Preoperative evaluation is one of important thing in managing a successful operation without it ,a pateint may encounter life threating condition during or after surgery

1. The Department of Surgery, RCSI
Preoperative & Postoperative
Management
The Department of Surgery,
The Royal College of Surgeons in Ireland.

2. The Department of Surgery, RCSI
Principle of pre-operative
assessment
 History and examination to identify patients at
high risk for surgery
 Planning for Surgery
- Diagnosis
- Operation
- Anaesthesia
- Fitness for operation
- High risk
- Consent

3. The Department of Surgery, RCSI
Planning for Surgery -
Diagnosis
 What is the (provisional )diagnosis
 How confident is the diagnosis
 What are the important features in the history
 What are the findings on examination
 What are the results of investigations already
performed
 Any further investigations needed

4. The Department of Surgery, RCSI
Planning for Surgery -
Operation
 Have circumstances changed re the
planned operation
 Any new diagnostic info (?mets on CXR)
 Any specific preop planning; cords for
thyroid.

5. The Department of Surgery, RCSI
Planning for Surgery -
Anaesthesia
 What type of anaesthesia is to be
employed
 Can any anaesthetic complications be
anticipated
- post op chest infection post thoracotomy
- Inhalation of vomit in bowel obstruction

6. The Department of Surgery, RCSI
Planning for surgery
- Fitness for operation
 Is the patient fit for the planned anaesthetic
 Are there intercurrent disease inadequately
treated
- IDDM
- Rheum Arthritis
- Cervical spine involvement
 Preop treatments for intercurrent disease
 Is the patient taking drugs
-MAOIs or Steroids

7. The Department of Surgery, RCSI
Planning for Surgery - High Risk
 Patients over 60 years
- Cardiovascular disease, Confusion
 Smokers
-Post op chest problems, Risk of MI
 Obese patients
- Risk of DVT
 Patients with intercurrent medical disease
- Diabetes, Hypertension, COAD.

8. The Department of Surgery, RCSI
Specific preop medical
problems and action plans -1
 Diabetes - Random glucose
 Obesity - Low mol Wt heparin
 Hypertension - ?Drug therapy
 Short of breath - ECG and CXR
 Poor urinary stream - ?Prostate
 Smoker - Pre-op physio
 Diuretics - U+E

9. The Department of Surgery, RCSI
Specific preop medical
problems and action plans -2
 Aspirin - Stop 7 days before
 Penicillen allergy - ?Use alternative
 Cardiac Murmur - ?antibiotics
 Low HB - ?inx large bowel
 Needs Stoma - ?Skin marked
 Bowel Surgery - ?Prophylactic surgery
 DVT risk - ?prophylaxis

10. The Department of Surgery, RCSI
Other issues related to
preoperative care
 Bowel preparation
 Skin Preparation
 Fasting from midnight
 Patients ID
 Informed Consent
 Premed

11. The Department of Surgery, RCSI
Principles of Post Operative
Care
 All post op patients should be seen soon after
surgery
 Prevention of predicted complications elucidated
from the pre op assessment.
 Monitoring of Cardiac, Respiratory parameters,
and Urine output
 Adequate analgesia to enable pain free deep
respirations

12. The Department of Surgery, RCSI
Respiratory Complications
 Atelectasis - commonest cause post op temp in 48hrs
- collapse of alveoli from inadequate
expansion
- Temp, tachypnea, tachycardia, air entry.
 Pneumonia-secondary to basal atelectasis or aspiration
- supine position and  protective responses
- Obese, elderly, immobile, those post thoracic
or abdominal surgery at greatest risk
-Temp, tachycardia, tachypnnea,  A/E,
creps.

13. The Department of Surgery, RCSI
 Pulmonary Embolus-
 ? Missed DVT
 ensure heparin prophylaxis
 adequate analgesia to facilitate early mobilisation
 high index of suspicion in those with ‘chest pain’
 O2, ABG, CXR, CTPA
 Therapeutic heparin anticoagulation while awaiting
definitive investigations.

14. The Department of Surgery, RCSI
GI Complications
 Paralytic Ileus- bowel sounds should return day 3-4
abdominal surgery.
Prolonged in hypoproteinaemia and hypokalaemia
Hydrate and correct electrolyte imbalances
Manage by ‘drip and suck’,
TPN considered if >5-7 days
Most resolve, some may become obstructed - surgery

15. The Department of Surgery, RCSI
 Diarrhoea- common post op
may indicate ileus or pelvic sepsis.
Occurs post, ileoanal anastomosis, ileal pouch, truncal
vagotomy and right hemicolectomy.
Send stool for C. diff, bacteria, protozoa.
Abdomeno- pelvic Ultrasound
 Nausea and Vomiting- very common
usually anaesthetic, analgesia are causes, outrule
obstruction and ileus then treat symptomatically
? Change analgesia

16. The Department of Surgery, RCSI
Haemorrhage
 Primary - Occurs during surgery and continues
 Reactionary - Occurs within the first 24 hours. It
may follow primary haemorrhage or occur as a result of
the slipping of a ligature / removal of a clot as a result of
coughing, increasing post-operative blood pressure.
 Secondary - Typically due to infection. Occurs 7-10
days post-operatively

17. The Department of Surgery, RCSI
Urinary Complications
 Acute urinary Retention- very comon, esp elderly men
anxiolytics may help, usually require catheterisation
must have >500mls residual to be in retention
 Renal failure – urine output < 25ml/hr assoc  urea and
creatinine.
Pre- renal, renal, post renal causes.
Strict Ins/Outs, adequate hydration, stop Nephrotoxic drugs
flush/change blocked catheter.
Consider dialysis in worsening or refractory cases.

18. The Department of Surgery, RCSI
Wound Complications
 Prevention, Prevention, Prevention!!!
 Wound infection- 1-5-% without prophylactic antibiotics
 ? Surgery, clean, clean contaminated, contaminated, dirty
Diabetes, poor nutrition, steroids are predisposing factors
Signs: cellulitis, pus, pain
‘If there is pus in it ….. Let it out’ ie drain all infected
collections.
Use antibiotics where there is surrounding celulitis.

19. The Department of Surgery, RCSI
 Wound dehiscence –
 Wound breakdown at the level of the fascia
 Poor nutrition, poor technique, infection
 Day 7- copious amounts serous fluid from the wound
 Cover wound with sterile non-adherent dressing or
delayed resuturing

20. The Department of Surgery, RCSI
Cardiovascular Complications
 Myocardial Infarction –
 Have appropriate index of suspicion in those with
premorbid disease.
 Many will be asymptomatic!
 New onset CCF, arrhythmias, hypotension
 Treatment MONA (morphine, oxygen, nitrate, aspirin)
 Thrombolysis is contraindicated in the post op patient.