Preoperative Assessment and Care

• Mohamed Saad Aboul-Enein MD FEBS FRCS is the author.

Preoperative Care

• Involves preoperative assessment, investigation, clinical review, medication considerations, and preparations for the day of surgery.

Preoperative Assessment - Investigations

• Includes blood tests for blood group, cross match, CBC, urea, creatinine, liver function.
• Also includes coagulation profile (Prothrombin time, INR), virology (HBV, HCV, HIV), and HBA1C for diabetic patients.
• A chest X-ray and ECG are part of the assessment.
• Special tests such as echocardiograms for cardiac or elderly patients may be needed.
• Pulmonary function tests for patients with underlying lung disease or obese patients are also considered.

Preoperative Assessment - Clinical Review

• Entails monitoring vital signs (pulse, blood pressure, temperature).
• Listen to the patient’s chest.
• Performing a systematic review.
• Reviewing investigation results and current medications.

Preoperative Assessment - Medications

• Assessing diabetes medications (type and dosage) and ensuring antihypertensive medications are continued.
• Anticoagulant medications are examined.
• Aspirin typically doesn't need to be stopped.
• Antiplatelet medications like Clopidogrel (Plavix) may need to be stopped 5-7 days.
• Warfarin may need to be stopped 5 days prior.
• LMWH (Low Molecular Weight Heparin) may need to be stopped 12-24 hours before surgery.
• Newer anti-coagulants like Apixaban may need to be stopped 24-48 hours before.
• A medication restart or replacement plan is crucial, especially for patients who will be NPO postoperatively.

On The Day Of Surgery - Checklist

• Patients typically fast for 6 hours for food and 2 hours for clear fluids, but infants can fast for 4 hours.
• Breastfeeding-dependent infants can fast for 2 hours.
• Patients should wear identification with their name, date of birth, and hospital file number.
• Consent must be explained and signed.
• The operation site should be marked before anesthesia.
• Shaving is necessary if operating in a hairy area, and nails should be trimmed.
• Confirm that patients have no internal metal (knee, hip, pacemaker).
• Patients should remove all jewelry before surgery.

Postoperative Complications

• Includes classification, risk factors, management strategies, and an overview of common complications.

Classifications of Postoperative Complications

• According to time of occurrence can be immediate, early, or late.
• Immediate complications occur within 24 hours of surgery.
• Early complications occur within 30 days.
• Late complications occur after 30 days.
• May be determined by general complications such as pyrexia, hemorrhage, venous thromboembolism, or wound complications.
• Surgical site infections are also considered, in addition to complications specific to the type of operation like anastomotic leaks, infections of prosthetic material, hypocalcemia, or jaundice following surgery.
• Can depend on complications related to the patient's comorbidity.
• Are related to a pre-existing disease or can affect any system: cardiac, respiratory, or gastrointestinal.

Risk Factors For Postoperative Complications

• Extremes of age
• Emergency operations
• Cardiovascular, respiratory, or renal disease
• Hepatic disease
• Steroid use
• Immunosuppressive therapy
• Malignancy

Successful Management Factors

• Prophylaxis
• Early recognition
• Early treatment

General Postoperative Complications - Postoperative Pyrexia

• Pyrexia is common.
• The underlying cause needs to be identified.
• Time scales after the operation should be regarded as a guide.
• In the first 24 hours, it can result from a systemic response to trauma or a pre-existing infection.
• From 24 to 72 hours, it can stem from pulmonary atelectasis, chest infection, or line infection.
• From 4 to 7 days, it may result from chest, wound, or line infections, urinary tract infections, or anastomotic leaks.
• From 7 to 10 days, it may result from intraperitoneal sepsis, deep vein thrombosis (DVT), or pulmonary embolus.

General Postoperative Complications - Hemorrhage

• Primary hemorrhage occurs during surgery and should be controlled by the end.
• Reactionary hemorrhage occurs within 24 hours due to rising blood pressure post-anesthesia.
• Secondary hemorrhage occurs 7-10 days postoperatively due to infection or sloughing of necrotic tissue/clot.

Predisposing Factors For Postoperative Hemorrhage

• Steroid therapy
• Hepatic patients
• Disorders of coagulation
• Obstructive jaundice
• Recent transfusion of stored blood
• Platelet disorders
• Anticoagulant therapy

Prevention Of Hemorrhage

• Identify patients with risk factors.
• Reverse predisposing factors.
• Correct coagulation disorders.
• Control infection.
• Meticulous hemostasis during surgery is essential.

General Postoperative Complications - Wound Dehiscence

• Affects about 2% of midline laparotomy wounds.
• Serious complication with a mortality rate of up to 30%.
• Typically occurs between 7 and 10 days postoperatively.
• Often indicated by serosanguinous discharge.
• Due to failure of the wound closure technique (broken suture, slipped knots, or inadequate muscle bites).

Management of Wound Dehiscence

• Sterile dressing to the wound
• Fluid resuscitation
• Early return to the theatre
• Resuture under general anesthesia

General Postoperative Complications - Venous Thromboembolism

• Venous thrombosis is a significant cause of morbidity and mortality.
• A pulmonary embolus accounts for 10-25% of hospital deaths.
• Most calf DVTs are clinically silent (Silent killer).
• DVT occurs in 50% of patients undergoing major surgery if no prophylactic measures are taken.
• 20% of DVT patients are at risk of PE.

Risk Factors Predisposing to DVT

• Patient factors: age >40, previous DVT or PE, OCP use, obesity, pregnancy, and immobility.
• Surgical procedure/disease factors include pelvic or lower limb trauma/surgery, malignancy, lengthy operations, and congestive heart failure.

Prevention Of Thromboembolism

• Prevention of stasis.
• Early mobilization.
• Graduated compression stockings.
• Intermittent pneumatic compression.
• Medications like heparin.