Elective surgery. What to do? pre-operative process and the important bits you need to know :)

1. Pre-Operative Assessment
Ihewa M Gaula MD3

3. Table of Contents
●
Introduction
●
Pre-Operative History and Other Histories
●
Pre-Operative Examination
●
Assessment of Risk of Surgery
●
Pre-Operative Investigation
●
Pre-Operative Management
●
References

4. Introduction
●
Pre-operative assessment is an opportunity to
identify co-morbidity that may lead to patient
complications during the anaesthetic, surgical, or
post-operative patient
●
2 main goals:
1. Evaluate the general health of the patient
2. Anticipate possible commplication
●
Done 2-4 weeks before surgery

5. Pre-Operative History
●
Should be brief
●
Why the patient first came?
●
What procedure they will be undergoing?
●
Confirm the side which the operation will take
place ( if applicable)

6. Past Medical History
●
Cardiovascular disease- hypertension, exercise
tolerance risk of acute cardiac event during
anaesthesia
●
Respiratory disease- adequate oxygenation
reduce risk acute ischaemia
●
Renal disease- anaemia, coagulopathy- risk
surgical complication
●
Endocrine disease- diabetic mellitus and thyroid
disease-medication modification

7. Past Surgical History
●
Any previous operations​?
●
What?
●
When?
●
Why?
●
Complications?

8. Past Anaesthetic History
●
Any anaesthesia before?
●
Were there any issues?
●
Were they well post-operatively?
●
Post-operative nausea and vomiting?

9. Drug History
●
Some medication require stopping or altering
prior to surgery
●
Drug allergies

10. Family History
●
Malignant hyper-pyrexia (malignant
hyperthermia)
●
Autosomal dominant condition- leads to muscle
rigidity ( despite neuromuscular blockade),
followed by a rise in temperature

11. Social History
●
Smoking
●
Alcohol
●
Substance abuse
●
Exercise tolerance

12. Pre-Operative Examination
●
General examination (underlying pathology)
and airway examination ( predict difficult in
intubation)

13. Mallampati Classification

14. Retrognathia

15. Assessment of Risk of Surgery
( ASA Grading)

16. Pre-Operative Investigation
Depends on co-morbidities, age and
seriousness of procedure
●
CBC
●
Urea and electrolyte
●
Liver Function tests
●
Clotting Screen
●
Imaging: ECG, Chest-X ray

17. Pre-Operative Management
●
Mnemonic: RAPRIOP
●
Reassurance
●
Advice
●
Prescription
●
Referral
●
Investigation
●
Observation
●
Patient

18. Reassurance
●
Calming an anxious patient
●
Kind words

19. Advice
Fasting
●
Stop eating- 6 hours before procedure
●
Stop dairy product (including tea and coffee)- 6
hours before
●
Stop clear fluids- 2 hours before
●
Stomach empty of contents- reduces risk
pulmonary aspiration

20. Prescription
●
Drugs to stop, alter and start

21. Drugs to stop: CHOW
●
Clopidogrel- 7 days before ( risk of bleeding)
●
Hypoglycaemics
●
Oral Contraceptive pill or Hormone replacement
therapy-4 weeks before (risk of DVT)
●
Warfarin- 5 days before (risk of bleeding)

22. Drugs to alter
●
Subcutaneous insulin-switched to IV variable
rate insulin infusion
●
Long-term steroids- must be continued due to
risk of Addison crisis if stopped.

23. Drugs to start
●
Low molecular weight heparin
●
TED stocking
●
Antibiotic prophylaxis- orthopaedic, vascular or
GI surgery

24. Diabetic Mellitus
●
Type 1- should be first on morning list
●
Reduce subcutaneous basal insulin dose by 1/3
●
Omit morning insulin and start an IV variable rate
insulin infusion
●
5% dextrose. Check glucose levels every 2 hours
●
Continue until patient can eat and drink. Give SC
rapid acting insulin 20 min before meal and stop
IV 30-60 minutes after meal

25. ●
Type 2- Depends on the way it is controlled
●
Diet controlled- no action required
●
Oral hypoglycaemics- metformin stopped
morning before surgery, other drugs stopped 24
hours before operation, continue management
as type 1

26. Bowel preparation
●
Laxatives or enemas- to clear colon before
operation

27. Referral
●
HDU or ITU beds

28. Investigations
●
Co-morbidities, age, seriousness of procedure

29. Patient
●
Ensure patient is fully informed and
understands the plan for their care and
discharge

30. References
●
http://teachmesurgery.com/perioperative/preop
erative/assessment/
●
http://www.anaesthesia.med.usyd.edu.au/resou
rces/lectures/Preop_JL.html
●
https://www.mdcalc.com/modified-mallampati-cl
assification
●
General Surgery Lecture Notes by Harold Ellis,
Sir Roy Calne, Christopher Watson 13th Edition
●
https://www.healthline.com/health/retrognathia

31. Love God?Love others! ( Matthew 22:38-39)
Thanks :)