only for education purpose

1. APPROACH patient underwent surgery
Preoperative care
 intraoperative care
 Postoperative care

3. Preoperative preparation
INTRODUCTION :-Many patients requiring inpatient elective procedures arrive in
hospital on the day of surgery. Therefore a ‘preoperative assessment’ clinic may be
the only opportunity to gather all information, optimize comorbidities, and then
organize anesthetic, surgical and postoperative care before surgery actually takes
place
First, a history should be taken, examination performed and the relevant
investigations ordered. Focus should then turn to the specific problems uncovered.
All sources of information should be exploited including the patient, the general
practioner (GP) and hospital records.
GPs can offer valuable help by monitoring chronic conditions, adjusting
medications, facilitating weight reduction, as well as encouraging the patient to take
exercise and stop smoking

4. Patients with severe comorbidities should be referred to the relevant specialist
to quantify the risks and to take appropriate measures to minimize operative
morbidity. Surgery cannot be made risk free, but risks must be known so
that the patient can make an informed decision.
Patients should be given advice on when they should be Nil by mouth (NBM
OR NPO) and what to do about regular medications and premedication.
Finally, a plan for the operating list should be drawn up and
all those involved in making the list run smoothly should be informed

5. PATIENT ASSESSMENT
Admission note/preoperative note The preoperative assessment should be
documented, including a full history and physical examination, as well as the
management plan and patient consent
THE AIM of a structured assessment is to learn to look actively for risks and
manage them so as to enable surgery to go ahead safely. Assessment is done by
the surgical, nursing team and/or anaesthetic team at outpatient or inpatient
setting

7. investigations
Full blood count:- A full blood count (FBC) is needed for major
operations, in the elderly and in those with anemia or pathology with
ongoing blood loss.
Urea and electrolytes:- Urea and electrolytes (U&E) are needed
before all major operations, in most patients over 60 years of age
especially with cardiovascular, renal and endocrine disease or if
significant blood loss is anticipated. It is also needed in those on
medications which affect electrolyte levels, e.g. steroids, diuretics,
digoxin, NSAIDs (non-steroidal anti-inflammatory drugs), intravenous
fluid or nutrition therapy
Electrocardiography:- Electrocardiography (ECG) is required for those
patients aged over 60 years, cardiovascular, renal and cerebrovascular
involvement, diabetes and in those with severe respiratory problem

8. Clotting screen:- If a patient has a history suggestive of bleeding diathesis,
liver disease, eclampsia, cholestasis or has a family history of bleeding disorder,
or is on antithrombotic or anticoagulant agents, then coagulation screening will
be needed.
 Chest radiography:- A chest x-ray is not required unless the patient has a
significant cardiac history, cardiac failure, severe chronic obstructive pulmonary
disease (COPD), acute respiratory symptoms, pulmonary cancer, metastasis or
effusions, or is at risk of tuberculosis.
 Urinalysis. Dipstick testing of urine should be performed on all patients to
detect urinary infection, biliuria, glycosuria and inappropriate osmolality
b-Human chorionic gonadotrophin:- Pregnancy needs to be ruled out in all
women of childbearing age.
 Blood glucose and HbA1c:- These should be performed in patients with
diabetes mellitus and endocrine problems. HbA1c indicates how well diabetes
has been controlled over a longer duration

9. Nil by mouth and regular medications
Nil by mouth and regular medications : Patients are advised not to take
solids within 6 hours and clear fluids (isotonic drinks and water) within 2
hours before anesthetic to avoid the risk of acid aspiration syndrome.
Infants are allowed a clear drink up to 2 hours, mother’s milk up to 3
hours and cow or formula milk up to 6 hours before anesthetic. If the
surgery is delayed, oral (until 2 hours of surgery) or intravenous fluids
should be started especially in the vulnerable groups of patients, e.g.
children, elderly and diabetics. Patients can continue to take their
specified routine medications with sips of water in the nil by mouth
period

10. RISK ASSESSMENT AND CONSENT
All life- or limb-threatening complications and all complications with an
incidence of 1 per cent or more should be discussed with the patient (Table
16.5). The risk of death doubles with every seven years of adult life lived. The
presence of peripheral vascular disease, stroke, heart failure, myocardial
infarction or renal failure each independently increases the risk of death by

11. Drains
 NGT:-indications: gastric decompression, analysis of gastric contents,
irrigation/dilution of gastric contents, feeding, if necessary
2 types: NGT (for drainage or feeding) and for feeding only)
■ insertion should be done in stages with x-ray protocol to avoid injury
■ contraindications: suspected basal skull fracture, obstruction of nasal
passages, esophageal stricture, esophageal varices
 Foley catheter with urometer
■ indications: to accurately monitor urine output, decompression of bladder,
relieve obstruction, rapidly expanding suprapubic mass
■ contraindications: suspected urethral injury, and difficult insertion of catheter

12. Perioperative teams.
Ward, theatre and specialist nursing staff
Anesthetic and surgical teams
Radiology, pathology involvement
Rehabilitation and social care workers
Specific personnel in individual cases

13. ARRANGING THE THEATRE LIST
The date, place and time of operation should be matched with availability of
personnel.
Appropriate equipment and instruments should be made available. The
operating list should be distributed as early as possible to all staff who are
involved in making the list run smoothly (Table 16.5).
Priorities patients, e.g. children and Diabetic patients should be placed at the
beginning of the list;
life- and limb-threatening surgery should take priority;
 cancer patients need to be treated early.

15. Operating Room Records
Operating room records can be kept in a book or can be kept as separate notes
on each procedure. Standardized forms save time and encourage staff to record
all required information
A theatre record usually includes:
-Patient identity
-Procedure performed
-Persons involved
-Complications.
By looking at records of all procedures, a hospital can evaluate occurrences
such as complications and postoperative wound infections or review the type
and number of procedures being performed. Such evaluation, which should
be the regular duty of one member of the hospital team, permits assessment
of the application of aseptic routine within the hospital and allows for future
planning

16. CARE IN THE OPERATING ROOM
SURGICAL SAFETY CHECKLIST:- In 2008, the World Health
Organization (WHO) published guidelines of recommended practices to
reduce the rate of preventable surgical complications and death
worldwide. A core set of checks have been incorporated into the WHO
surgical safety checklist, which should be completed for every patient
undergoing a surgical procedure. In the UK, a five-step process is used
to improve theatre team communication and to verify and check
essential care interventions

18. Prelist briefing:-A short meeting before the start of the operating list provides
an opportunity for the theatre team to introduce themselves, share information
about potential safety problems and highlight concerns about specific patients
to ensure smooth running of the list. For example, patient issues such as
positioning, allergies and imaging, anticipated surgical complications, last
minute list order changes and the need for antibiotics and thromboembolism
prophylaxis may be discussed at this time

19. Sign in
The sign in checklist should be read out prior to induction of anaesthesia:
 Has the patient confirmed their identity, site of surgery, procedure and
consent?
 Is the surgical site marked?
 Is the anaesthesia machine and medication check complete?
 Does the patient have a known allergy?
 Does the patient have a difficult airway risk or risk of aspiration?
 Does the patient have a risk of >500 mL blood loss (7 mL/ kg in children)
and if yes, is adequate intravenous access and
fluid/blood replacement planned

20. Time out’
This must be performed immediately before the surgical procedure starts: it
includes team introductions, verbal confirmation of the patient’s identity,
operative site and procedure to be performed, as well as discussion of
anticipated critical events by the surgeon, anaesthetist and nursing team.
Confirmation of antibiotic prophylaxis and review of essential imaging (if
required) is carried out at this stage. Specific additional checks including the
areas outlined below may be included according to local adaptations of the
checklist

21. Sign out’
Before any personnel leave theatre, the WHO ‘sign out’ checks
should be completed. These include checking that the procedure
has been recorded, that instrument and swab counts are correct,
that there have been no equipment problems requiring further
action and the key concerns for recovery recorded for the staff
taking over care of the patient
The operation note should be completed at the time of surgery and contain
full patient, personnel and operative information
Clear postoperative instructions are vital

22. Hair removal:- This may be necessary over the operative field to facilitate
exposure (for incision, suturing and dressing application) or the diathermy
plate site (to maximise plate contact with skin). Surgical site infections may
be reduced if hair is clipped rather than shaved; there is a lack of evidence to
determine whether the timing or location of hair removal affects the incidence
of wound infection.
Glycemic control:-The blood glucose needs careful monitoring and
controlling in the diabetic patient. Hyperglycemia perioperatively may
increase the incidence of postoperative wound infection. If unrecognized,
hypoglycemia may lead to seizures and death

23. Infection control
Asepsis and universal precautions:- Cross-infection between patients or
between staff member and patient (in either direction) is potentially disastrous and every
effort must be made to minimise this risk. In addition to some of the specific areas
considered below, universal precautions should be taken in every case involving exposure to
body fluids. These include the following:
 protective non-porous gloves, eyewear, mask, apron for staff
safe sharps handling techniques and adequate provision of
sharps bins;
staff vaccination for hepatitis B;
staff with infected wounds or active dermatitis should not
work in theatre.
In particular, surgeons handling sharp instruments are responsible for placing them in a safe
container (bowl or tray) for
transfer, one at a time

24. Scrubbing up:-The risk of transfer of microbes between staff and
patients is minimized by meticulous ‘scrubbing up’ (washing hands
and arms and putting on gown and gloves) (Figures 18.3 and 18.4)
(Summary box 18.5).
Instrument trays are prepared by the scrub nurse; supplies are
brought to the sterile team members by the non-sterile circulating
nurse who opens the outside wrappers and passes the item to

26. Prepping and Draping the patient
‘Pre-prep’ may be indicated where there is visible debris to be
removed; it consists of washing the skin with soapy disinfectant,
then water or saline, then surgical disinfectant (Figure
Draping aims to create a protective zone around the operative site to avoid
contamination of items used for the procedure (Figure 18.6). Both disposable
and reusable drapes are suitable, and should be handled only by scrubbed
personnel. They should be sited to allow full access to the incision (or any
possible extension). Once in place, they should not be disturbed. Skin
immediately around the incision site may also be covered with a self-adhesive
transparent drape. Diathermy and suction equipment are attached to the drape

27. Movement in theatre
Scrubbed personnel should:
keep their hands and arms on the
operating table where
possible;
 keep their hands away from their faces;
 touch only sterile items or areas;
 watch the sterile fields to avoid
contamination;
 not lean over unsterile fields;
 pass each other back-to-back or front-to-
front
Unscrubbed personnel should:
touch only unsterile items or areas;
 face and observe a sterile area when
passing it to be sure that
they do not touch it;
 avoid walking between the patient
and trays;
 minimise activity near the sterile
field.

28. POSTOPERATIVE CARE
Writing the operation note:-
1. The following information should be included:
2. Patient details (name, date of birth, hospital number, address,
ward)
3. Date and start/finish times of the operation
4. Location of the operation
5. Name of the operation
6. Surgeon, assistant and anaesthetist
7. Anaesthetic type
8. Patient position and set up

29. The operative note
After a surgical procedure, an “operative note” must be written in the
patient’s clinical notes. Include orders for postoperative care with your
operative not
All patients should be assessed at least once a day, even those who are not
seriously ill. Vital signs should be taken as dictated by the patient’s
condition and recorded; this can be done on a standard form or graph and
can also include the fluid balance record. Progress notes need not be long,
but must comment on the patient’s condition and note any changes in the
management plan. They should be signed by the person writing the note

30. Notes can be organized in the “SOAP” format:
1. subjective :-How the patient feels
2. Objective:- Findings on physical examination, vital signs and
laboratory results
3. Assessment:- What the practitioner thinks
4. Plan:- Management plan; this may also include directives
which can be written in a specific location as “orders

31. Discharge note
On discharging the patient from the ward, record:
- Admitting and definitive diagnoses
-Summary of patient’s course in hospital
- Instructions about further management as an outpatient, including any
-medication and the length of administration and planned follow-up.
Standard operating procedures:- Create and record standard operating
procedures for the hospital. These should be followed by all staff at all times.
Keep copies of these procedures in a central location as well as the place
where each procedure is performed so they are available for easy reference.

32. Surgical Complications
general principles in preventing complications during the post-operative
period include:
■ frequent examination of the patient (daily or more) and their wound
■ removal of surgical tubes as soon as possible (e.g. Foley catheters and
surgical drains)
■ early ambulation
■ monitor Fluid balance and electrolytes
■ analgesia - enough to adequately address pain, but not excessive (minimize
opioids)
■ skillful nursing care

33. Post-Operative Fever
fever does not necessarily imply infection particularly in the frst 24-48 h post-operative
 fever may not be present or is blunted if patient is receiving chemotherapy, glucocorticoids,
or other
immunosuppression
5 Ws of Post-Operative Fever
Wind POD #1-2 (pulmonary – atelectasis,
pneumonia)
Water POD #3-5 (urine – UTI)
Wound POD #5-8 (wound infection - if
earlier think streptococcal or clostridial
infection) Walk POD #8+ (thrombosis – DVT/PE)
Wonder drugs POD #1+ (drug)

34.  timing of fever may help identify cause
■ hours after surgery – POD #1
◆ inflammatory reaction in response to trauma from surgery (physiologic); unlikely to be
infectious (unless necrotizing fasciitis or another severe infection)
◆ reaction to blood products received during surgery
◆ malignant hyperthermia
 POD #1-2 (acute)
◆ atelectasis (most common cause of fever on POD #1)
◆ early wound infection (especially Clostridium, Group A Streptococcus – feel for crepitus and look
for “dishwater” drainage)
◆ aspiration pneumonitis
◆ other: Addisonian crisis, thyroid storm, and transfusion reaction
 POD #3-7: likely infectious
◆ UTI, surgical site infection, IV site/line infection, septic thrombophlebitis, and leakage at bowel
anastomosis (tachycardia, hypotension, oliguria, and abdominal pain)
 POD #8+
◆ intra-abdominal abscess, DVT/PE (can be anytime post-operative, most commonly POD #8-10,
may occur earlier but recognition is often delayed), and drug fever
◆ other: cholecystitis, peri-rectal abscess, URTI, infected seroma/biloma/hematoma, parotitis, C.
difficile colitis, and endocarditis

35.  Gather and record all relevant information
 Optimise patient condition
 Choose surgery that offers minimal risk and maximum
benefit
 Anticipate and plan for adverse events
 Inform everyone concerned
Principles of history taking
■ Listen: What is the problem? (Open questions)
■ Clarify: What does the patient expect? (Closed questions)
■ Narrow: Differential diagnosis (Focused questions)
■ Fitness: Comorbidities (Fixed questions
Summary of the Preoperative plan for the best
patient outcomes

36. Examination
General: Positive findings even if not related to the
proposed procedure should be explored
 Surgery related: Type and site of surgery, complications
which have occurred due to underlying pathology
 Systemic: Comorbidities and their severity
 Specific: For example, suitability for positioning during
surgery

37. Pre- and Post-Operative Orders ADDAVIDS
1. Admit to ward X under Dr. Y
2. Diagnosis
3. Diet
4. Activity
5. Vitals (q4h from ED and post-operative is
standard)
6. IV, Investigations, Ins and Outs
7. Drugs, Dressings, Drains
8. Special procedures

38. Risk assessment and consent
Risks: Related to the comorbidities, anesthesia and surgery
Explain: Advantages, side effects, prognosis
 Language: Simple, use daily life comparisons to explain risks
 Consents: Valid consent is necessary except in life-saving circumstances

39. Ground rules for anaesthesia
 Safe surgery is achieved by close teamwork between
surgeon and anaesthetist
 Safety checklists make sure that things are not
forgotten
 Risk assessment allows the best strategy to be chosen
 Anaesthetists are extending their care into the pre- and
postoperative phase
The general anaesthetic triad
■ Amnesia: loss of awareness
■ Analgesia: pain relief
■ Muscle relaxation

40. Theatre team preparation
Patient must be seen by anaesthetist and operating surgeon
preoperatively
 Communicate early with theatre team regarding specific
requirements
 Arrange theatre list appropriately for the case-mix and
resources available
Preoperative planning should cover all aspects of the surgical process. Close
communication and coordination between preoperative departments and operating
theatres allows timely preparation and improves efficiency and safety in the operating
theatre.
Every hospital will have a policy for booking and scheduling
of elective and emergency theatre cases.