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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?