Transcript Pre Op Assessment of the Surgical Patient

PRE OP ASSESSMENT
OF THE SURGICAL
PATIENT
Who goes to PAC?

When patient is seen at clinic the doctor
deciding their need for an operation
thinks they need to be seen in the pre-op
setting to ensure the patient’s readiness
for theatre
Why have Pre op assessment?

Chance to be assessed by all teams
involved in the care of the surgical patient
◦ Surgical resident/intern
◦ Anaesthetics
◦ Nursing staff
What is included in the Pre Op
assessment?
History
 Examination
 Blood tests
 Radiology
 Consent
 Tissue bank (if required)

Important Questions to ask
What surgery they are having
 Natural history of the disease process,
and any worsening since last seen in clinic

◦ E.g., further obstruction in a patient having a
thyroidectomy
Important Questions to ask
•
Medical history
– Diabetes (T1DM vs T2DM)
– HTN
– Asthma/COPD/OSA  are they on CPAP
usually?
– Heart disease
• Recent AMI/valvular disease/CABGs/AF
– Strokes
– Thyroid disease
– Steroid dependent/Immunosuppressed
– etc.
Important Questions to ask
•
Medications
– Anticoagulation
• Clopidogrel vs warfarin vs aspirin
– Diabetic meds
• Insulin vs metformin
– Immunosuppressants/steroids
– Thyroxine
– Parkinsons medications
– etc
Examination
Usually heart, lungs depending on history
 Then specific examination for particular
system being operated on

Bloods and radiology
FBC, UEC, coags
 LFT/CMP if you are concerned.
 Extended G+H if surgery is more than 3
days away
 CXR

◦ Only if indicated

Limb/pelvis for orthopedic patients
Consent/tissue bank
If unsure call registrar
 Often done when request for admission
is done in clinic, need to check it is
properly signed.
 Often will just need to answer any further
questions
 Tissue bank consent for any tumours

CASE STUDIES
Orthopedics
70 F for right total knee replacement
 Hx

◦ On aspirin for TIAs
◦ HTN, COPD, OSA on CPAP
Radiology is over 1 year old
 What do we need to think about for this
patient?

Orthopedics

Aspirin
◦ Some surgeons don’t mind patient being on Aspirin,
call registrar if unsure. If clopidogrel, MUST stop
◦ Will need eG+H, often bleed +++

CPAP
◦ Will need to bring in her machine or book a
bed in RCU  may need respiratory R/V /
recent RFTs

Radiology
◦ need recent films. If knee replacement, needs
long leg views as well as AP, lat and skyline.
Colorectal surgery
25 F for colonoscopy
 Hx

◦ Type 1 DM
◦ Nil other medical history

What do we have to think about for this
patient?
Colorectal surgery

Type 1 diabetic
◦ On insulin, CANNOT stop it
◦ Patient will be fasting, not good for a type 1.
Will need bowel prep.
 Likely will need admission the night
before or morning of procedure for
insulin/dextrose infusion to control BSLs

Plastics
80 M LLC NH resident for excision 3 x
lower leg SCCs
 Hx

◦
◦
◦
◦
St Judes MVR on warfarin
CAD, no recent AMIs
HTN, CRF Creat 120
What do we need to think about for this
patient?
Plastics

Warfarin
◦ Will need to be stopped as bleeding is high
risk
◦ At LLC NH
◦ Will need to continue theraputic clexane due
to metal heart valve
 Made easier as at NH, usually call nursing staff at
NH to help organise
◦ Need a clear plan on stopping and restarting
warfarin.
Neurosurgery
52 M ASAP PAC for symptomatic
meningioma
 Otherwise healthy
 What do we need to think about for this
patient?

Neurosurgery
Usually special set of rules for neurosurg
 Bloods including coags, G+H
 Usually you do consent in emergency
PAC situations
 Will need CT/MRI with fiducials if using
brainlab technology  will need to
organise
 Tissue bank very important

Summary
Pre operative assessment extremely
important
 Any problems ALWAYS call your senior

◦ Always better to look a bit silly in front on
them than in front of the surgeon once
patient is in theatre
◦ Remember you have an anaesthetics registrar
around if you need help