
• Appendectomy
• Colorectal surgery

Postoperative management

• Monitor blood pressure, pulse, oxygen saturation, temperature, urine output, and surgical drain output.
• If a patient has a urine output < 0.5 mL/kg/hour for > 6 hours: Check catheter patency.
• Supportive care in intubated patients
• Pain management according to WHO analgesic ladder
• Stress ulcer prophylaxis with proton pump inhibitors
• Thromboprophylaxis with low-dose LMWH or UFH before and after surgery, especially for immobile, bedridden patients
• Incentive spirometry and breathing exercises in order to prevent lung atelectasis
• Fluids: replacement of ongoing fluid loss and maintenance fluid therapy
• Enteral nutrition should be started as soon as possible to prevent villous atrophy.
• Daily examination of the surgical wound
• Early mobilization

Postoperative complications

Wound-related complications

• Postoperative hemorrhage
• Wound hematomas or seromas
• Surgical site infection
• Wound dehiscence
• Incisional hernia (late)

General postoperative Postoperative cardiac Postoperative pulmonary Renal and urinary tract
problems complications complications complications

• Postoperative fever • Myocardial infarction • Postoperative atelectasis• Acute kidney injury

• Postoperative delirium • Pneumonia

Perioperative Reda Harby Notes 3

 Wound-related complications

• Postoperative nausea and
vomiting
• Postoperative ileus
• Deep vein thrombosis
• Pressure ulcers
• Arrhythmias (especially atrial • Pulmonary embolism • Postoperative urinary
fibrillation) retention
• Catheter-associated urinary
tract infection

Type of surgical Definition Incidence of SSI

wound

Clean • All of the following: • 1.5%

• Noninflamed operative wound

• The respiratory, alimentary, genital, and urinary tracts have not been entered

during surgery.

• Wound is closed primarily with or without a drain

Clean-contaminated• Noninflamed operative wound • 8%

• The respiratory, alimentary, genital, and/or urinary tracts have been entered.

Contaminated • Fresh, open, accidental wounds • 15%

• Inflamed operative wound without purulent drainage

• Clean or clean-contaminated wounds with a break in sterile technique during

surgery

Dirty or infected • Old traumatic wounds • 40%

wounds • Inflamed operative wound with purulent drainage

Postoperative nausea and vomiting

• Epidemiology:
• Incidence
• 30–50% among postsurgical patients in the general population
• Up to 80% in high-risk groups
• Sex: >

Perioperative Reda Harby Notes 4

 PONV risk factors Adults Children

Patient-related • Female sex • Age > 3 years

• Past history of PONV • Past history or family history
• History of motion sickness of PONV
• Non-smoker
• Age < 50 years

Procedure or treatment
• Volatile general anesthetics including nitrous oxide • Surgery lasting ≥ 30 minutes
related • Perioperative opiate use • Strabismus surgery
• Emetogenic procedure (laparoscopy, gynecological procedures,
and cholecystectomy)

• Differential diagnosis
• < 1 week after surgery: self-limiting gastric or intestinal atony, or a more severe paralytic ileus
• > 1 week after abdominal surgery: early mechanical bowel obstruction
• PONV prophylaxis
• Reduction of baseline risk
• Choose regional anesthesia over general anesthesia whenever possible.
• If general anesthesia is required, avoid the use of nitrous oxide and volatile anesthetics; use a propofol infusion instead.
• Minimize the perioperative use of opiates.
• Adequate hydration
• Additional measures
• 0–1 PONV risk factors (low PONV risk): no antiemetic
• 2 PONV risk factors (medium PONV risk): one antiemetic
• ≥ 3 PONV risk factors (high PONV risk): two or more antiemetics of different classes
• Treatment: Use an antiemetic that was not used for prophylaxis.
• Complications
• Prolonged hospital stay
• Increased risk of aspiration pneumonia
• Secondary hemorrhage due to retching

Postoperative urinary retention

• Definition: failure to void > 4 hours after surgery

• Risk factors
• Patient-related
• Age > 50 years
• Male patient
• Pre-existing obstructive urinary tract symptoms (e.g., BPH)
• Neurological disease (e.g., multiple sclerosis, diabetic neuropathy)

Perioperative Reda Harby Notes 5

 • Procedure-related
• Long duration of procedure
• Inguinal hernia repair, gynecological, anorectal surgery, joint arthroplasty
• Severe postoperative pain
• Excessive administration of intravenous fluids (> 750 mL)
• Spinal or epidural anesthesia
• Use of sedatives and or opioid analgesics
• Perioperative administration of α-blockers or anticholinergics (e.g., atropine)
• Diagnostics: Bladder ultrasound is not required but may be performed to assess the bladder volume.
• Treatment
• If the patient is catheterized preoperatively
• Check the catheter for kinking or blocks in the lumen.
• If no kinking is present, consider acute kidney injury.
• If the patient is not catheterized preoperatively
• First-line
• Trial of voiding
• Adequate analgesia with NSAIDs
• Second-line: intermittent catheterization or the placement of an indwelling catheter
• Complications
• Acute hydronephrosis → postrenal cause of acute kidney injury
• Urinary tract infection
• Prolonged hospital stay → increased risk of hospital-acquired infections

If a catheterized patient develops signs of urinary retention (e.g., lower abdominal pain, bladder fullness), check
the catheter for kinks or blockage.

Postoperative ileus

• Risk factors
• Open surgery
• Excessive bowel handling during intra-abdominal surgery
• Electrolyte imbalances (e.g., hypokalemia)
• Use of opiates
• Pathophysiology
• Physiologic postoperative ileus: impaired gastrointestinal motility that occurs following surgery and resolves
spontaneously within 2–3 days
• Prolonged postoperative ileus: impaired gastrointestinal motility for > 3–5 days
• Clinical features
• Failure to pass flatus
• Nausea and vomiting may be present.
• Abdominal distention may be present.
• Absence of bowel sounds on auscultation
• Differential diagnosis: early mechanical bowel obstruction

Perioperative Reda Harby Notes 6

 • Management
• Physiologic postoperative ileus
• Conservative measures only
• Avoid excessive fluid administration.
• Preferential use of NSAIDs (e.g., ketorolac) over opiates
• Early mobilization if possible
• Early initiation of enteral feeding if possible
• Nasogastric tube only if abdominal distention is prominent
• Prolonged postoperative ileus
• See bowel obstruction.

Discontinuation of medication prior to surgery

Common long-term medications Recommendations

Antidiabetic drugs • Oral hypoglycemics

• Metformin: discontinue 2 days before and after surgery
• Discontinue other oral hypoglycemics on the day of surgery and postoperatively until the
patient is no longer NPO.
• Insulin

• Discontinue insulin on the day of surgery but administer IV intraoperatively.

• Continue insulin therapy postoperatively until glucose levels are stable and oral
antihypoglycemics can be resumed.

Antihypertensive drugs • Discontinue the following antihypertensives one day before surgery and continue
postoperatively:
• ACE inhibitors
• ARBs
• Diuretics
• Continue all other antihypertensives

Antianginal drugs • Continue

Statins • Continue

Oral contraceptives • Discontinue 4 weeks before surgery

Psychiatric drugs • Benzodiazepines

• May be continued
• In patients with cardiac disease: Discontinue several days before surgery by tapering down.
• Lithium: Discontinue 3 days before surgery.
• Tricyclic antidepressants: Discontinue intraoperatively.

Perioperative Reda Harby Notes 7

Common long-term medications Recommendations

• Nonselective, irreversible MAO inhibitors (e.g., tranylcypromine): Discontinue 2

weeks before surgery.
• Other neuroleptics and antidepressants: case-by-case decision

Antiepileptics • Continue

Anticoagulant or antiplatelet• Antiplatelet drugs (e.g., aspirin, clopidogrel)

drugs • Discontinue all antiplatelet drugs one week before surgery.
• Anticoagulants
• Patients on direct oral anticoagulants (e.g., dabigatran, rivaroxaban)
• Discontinue medication 2 days before surgery.
• No bridging anticoagulation
• Patients on warfarin

• Discontinue warfarin 5 days before surgery.

• Bridging anticoagulation with heparin (preferably an LMWH such as dalteparin)

when INR levels become subtherapeutic
• Low risk of thromboembolism: no bridging anticoagulation
• High risk of thromboembolism: initiate bridging

• Discontinue LMWH 24 hours or unfractionated heparin 4–5 hours before the procedure

• Continue heparin and warfarin postoperatively

Thyroxine • Discontinue intraoperatively and resume postoperatively.

NSAIDs • Short-acting NSAIDs: discontinue 2–3 days before procedure

• Long-acting NSAIDs: discontinue one week before procedure

Antianginal medications, antiepileptics, statins, most antihypertensive drugs (except ACE inhibitors, ARBs,
and diuretics), and most neuroleptics (except lithium) should be continued on the day of surgery!

Preoperative preparation

• Discontinue certain medications (see discontinuation of medication prior to surgery above).

• Fasting
• 8 hours before surgery: no meat or fried, fatty food
• 6 hours before surgery: no milk or solid food
• Breast-fed infants: no breast milk 4 hours before surgery
• 2 hours before surgery: nil per os (NPO)

Perioperative Reda Harby Notes 8

 The preoperative fasting recommendations can be remembered with the “2, 4, 6, 8 rule”!

• Anesthesia (see general anesthesia and regional anesthesia)

• Perioperative antibiotic prophylaxis
• Aim: to reduce the incidence of postoperative surgical site infections
• Antibiotic of choice
• First-line: intravenous cefazolin
• In patients with beta-lactam allergy: clindamycin or vancomycin
• Add intravenous metronidazole for:
• Patient with small intestinal obstruction
• Appendectomy
• Colorectal surgery

The ERAS Protocol ( enhanced-recovery )

The ERAS protocol can be divided into the 3 stages of the patient journey, each comprising several elements

Pre-Operative

• Patient education regarding the surgery and the expected post-operative course and milestones
o Most units will have developed a handbook for the patient so they know what to expect every day
• Ensuring the patient is as healthy as possible prior to surgery, through exercise and weight loss
• Optimising medical management, including smoking and alcohol cessation
• Optimal pre-operative fasting guidelines
o Altered diet prior to surgery to enhance bowel recovery and avoid bowel prep if appropriate
o Solids allowed until 6 hours pre-operatively (unless contra-indicated)
o Intake of clear fluids until 2 hours prior to surgery
o Loading with 12.5% carbohydrate beverage within 2 hours of surgery

Intra-Operative

• Use of multimodal and opioid-sparing analgesia, including regional anaesthesia and continuous wound infusion where
possible
o Including avoidance of short-acting benzodiazepines in the elderly
• Use of multimodal postoperative nausea and vomiting prophylaxis
• Use of minimally invasive surgery
• Targeting a goal-directed fluid therapy regime, including goal-directed haemostasis management
o Use of balanced salt-solutions where warranted

Post-Operative

• Ensure adequate pain control is achieved to allow for early ambulation

• Early oral intake
• Multi-disciplinary post-operative patient follow-up, including in the post-acute care phase

Perioperative Reda Harby Notes 9

Perioperative Reda Harby Notes 10
This page intentionally left blank

Perioperative Reda Harby Notes 11

 American Society of Anaesthesiologists Grade

Pre-Operative Management
e assessment, which has been subjectively assessed and based on the criteria below. A patient’s ASA grade directly
correlates with their risk of post-operative complications and absolute mortality.

American Society of Anaesthesiologists Grade

ASA Absolute Mortality
Definition
Grade (%)

I Normal healthy patient 0.1

II Mild systemic disease 0.2

III Severe systemic disease 1.8

Severe systemic illness that is a constant

IV 7.8
threat to life

Moribund, who is not expected to survive

V 9.4
without the operation

E Suffix added if an emergency operation –

On all anaesthetic charts, a patient will be given an American Society of Anaesthesiologists (ASA) grade after
their pre-operative assessment, which has been subjectively assessed and based on the criteria below. A
patient’s ASA grade directly correlates with their risk of post-operative complicationsGroup and Save versus
Cross-Match

Drugs To Stop

These commonly stopped medications can be remembered as ‘CHOW’.

• Clopidogrel – stopped 7 days prior to surgery due to bleeding risk. Aspirin and other anti-platelets can often be continued
and minimal effect on surgical bleeding

• Hypoglycaemics – see ‘Diabetes Mellitus’ below

• Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) – stopped 4 weeks before surgery due to DVT
risk. Advise the patient to use alternative means of contraception during this time period.

• Warfarin – usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular
weight heparin
o Surgery will often only go ahead if the INR <1.5, so you may have to reverse the warfarinisation with PO or IV Vitamin K
and better by PCC if the INR remains high on the evening before

Perioperative Reda Harby Notes 12

 Drugs To Alter
• Subcutaneous insulin – may be switched to IV variable rate insulin infusion, as discussed below

• Long-term steroids – must be continued, due to the risk of Addisonion crisis if stopped If the patient cannot take these
orally, switch to IV (a simple conversion rate is 5mg PO prednisolone = 20mg IV hydrocortisone)

Drugs To Start
• Low Molecular Weight Heparin – the admitting doctor should complete a VTE Risk Assessment and prescribe
appropriately
o Most patients will receive this, with the exception of those with either contraindications or who are having neck or endocrine
surgery
o Patients undergoing major GI surgery for cancer (including oesophageal, gastric, pancreatic, liver and colonic resections)
and lower limb joint replacement should be discharged with TEDs and 28 days of prophylactic dose low molecular weight
heparin (in the absence of contraindications).

• TED stockings – all patients (with the important exception of vascular surgery patients) will receive below knee TED
stocking. These need to be prescribed but check for contraindications (especially in the elderly). Contraindications include
severe peripheral vascular disease, peripheral neuropathy, recent skin graft, severe eczema.

• Antibiotic prophylaxis – patients having orthopaedic, vascular, or gastrointestinal surgery will require prophylactic
antibiotics. Generally, these will be prescribed by the anaesthetist or the surgeon but if in any doubt, call your senior to
discuss

Diabetes Mellites
The perioperative care of patients with diabetes mellitus (DM) is becoming increasingly common. The exact pre-
operative management varies between patients, but the following can be used as a basis.

Type I Diabetes Mellitus

All patients with Type I DM should be first on the morning list and they may need admitting on the night before the operation
(depending on how major the procedure is)

• On the night before surgery, reduce their subcutaneous basal insulin dose by 1/3rd. Omit their morning insulin and
commence an IV variable rate insulin infusion pump (commonly termed ‘sliding scale’), which is a syringe driver that
usually contains 49.5mL of normal saline with 50 units of Actrapid.

• Whilst the patient is nil by mouth, you will also need to prescribe an infusion of 5% dextrose, which is usually given at a
rate of 125mL/hr. Ask the nurse to check the capillary glucose (‘BM’) every 2 hours and to alter the infusion rate
accordingly.

• Continue until the patient is able to eat and drink. Once they are doing so, you must overlap their IV variable rate insulin
infusion stopping and their normal SC insulin regimens starting. To do this, give their SC rapid acting insulin ~20 minutes
before a meal and stop their IV infusion ~30-60 minutes after they’ve eaten.

Type II Diabetes Mellitus

Management is dependent on they way that their Type II DM is controlled. If diet controlled, no action is required peri-
operatively.

Perioperative Reda Harby Notes 13

 If, however, the patient is controlled by oral hypoglycaemics, metformin should be stopped on the morning of surgery,
whilst all others should be stopped ~24 hours before the operation. These patients will then be put on IV variable rate
insulin infusion along with 5% dextrose as described above and managed peri-operatively the same as a Type I diabetic.

Bowel Preparation
Patients having colorectal surgery may need bowel preparation (laxatives or enemas) to clear their colon pre-operatively.

Bowel preparation is used less frequently, as the fluid shifts can be harmful to patients who are elderly or have cardiac or
renal disease. Additionally it has been shown that use of bowel preparations can prolong patient recovery and length of
stay.

The exact protocol will vary between hospitals but a general guide is:

• Upper GI, HPB, or small bowel surgery: none required

• Right hemi-colectomy or extended right hemi-colectomy: none required

• Left hemi-colectomy, sigmoid colectomy, or abdo-peroneal resection: Phosphate enema on the morning of surgery

• Anterior resection: 2 sachets of picolax the day before or phosphate enema on the morning of surgery

Blood Products
A blood product is any part of the blood that is collected from a donor for use in a blood transfusion. Although
prescribing blood products may feel much the same as prescribing any other fluid, it is a decision that should be taken
seriously, for a number of reasons:

• Transfusion reactions are relatively common, even in those with appropriately cross-matched blood.
• Blood products are scarce and should therefore only be used when necessary.
• Blood group incompatibility is a rare but life-threatening complication. Blood products therefore need to be appropriately
cross-matched and checked to avoid severe consequences.

Current NICE guidelines recommend a restrictive haemoglobin concentration threshold of 70 g/L for those who need red
blood cell transfusions (without any major haemorrhage or acute coronary syndrome) and a haemoglobin concentration
target of 70-90 g/L after transfusion

Requesting Blood Products

At every stage of requesting blood products, strict adherence to the procedures in place is required to prevent the patient
being given incorrect blood, including:

• Using 3 points of identificationto check you are with the correct patient (name, Date of Birth (DOB), and patient number).
• Consent the patient appropriately – many transfusion request forms will now have a script on them, which you should read
to the patient. A consent form (as you would use for consent for any procedure) is completed.
• Labeling the bottle at the bedside (pre-printed stickers for blood transfusion are usually not allowed in many countries,
including the UK)
• Completing the transfusion request form at the bedside. Before you put the blood bottle into the request bag, check with
the patient that they are happy you have labelled things correctly.

Perioperative Reda Harby Notes 14

 Administering Blood Products
If a patient requires more than one unit of blood, each unit must be prescribed individually. Whilst the patient is receiving
the transfusion, there are specific observations timings that should be carried out:

• Before the transfusion starts.

• 15-20 minutes after it has started.
• At 1 hour.
• At completion.

Blood products should only be administered through a green (18G) or grey (16G) cannula, otherwise the cells haemolyse
due to sheering forces in the narrow tube.

NICE guidelines suggest single unit red blood cell transfusions for the surgical patient who does not have active bleeding,
reassessing the patient after each transfusion

Types of Blood Products

When blood is harvested from donors, it is separated into its constituent parts.

Remember to ensure that all of the above products are administered through a blood giving set rather than a normal fluid
giving set. A blood giving set contains a filter in the chamber, whereas a normal fluid giving set does not.

Packed Red Cells

• Major constituents– Red blood cells

• Indications– (i) Acute blood loss; (ii) Chronic anaemia, where the Hb ≤70g/L (or ≤100g/L in those with cardiovascular
disease) or symptomatic anaemia
• Duration over which it is administered –2-4 hours. It must be completed within 4 hours of coming out of the store

1 unit of blood should increase a patient’s haemoglobin by around 10g/L. Patients given red blood cells may produce
autoantibodies to donor surface antigens (of which there are many, other than ABO and RhD). Because of this, before any
future transfusions, a new G&S will need to be sent (unless the last G&S was sent and processed within around 3 days of
the most recent transfusion).

Platelets

• Major constituents: Platelets

• Indications – (i) Haemorrhagic shock in a trauma patient; (ii) Profound thrombocytopenia (<20 x 109/L; normal range 150
– 400); (iii) Bleeding with thrombocytopenia; (iv) Pre-operative platelet level <50 x 109/L
• Duration over which it is administered – 30 minutes
• 1 ATD (adult therapeutic dose) of platelets should increase platelet levels by around 20-40 x 109/L.

Fresh Frozen Plasma (FFP)

• Major constituents– Clotting factors

• Indications– (i) Disseminated Intravascular Coagulation (DIC); (ii) Any haemorrhage secondary to liver disease; (iii) All
massive haemorrhages (commonly given after the 2ndunit of packed red cells)
• Duration over which it is administered– 30 minutes

Cryoprecipitate

• Major constituents – Fibrinogen, von Willebrands Factor (vWF), Factor VIII and fibronectin

Perioperative Reda Harby Notes 15

• Indications – (i) DIC with fibrinogen <1g/L; (ii) von Willebrands Disease; or (iii) Massive haemorrhage
• Duration over which it is administered – Stat (Immediately)

Group and Save (G&S) and Cross-Match (X-match) are two tests often cause a great deal of confusion:

• A G&S determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies. The
process takes around 40 minutes and no blood is issued. A G&S is recommended if blood loss is not anticipated, but blood
may be required should there be greater blood loss than expected.

• A X-match involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction
takes places. If it does not, the donor blood is issued and can be transfused in to the patient, otherwise alternative blood
is trialled. This process also takes ~40 minutes (in addition to the 40 minutes required to G&S the blood, which must be
done first). A X-match is done if blood loss is anticipated, which the surgeon should inform you of plications and absolute
mortality.

Fluid Management
• Fluid management is a major part of junior doctor prescribing; whether working on a surgical firm with a patient who
is nil-by-mouth or with a dehydrated patient on a care of the elderly firm, this is a topic that a junior doctor utilises on
a regular basis.
• Ensuring considered fluid and haemodynamic management is central to peri-operative patient care and has been
shown to have a significant impact on post-operative morbidity and the length of hospital stay. Hence it is
essential to gain a firm understanding of the physiology of fluid balance and the compositions of each fluid being
prescribed.

Introduction
Firstly it’s important to think about why fluids should be prescribed in the first place. The reasons for fluid prescription are:

• Resuscitation
• Maintenance
• Replacement

The relative importance of each of these varies between patients. Perhaps the most important point to remember therefore
is that correct fluid prescription varies depending on the individual patient and it is essential to take individual patient
characteristics into account before prescribing fluid.

The general key considerations to remember with every patient are:

• Is the aim of the fluid for resuscitation, maintenance, or replacement?

• What is the weight and size of the patient?
o The fluid requirements of a frail 45kg 80yr female and a healthy 100kg 40yr male will be significantly different
• Are there any co-morbidities present that are important to consider, such as heart failure or chronic kidney disease?
• What is their underlying reason for admission*?
• What were their most recent electrolytes?

*After some operations, patients are deliberately run “on the dry side”, whilst septic patients or patients in bowel obstruction
will need aggressive fluid prescribing.

Perioperative Reda Harby Notes 16

Fluid Compartments
Around 2/3rd of total body weight is water (‘total body water’). Around 2/3 of this distributes in to the intracellular fluid and
the remaining 1/3 will distribute in to the extracellular fluid.

Of that fluid in the extracelular space, around 1/5th stays in the intravascular space and 4/5th of this is found in
the interstitium, with a small proportion in the transcellular space.

For the general maintenance of hydration, it is necessary for fluid to distribute into all compartments. However, if the
aim is to fluid resuscitate a patient (improving tissue perfusion by raising the intravascular volume), it is more important
these fluids stay within the intravascular space. This concept will help us understand why different fluids

The Septic Patient

In patients who are septic, the tight junctions between the capillary endothelial cells break down and vascular permeability
increases. As a result, increasing hydrostatic pressures and reducing oncotic pressure lead to fluid leaving the vasculature
and entering the tissue.

It is often therefore necessary to give relatively large volumes of intravenous fluid to maintain the intra-vascular volume,
even though the total body water may be high. Close monitoring of the fluid balance will be required.

Fluid Input-Output
The proportions of fluid that are gained and lost from various sources are shown in Table 1

Note that these figures are the average for a 70kg man. The actual amount varies considerably depending on physiological
status and body weight (which in adult patients can vary from around 40kg to 200kg).

Fluid Input
Only 3/5th of our fluid input comes through fluids via the enteric route, with the remainder from both food and metabolic
processes. Hence, when a patient is nil by mouth (NBM), it is important that all sources are replaced via the parenteral
route.

Fluid Output
Losses from non-urine sources are termed insensible losses; insensible losses will rise in unwell patients, who may be
febrile, tachypnoeic, or having increased bowel output. These factors should be taken into account when deciding how
much fluid a patients needs replacing.

When patients start to clinically improve, their vascular permeability returns to baseline state. They therefore often
“correct themselves” and urinate out the excess fluid that was previously required to maintain their intravascular volume
and tissue perfusion. In such patent, monitor the electrolytes and allow this correction to occur, as this is normal and is to
be expected (rarely will supplementary IV fluids will be warranted in such cases).

Perioperative Reda Harby Notes 17

 Assessment of Fluid Status
It is essential to utilise various clinical parameters to continually assess the patient’s fluid status. A doctor’s first
assessment is, of course, the patient’s clinical status.

In the fluid depleted patients, one should be looking for:

• Dry mucous membranes and reduced skin turgor

• Decreasing urine output (should target >0.5 ml/kg/hr)
• Orthostatic hypotension
• In worsening stages:
o Increased capillary refill time
o Tachycardia
o Low blood pressure

In patients who may be fluid overloaded, one should be looking for:

• Raised JVP
• Peripheral or sacral oedema
• Pulmonary oedema

Ensure that the patient has a fluid input-output chart and daily weight chart commenced; you will need to ask the
nurses to begin one of these (despite commonly being poorly maintained). Also ensure to monitor the patient’s urea and
electrolytes (U&Es) regularly, for any evidence of dehydration, renal hypoperfusion, or electrolyte abnormalities.

Daily Requirements
Patients do not just require water, they also need Na+, K+, and glucose replacing too, particularly if they are nil by mouth.
You will find numerous ways of calculating the daily requirements of these 4 components and they are invariably based
on the patient’s weight.

Current NICE guidelines suggest the following:

• Water: 25 mL/kg/day
• Na+: 1.0 mmol/kg/day
• K+: 1.0 mmol/kg/day
• Glucose: 50g/day

Based on these required, it is necessary to consider the fluids that are available for prescription and what exactly they
contain, to be able to prescribe appropriately

Intravenous Fluids
IV fluids can be broadly categorised in to two groups, crystalloids and colloids (as detailed in Table 2):

• Crystalloids – Crystalloids are more widely used than colloids, with research supporting the idea that neither is superior
in replenishing intravascular volume for resuscitation purposes (with crystalloids also significantly cheaper). Therefore,
crystalloids are used very commonly in the acute setting, in theatres, and for maintenance fluids.
• Colloids – Colloids have a high colloid osmotic pressure and theoretically should raise the intravascular volume faster
than their crystalloid counterparts, yet clinical trials have not shown any significant benefit or effect in practice so their use
in many hospitals is decreasing

Perioperative Reda Harby Notes 18

 Post-Operative Nutrition
There is good evidence that early post-operative feeding reduces post-operative complications and the Enhanced
Recovery After Surgery (ERAS) protocol is designed to start post-operative feeding as soon as possible (coupled with
early mobilisation to reduce muscle loss).

It is now recognised that most surgical patients can safely tolerate an enteral diet within 24 hours of uncomplicated
gastrointestinal surgery without increasing the risk of post-operative complications.

Fluid Prescribing
Maintenance Fluids

As an example, let us say that our patient is a 70kg healthy male*. From the above section, we know in total, we need to
prescribe fluids over 24 hours that provide 1750mL of water (70kg x 25mL/kg/day), 70mmol of Na+ (70kg x
1.0mmol/kg/day), 70mmol of K+ (70kg x 1.0mmol/kg/day), and 50g (50g/day) of glucose. Consequently, a typical fluid
maintenance regimen is as follows:

• First bag: 500mL of 0.9% saline with 20mmol/L K+ to be run over 8 hours
o This provides all of their Na+, ~1/3rd of their K+, and a quarter of their water

• Second bag: 1L of 5% dextrose with 20mmol/L K+ to run over 8 hours

Perioperative Reda Harby Notes 19

o This provides a further 1/3rd of their K+, and half of their water, as well as glucose

• Third bag: 500mL of 5% dextrose with 20mmol/L K+ to run over 8 hours

o This provides the remaining 1/3rd of their K+, and a quarter of their water, as well as glucose

*Providing the patient’s renal function is adequate and they are clinically euvolemic, these do not have to be replaced
exactly but should be targeted, to permit ease of prescribing

Correcting a Fluid Deficit

Where the patient is initially dehydrated, you will need to correct this deficit with fluids, in addition to those prescribed
as maintenance. However, in practice it is relatively uncommon to find a patient that is so profoundly dehydrated that this
deficit needs to be calculated specifically. Instead, a subjective assessment is made based on clinical parameters, patient
size, and any comorbidities.

Any reduced urine output (<0.5ml/kg/hr) should be managed aggressively, giving a fluid challenge and the clinical
parameters, including urine output, subsequently rechecked (also ensuring any catheter is not blocked or patient not
retaining urine)

The fluid challenge should be either 250ml or 500ml over 15-30mins, depending on the patient’s size and co-morbidities.
For example a 120kg 30yr male may need >500 ml to make any difference to their intravascular volume, whereas in a
frail 80yr lady with ischaemic heart disease and renal disease, 250ml may be more appropriate.

Replacing Ongoing Losses

Like much of fluid prescribing, there is a degree of subjective assessment in this aspect too. With reference to Table 1,
one should assess if there are excess losses in any of the 4 secretions. Aspects to be assessed may include:

• Are there any third-space losses?

o Third-space losses refer to fluid losses into spaces that are not visible, such as the bowel lumen (in bowel obstruction) or
the retroperitoneum (as in pancreatitis).

• Is there a diuresis?
• Is the patient tachypnoeic or febrile ?
• Is the patient passing more stool than usual (or high stoma output)?
• Are they losing electrolyte-rich fluid?

Common scenarios of electrolyte imbalances though fluid losses that may be encountered include dehydration (high
urea:creatinine ratio and high PCV), vomiting (low K+, low Cl–, and alkalosis), or diarrhoea (low K+ and acidosis)

Ongoing Monitoring
When prescribing fluids, it is important to remember to regularly assess their fluid status, what they are managing orally,
and amend their fluid prescription accordingly. Use your clinical assessment, nursing charts (fluid input-output charts ±
daily weights) and U&Es to guide this.

Perioperative Nutrition
Malnourished patients make poor surgical candidates. Surgery causes physiological stress with a resultant hyper-
metabolic state and catabolic response, which is not favoured in the malnourished patient.

A proportion of surgical patients will have a degree of malnutrition owing to their underlying disease process
thus reducing their nutritional reserves in the post-operative period. Malnourished patients are at increased risk
of post-operative complications, such as reduced wound healing, increased infection rates, and skin breakdown.

Perioperative Reda Harby Notes 20

Clearly it is important that any patient undergoing elective or semi-elective surgery should be assessed for evidence of
malnutrition and where possible this should be corrected or nutrition supported both pre- and post-operatively.

Assessment
All patients admitted to hospital should be screened for malnutrition and have their nutritional state assessed.

Screening for malnutrition can be achieved using the Malnutrition Universal Screening Tool (MUST). The MUST score
can easily be calculated by any health professional, however this may be unnecessary as disease-related cachexia
is usually obvious with bedside observation, noting features such as muscle wasting, loose skin, and the patient’s usual
clothes no longer fitting*.

Following screening, nutritional assessment requires expert input from a Registered Dietitian (RD). Tools used to
assess nutritional state are weight, Body Mass Index (BMI), Grip Strength, Triceps Skin Fold thickness and Mid Arm
Circumference.

BMI = Weight(kg) / Height(m)2 (normal range 18.5-24.9 kg/m2)

*Additional features such as aphthous ulcers, angular cheilitis, and pressure sores can provide additional clues

Pre-operative Nutritional Support

If malnutrition is identified then nutritional support may be appropriate as this improves surgical outcomes. The decision
when and how to deliver nutritional support, and the timing of subsequent surgery, should be decided on a case-by-case
basis.

An appropriate schedule for nutritional support should be given with the assistance and under the direction of
a registered dietitian. The type of nutritional support that can be offered will depend largely on the pathology present.

As a general principle, it is always best to give enteral nutrition via the oral route wherever possible (this applies to both
pre- and post-operative nutrition). However for many patients it may not be possible to administer sufficient calories via
this route and alternative nutrition support strategies will need to be considered.

There is a simple hierarchy of feeding methods that should be followed and applied appropriately.

Perioperative Reda Harby Notes 21

 MRCS Nutrition Cases

For EN therapy lasting >4 weeks, more permanent access

RTA
Short term < 3-6 weeks NGT
Long term > 4 ( will tell long term weeks PEG
Nasogastric tubes (NGTs) are recommended for those requiring tube feeding for no longer than 4–6 weeks.

Oesophagectomy Jejunostomy
Oesophageal Perforation TPN

Patients with Intestinal Failure

Patients with intestinal failure often (but not always) need parenteral nutrition. Timing of surgery is therefore crucial and
it is helpful to remember the mnemonic SNAP for such cases:

• Sepsis – Any overwhelming infection present must be corrected otherwise feeding will be largely useless
• Nutrition – Once the infection is corrected, suitable nutritional support should be provided
• Anatomy – Define the anatomy of the GI tract so that surgery can be planned
• Procedure – Definitive surgery once any infection eradicated, the patient nourished, and the anatomy defined

The Albumin Myth

Whilst a low serum albumin is associated with poorer surgical outcomes there is a common misunderstanding that low
serum albumin reflects nutritional state. It does not.

A low serum albumin reflects either chronic inflammation, protein losing enteropathy, proteinuria, or hepatic dysfunction,
but does not reflect malnutrition (as witnessed by the fact that patients with severe anorexia nervosa have a normal serum
albumin).

The concept of a ‘period of pre-operative feeding to improve the albumin’ is incorrect and unachievable, and it is the
underlying cause of the low albumin that should be treated rather than simply feeding the patient.

Intra-Operative Nutrition
It is now recognised that the age-old surgical mantra of very slow reintroduction of oral diet and mobilisation post-
operatively was misplaced.

The introduction of Enhanced Recovery After Surgery (ERAS) was revolutionary engendering real change and is now
an established part of surgical practice. The basic tenets behind ERAS consist of:

• Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)

• Pre-operative carbohydrate loading
• Minimally invasive surgery
• Minimising the use of drains and nasogastric tubes
• Rapid reintroduction of feeding post-operatively
• Early mobilisation

Perioperative Reda Harby Notes 22