Pre Op Planning

Question 1

What is Pre-op care?

Answer 1

Pre-operative care is the preparation and assessment, physical and psychological of a patient before surgery (Mallett & Dougherty 2000).

Question 2

What are the aims of pre op assessment?

Answer 2

• Including explaining procedures, their associated risks and aftercare - Informed decisions. - Identifying co-existing medical conditions and how to optimise the patient’s health, while appreciating the urgency of their operation.

Question 3

What is the peri-operative physical assessment score (ASA)?

Answer 3

ASA 1: Healthy patient ASA 2: Mild systemic disease. No functional limitation ASA 3: Moderate systemic disease. Definite functional limitation ASA 4: Severe systemic disease that is a constant threat to life ASA 5: Moribund patient. Unlikely to survive 24 hours, with or without treatment Postscript E indicates emergency surgery

Question 4

What are the grades of surgery?

Answer 4

Grade 1: Minor procedures e.g diagnostic endoscopy, breast biopsy Grade 2: Inguinal hernia repair, varicose veins adenotonsillectomy, knee arthroscopy Grade 3: Total abdominal hysterectomy, TURP, lumbar discectomy, thyroidectomy Grade 4: Major procedures, e.g. total joint, artery reconstruction, colonic resection, radical neck dissection

Question 5

How do you determine the ASA level?

Question 6

What pre-op investigations may be done?

Answer 6

—- Identify the essential pre-operative investigations required for all surgical patients, including: blood tests

—- (FBC, U+Es, creatinine) and ECG, also pregnancy test, sickle cell test and chest x-ray if appropriate.

—1. Identify and explain the more specific pre-operative investigations required for individual patients according to condition, comorbidities or procedure being performed.

—2. State the basic fasting guidelines for children and adults.

Question 7

What may be some associated medical conditions?

Answer 7

• Difficult airway, obesity, cardiac disease, respiratory disease, gastrointestinal disease,
• Renal failure,
• Diabetes,
• Haematological disorders - anaemia, sickle cell anaemia,
• Allergic reactions, and those rendering patients at high risk
• Additional investigations for specific illnesses – such as cardiopulmonary exercise testing to evaluate both cardiac and pulmonary function

Question 8

What are some common conditions that can affect peri operative care?

Answer 8

—Ischaemic heart

—Congestive cardiac

—Chronic respiratory

—Diabetes

—Liver or kidney

Question 9

What is the cardiac risk index?

Answer 9

1 procedure-related risk factor: intrathoracic surgery, intra-abdominal surgery, or suprainguinal vascular surgery

—

5 patient-related risk factors

—Ischaemic heart disease

—Congestive heart failure

—History of stroke or TIA

—Creatinine > 2.0 mg/dL

—Insulin-dependent diabetes mellitus

—

Poor functional capacity: patients who become breathless and/or have chest pain while climbing a flight of stairs, walking on level ground at 4 km/hr, or performing heavy work around the house

Question 10

What investigations would you consider doing?

Answer 10

Blood tests

FBC, U&E, LFT, Coagulation Screen, G&S (anything else?)

—

Electrocardiogram

Hospital protocol may require a baseline electrocardiogram.

It could be a key comparison in the event of any adverse cardiac events postoperatively.

—

Chest radiograph

Sometimes (when)?

Group and Save

Question 11

When would you need an ECG?

Answer 11

—Patients with > 1 RCRI risk factor and one of the following: Age > 65 years

—COPD

—Peripheral vascular disease

—Arrhythmias

Question 12

When do you need an echo?

Answer 12

—Exacerbation or new onset of cardiac symptoms (e.g., dyspnea, chest pain, syncope)

—Patients with moderate or severe valvular regurgitation or stenosis who have not had an echocardiogram in the past year

Question 13

When would you need a chest Xray?

Answer 13

—Surgeries of the head and neck, thorax, upper abdomen

—Clinical features and/or a history of cardiac or pulmonary disease (e.g., COPD, congestive heart failure)

—> 60 years

—ASA score > 2Hypoalbuminemia

—Emergency procedures

—Prolonged surgeries (> 3 hours)

Question 14

When would you do pulmonary function tests?

Answer 14

Unexplained dyspnoea or exercise intolerance in patients who are about to undergo thoracic or upper abdominal surgery

Patients with COPD or bronchial asthma who have not had a baseline pulmonary function test

Question 15

What can be the issue in each of the 9 regions?

Question 16

What do you think about when monitoring post op patients?

Answer 16

—Monitor blood pressure, pulse, oxygen saturation, temperature, urine output, and surgical drain output.

—If a patient has a urine output < 0.5 mL/kg/hour for > 6 hours: Check catheter patency.

—Supportive care in intubated patients

—Pain management according to WHO analgesic ladder

—Stress ulcer prophylaxis with proton pump inhibitors

—Thromboprophylaxis with low-dose LMWH or UFH before and after surgery, especially for immobile, bedridden patients

—Incentive spirometry and breathing exercises in order to prevent lung atelectasis

—Fluids: replacement of ongoing fluid loss and maintenance fluid therapy

—Enteral nutrition should be started as soon as possible to prevent villous atrophy.

—Daily examination of the surgical wound

—Early mobilization

Question 17

How do you assess fluid status and then manage?

Answer 17

1. Remind yourself of patient’s medical history, either past or ongoing.
2. Examine the patient and look at the observations, urine output, and fluid balance chart.
3. Assess the fluid status looking at lying and standing blood pressure, heart rate, jugular venous pressure, and mucous membranes.
4. Ensure you auscultate the chest and look at the peripheries for oedema.
5. Scan the drug chart to see if any drugs may be affecting fluid balance and whether any changes can be made.
6. Check the patient’s electrolytes—does any action need to be taken, or do these point to specific fluids to use?
7. Does the patient have any ongoing fluid and electrolyte losses that need to be taken into account?
8. Can fluids be taken orally instead of intravenously

Question 18

Who needs fluid optimisation?

Answer 18

• diarrhoea and vomiting
• where the patient has been immobile / debilitated for a prolonged period prior to admission (which has decreased fluid intake)
• elderly patients with reduced renal function that makes fluid balance maintenance more challenging
• drugs that lower renal fluid exchange functions
• low BMI patients in whom ‘normal’ fluid loss volumes will be more significant.

Question 19

How often do surgical complications occur?

Answer 19

• Patients who have complications are more likely to die, even 5 years after surgery.
• About 20,000 to 25,000 deaths occur every year in UK hospitals following surgery, of which about
• 80% occur in a small group of “high risk patients”. These patients account for 10% of surgical inpatients and are at increased risk of mortality and morbidity
• The likelihood of postoperative complications is influenced by the type of surgery, the patients pre-existing comorbid state and perioperative management.
• Postoperative complications can be general or specific to particular operations and can also be classed according to their time of onset: immediate, early and late.

Question 20

What acute complications may occur?

Answer 20

—2ry to GA

—Haemorrhage or anaemia

—Hypovolaemia

—Respiratory compromise

—Uncontrolled pain

—Emboli

—Damage to surrounding structures

Question 21

What do you wanna check post op?

Answer 21

—Assessment of the patient’s airway patency (openness of the airway), vital signs , and level of consciousness. The following is a list of other assessment categories:

—surgical site (intact dressings with no signs of overt bleeding)

—patency (proper opening) of drainage tubes/drains

—body temperature (hypothermia/hyperthermia)

—patency/rate of intravenous (IV) fluids

—circulation/sensation in extremities after vascular or orthopedic surgery

—level of sensation after regional anesthesia

—pain status

—nausea/vomiting

Question 22

What do you need to check post op in the first 24 h?

Answer 22

—Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours.

—Body temperature must be monitored, since patients are often hypothermic after surgery, and may need a warming blanket or warmed IV fluids.

—Respiratory status should be assessed frequently, including assessment of lung sounds (auscultation) and chest excursion, and presence of an adequate cough.

—Fluid intake and urine output should be monitored every 1-2hours.

—If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate.

—If the patient had a vascular or neurological procedure performed, circulatory status or neurological status should be assessed as ordered by the surgeon, usually every one to two hours.

—The patient may require medication for nausea or vomiting, as well as pain.

—Patients with a patient-controlled analgesia pump may need to be reminded how to use it.

—Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.

—Movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear; they will be much more likely to perform these tasks.

Question 23

What do you need to check after 24h?

Answer 23

—Vital signs can be monitored every four to eight hours if the patient is stable.

—The incision and dressing should be monitored for the amount of drainage and signs of infection.

—The hospitalized patient should be sitting up in a chair at the bedside and ambulating with assistance by this time.

—Respiratory exercises are still be performed every two hours

—Bowel sounds are monitored, and the patient’s diet gradually increased as tolerated, depending on the type of surgery.

—Monitor for any evidence of potential complications, such as

—leg edema, redness, and pain (deep vein thrombosis), shortness of breath (pulmonary embolism), dehiscence (separation) of the incision or ileus (intestinal obstruction).

Question 24

What early complications may occur?

Answer 24

—Delirium

—DVT/PE

—Infection/Sepsis

—Poor wound healing/Dehiscence

—Reperfusion injuries

—Pressure sores

—Late haemorrhage

Question 25

What late complications may occur?

Answer 25

—Damage to local structures -> loss of function

—Scarring

—Chronic pain

—Recurrence/Failure of surgery

Question 26

What are early signs and symptoms of sepsis?

Answer 26

—Respiratory acidosis

—Decreased cardiac output

—Hypoglycemia

—Increased arteriovenous oxygen difference

—Cutaneous vasodilationxx