Pre Op Assessment of the Surgical Patient

1. Pre Op Assessment of the Surgical Patient

2. 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

3. 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

4. What is included in the Pre Op assessment? • History • Examination • Blood tests • Radiology • Consent • Tissue bank (if required)

5. 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

6. 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.

7. Important Questions to ask • Medications • Anticoagulation • Clopidogrel vs warfarin vs aspirin • Diabetic meds • Insulin vs metformin • Immunosuppressants/steroids • Thyroxine • Parkinsons medications • etc

8. Examination • Usually heart, lungs depending on history • Then specific examination for particular system being operated on

9. 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

10. 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

11. Case studies

12. 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?

13. 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.

14. Colorectal surgery • 25 F for colonoscopy • Hx • Type 1 DM • Nil other medical history • What do we have to think about for this patient?

15. 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

16. 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?

17. 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.

18. Neurosurgery • 52 M ASAP PAC for symptomatic meningioma • Otherwise healthy • What do we need to think about for this patient?

19. 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

20. 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