Zaid Azhar 2017-097

PREOPERATIVE AND POSTOPERATIVE

ASSESSMENT

• Pre-op assessment Slides 1-16

• Post-op assessment Slides 21-32

Content

When patient is seen at clinic, the doctor deciding their need for an operation thinks they need to be seen in the pre-op setting to ensure the patient’s readiness for theatre.

Who goes for pre-operative assessment?

Identify patient’s medical problems

Check if further information is needed to characterize patient’s medical status

Establish if patient’s condition is medically stable

Confirm appropriateness of the planned procedure

Establish plan to minimize risk to the patient

Goals of Pre-Op Assessment

• History• Examination• Investigations• Consent

What’s included in the Pre Op assessment?

History of Presenting Complaint Past medical history Past surgical history Family history of disease Social history/substance abuse Medication Drug allergy Past Anesthetic history

History

Year Procedure Type of Anesthesia Complications e.g DVT,

MRSA wound infection.

Past surgical history

Smoking Alcohol Substance abuse

IV abuse - screening for HBV, HCV, HIV

Social History

Drugs that may cause concern: Warfarin Aspirin - stop at least 10 days pre-

operatively OCP

DVT Pulmonary Embolism Discontinue 6 weeks before surgery

Steroids-dependent patients will need hydrocortisone injection to over come peri-operative stress.

Immunosuppression Diuretics

Electrolyte imbalance

Medication

Take history of any reaction in the past or in family history

Consider allergy to: Anesthetics Antimicrobial Drugs Antiseptics e.g iodine Wound dressings

Drug Allergy

• Difficult intubation

• Aspiration during anesthesia

• Psedocholinesterase deficiency

• Scoline apnea

• Malignant Hyperthermia

Past anesthetic history

BMI

GPE Vitals

Pulse Blood pressure Temperature Respiratory rate

CVS, RES, CNS

Intubation Mallampati score Dentition Neck movement TMJ movement

Examinations

Cormack-Lehane grade Mallampati score

Ease of intubation

ASA scoring system

Information : patient should be aware of his surgeon, staff and procedure

Teamwork: Operative team should be on the same page

Recording information: all important information should be recorded clearly in the patient notes

Communication

• Antibiotics

• Transfusion

• Nutrition

• Thromboprophylaxis

Preoperative treatment

Cases

Aspirin• Some surgeons don’t mind

patient being on Aspirin, call registrar if unsure. If clopidogrel, MUST stop

• Will need eG+H, often bleed +++CPAP• Will need to bring in her machine

or book a bed in RCU may need recent RFTs

Radiology • need recent films. If knee

replacement, needs long leg views as well as AP, lat and skyline.

• 70 F for right total knee replacement• Hx

• On aspirin for TIAs• HTN, COPD, on CPAP

• Radiology is over 1 year old

• What do we need to think about for this patient?

Case 1

• Type 1 diabetic• On insulin, CANNOT stop it • Patient will be fasting, not

good for a type 1• Will need bowel prep.• Likely will need admission

the night before or morning of procedure for insulin/dextrose infusion to control BSLs

• 25 F for colonoscopy• Hx • Type 1 DM

• What do we have to think about for this patient?

Case 2

• Warfarin• Will need to be stopped as

bleeding is high risk

• Will need to continue theraputic clexane due to metal heart valve

• Need a clear plan on stopping and restarting warfarin.

• 80 M for excision lower leg SCC• Hx• On warfarin • Mitral valve replacement

• What do we need to think about this patient?

Case 3

Post operative assessment

• Postoperative care is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating room and post anesthesia care unit (PACU), as well as during the days following surgery.

• The post operative period begins from the time the patient leaves the operating room and ends with the follow up visit by the surgeon.

Post-operative care

Care of the surgical patient who has been transferred from the Phase I post op unit

Patient requiring less observation and less nursing care than Phase I

This phase is also known as Step down or progressive care unit

• It is the immediate recovery phase and requires intensive nursing care to detect early signs of complication

• Receive a complete patient record from the operating room which to plan post operative care

• Designated for care of surgical patient immediately after surgery and patient requiring close monitoring

Post Op PeriodPhase 1 Phase 2

• Clinical assessment and monitoring• Respiratory management• Cardiovascular management• Renal Management (urine

output)• Fluid and electrolyte balance• Control of sepsis• Nutrition

Post op care instructions

Immediate post-operative assessment

• Assess the patient’s:

i. Pulseii. BPiii. Temperatureiv. RRv. Oxygen saturationvi. Level of

consciousness

Immediate post-operative assessment

• Analgesia relieves suffering

• Inadequately controlled pain increases sympathetic outflow, leading to an increase HR, vasoconstriction and increased O2 demand, particularly in the myocardium and may contribute to MI

• Pain (from e.g. abdominal and thoracic procedures) may impair Respiratory function leading to atelectasis/Pneumonia

• Good analgesia allows for rehabilitation

Post Op Analgesia

ParacetamolShould be given regularly,

oral, rectal or IVNSAIDsUsed as adjuncts, Increase

efficacy and reduce opioid use

Can affect haemostasis and renal function gastric ulceration

OpioidsGold standard in severe pain

Post Op Analgesia

• Cardiovascular complications

• Postoperative pulmonary dysfunction

• Aspiration

• Postoperative renal complications

• Metabolic complications

• Electrolytes and glucose imbalance

• Miscellaneous complications

Complications

• Local complications• Skin blisters/ bed sores• Muscle tear and atrophy• Tendon tear, tendinitis• Nerve compression and

neuritis• Vascular injury• Bone malunion• Contractures

• General complications• Shock• DVT• Tetanus• Gas gangrene• Fever• Fat embolism• Delerium tremors

Post operative complications

When is the patient discharged?