Pre Op Assessment of the Surgical Patient

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Pre Op Assessment of the Surgical Patient
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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 patients readiness for theatre

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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

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What is included in the Pre Op assessment?

• History
• Examination
• Blood tests
• Radiology
• Consent
• Tissue bank (if required)

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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

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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.

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Important Questions to ask

• Medications
• Anticoagulation
• Clopidogrel vs warfarin vs aspirin
• Diabetic meds
• Insulin vs metformin
• Immunosuppressants/steroids
• Thyroxine
• Parkinsons medications
• etc

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Examination

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

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Bloods and radiology

• FBC, UEC, coags
• LFT/CMP if you are concerned.
• Extended GH if surgery is more than 3 days away
• CXR
• Only if indicated
• Limb/pelvis for orthopedic patients

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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

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Case studies
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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?

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Orthopedics

• Aspirin
• Some surgeons dont mind patient being on
  Aspirin, call registrar if unsure. If
  clopidogrel, MUST stop
• Will need eGH, 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.

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Colorectal surgery

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

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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

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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?

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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.

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Neurosurgery

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

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Neurosurgery

• Usually special set of rules for neurosurg
• Bloods including coags, GH
• 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

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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