Peri-operative Care Protocols (for Residents and Registrars)

DVT Prophylaxis

ALL ADMISSIONS SHOULD HAVE TED STOCKINGS UNLESS MEDICALLY CONTRAINDICATED.

All major abdominal cases should have Sequential Calf Compression Devices.

All patients having abdominal surgery except day only cases, open groin hernias and small umbilical hernias MUST receive subcutaneous Clexane 20mgs or 40mgs, depending on their risk situation, from the time of their admission unless they are scheduled for an epidural in which case Clexane should be withheld until after insertion.  This includes acute admissions. Trauma patients should commence 48 hours after admission unless medically contraindicated (eg GIH).

All patients to have their outpatient notes in the Theatre at the time of their surgery together with all X-RAYS (hospital and private).  Patients who have come from Dr Gani’s private rooms should have a copy of their last letter from the rooms faxed through to the ward and included in their medical records prior to surgery.

Acute Pancreatitis

Most patients to have an IDC with hourly urine measures, BSL monitoring/SaO2 monitoring, and daily EUC, while on IV fluids.  Amylase and lipase do not need checking once the diagnosis has been made.   ABGs, Ca2+, EUC, LFTs, BSL, amylase/lipase and coags are required on admission.

ERCP

All patients require detailed informed consent as this procedure carries a morbidity and mortality beyond that of simple upper GI endoscopy.  Information sheets should be given to all patients.  All patients who may require an endoscopic sphincterotomy would have a normal INR before undertaking the procedure and if this has not been obtained the procedure will be cancelled.  All ward patients should have a cannula inserted before being sent to endoscopy.  All jaundiced patients should have IV Vitamin K 10mg the evening the procedure, and IV fluids while fasting.

Colonoscopy

All inpatient colonoscopies to have 3 litres of colonic lavage. If the patient has active colonic bleeding, this volume may need to be increased. An IVI may be necessary. Colonoscopy patients are to be fasted for 4 hours prior to the procedure although they can drink H2O up until 2 hours prep.

Gastroscopy

Patients are to be fasted for six hours prior to gastroscopy.  Patients with oesophageal strictures are to be on clear fluids for 24 hours prior to gastroscopy.

Gastrectomy

Some patients will require bowel preparation pre-operatively some patients may need pre-op vaccination (HIB, Pneumovax, & Menningovax > 7 days pre-operatively) if splenectomy id contemplated.

Jejunostomy

A Foley catheter is usually used as the jejunostomy tube.  The balloon is inflated to 1-2mls.  The jejunostomy is not to be removed until 4 weeks after insertion and the balloon must be let down prior to extraction.

Laparoscopic Peritoneal Dialysis Catheter Insertion

These catheters will have been inserted in theatre and Heparin locked.  They require no further flushing on the ward until dialysis is to start.  Dialysis training is to be undertaken at the Wansey Centre and can be commenced after 3-5 days depending on the speed of the patient’s recovery.  The Renal Department will organise this prior to the discharge of patients and she should also be contracted pre-operatively to “site” the catheter wherever possible.  The laparoscopic port site wounds will be dressed with spray and a waterproof dressings and the exit site will be dressed the Lyofoam.  It is vitally important that the catheter exit site remain dry and patients should not be showered without completely waterproof protection over the catheter exit site.  However if this remains dry it need not be changed prior to the patient being discharged for catheter training.

Lower Gastrointestinal Surgery

Most right hemicolectomies do not require bowel preparation.

All colonic resections that require bowel preparation to have 3 litres of colonic lavage the day before surgery and IV fluids running over night pre-op. All lower GI cases to have 2gm of Cephazolin and 500mg of Flagyl at induction.

Upper Gastrointestinal Surgery

All open upper GI cases to have 2gm Cephazolin IVI at Induction (eg gastrotomy, oesophagectomy, pancreatectomy, hepatectomy) unless they have a sensitivity to Β-lactamase antibiotics.

Laparoscopic Cholecystectomy

All cases to have appropriate pre-operative prophylactic antibiotics (usually Cepazolin 2gm IVI at induction).

HPB Cases

All jaundiced cases to have IV fluids and Vitamin K 10mg the night before surgery or ERCP. INR needs to be rechecked prior to any procedure.

All pancreatic resections to have Sandostatin 100 micrograms QID starting in the operating theatre on the morning of surgery. SCI

Splenectomy.

Patients having elective splenectomy, or distal pancreatic resections (or any other operation in which splenic injury might be anticipated) need pre-operative Pneumovax, HIB and Menningococcal Vaccine (optimally given more than 7 days pre-operatively)

Blood Transfusion & Use of Blood Products

In the non-emergency setting blood or blood products should not be given without prior discussion with the consultant.

Discharge Medications

Patients of Dr Gani are not to be discharged on Oxycontin/Targin or any slow release opiates without discussion with Dr Gani prior to discharge. Long term prescription of opiates for wound pain should never be necessary.