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This page intentionally left blank
Fundamentals of Surgical
Practice
Third Edition
Fundamentals of Surgical
Practice
Third Edition
Edited by
Andrew N. Kingsnorth MS, FRCS, FACS
Consultant Surgeon, Derriford Hospital and Honorary Professor of Surgery,
Peninsula College of Medicine and Dentistry, Plymouth, UK

Douglas M. Bowley FRCS [Gen Surg]

Consultant Surgeon, Heart of England NHS Foundation Trust and Senior Lecturer,
Academic Department of Military Surgery and Trauma,
Royal Centre for Defence Medicine, Birmingham, UK
CAMBRID GE UNIVERSIT Y PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town,
Singapore, São Paulo, Delhi, Tokyo, Mexico City

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University

Press, New York

www.cambridge.org
Information on this title: www.cambridge.org/9780521137225

c Cambridge University Press 1998, 2006, 2011

This publication is in copyright. Subject to statutory exception and to

the provisions of relevant collective licensing agreements, no
reproduction of any part may take place without the written permission
of Cambridge University Press.

First published by Greenwich Medical Media 1998

Second Edition published by Cambridge University Press 2006
Third Edition published 2011

Printed in the United Kingdom at the University Press, Cambridge

A catalogue record for this publication is available from the British

Library

Library of Congress Cataloguing in Publication data

Fundamentals of surgical practice / edited by Andrew N. Kingsnorth,
MS, FRCS, FACS, Consultant Surgeon, Derriford Hospital and
Honorary Professor of Surgery, Peninsula College of Medicine and
Dentistry, Plymouth, UK, Douglas M. Bowley, FRCS [Gen Surg],
Consultant Surgeon, Heart of England NHS Foundation Trust and
Senior Lecturer, Academic Department of Military Surgery and
Trauma, Royal Centre for Defence Medicine, Birmingham, UK. – Third
Edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-521-13722-5 (pbk.)
1. Surgery. I. Kingsnorth, Andrew N., 1948– editor.
II. Bowley, Douglas M., editor.
[DNLM: 1. Surgical Procedures, Operative. WO 500]
RD32.F86 2011
617 – dc22 2010048439

ISBN 978-0-521-13722-5 Paperback

Cambridge University Press has no responsibility for the persistence or

accuracy of URLs for external or third-party internet websites referred
to in this publication, and does not guarantee that any content on such
websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurate
and up-to-date information which is in accord with accepted standards
and practice at the time of publication. Although case histories are
drawn from actual cases, every effort has been made to disguise the
identities of the individuals involved. Nevertheless, the authors, editors
and publishers can make no warranties that the information contained
herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material contained in
this book. Readers are strongly advised to pay careful attention to
information provided by the manufacturer of any drugs or equipment
that they plan to use.
Contents
List of contributors vii
Preface x

Section 1 – Basic Sciences 10 Fundamentals of cancer management 151

Mark Duxbury
Relevant to Surgical Practice
1 Pharmacology and the safe
prescribing of drugs 1 Section 4 – Perioperative Care of
Jamie J. Coleman, Anthony R. Cox and the Surgical Patient
Nicholas J. Cowley
11 Fundamentals of intestinal failure and
2 Fundamentals of general pathology 15 nutrition 173
Gerald Langman Tim Campbell Smith and Alistair Windsor
3 Fundamentals of surgical 12 Enhanced recovery after surgery 181
microbiology 41 John Evans and Robin H. Kennedy
Richard Cunningham
13 Fundamentals of intensive care 190
4 Fundamentals of radiology 54 Angela L. Neville
Arvind Pallan
14 Caring for surgical patients:
complications and communication 230
Section 2 – Basic Surgical Skills Douglas M. Bowley

5 Surgical techniques and technology 71 15 Management of sepsis 248

Michael A. Scott and Mark G. Coleman Mark J. Midwinter

6 Professionalism – including academic

activities: clinical research, audit, Section 5 – Common Surgical
consent and ethics 94
Evangelos Mazaris, Paris Tekkis and Conditions
Vassilios Papalois 16 Assessment and early treatment of
7 Fundamentals of palliative and end of patients with trauma 253
life care 103 Ross Davenport and Nigel Tai
Chantal Meystre and Riffatt Hussein 17 Fundamentals of the central nervous
system 276
James Palmer and Anant Kamat
Section 3 – The Assessment and
18 Fundamentals of head and neck
Management of the Surgical Patient surgery 306
8 Preoperative assessment 127 John K.S. Woo and Walter W.K. King
Jeffrey L. Tong 19 Fundamentals of thoracic surgery 330
9 Fundamentals of anaesthesia 134 Richard S. Steyn and Deborah Harrington
Jeffrey L. Tong

v
 Contents

20 Oesophago-gastric surgery 343 27 Fundamentals of vascular surgery 505

Tim Wheatley Donald J. Adam, Martin W. Claridge and
Antonius B.M. Wilmink
21 Fundamentals of hepatobiliary and
pancreatic surgery 358 28 Fundamentals of orthopaedics 521
Mark Duxbury and Rowan Parks Jon Clasper
22 Fundamentals of endocrine surgery 378 29 Fundamentals of plastic surgery 537
Peter Cant Tania C.S. Cubison
23 Fundamentals of the breast 392 30 Surgical care of the paediatric patient 564
Steven D. Heys Paul K.H. Tam
24 Lower gastrointestinal surgery 430 31 Fundamentals of organ
Chris Cunningham transplantation 608
Matthew Bowles
25 Fundamentals of the genitourinary
system 453
Angela Cottrell and Andrew Dickinson
26 Hernias 480 Index 625
Andrew N. Kingsnorth

vi
Contributors

Donald J. Adam Mark G. Coleman

Consultant Surgeon, Heart of England NHS Consultant Surgeon, Department of Surgery,
Foundation Trust and Senior Lecturer, Department of Derriford Hospital, Plymouth, UK
Vascular Surgery, Birmingham University,
Birmingham, UK Angela Cottrell
Department of Urology, Derriford Hospital,
Matthew Bowles Plymouth, UK
Consultant Surgeon, Derriford Hospital, Plymouth,
UK Nicholas J. Cowley
Specialist Registrar, Department of Anaesthesia,
Douglas M. Bowley University Hospitals Birmingham NHS Foundation
Consultant Surgeon, Heart of England NHS Trust, Birmingham, UK
Foundation Trust, and Senior Lecturer, Academic
Department of Military Surgery and Trauma, Royal Anthony R. Cox
Centre for Defence Medicine, Birmingham, UK Lecturer in Clinical Therapeutics, School of
Pharmacy, Aston University, Birmingham,
Tim Campbell Smith UK
Department of Colon and Rectal Surgery, University
College London Hospitals, London, UK Tania C.S. Cubison
Consultant Surgeon, Department of Burns,
Peter Cant Reconstruction and Plastic Surgery, Queen Victoria
Consultant Surgeon, Department of Surgery, Hospital, East Grinstead, East Sussex, UK, and Royal
Derriford Hospital, Plymouth, UK Army Medical Corps, UK
Martin W. Claridge Chris Cunningham
Specialist Registrar in Surgery, Birmingham Colorectal Surgeon, Department of Colorectal
University Department of Vascular Surgery, Heart of Surgery, John Radcliffe Hospital, Oxford, UK
England NHS Foundation Trust, Birmingham, UK
Richard Cunningham
Jon Clasper Consultant Microbiologist, Department of
Consultant Surgeon, Frimley Park NHS Foundation Microbiology, Derriford Hospital, Plymouth,
Trust and Defence Professor of Trauma and UK
Orthopaedics, Academic Department of Military
Surgery and Trauma, Royal Centre for Defence Ross Davenport
Medicine, Birmingham, UK Trauma Research Fellow, Trauma Clinical Academic
Unit, Royal London Hospital, Whitechapel, London,
Jamie J. Coleman UK
Senior Lecturer, Department of Clinical
Pharmacology, College of Medical and Dental Andrew Dickinson
Sciences, University of Birmingham, Birmingham, Consultant Surgeon, Department of Urology,
UK Derriford Hospital, Plymouth, UK

vii
 List of contributors

Mark Duxbury Chantal Meystre

Clinical Scientist and Honorary Consultant Surgeon, Consultant, Palliative Care Physician, Heart of
University of Edinburgh, Royal Infirmary, Edinburgh, England NHS Foundation Trust and Medical
UK Director, Marie Curie Hospice, Solihull, Birmingham,
UK
John Evans
St. Mark’s Hospital, Middlesex, UK Mark J. Midwinter
Consultant Surgeon, University Hospitals
Deborah Harrington Birmingham NHS Foundation Trust and Defence
Specialist Registrar, Department of Thoracic Surgery, Professor of Surgery, Royal Centre for Defence
Heart of England NHS Foundation Trust, Medicine, Birmingham, UK
Birmingham, UK
Angela L. Neville
Steven D. Heys Assistant Professor of Surgery, Harbor-UCLA
Professor of Surgical Oncology and Consultant Medical Center, Los Angeles, CA, USA
Surgeon, Deputy Head, Division of Applied
Medicine, School of Medicine and Dentistry, Arvind Pallan
University of Aberdeen, Aberdeen, UK Consultant Radiologist, Heart of England NHS
Foundation Trust, Birmingham, UK
Riffatt Hussein
Education Fellow, Heart of England NHS Foundation James Palmer
Trust, Birmingham, UK Consultant Surgeon, Department of Neurological
Surgery, Derriford Hospital, Plymouth, UK
Anant Kamat
Consultant Surgeon, Department of Neurological Vassilios Papalois
Surgery, Derriford Hospital, Plymouth, UK Consultant Transplant and General Surgeon, The
West London Renal and Transplant Centre, Imperial
Robin H. Kennedy College NHS Healthcare Trust, Hammersmith
Consultant Surgeon, Department of Colorectal Hospital, London, UK
Surgery, St. Mark’s Hospital, Middlesex, UK
Rowan W. Parks
Walter W.K. King Consultant Surgeon, Edinburgh Royal Infirmary and
Clinical Professor, Department of Surgery, Chinese Reader in Surgery, Department of Clinical and
University of Hong Kong and Centre Director, Plastic Surgical Sciences, University of Edinburgh,
and Reconstructive Surgery Centre, Hong Kong Edinburgh, UK
Sanatorium and Hospital, Hong Kong
Michael A. Scott
Andrew N. Kingsnorth Consultant Surgeon, Department of Surgery,
Consultant Surgeon, Derriford Hospital and Gloucestershire Royal Hospital, Gloucester, UK
Honorary Professor of Surgery, Peninsula College of
Medicine and Dentistry, Plymouth, UK Richard S. Steyn
Consultant Surgeon, Department of Thoracic
Gerald Langman Surgery, Heart of England NHS Foundation Trust,
Consultant Histopathologist, Heart of England NHS Birmingham, UK
Foundation Trust, Birmingham, UK
Nigel Tai
Evangelos Mazaris Consultant Trauma and Vascular Surgeon, Trauma
PhD Student, The West London Renal and Transplant Clinical Academic Unit, Royal London Hospital and
Centre, Imperial College NHS Healthcare Trust, Senior Lecturer, Royal Centre for Defence Medicine,
Hammersmith Hospital, London, UK Birmingham, UK

viii
 List of contributors

Paul K.H. Tam Tim Wheatley

Chair Professor and Chief of Paediatric Consultant Surgeon, Department of Upper
Surgery and Pro-Vice Chancellor and Gastrointestinal Surgery, Derriford Hospital,
Vice-President (Research), The University Plymouth, UK
of Hong Kong, Queen Mary Hospital,
Hong Kong Antonius B.M. Wilmink
Consultant Vascular Surgeon, Birmingham
Paris Tekkis University Department of Vascular Surgery, Heart of
Consultant Colorectal Surgeon, Chelsea and England NHS Foundation Trust, Birmingham, UK
Westminster Hospital and The Royal Marsden
Hospital, London, UK Alistair Windsor
Consultant Surgeon, Department of Colorectal Surgery,
Jeffrey L. Tong University College London Hospitals, London, UK
Consultant Anaesthetist, University Hospitals
Birmingham NHS Foundation Trust, Department John K.S. Woo
of Anaesthesia and Critical Care, Royal Centre Clinical Associate Professor, Chinese University of
for Defence Medicine, Birmingham, Hong Kong and Consultant, Department of Surgery,
UK Prince of Wales Hospital, Hong Kong

ix
 Preface

The surgeon of today is witness to unprecedented skills, technical skills and professional attitudes, a sur-
change in the delivery of healthcare. Our populations geon must develop skills as a Communicator, Collabo-
are ageing and the available options for treatment are rator, Manager, Health Advocate, Scholar and Profes-
expanding. Surgeons are becoming increasingly spe- sional. These are admirable goals and the examination
cialist and patients in hospital are sicker than ever system is indeed evolving to assess the full range of
before. Pressures on trainees include a shorter work- these qualities.
ing week and there is an emphasis on operating the- This new edition of Fundamentals of Surgical Prac-
atre efficiency, which reduces opportunity for super- tice is aimed at the surgeon in training preparing for
vised trainee operating. Add to this the increasing the Intercollegiate MRCS Examination. The book fol-
scrutiny of an individual surgeon’s outcomes that can lows the syllabus for the examination, which has been
act to limit a trainee’s exposure to operative experi- agreed by, and is common to, the Surgical Royal Col-
ence. Traditional team structures of surgical firms and leges of Great Britain and Ireland. The syllabus inte-
the apprentice-style training have been consigned to grates basic sciences, principles of surgery-in-general
history. and important generic surgical topics. The authors are
Over recent years, the examination process in dedicated surgical educators and we hope this book
surgery has also changed and the Intercollegiate Sur- will communicate some of our passion for surgery to
gical Curriculum Project now emphasizes the differ- you as much as we hope it helps you progress in your
ent domains of surgical practice, based on the Can- professional careers.
MEDS framework and underpinned by the principles
of Good Medical Practice. As well as becoming a sur- Andrew Kingsnorth and Douglas Bowley
gical expert, with the appropriate knowledge, clinical

x
 Section 1 Basic Sciences Relevant to Surgical Practice
Chapter
Pharmacology and the safe prescribing

1 of drugs
Jamie J. Coleman, Anthony R. Cox and Nicholas J. Cowley

Understanding the pharmacological principles and experienced surgical staff prior to any operative inter-
safe use of drugs is just as important in surgical vention. Whilst not possible in emergency situations, it
practice as in any other medical specialty. With an is also wise to involve any other specialists who provide
ageing population with often multiple comorbidi- ongoing treatments in the discussion about elective,
ties and medications, as well as an expanding list of planned surgery well in advance. The general rule is
new pharmacological treatments, it is important that that medications with withdrawal potential should be
surgeons understand the implications of therapeutic continued perioperatively, non-essential medications
drugs on their daily practice. The increasing emphasis that increase surgical risk should be stopped before
on high quality and safe patient care demands that doc- surgery, and clinical judgement should be exercised in
tors are aware of preventable adverse drug reactions other circumstances. Many hospitals also have poli-
(ADRs) and interactions, try to minimize the poten- cies or protocols relating to perioperative prescribing:
tial for medication errors, and consider the benefits prescribers should be familiar with these and follow
and harms of medicines in their patients. This chapter them.
examines these aspects from the view of surgical prac-
tice and expands on the implications of some of the
most common medical conditions and drug classes in Medication history
the perioperative period. An accurate medication history is essential for the safe
The therapeutic care of surgical patients is obvi- prescribing of medication, and there is evidence that
ous in many circumstances – for example, antibacter- there is an unintentional variance between preadmis-
ial prophylaxis, thromboprophylaxis, and postopera- sion and on admission medicines of between 30%–
tive analgesia. However, the careful examination of 70% across all types of hospital admissions. Failure to
other drug therapies is often critical not only to the sus- accurately resolve differences in the medication his-
tained treatment of the associated medical conditions tory across boundaries in clinical care, which is often
but to the perioperative outcomes of patients undergo- referred to as medicines reconciliation, can lead to pre-
ing surgery. The benefit–harm balance of many thera- ventable adverse drug events. As a result of this, a
pies may be fundamentally altered by the stress of an technical patient safety solution for medicines recon-
operation in one direction or the other; this is not a ciliation on hospital admissions was jointly issued by
decision that should wait until the anaesthetist arrives the National Institute for Health and Clinical Excel-
for a preoperative assessment or one that should be left lence (NICE) and the National Patients Safety Agency
to junior medical or nursing staff on the ward. Think (NPSA) in 2007. In the surgical setting, knowledge of
for example of the difference between the need to stop the patient’s drugs and their comorbidities is essential
oral anticoagulants used for atrial fibrillation versus so that the risk of perioperative decompensation can
the abrupt cessation of long-term corticosteroids. The be determined.
strategy for different patients, for different conditions, The latest advice is that in order to properly recon-
and for different drug treatments is, not surprisingly, cile a patient’s medication history at least two sources
varied. There are some basic rules for many circum- of information about the drugs should be sought, with
stances and these should be considered carefully by one source preferably being the patient themselves.

Fundamentals of Surgical Practice, Third Edition, ed. Andrew N. Kingsnorth and Douglas M. Bowley.
Published by Cambridge University Press.
C Cambridge University Press 2011.

1
 Section 1: Basic Sciences Relevant to Surgical Practice

Table 1.1 CASES – a useful mnemonic to remember important and related drugs) is commonly obtained, drug his-
aspects within a surgical history
tory taking also provides an important opportunity to
Surgical relevance explore any previous exposure to other agents used in
the perioperative period (e.g. anaesthetic gases, anal-
Contraception Pregnancy in female patients
Risk of venous thromboembolism
gesics). This information is useful if the patient has
had prior adverse reactions to medicines, in which case
Anticoagulation Risk of bleeding
Need for decision about perioperative a more extensive review of the history and previous
continuation or other management medical notes may be required. The appropriate flag-
Steroids Requirement for steroids in surgery to ging and documentation of any intolerances or aller-
prevent Addisonian crisis gies is vitally important. For example, the prescrip-
Ethanol Risk of alcohol withdrawal tion of a penicillin-related drug to a penicillin-allergic
Interaction with anaesthetic patient is deemed a ‘never happen event’ in the health
Smoking Lung disease service.

The process should also involve a pharmacist, but Adverse drug events
this is not always possible. The overall process should Adverse events in healthcare are an inevitable outcome
ensure that important medicines aren’t stopped inad- of both acute and elective admissions – but are much
vertently on admission and that new medicines are less acceptable when considered to be preventable.
prescribed, with a complete knowledge of what a Adverse drug reactions (ADRs) are defined as appre-
patient is already taking. ciably harmful or unpleasant reactions, resulting from
Taking a medication history is not always as simple an intervention related to the use of a medicinal prod-
as asking a patient what drugs they are on. Attempts uct; adverse effects usually predict hazard from future
to obtain accurate primary care records from the gen- administration and warrant prevention, or specific
eral practitioner should be made. However, patients treatment, or alteration of the dosage regimen, or with-
can stop prescribed medicines without informing their drawal of the product. ADRs are a common factor in
general practitioner, or even tailor their own dosage hospital admissions, accounting in a large UK study
(for example, to avoid a suspected adverse reaction). for 6.5% of acute hospital admissions in whole or part
Focused questions should be asked to uncover infor- (Pirmohamed et al. 2004). In most cases these ADRs
mation that will subsequently be useful in the patient’s were judged to be potentially or definitely avoidable.
journey. Whilst the majority of these events result in medical
Elements of the medication history that are admissions, rather than surgical admissions, there are
often missed are over-the-counter medicines; non- some notable drug-attributable symptoms that may
oral medicines (e.g. eyedrops, creams or inhalers); masquerade as surgical emergencies. It is fairly com-
the oral contraceptive; complementary and alterna- mon knowledge that angiotensin-converting enzyme
tive therapies (including potent herbal products that (ACE) inhibitors have been associated with cases of
can interfere with cytochrome P450 enzymes, such as pancreatitis, but much less commonly known that
St John’s Wort) and ‘borderline substances’ (e.g. vita- the same agents can cause intestinal angioedema and
mins, food supplements). Such substances should be lead to repeated laparotomies for suspected peritonitis
specifically asked about, as many patients may not con- before the true diagnosis is made (Coleman 2007).
sider them medicines or will not volunteer them due Adverse drug reactions and medication errors can
to possible concerns that healthcare professionals will also cloud an inpatient admission, leading to increased
not approve of their use. In surgical practice there morbidity, increased length of stay, and occasionally
are some additional questions that are worth asking more serious outcomes or death. Approximately 15%
about which have been given the acronym CASES (see of inpatients will experience an ADR during hospital
Table 1.1). admission, although a lower proportion of surgical
A further part of the medication history – which patients (12%) experience adverse drug reactions
ties in with the past medical and surgical history – during their stay (Davies et al. 2009). The most com-
is prior drug exposure. While prior history of aller- monly implicated drugs are: loop diuretics, opioids,
gies from exposure to drugs (especially penicillin compound analgesics (e.g. cocodamol), systemic

2
 Chapter 1: Pharmacology and the safe prescribing of drugs

Table 1.2 Selected potential drug interactions with anaesthetics and neuromuscular blockers

Drug group Interacting drug Interaction

Anaesthetic agents Alpha-blockers Enhanced hypotensive effect
Antipsychotics Hypotension
ACE inhibitors and angiotensin-II receptor Severe hypotension. May need discontinuing
antagonists 24 hours prior to surgery
Adrenaline (epinephrine) Risk of arrhythmias with volatile general anaesthetics
Calcium channel blockers Enhanced hypotensive effect (and AV delay with
verapamil)
Lithium Enhance effects of muscle relaxants
Methylphenidate Risk of hypertension with volatile general anaesthetics
Monoamine oxidase inhibitors (MAOIs) British National Formulary advises should be stopped
2 weeks before surgery (risk of hypo- and
hypertension). May be due to confounding by
other drugs such as pethidine and ephedrine
Tricyclic antidepressants Increase risk of arrhythmias and hypotension during
anaesthesia
Neuromuscular blockers Anticonvulsants Effects of competitive neuromuscular blockers are
reduced and shortened with chronic use of
phenytoin and carbamazepine
Antibiotics: aminoglycosides, vancomycin, Neuromuscular blockade prolonged and increased
clindamycin and polymixins
Digitalis glycosides (e.g. digoxin) Risk of ventricular arrhythmias with suxamethonium
Lithium Effects of neuromuscular blockers enhanced

corticosteroids, inhaled beta-agonists, antibiotics events related to interactions between drugs. One par-
(penicillins, cephalosporins and macrolides), oral ticular concern in the perioperative setting is the
anticoagulants and low molecular weight heparins. interaction between pre-existing medications and the
Again, as with drug-induced admissions, over potential drugs used in the operative setting (e.g.
half of ADRs emerging during a hospital stay are anaesthetic drugs, analgesics). Drug interactions can
preventable. be broadly split into pharmacokinetic and pharma-
Suspected ADRs can be reported to the Yellow codynamic interactions. Pharmacokinetic interactions
Card scheme, which was started in 1964 in the wake are those influencing the absorption, distribution,
of the thalidomide disaster. The scheme is a sponta- metabolism and excretion of drugs. Pharmacody-
neous reporting scheme – incidents are detected and namic interactions occur when the effects of one drug
reported by healthcare professionals. For new drugs are influenced by the presence of a competitor drug at
and vaccines under intensive surveillance – identified its specific receptor site, or by indirect effects. These
by the inverted black triangle symbol in the British can be antagonistic or additive or synergistic in nature.
National Formulary – all suspected ADRs should be Judging the importance of a particular drug inter-
reported regardless of how trivial they may appear. action can be difficult. Evidence from clinical stud-
For established drugs and vaccines, only seri- ies is generally lacking, and when available can
ous suspected reactions should be reported. Serious be from pharmacokinetic/pharmacodynamic studies
reports include disability, life-threatening or deadly performed in small numbers of healthy young volun-
reactions, and medically significant reactions, such as teers, who are not representative of the patient groups
bleeding or congenital birth defects. Further guidance in which interactions may occur. Case reports and case
on ADR reporting is given in the British National For- series can therefore be important sources of informa-
mulary and at the MHRA Yellow Card reporting web- tion about interactions, although care must be taken
site http://www.yellowcard.gov.uk. due to the inherent limitations of such evidence in
terms of causality. Information sources such as the
British National Formulary and Stockley’s Drug Inter-
Drug interactions actions handbook provide useful summarized infor-
Drug interactions are an important cause of adverse mation for clinicians. Some interactions with drugs
drug reactions, with around 17% of adverse drug used in the operative setting are given in Table 1.2.

3
 Section 1: Basic Sciences Relevant to Surgical Practice

Medication errors cause harm until events conspire to allow an error to

pass the normal defences.
Medication errors have been defined as ‘a failure in the
treatment process that leads to, or has the potential
to lead to, harm to the patient’. These can occur either Nil by mouth
because the wrong plan has been chosen (i.e. a con- Whether a patient can take food or fluids by mouth
traindicated drug prescribed due to lack of knowl- prior to surgery often seems to influence whether the
edge), or because a good plan has been implemented patient will receive medications via the oral route. For
poorly, preventing the intended outcome (i.e. poor adult elective surgery in healthy adults without gas-
handwriting on a prescription leading to the admin- trointestinal disease it is usual to restrict oral solids for
istration of the wrong drug). 6 hours before surgery, with only water or clear flu-
Errors can be at the skill-based level (slips and ids allowed up until 2 hours before surgery. In most
lapses), the rule-based level (poorly chosen or inappro- instances therefore it is allowable to give routine med-
priate rules) and the knowledge-based level (applica- ications with these clear fluids until 2 hours before
tion of knowledge to a novel situation). Errors have two the operation. If gastrointestinal problems are present
broad categories: errors in the planning of an inten- preoperatively and certainly in operations where the
tional act, known as mistakes; and errors in execu- patient is starved postoperatively, alternative methods
tion of an act, known as slips (acts of commission) and of drug administration or medication strategies must
lapses (acts of omission). be employed (for example converting to a parenteral
Slips and lapses are unconscious acts or omissions preparation for a period of time). Many other pro-
and occur when a prescriber has the correct plan cesses will affect the absorption of oral medications
for treatment, but fails to carry it out accurately. An during this period, including diminished blood flow to
example might be picking the wrong drug strength the gut, villous atrophy, mucosal ischaemia and dimin-
from a computer list when prescribing. These are not ished motility from postoperative ileus. Local guide-
amenable to training or threats. lines or medicine information department or senior
Mistakes occur when error arises in an attempt to clinical/pharmacist advice may be required to ensure
deal with a complex situation, through lack of knowl- that the right dose for the medicine is used for the
edge, or the application of poor or inappropriate rules. chosen route of administration. Staff administering the
An example would be an inadvertent overdose due to drugs should be clear which drugs are intended to
lack of knowledge of the use of a drug in renal failure. be given on the day of operation and which are pur-
Another subset are violations, which are defined as posely omitted, otherwise the prescriber’s intent may
deliberate – but not always reprehensible – deviations not be followed.
from those practices deemed necessary to maintain the
safe operation of a potentially hazardous system. In the
context of prescribing, an example might be the taking Discharge at home drugs
of deliberate short-cuts in a badly designed electronic Ensuring that patients are discharged on the correct
prescribing system. medication is an essential part of good surgical prac-
Accurate information about patients and access to tice. It is tempting to only provide details about new
good information about drugs can mitigate some pre- medications relevant to the surgery, but unless this
scribing errors. Adherence to good principles of pre- is obvious to other care providers there is a risk of
scribing and hospital policies can also help reduce the failing to communicate essential information about
opportunity for some medication errors. For example, the patient. This process also helps to ensure that the
writing micrograms in full rather than the abbrevia- intended resumption of long-term medicines is not
tion mcg can prevent confusion between micrograms overlooked. When the patient leaves the hospital the
(mcg) and milligrams (mg). provision of appropriate advice both to the patient and
Distractions and momentary loss of attention will within the discharge letter is essential. Think of the
always have the potential to cause medication errors. example of a patient with a recent splenectomy; pro-
Additionally, complex systems of care can contain so- viding the correct advice will ensure that the general
called ‘latent’ errors within the system. These built-in practitioner is aware that the oral penicillin has to be
failures, due to policies or custom and practice, do not given for life as well as ensuring that the patient knows

4
 Chapter 1: Pharmacology and the safe prescribing of drugs

the precautions to be taken for the future. Another Table 1.3 Opioid strength to achieve equivalence to 10 mg
oral morphine
example would be providing the correct advice about
the cessation of anti-anginal therapy but continuation Opioid analgesic Relative potency Dose of drug
of antiplatelet treatment following coronary artery
Morphine (oral) 1 10 mg
bypass surgery – failure to get this right may lead to
Codeine (oral) 0.1 100 mg
adverse outcomes for the patient. The surgical practi-
tioner must ensure that the discharge at home drugs Tramadol 0.2 50 mg
are clearly recorded on the discharge letter, particularly IV/IM morphine 4 2.5 mg
noting the reasons and intended length of course for IV/IM pethidine 0.3 30 mg
new medications and the reasons for stopping previ- Oxycodone (oral) 2 5 mg
ous at home medicines.
Buprenorphine (oral) 40 250 mcg
The next section of the chapter concentrates on
Fentanyl (oral) 75 130 mcg
specific diseases and drug classes known to be rele-
vant for surgical patients in clinical practice. Specific
increased dosing of all other drugs within the opioid
information about individual drugs should always be
family. There is no reason why a patient maintained on
sought from an up-to-date reference source such as the
a fentanyl patch for chronic pain should not continue
British National Formulary (BMJ 2009).
this through the perioperative period, with standard
intermittent morphine prescription for breakthrough
Analgesics pain. Knowledge of the relative strength of one opioid
Analgesics for surgical patients may be divided into compared to another is valuable in determining likely
those serving to relieve chronic pain unrelated to any requirements for breakthough pain (see Table 1.3).
planned surgical intervention, chronic pain related to The choice of route of administration of an anal-
the condition being managed or acute pain related to a gesic drug will be influenced by the type of surgery,
surgical intervention. Although the therapies used to and by the postoperative monitoring environment.
manage each form of pain may overlap, it is impor- Abdominal surgery may reduce the likelihood of
tant to understand why each analgesic is prescribed, in enteral absorption of analgesics, and an alterna-
order to predict fluctuations in analgesic requirement tive route of administration should be used until
in the perioperative period. For example, a patient good absorption can be guaranteed. Care must be
may attend for elective cholecystectomy with a back- taken, particularly in patient groups with abnormal
ground of chronic intermittent abdominal pain, in metabolism or excretion of drugs such as the elderly
addition to weight-related chronic back pain. He or or those with acute or chronic renal impairment, not
she may already be taking a significant number of to allow accumulation of potent analgesics such as
analgesics to control their pain. Without prior knowl- morphine with resultant respiratory depression and
edge of the reasons for taking each analgesic and their over-sedation. Patient-regulated analgesics such as ‘as
doses, it would be difficult to plan their postopera- required’ analgesics or patient-controlled analgesia
tive analgesic requirements. In particular, opiates are (PCA) opiate infusions are inherently safer than using
frequently under-dosed in the postoperative period in regular potent analgesics or infusions, particularly
tolerant individuals. A patient maintained on a large outside a high-dependency environment. PCA must
dose of sustained-release morphine for chronic pain not, however, be used as the exclusive form of analge-
will not respond to a conventional acute dose peri- sia, as this will result in fluctuating levels of pain, and
operatively, and the dose will need to be individually in particular interfere with rest and sleep in the early
tailored. postoperative period. Again, regular analgesia must be
adjusted with knowledge of baseline requirements, and
Routes of administration of analgesics regularly reviewed in the postoperative period, titrated
Different classes of opioid, or different routes of to the patient’s pain. A useful method of titrating regu-
administration – for example the transcutaneous fen- lar analgesic requirement is to review the ‘as required’
tanyl patch – have differing pharmacokinetic profiles. or PCA dose delivered over the preceding 24 hours,
Importantly, however, there is a class effect in which and to use this dose to guide the regular analgesic
tolerance from one form of opioid will necessitate requirement over the following 24 hours.

5
 Section 1: Basic Sciences Relevant to Surgical Practice

Un-ionized LA Extracellular Fluid

Ionized LA
blocks Na++ Neuronal Lipid Membrane
channel on inner
membrane

Intracellular Fluid

Un-ionized LA penetrates nerve

Portion of LA becomes ionized
sheath and neurolemma

Figure 1.1 Diagram showing LA dissociation/neuronal penetration.

The World Health Organization (WHO) effective strategy will include liberal use of non-
opiate analgesics, and regional analgesia where possi-
pain ladder ble. When opiates are required, it should be accepted
The WHO pain ladder provides a simple strategy to that small doses may be ineffective, and an increase
pain management on the basis that analgesics have dif- in dose should be prescribed with careful supervision
ferent and synergistic modes of action (WHO 2009). and clear patient boundaries. The inpatient perioper-
Additionally, it is clear that analgesic drugs have ative period is not the time to be attempting to wean
adverse effects, and these are usually dose-dependent. the patient’s opiate dependence, and attempting to do
With these two points in mind, the WHO pain ladder, so will make the working environment strained. How-
originally devised for management of cancer-related ever, a degree of common-sense prescribing is also
pain, advises the initiation of simple analgesics such clearly required.
as paracetamol, followed by the addition (rather than
replacement) of weak and then strong opiates. Non- Local anaesthetics
steroidal anti-inflammatory drugs (NSAIDs) are excel-
As well as systemic administration of drugs, local
lent forms of postoperative pain relief, again work-
anaesthetics provide a valuable form of pain relief in
ing synergistically with paracetamol and opiates. These
the perioperative period. Local anaesthetics work on
drugs may be used regularly for short durations unless
nerve conduction locally, to prevent transmission of
there are contraindications (e.g. peptic ulcer disease).
the pain impulse, specifically by blocking the neu-
They should be used with extreme caution in the
ronal Na2+ channels. Knowledge of their mechanism
elderly and those with renal impairment or heart fail-
of action can help in their effective practical applica-
ure, and where their antiplatelet function is undesir-
tion. Local anaesthetics are all weak bases. They are
able. A single dose of diclofenac in a critically unwell
fully ionized in an acidic solution at the point of injec-
postoperative patient could well render them anuric.
tion, where upon entry into tissue at neutral pH they
become only partially dissociated. Only the un-ionized
Drug dependence and perioperative portion of the drug is able to pass through the lipid
membrane of a nerve to the internal surface where the
analgesia Na2+ channel is accessed and blocked. It is for this
Patients with a background of illicit opiate drug abuse reason that local anaesthetics penetrate infected tissue
are likely to be tolerant to conventional doses of opiate poorly; the acidic environment favours ionization of
analgesics. Postoperative analgesia is therefore often a the local anaesthetic, and therefore poor penetration
problem in these patients. Clearly drug abusers feel of the neuronal lipid membrane (Figure 1.1).
pain just as the rest of us do, and it is not good A surgeon will regularly infiltrate local anaesthetic,
practice to ignore their analgesic requirements. An and therefore knowledge of the choice, dosing and

6
 Chapter 1: Pharmacology and the safe prescribing of drugs

toxicity is essential. There are recommended maxi- be used to treat infection empirically or based on the
mum doses of local anaesthetics which aim to avoid results of isolated organisms from microbiological cul-
toxicity. Rather confusingly though, maximum doses tures. Choice of prophylactic or empirical antibiotic
for local anaesthetic drugs are published in milligrams, therapy should be guided by local microbial resistance
or milligrams per kilogram, whereas local anaesthet- patterns, and will differ from one geographical region
ics are usually available as percentage solutions. For to another and even from one specialty to another.
example a 1% solution of lidocaine (lignocaine) con- There has been a drive to reduce excessive antibiotic
tains 1g (1000 mg) of lidocaine in 100 ml of solvent. administration in the perioperative period in order to
Therefore, each millilitre of 1% lidocaine will contain reduce the incidence of resistant organisms, as well
10 milligrams (1000/100 mg) of the active drug. as inadvertent gut proliferation of organisms such as
Local anaesthetic toxicity is caused by systemic Clostridium difficile. When indicated, a single dose of
absorption and relates specifically to peak serum con- prophylactic antibiotic, given at full treatment dose,
centrations of drug, and subsequent adverse central should be administered within 30–60 minutes of skin
nervous system and cardiovascular effects. Peak serum incision. Generally speaking, this will be on arrival
concentration is not always directly proportional to in theatre at the time of anaesthesia or during surgi-
the dose given, although the recommended dose max- cal site preparation. Whilst the majority of antibiotics
imums for each drug are a good guide. Peak serum may be administered as an intravenous bolus, there
concentration is related to the rate of systemic absorp- are a few notable exceptions, including vancomycin,
tion of the drug in the tissue being infiltrated, which ciprofloxacin and erythromycin, which must be deliv-
can depend on the vascularity of the site or concurrent ered slowly in a diluted solution; this becomes relevant
administration of local vasoconstrictors. Infiltration of when antibiotics should be initiated prior to arrival in
local anaesthetic with adrenaline into poorly vascu- the theatre suite in order to achieve adequate serum
larized lipomatous tissue, for example, will result in a concentrations at the initiation of surgery to minimize
very slow rate of systemic drug absorption, and ongo- risk of infection.
ing metabolism of drug during this period will prevent Route of administration may also be best decided
a high peak concentration even with fairly high dos- on with knowledge of each antibiotic’s bioavailability.
ing. Conversely, a very small inadvertent intravascular For example, the quinolones, such as ciprofloxacin, are
injection, even within the recommended dose range, absorbed so well orally that even in the presence of
will lead to an immediate spike in serum concentra- severe infection the intravenous route is only indicated
tion, and have the potential to cause cardiovascular if there is concern about the effectiveness of enteral
collapse. The treatment of severe local anaesthetic tox- absorption.
icity is therefore a prerequisite for safe surgical prac- Use of prophylactic antibiotics for certain surgical
tice. Seizures and cardiovascular collapse should be procedures has been until recently recommended for
treated using standard resuscitation protocols (i.e. an groups of patients with structural cardiac lesions or
airway, breathing, circulation algorithm). Cardiopul- prosthetic valves in order to prevent infective endo-
monary resuscitation in the event of cardiorespira- carditis. Although there is conflicting advice from one
tory arrest may have to be prolonged to allow drug authority to another, it is now generally considered
metabolism to less toxic levels and return of sponta- that the risk of infective endocarditis may be actually
neous cardiac output. More recently, however, proto- lower than the incidence of severe antibiotic-related
cols for administration of a lipid emulsion infusion complications from blanket antibiotic use. Currently
(Intralipid
R
) have been developed (AAGBI 2007). The the advice is to consider the risk on a case by case basis
lipid emulsion preferentially absorbs the un-ionized (NICE 2008).
local anaesthetic in a similar way to the lipid neuronal When treating established infections, awareness of
membrane, lowering serum concentrations and speed- the differences in mechanism of action of antibiotics
ing recovery markedly. can have practical implications for patient manage-
ment. For instance, aminoglycoside antibiotics such
as gentamicin are most efficacious at peak serum
Antibiotics concentrations – favouring large, once-daily, dosing
Antibiotics may be administered prophylactically to regimens. Other antibiotics, such as the glycopep-
reduce the incidence of surgical site infections, or may tides including vancomycin, work best when a serum

7
 Section 1: Basic Sciences Relevant to Surgical Practice

concentration is steadily maintained, and are less effec- ous, rapid correction of blood pressure may actually
tive if levels are allowed to dip. The site of infection may worsen morbidity by reducing perfusion pressures
also dictate the choice of antibiotic. Although a micro- to organs without sufficient time for end organs to
biological sample may reveal that a bacterium is sensi- compensate.
tive to a number of classes of antibiotic, it does not fol-
low that each antibiotic will be equally as effective. For
example, quinolones will penetrate lung parenchyma Beta-adrenoceptor blocking drugs
much more effectively than most penicillins (Honey- This drug class deserves a special mention with regards
bourne 1994). to the perioperative period. Beta-adrenoceptor block-
ing drugs (beta-blockers) are commonly prescribed
for both hypertension and for ischaemic heart disease.
Cardiovascular medications When prescribed for ischaemic heart disease, they
Cardiovascular morbidity is present in many surgi- should not be abruptly discontinued, as the patient
cal patients and there are a large number of associ- will be at higher risk of perioperative cardiovascu-
ated drug classes used to control hypertension, symp- lar adverse events if stopped. Beta-blockers prevent
toms of heart failure or ischaemic heart disease, and peri- and postoperative tachycardia, thus increasing
to limit cardiovascular disease progression. A patient’s the time spent in diastole for good myocardial perfu-
usual medication should be noted, and only adjusted if sion. Conversely, initiating beta-blockers in the peri-
there is a good clinical reason to do so. It is not accept- operative period in those at high risk of cardiovascular
able for a patient with significant cardiovascular dis- events may not be the right thing to do. A recent Cana-
ease on multiple medications for disease control to dian trial has examined the evidence and concluded
have these drugs omitted because of admission to a that reduced cardiovascular mortality is offset by an
surgical ward. increased incidence of stroke in this group (POISE
2008). The ability to mount a tachycardic response to
Hypertension a state of hypovolaemia will be blunted in patients
Perioperative cardiovascular instability is related to the recently started on beta-blockers, and in a postoper-
degree of chronic uncontrolled hypertension. Medi- ative ward with infrequent monitoring this may be
cations used to control high blood pressure should missed, leading to serious adverse events.
be established weeks to months before attending for
surgery. It is important to understand why hyperten- Angiotensin-converting enzyme (ACE)
sion needs to be controlled, in order to appreciate
why the acute correction of blood pressure does not inhibitors
appreciably reduce perioperative cardiovascular risk. ACE inhibitors and angiotensin receptor blockers are
The chronic hypertensive patient will develop left ven- potent drugs, with significant benefits in many patients
tricular hypertrophy, and so at times of surgical or with chronic cardiovascular disease. They have potent
postoperative stress the bulky myocardium will have vasodilating properties, and there is some concern
an increased oxygen demand, but a reduced period about their use immediately prior to anaesthesia.
of perfusion (occurring during diastole) and there- Certainly patients treated with ACE inhibitors may
fore an increased chance of perioperative myocardial already fit into a high-risk category for general anaes-
ischaemia. The chronic hypertensive patient will also thesia. The vasodilatation caused by general anaes-
have a relatively high peripheral vascular resistance. thesia or neuraxial (spinal) blockade will act syner-
This leads to significantly higher demands on the gistically with ACE inhibitors and rarely may cause
heart, which is pumping against high resistance, and refractory hypotension during anaesthesia, which may
a tendency towards cardiovascular lability in the peri- be difficult to control with standard vasoconstrictors
operative period; particularly following the adminis- (Colson et al. 1999). This problem is usually manage-
tration of vaso-active drugs such as general anaes- able during the period of close monitoring at anaes-
thetic agents. It is vital that long term preoperative thesia and rarely leads to patient harm. Protocols of
cardiovascular optimization has taken place, as these discontinuing one cardiac medication but continu-
highlighted problems will persist until cardiovascu- ing another often lead to confusion and as a result
lar remodelling has taken place. In fact overzeal- the omission of all drugs preoperatively; this situation

8
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