1) Pre-operative evaluation and preparation is important to assess patient risk and optimize their health status prior to surgery. It involves diagnostic testing, assessing any medical conditions, and preparing the patient with things like diet, medication adjustments and consent. 2) Post-operative care begins during surgery and involves close monitoring in the recovery room and ICU if needed to watch for complications like bleeding, infection and instability in vital functions. Patients are monitored and treated according to individualized post-op orders tailored to their procedure and needs. 3) Careful pre-operative and post-operative management can help avoid unnecessary risks and complications for patients undergoing even elective surgical procedures.

1. PRE OP AND POST OP CARE
Dr Anteneh B.
Department of surgery
01/05/2010 E.C

2. objectives
• Describe the importance of pre operative and post operative care,
• Describe the approaches to pre operative evaluation and preparation,
• List of non surgical disease and special factors affecting the operative risk,
• Describe post op care, monitoring and post op order

3. Introduction
• The preoperative period runs from the time the patient is admitted to
the hospital to the time that the surgery begins.
• Pre-operative assessment is necessary prior to the majority of
elective surgical procedures in order to;-
• Ensure that patient is fit to undergo surgery
• To highlight issues that the surgical or anesthetic team need to be aware
of during the peri- operative period,
• To ensure patients safety
• To avoid unnecessary cancellation or complication due to inappropriate
surgery

4. • Appropriate monitoring and repeated clinical assessment are
required, along with support for all major organ systems, including
cardiorespiratory function, renal function and fluid and electrolyte
balance, and awareness for signs of early surgical complications
such as bleeding and infection
• The post-operative management of elective surgical patients
begins during the peri-operative period and involves
the surgical team,
anaesthetic staff, and
allied health professionals.
Cont…

5. Care of a patient with major surgical problem Pre – operatively
involves
1. Diagnostic work up
2. Pre operative evaluation
3. Pre operative preparation

6. 1. Diagnostic work up
• Determining the cause and extent of the patient illness.
• Hx, P/E , and lab – investigation for the cause of presenting
complaint.

7. 2. Pre – operative evaluation
• It is an over all assessment of the patient to identify co-
morbidities , that increase operative risk or adversely influence
recovery.
• This evaluation is driven by findings on the Hx and P/E suggestive
of organ system dysfunction or by epidemiologic data suggesting
the benefit of evaluation based on age, gender, or patterns of
disease progression
• If preoperative evaluation uncovers significant comorbidity or
evidence of poor control of an underlying disease process, consultation
with an internist or medical subspecialist may be required,

8. Investigations for pre-operative evaluation
• CBC
• Renal function test and electrolytes
• Liver function test
• Coagulation profile
• RBS
• Urine analysis
• Arterial blood gases
• Hepatitis, and HIV test
• Pregnancy test : - in all female patients of childbearing age
Cont…

9. Cont…
• Imaging studies
 CXR Rarely indicated as screening tool
 EKG : Males >40, Females >50 ?Baseline
• History of CVD, DM. HTN
• Planned thoracic, aortic, intraperitoneal or emergency
surgery
 Other radiological investigations
• Like lateral neck x-ray for
rheumatoid arthritis, etc…

10. Non- Surgical diseases affecting operative risk
•CVS
Hypertation ; - if Bp ≥ 160 systolic ≥ 95 diastolic – surgery deferred till control of
BP
IHD/recent MI ; - no surgery < six months
Arrhythmias
Cardiac failure; - Oxygenation and fluid balance are of critical importance in these
patients
Anaemia and blood transfusion ; - Consider transufion if Hgb < 8g/dl or if the patient is
symptomatic or actively losing blood.
Prosthetic valves ; - Prophylactic antibiotic cover is usually necessary in these patients

11. • Respiratory system
Infection ; - should be treated before surgery except when the surgery is
life saving.
Asthma ; - continue inhalers and may need oral steroid cover
COPD ; - anesthetist must be informed if it is significant and regional
anesthetic techniques may need to be considered.
Pulmonary fibrosis
NB. Patients should Stop smoking at least 4 wks before the surgery
Cont…

12. • GIT
Malnutrition ; -Nutritional support is required a minimum of 2 weeks prior
to surgery
Regurgitation risk : -No solids – 6hrs/ no fluids- 2 hrs before surgery, H2-
receptor blockade, Ng tube and specific anesthetic techniques
jaundice
Cont…

13. • Genitourinary system
Renal impairment ; - Categorize- pre-renal , renal & post-renal
UTI ; - Start antibiotics and care taken to maintain good urine
out put
Cont…

14. • Metabolic disorders
Diabetes; - a careful preoperative assessment of their cardiovascular,
peripheral vascular and neurological status should be always be made.
Adrenocortical suppression
Require extra dose steroids to avoid an addisonian crisis
Rare disorders
Familial porphyria, malignant hyperpyrexia & phaeochromocytoma
Cont…

15. • Coagulation disorders
Drugs interfere with the clotting cascades ; - Thromboprophylaxis
for High risk groups/ stopping of anticoagulant drugs
Acquired coagulopathy ; -Complex bleeding disorders like DIC and
haemophilia- consult hematologist and correct hypothermia
Thrombophilia ; - mechanical and /or pharmacological prophylaxis
may be used.
Cont…

16. • Other disorders
Neurologic and psychiatric disorders:
• neuropathies/myopathies –need prolonged ventilation postoperatively
• Anticonvulsants need to be continued
• Psychiatric patients require general anaesthesia
• Locomotor ; - Specific complications of the inflammatory arthropathies
should be identified preoperatively
Cont…

17. • Remote infection
• Sources of bacteremia
 artificial material – joint replacement surgery/ arterial grafting
Infected toes / teeth
• Prophylactic antibiotic best administered just prior to induction
Cont…

18. Special factors affecting operative risk
• Elderly patient
Operative risk judged on the basis of physiology rather than chronologic
age.
Elderly patient should not be denied a needed operation because of age
alone..
Assume that every pt over 60years has some generalized arteriosclorosis
and potential limited myocardial and renal reserve

19. Cont…
Medication
Smaller doses of strong narcotics
Sedative and hypnotic should be used cautiously
Pre- anesthetic mediation should be limited to atropine and sedatives
Anesthetic a gents should be administered in minimal amounts

20. Cont…
• Obese patient
Greater than normal tendency to seriously concomitant disease
Higher incidence of post – op wound and thrombo embolic
complication
Increased technical difficult of operation and anesthesia
It may be advisable to delay elective operation until the patient
loses weight by appropriate dietary measures.

21. Cont…
• Compromised or altered host
Capacity of their systems and tissues to respond normally to infection and
trauma, has been significantly impaired by some disease or agent
 increased susbtibility to infection
delayed wound healing

22. Consultations
• Opinion of a qualified consultant should be obtained when it may
• Be of benefit to patient
• When it may be of medico legal importance
• Treatment proposed controversial or exceptionally risky or
when dangerous complications occur.
• When the physician senses that the patients or family
members are unduly apprehensive regarding the plan of Mx
or the course of events.
• Anesthesia consultation is always requested prior to major surgery

23. Summary
Preoperative evaluation should be ; -
• Comprehensive - to assess overall state of health
• To determine the risk of the impending surgical
treatment
• To guide the preoperative preparation

24. 3. Pre – op preparation
• Major operations __ create surgical wounds
__ Cause sever stress
(both of which subjects the patient to infection and metabolic and
other derangement)
• Appropriate preop- preparation makes the patient condition optimal.
• Emergency patient less time for pre – op preparation

25. Cont…
• Includes the following steps __
A. Informed consent to the patient
• Psychological preparation and reassurance
• Appropriate explanation of Purposed pre op studies and treatment
establishes confidence
• Surgeons responsibility to describe
Planned surgical procedures
Its risks
Possible consequence in understandable terms to the
patient family

26. Cont…
• Operative permit
Patient or the legal guardian of the patient must sign
Emergency life saving operative procedures may have to be
done with out a permit .every effort should be made to obtain
adequate consultations , and director of hospital should be
informed in advance if possible.
Know and follow – local regulation

27. Cont…
B. Pre – Op order
Include the following ; -
Skin preparation
• On the day before operation
wash with water and soap
• shaving not necessary or done
on table
• In the operating room __
aseptic technique savlon,
iodine, alcohol
• Hand scrabing and washing
 Diet
Omit __ Solid food for 12 hour before surgical
__ Fluid for 8 hours
__ Special orders for diabetic and infant and
children

28. Cont…
Enema
 Not given routinely except in
the case of operations on the
colon rectum , and anal
region.
 Or operations likely to result in
paralytic ileus and delay in
bowel function
 Bed- time and pre anesthetic
medication
 Special orders
 Blood transfusion
 N-G tube
 Catheterization
 Venous or arterial Catheter
 Continuing medication
 Prophylactic antibiotic

29. Post – op – care
 Care of patient who are seriously ill
after major surgical procedure

30. Cont…
• Done the following way
• Post anesthetic observation _ recovery room
• Intensives care __ ICU
• Intermediate care __ General Nursing unite
• Convalescent care __ Home or extended care unite
• Hospitals need special units in which serious ill patients .receive _
close observation, intensive 24 hours nursing care, emergency
resuscitation and other complex treatments.

31. Cont…
• Large – medical centers – have variety of
unites
• Post – anesthetic recovery room
• Medical _ ICU
• Surgical – ICU
• Pediatric -ICU
• Coronary unite
• Respiratory care unite
• Renal dialysis unit
• Burn unite
• Neonatal ward
• Qualified person
• Special equipment
Recovery room and ICU for most effective
surveillance and Rx post – Op patients

32. Cont…
• Recovery room
• Should be connected directly to the operating room
• One or 2 beds generally required for every operating room
• Most are open style __ with beds located so that all patients can be seen by
the nurse .
• Patient kept until danger of adverse circulatory respiratory, or other
immediate, post – op cxn has passed
Stay in the recovery room is usually a few hours at most patient is then
transferred to the general nursing unite or ICU

33. Cont…
• ICU
• Design and organization of ICU depends upon the number of beds &
characteristic of patient being treated
• Major post – op cxns seen in an ICU are
• Cardiac arrhythmias , and failure
• Respiratory failure,
• Shock
• Fluid, electrolyte and acid base imbalance
• Renal failure
• Sepsis , coagulation problem

34. Monitoring
• Define:- Close surveillance using all available methods to obtain
necessary data , either continuously or intermittency regarding the
patients changing condition.
• Monitory of critically ill patient is facilitated by
• Electronic devices
• Repeated lab tests
• Bed side measurement

35. Parameters monitored
1. CVS
• PR,EKG, arterial BP, CVP
• Pulmonary arterial and wedge pressures
• CO, total periphery resistance
2. RS
• RR, RV, RFR,RP, respiratory compliance
• Respiratory gases (P02,Pc02)
• Blood gases (PH,Pao2,Paco2)
• Chest tube drainage
• CXR
3. CNS
 EEG, ventricular pressure, GCS, sensory and motor
pattern

36. 4. GIT
 Intake by month
 NG enterostomy tube drainage
 Fishtula drainage
 Abdominal CXR
5. Hematopoietic system
 CBC, HCT
 Coagulation studies
 Platelat count
6. Urine system
 UO, U/A, Bun, creatinin
 Urine/ plasma osmolality ratio
 Urine electrolyte
7. Metabolism
• .ToC , body weight , IV fluid volume

37. Post Op orders
• Post – op patient should be accompanied by a physician or other
qualified attendant while – route to RR or ICU , or general nursing unite
A.Special observations
1.V/S BP, pulse RR – should be recorded at regular intervals
after all major operation (every 15-30minitus until stable
then qid ) or hourly
2. Continuous monitoring of EKG

38. 3. CVP – in patient __ in shock , borderline cardiac or respiratory status
Those who require large fluid volume replacement or those with renal
failure
4. Miscellaneous
 Wound bleeding, bleeding drainage
 Impaired circulation in extremity

39. Cont…
B. Position in bed
• flat , onside, sitting , foot of bed elevated
C. Mobilization
• Bed rest
• Sitting up in a chair
• Ambulation
• Standing to avoid while recovering from GA

40. • While recovering room anesthesia, patient should be turned
from side to side every 30 minutes until conscious and then
hourly for the 1st 8-12 hours.
• Require active position change and active motion of the feat
and legs every 1-2 hours . while awake until the patient is
ambulatory.
• Elastric bandages or anti emboli stocking for the legs are
favored by some for elderly patient or when ambulation is
delayed.
Cont…

41. Cont…
D. Respiratory care Should be ordered as required
• Hyperventilation
• Cough
• Tracheal suction
• O2 therapy
• Respiratory therapy
E. Intake and out put
F. Body weight patient with fluid balance problem
G. Drainage tubes

42. h. Medication
• Narcotic pain relief
• Sedative, antibiotics , ant emetics
• Resume essential pre op medications such as
digitalis insulin corticosteroids
i.Special laboratory examination
• Hct- indicator of blood loss
• Blood chemistry
• Arterial PH, P02, and PCo2, X- ray
Cont…

43. Thank you