Preoperative and postoperative care

1. Preoperative and postoperative
care
:Edited by Dr Salem Al-Shabahi

2. PREOPERATIVE
CARE

3. Pre-operative Management
• Pre-operative Assessment.
• Pre-operative Preparation.
• Premedication.

4. Pre-operative Assessment
• The purposes of pre-operative visit.
• Taking history .
• Physical Examination.
• Risk Assessment.
• Common causes for postponing Surgery.

5. The purposes of pre-operative visit
• Establish report with the patient.
• Taking a history .
• Order special investigation.
• Assess the risk of anaesthesia.
• Start pre-operative management.
• Discussion about pre-operative and plan the
anaesthetic management.
• To avoid any drug induction or not.
• Introduce a treatment in early post-operative period.
.

6. History Taking
• Chart review
• Present illness
• Family History: porphyria, malignant
hyperpyraxia, haemophilia, Cholinesterase
abnormalities and dystrophy myotonica .
• Disease of C.V.S & Respiratory, dyspnoea,
paroxysmal nocturnal dyspnoea, orthopnoea,
angina , MI .

7. History Taking
• Hematological Disease : Anemia , Clotting
abnormalities , Thromboprophylaxis .
• Musculoskeletal Disease : Rheumatoid Arthritis .
• Renal Disease : Renal Failure , Patients on Dialysis
.
• CNS Disease: Seizures , TIA , Stroke, Raise ICP.
• GI: Liver Disease , hepatitis, vomiting , diarrhea
• Endocrine Disease: Diabetes Mellitus

8. A history of previous anaesthesia .
• Allergy to drugs .
• Sore throat and headache
• Post-operative nausea or vomiting.
• Expose to Halothane within 3 months prior to
Surgery
• DVT or Respiratory problems.
• Difficulties with tracheal intubation.

9. History Taking
• Allergy to drugs, food, antibiotics, anesthetic
agent, latex allergy and atopic patient
• HBV,HCV,HIV carriers have additional risk on
staff.
• Taking a special method with infected patient:

10. Pregnancy
• If it’s elective surgery then postpone it till
delivery.
• Many anaesthetic are teratogenic
especially in early stage.
• They my induct spontaneous abortion.

11. Smoking
• Smoking indicate: CVS problems , chronic
bronchitis or Lung CA.
• It cause tachycardia, increase peripheral
resistance, decrease the availability of
O2 by 25%, and the Respiratory
complication will increase by 6 folds.
• It must be stopped 1 month to
operation
Or at least 6 hours before anesthesia .

12. Alcohol
• Alcohol: it cause induction of liver enzyme,
hepatic & cardiac damage, delirium tremors
post-operatively as result of drug withdrawal.
• Drug history: many drugs interact with the
anaesthesia
• Drugs must be stooped before surgery and
anesthesia (contraceptive tablets .warfarin
and MAOI )

13. Drug History
• CVS medication: ACE Inhibitors, Diuretics, B-
Blockers, Calcium channel blockers
• Antibiotics: Aminoglycosides,Sulphonamides.
• Anticoagulant: Warfarin, Aspirin,
contraceptive, hormone replacement therapy
• Lithium and Insulin .

14. Physical Examination
• Full examination must be done even if it’s a minor
surgery.
• General: color, activity, weight, dehydrated, & type
of breathing.
• CVS: pulse volume, rate, and pressure, heart sounds,
& BP.
• RS: Breathing sound, chest , airway and trachea.
• Assessment of the ease of tracheal intubation.

15. Physical Examination
• Mouth opening – Flexion of cervical spine &
extension of Atlanto-occipital joint.
• CNS : cranial nerve examination , Eye
Examination , Peripheral sensory & Motor
Dysfunction

16. Investigation
• Routine investigation : urine analysis & CBC
• Medically fit pt less than 40 yr old ( Hb & sugar
in urine )
• Medically fit pt more than 50 yr old ( Hb &
sugar in urine + chest X-ray & ECG )
• More investigation, if the pt has any medical
diseases.

17. Risk Assessment
• Overall mortality rate from surgery is 0.6% while
from anaesthesia 1/1000.
• The information gathered is used to predict the
patient absolute mortality
Grade status absolute mortality
1 a normal healthy patient 0.1
2 mild systemic disease 0.2
3 severe systemic disease 1.8
4 incapacitating systemic disease 7.8
5 a moribund patient 9.8

18. Causes of death due to anaesthesia
• Inadequate preoperative assessment.
• Inadequate supervision & monitoring inter-
operative period.
• Inadequate post-operative care.

19. Common causes for postponing surgery
• Acute upper respiratory tract infection.
• Untreated medical diseases.
• Inadequate resuscitates pt in emergency( 1/3
of fluid lost ) in dehydrated pt & 100 BP in
shock pt.
• Recent ingestion of food.
• Failure to obtain informed consent.
• MI : wait 6 months

20. Pre-operative preparation
for surgery & anaesthesia
• History , physical examination & investigation
• Preoperative fasting
• Providing information to the patient & gaining
a consent
• Collect or Prepare of the blood product
• Organize appropriate staff and equipment in
the theater

21. Pre-operative preparation
for surgery & anaesthesia
• BP should not be more than 100-105 mmhg
diastolic.
• Control cardiac diseases,
• FBS = 130-180 mg/100cc bld.
• Bld preparation for major surgery.
• Drugs which may be given in the day of
operation: steroid, aminophyline, heparin,
antibiotic, & insulin.

22. Pre-Medication
The objective of pre-medication
• Allay anxiety and fear.
• Reduce secretions.
• Enhance the hypotonic effect of anaesthetic agents.
• Reduce postoperative nausea & vomiting.
• Produce amnesia.
• Reduce the volume & increase pH of gastric
contents.
• Reduce vagal reflexes.
• Limitation of sympathoadrenal response

23. Anti cholinergic
• They are used to :
1- antisialagogue effect ( reduce secretion )
2- sedative and amnesic effect
3- prevention of reflex bradycardia : as
prophylactic and treatment of bradycardia

24. Anti cholinergic
• Atropine:
• given IM in a dose 0.6 mg for adult & 0.01 mg/kg.
• It reduce the oral and respiratory secretion.
• It’s highly indicated in anal surgery, eye surgery,
bronchoscope, suxamethonium single dose, and
Ketamine.
• It should not be used for pt with high tem,
thyrotoxicosis, heart failure controlled by digoxin.

25. Anti cholinergic
• Scopolamine:
• Given IM,IV, or SC in a dose 0.4.
• It produce amnesia, hallocination, and reduce
salivation.
• It should not be given to a pt below 6 yr and
above 60 yr.

26. Anti cholinergic
• Side effects :
1 - CNS toxicity : restlessness , agitation ,
somnolence , convulsion & coma
2 - reduction in lower esophageal sphincter tone
3 - tachycardia
4 – visual impairment
5 – pyrexia
6 – excessive drying

27. Benzodiazepines
• They are used to :
1 – relief anxiety
2 – sedation
3 – anterograde amnesia
4 – muscle relaxants

28. Benzodiazepines
• Diazepam: 0.2 mg/kg. long acting, night
before the operation.. It produce light
anaesthesia.
• Midazolam: 0.1 mg/kg. shorter in action.
Hepatic & non-hepatic elimination and
doesn’t cause thrombosis.

29. Narcotic
• They are used to :
1 – production sedation
2 – relieve pain
3 – when using opioids ,lower concentration of
anesthetic agent is required for maintenance
of anesthesia because of its synergistic effects
with anesthetics .

30. Narcotic
• Pethidine: 1.5 mg/kg with mild atropine like
action. Moderate to sever pain.
• Morphine: 0.15 mg/kg. It’s more potent with
incidence of vomiting.
• Omnapone: it’s extract of opiate. 50%
morphine, 25% morphine like action, and 25%
papaverine.

31. Narcotic
• Side effect :
1 – depression of ventilation and delay
resumption of spontaneous ventilation at the
end of anesthesia .
2 – nausea and vomiting
3 – Rt upper quadrant pain

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