Pre and Post Op Management of Surgical Patients

7/31/2019 Pre and Post Op Management of Surgical Patients

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Preoperative Assessment

Dr Abhirup Lobo (Intern)


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Preoperative assessment

- Assess patients health

- Anticipate problems

- Informed consent

- Education

Goal???

To reduce a patients morbidity and mortality

By-product?

Reduces unnecessary cancellations


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HOPC

Whats the problem?

Is it acute or chronic?

What are the symptoms?

Local vs. systemic

Why is the patient having this operation?

Why now?


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Past surgical history

Includes past anaesthetic history

Reactions to anaesthetic

PONV

Difficult airways/IV

Rare: Malignant hyperthermia

Post surgical complications


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Past medical history by system

Cardiovascular (IHD inc angina, HF, AF,strokes/TIAs)

Respiratory (COPD, asthma, past/current PE)

Haematology (anaemia, bruising/bleeding) Renal (renal failure/disease)

Liver (Hep B/C, IVDU, past jaundice)

Endocrine (Diabetes hypo/hyperglycemia, BSLs,complications renal, eye, foot)

Arthritis


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Family history

Reactions to anaesthetic:

Malignant hyperthermia


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Medications

Continue:

Antihypertensives

Beta-blockers

Statins

Consider:

Anticoagulants inc aspirin, warfarin, clopidogrel

Diabetic meds: insulin, oral hypoglycemics

Other medications of concern: Steroids

OCP


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Medications (contd)

Allergies

Analgesia - NSAIDs


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Social history

Premorbid function inc ADLs

Occupation

Social supports Smoking

Alcohol

Drugs + tolerance to opioids


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Examination

Vitals

Airway assessment

Done by the anaesthetist in PAC

dentition

neck mobility

sex

Obesity Beard!!

Mallampati score (score III)

Thyromental distance (unreliable)


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Mallampati score


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Whats the ASA?

ASA I Healthy patient

ASA II Mild systemic disease with no functional limitation -for example, controlled hypertension

ASA III Severe systemic disease with definite functional

limitation - for example, chronic obstructive pulmonarydisease

ASA IV Severe systemic disease that is a constant threat tolife - for example, unstable angina

ASA V Moribund patient who is not expected to survive for

24 hours with or without surgery - for example, with anabdominal aortic aneurysm

Suffix E Emergency procedure


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Focussed examination

Cardiovascular

Respiratory

Consider:

Abdominal exam

Neurological exam

Joint exam

Vascular exam


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Investigations

Bloods

Imaging

Other

How much should you test?


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Group and Save X-match X-match X-match

Need for

transfusion

Unlikely Likely Definite Definite

Expected blood

loss


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The end of the consult

So what happens at the end of the consult?

Check for informed consent (inc form)

Instructions before the operation

Information about the surgery, recovery and likely

return to full activity


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Case example 1

20yo male with no past medical history

Presents for removal of lipoma

Famhx: an aunt died due to an anaestheticreaction


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Case example 2

70yo female presents for total hip

replacement

PMHx: AF, TIAs

Medication: Warfarin


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Case example 3

65yo male presents for elective TURP

PMHx: IHD, CABGx2, COPD

Smoking: 40 pk year hx


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Post-op complications

Dr Abhirup Lobo (Intern)


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Case 1

55yo female presents with fever of 38.0C post-THR. She has no relevant past medical history.

On examination,

- Vitals: PR80 reg, BP145/80, RR20, Sats 95% RA

- Resp exam: bibasal crackles

Whats the cause of her fever?


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Fevers,


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Case example 2

74yo male presents with fever of 38.4C post-cholecystectomy. He has no relevant past medicalhistory.

On examination,

- Vitals: PR95 reg, BP135/80 RR20, Sats 92% RA

Without further examination. What is yourdifferential diagnosis?

What investigations will you order?


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Fevers 24h-72h

Pulmonary causes eg. atelectasis, pneumonia

inc aspiration

Catheters!!

UTI related to foley catheter

Thromboplebitis from IV cannula


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Case example 3

You are the doctor on call overnight. You get

paged about Mr Hyatts. The page reads:

42yo male. 6d post op (L femur # ORIF). Temp is

now 38.0 C and pt is tachycardic not

responding to fluids.

What is your differential diagnosis?


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Fever >72h

- DVT!!!

- Infection

- Wound

- UTI

- Pulmonary


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5 Ws

- Wind

- Water- Wound

- Walking

- Wonder drugs


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Case example 4

60 yo male presents d5 post laparotomy with

urine output of 20mL/hour. He has been

ambulating. His catheter was removed earlier in

the day.

What do you have to think about?


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- Hx

- Ex

- Fluid balance- Pre-renal vs. Obstruction

Mx:

- Does the pt need rehydration?- Does the pt need a catheter?


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Case example 5

42 yo female presents with SOB 5 hours post-

partial thryoidectomy.

PHx: childhood asthma

Meds: Pravastatin

Smoking: 0.5pk/d for 20y

What are your differentials?


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Case example 5 contd

On examination, the pt is in respiratory distress

and is using her accessory muscles of

respiration. From the end of the bed, you can

hear a loud harsh sound whenever she tries totake a breath.

PR 110 reg, BP 150/80, RR24, T36.5, Sats 91% RA

Her wound is dressed.

CVR exam: NAD


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Case example 5

Whats your differential diagnosis?

Is this an emergency?

What are you going to do?


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Case example 6

The nurse on 3SW pages you urgently regarding

a 20yo male 3d post appendicectomy with a red,

purulent wound.

What predisposes you to a wound infection?


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Predisposing factors

Type of surgery

Pt characteristics

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Pre and Post Op Management of Surgical Patients