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Preoperative Assessment Notes for Medical Students

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PREOPERATIVE ASSESSMENT Notes:

  • Right Patient, Right Surgery, Right Side?
    • “Time out” is done in the OR; X-References Pt info with Operation etc.
    • Ask Pt what surgery?
    • Mark the correct side.
  • Informed Consent:
    • General Risks:
      • Anaesthetic Risks:
        • Atelectasis (Lung Collapse)
        • Pneumothorax (Lung Rupture)
        • Pneumonia
        • Aspiration
        • Mouth Injury
        • Sore Throat
        • Awareness
        • Coma
        • Malignant Hyperthermia (Rare ➔ Rhabdomyolysis & Fever ➔Usually Fatal)
        • Anaphylaxis (Anaesthetic Reaction)
        • Cardiac Arrest
        • Death
      • Surgical Risks:
        • Bleeding
        • Transfusion (+/- Reaction)
        • Wound (Pain, Scars)
        • Infection
        • DVT +/- PE
        • Disability
        • Death
        • Nerve Palsy
    • Specific Risks:
      • Brain Damage (Neurosurgery)
      • Stroke (Carotid Endarterectomy)
      • Hypothyroidism (Thyroidectomy)
      • Hypoparathyroidism (Thyroidectomy)
      • CBD Dissection (Cholecystectomy)
      • Ileus (Abdominal Surgery)
      • Adhesions (Abdominal Surgery)
    • Final Words:
      • Consent is NOT a contract; It can be revoked at any time.
      • Risks are relative & depend on Pt Health & Procedure.
      • Anaesthetic Mortality ≈1/200,000 healthy pts.
      • Benefits should outweigh Risks

Anaesthetic Risk Assessment:

  • Cardiorespiratory Function
  • Co-Morbidities?
    • IHD
    • Diabetes
    • Asthma
    • HTN
    • Epilepsy
    • Jaundice
    • Pregnant
  • Allergies
  • Smoker
  • Previous Anaesthesia + any complications?
  • FamHx of Malignant Hyperthermia

Drug Assessment:

    • Pt on Steroid Therapy?
      • Pts on steroids have suppressed adrenals :. need extra cortisol to cope with the stress of surgery. Give Hydrocortisone 50-100mg IV with premeds, then TDS for <3days.
    • Pt on Anticoagulants?
      • Typically Aspirin is fine.
      • Stop Warfarin >2-5days pre-op. (Emergency Reversal with Vitamin K +/- FFP.)
      • Stop Heparin 6hrs pre-op. (Emergency Reversal with Protamine)
      • (NB: When re-warfarinizing, DO NOT stop Heparin until INR is Therapeutic, as Warfarin is Pro-Thrombotic in the early stages)
      • (NB: Avoid Epidural, Spinal & Regional Blocks)
    • Pt on OCP/HRT?
      • ↑Oestrogen = ↑ DVT Risk, :. Stop OCP 4wks Pre-Op (major/leg surgery); Resume 2wks Post-Op.

Pre-Operative Checklist:

    • Fast The Patient:
      • NBM <2hr Pre-Op
      • Clear Fluids >2 Pre-Op
      • No Solids >6hrs Pre-Op.
    • IV Cannula
    • Cathetarise (if Necessary)
    • Group & Hold/Crossmatch
      • G&H for Moderate Surgery (Eg. Mastectomy, Cholecystectomy)
      • X-Match for Major Surgery (Eg. Caesarean=2U, Gastrectomy=4U, AAA=6U)
    • Usual Blood tests:
      • FBC (Hb)
      • U&E (if Diabetic/on Diuretics/Burns Pt/Renal Dx/Liver Dx/Ileus/on TPN)
    • Specific Blood Tests:
      • LFT (if Jaundiced/Malignancy/ETOH Hx)
      • Amylase (if Acute Abdomen)
      • Drug Levels (eg. Digoxin/Lithium)
      • TFT (if Thyroid Hx)
    • CXR (If Cardiac/Resp Hx, Possible Lung Mets, >65yrs)
    • ECG (If >55yrs/IHD/HTN/Other CVD)
    • Book any imaging

DVT Prophylaxis needed? (P580 oxford):

Graduated Compression Stockings (NOT FOR Vasculopaths!!!)

+ Heparin 5000Units SC 2hr Pre-Op (OR LMWH/Enoxaparin 20mg/d SC); then BD Post-Op until Walking

Prophylactic Antibiotics:

ProcedureLikely Pathogen/sAntibacterial Cover
General Surgery: Appendectomy (Non Perfd) Colorectal Surgery Biliary/Duodenal SurgeryEnteric G-Negs Enteric G-Negs + G-Pos Enterococcus, Anaerobes Enteric G-Negs + G-Pos CocciCefalexin / Gentamicin Cefalexin + Metronidazole Cefalexin + Metronidazole
Orthopaedic SurgeryStaphs + Streps + G-Neg Bacilli + AnaerobesCefalexin / Gentamicin
Vascular SurgeryStaphs + G-Neg Bacilli + G-Pos EnterococcusCefalexin / Gentamicin / Augmentin
Urologic SurgeryG-Neg Bacilli + G-Pos EnterococcusCefalexin / Ciprofloxacin
Gynaecologic Surgery: C-Section HysterectomyStaphs + Strep + G-Pos Enterococcus Enteric G-Negs + Group B Strep + G-Pos EnterococcusCefalexin / Gentamicin Cefalexin / Gentamicin / Ampicillin
 Egs:Effective Antibiotics:
G. Positives (“-cocci”)Enterococcus Spp. Staphylococcus Spp. Streptococcus Spp.Penicillins (Benz-Pen-G, Amoxicillin, Ampicillin, Fluclox) 1. (NB: Augmentin for β-lactamase resistant bacteria = Amoxil + Clavulonate) Cephalosporins (Ceftriaxione3, Cefipime4, Cepfalexin4) [Vancomycin (For resistant G-Pos/ if Penicillin Allergy)]
G. NegativesE. Coli Neisseria Spp. Pseudomonas Haemophilus Spp. Klebsiella Spp. Enterobacter Spp.Aminoglycosides (Gentamicin, Tobramycin, Streptomycin) 2. (NB: Used with Penicillins/Cephs for Synergy) Tetracyclines (Tetracycline, Doxycycline) Macrolides (Erythromycin, Azithromycin) Quinolones (Ciprofloxacin, Norfloxacin) Cephalosporins (Ceftriaxione3, Cefipime4, Cefalexin4) [Benz-Pen-G (For Neisseria Gono/Mening)]
AnaerobesBacteroides Spp. Clostridium Spp.[Metronidazole (For Bacteroides)] [Vancomycin (For C.Diff)]
AtypicalsMycoplasma LegionellaTetracyclines (Tetracycline, Doxycycline) Macrolides (Erythromycin, Azithromycin)

NB: Triple Therapy: –Ampicillin, Gentamicin, Metronidazole- give great ‘Broad Cover’. (Remember by AGM – Annual General Meeting…If you want to be around next year, take these 3)

Cardiovascular Pre-Op Assessment

  • Assess the Pump (Heart):
    • Power (Myocardium)
    • Valves (Stenosis/Regurg)
      • NB: Stenosis is worse than Regurg because they cap the CO under load/stress.
    • Piping (Vessels)
    • Control (Conduction)
  • CVS Systems Review:
    • Cardiac Failure:
      • Dyspnoea
      • PND
      • Orthopnoea
      • Peripheral Oedema/Ascites
    • IHD:
      • Angina (Stable/Unstable)
      • Prev. MI
      • FamHx of IHD
    • Valve Disease:
      • Hx of Rheumatic Fever
      • Old Age
    • PVD:
      • Claudication
      • Smoker?/Diabetic?
      • Dizziness/Blackouts/Prev. TIA
    • Conduction Deficits:
      • Palpitations
      • Arrhythmias
  • CVS Examination:
    • Signs of Failure:
      • Basal Crepitations (LVF)
      • Peripheral Oedema/Ascites/Organomegaly (RVF)
    • Signs of Structural Abnormality:
      • Displaced Apex (Dextrocardia/Cardiomegaly)
      • Parasternal Heave
      • Murmurs/Thrills
      • Previous Surgery
    • Signs of PVD:
      • Peripheral Pulses
      • CRT
      • Ulcers (Arterial/Venous)
    • Signs of Arrhythmias:
      • Irregular Pulse
      • Rapid Pulse
      • ECG
  • Medications:
    • Diuretics – because they ↓K+ & ↑Mg+
    • Antihypertensives
    • Antiarrhythmics
    • Anticoagulants – esp. Dagabatran (Irreversible)
    • Antibiotics

Thank You so Much. Happy Learning!!

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