Pre operative assessment

Elective surgery. What to do? pre-operative process and the important bits you need to know :)

1. Pre-Operative Assessment
Ihewa M Gaula MD3

3. Table of Contents
●Introduction
●Pre-Operative History and Other Histories
●Pre-Operative Examination
●Assessment of Risk of Surgery
●Pre-Operative Investigation
●Pre-Operative Management
●References

4. Introduction
●Pre-operative assessment is an opportunity to
identify co-morbidity that may lead to patient
complications during the anaesthetic, surgical, or
post-operative patient
●2 main goals:
1. Evaluate the general health of the patient
2. Anticipate possible commplication
●Done 2-4 weeks before surgery

5. Pre-Operative History
●Should be brief
●Why the patient first came?
●What procedure they will be undergoing?
●Confirm the side which the operation will take
place ( if applicable)

6. Past Medical History
●Cardiovascular disease- hypertension, exercise
tolerance risk of acute cardiac event during
anaesthesia
●Respiratory disease- adequate oxygenation
reduce risk acute ischaemia
●Renal disease- anaemia, coagulopathy- risk
surgical complication
●Endocrine disease- diabetic mellitus and thyroid
disease-medication modification

7. Past Surgical History
●Any previous operations
​?
●What?
●When?
●Why?
●Complications?

8. Past Anaesthetic History
●Any anaesthesia before?
●Were there any issues?
●Were they well post-operatively?
●Post-operative nausea and vomiting?

9. Drug History
●Some medication require stopping or altering
prior to surgery
●Drug allergies

10. Family History
●Malignant hyper-pyrexia (malignant
hyperthermia)
●Autosomal dominant condition- leads to muscle
rigidity ( despite neuromuscular blockade),
followed by a rise in temperature

11. Social History
●Smoking
●Alcohol
●Substance abuse
●Exercise tolerance

12. Pre-Operative Examination
●General examination (underlying pathology)
and airway examination ( predict difficult in
intubation)

13. Mallampati Classification

14. Retrognathia

15. Assessment of Risk of Surgery
( ASA Grading)

16. Pre-Operative Investigation
Depends on co-morbidities, age and
seriousness of procedure
●CBC
●Urea and electrolyte
●Liver Function tests
●Clotting Screen
●Imaging: ECG, Chest-X ray

17. Pre-Operative Management
●Mnemonic: RAPRIOP
●Reassurance
●Advice
●Prescription
●Referral
●Investigation
●Observation
●Patient

18. Reassurance
●Calming an anxious patient
●Kind words

19. Advice
Fasting
●Stop eating- 6 hours before procedure
●Stop dairy product (including tea and coffee)- 6
hours before
●Stop clear fluids- 2 hours before
●Stomach empty of contents- reduces risk
pulmonary aspiration

20. Prescription
●Drugs to stop, alter and start

21. Drugs to stop: CHOW
●Clopidogrel- 7 days before ( risk of bleeding)
●Hypoglycaemics
●Oral Contraceptive pill or Hormone replacement
therapy-4 weeks before (risk of DVT)
●Warfarin- 5 days before (risk of bleeding)

22. Drugs to alter
●Subcutaneous insulin-switched to IV variable
rate insulin infusion
●Long-term steroids- must be continued due to
risk of Addison crisis if stopped.

23. Drugs to start
●Low molecular weight heparin
●TED stocking
●Antibiotic prophylaxis- orthopaedic, vascular or
GI surgery

24. Diabetic Mellitus
●Type 1- should be first on morning list
●Reduce subcutaneous basal insulin dose by 1/3
●Omit morning insulin and start an IV variable rate
insulin infusion
●5% dextrose. Check glucose levels every 2 hours
●Continue until patient can eat and drink. Give SC
rapid acting insulin 20 min before meal and stop
IV 30-60 minutes after meal

25. ●Type 2- Depends on the way it is controlled
●Diet controlled- no action required
●Oral hypoglycaemics- metformin stopped
morning before surgery, other drugs stopped 24
hours before operation, continue management
as type 1

26. Bowel preparation
●Laxatives or enemas- to clear colon before
operation

27. Referral
●HDU or ITU beds

28. Investigations
●Co-morbidities, age, seriousness of procedure

29. Patient
●Ensure patient is fully informed and
understands the plan for their care and
discharge

30. References
●http://teachmesurgery.com/perioperative/preop
erative/assessment/
●http://www.anaesthesia.med.usyd.edu.au/resou
rces/lectures/Preop_JL.html
●https://www.mdcalc.com/modified-mallampati-cl
assification
●General Surgery Lecture Notes by Harold Ellis,
Sir Roy Calne, Christopher Watson 13
th Edition
●https://www.healthline.com/health/retrognathia

31. Love God?Love others! ( Matthew 22:38-39)
Thanks :)