Preoperative and postoperative

care

Edited by: Dr Salem Al-Shabahi

PREOPERATIVECARE

Pre-operative Management

• Pre-operative Assessment.

• Pre-operative Preparation.

• Premedication.

Pre-operative Assessment

• The purposes of pre-operative visit.• Taking history .• Physical Examination.• Risk Assessment.• Common causes for postponing Surgery.

The purposes of pre-operative visit

• Establish report with the patient.• Taking a history .• Order special investigation.• Assess the risk of anaesthesia.• Start pre-operative management.• Discussion about pre-operative and plan the

anaesthetic management.• To avoid any drug induction or not.• Introduce a treatment in early post-operative period..

History Taking

• Chart review• Present illness• Family History: porphyria, malignant

hyperpyraxia, haemophilia, Cholinesterase abnormalities and dystrophy myotonica .

• Disease of C.V.S & Respiratory, dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea, angina , MI .

History Taking

• Hematological Disease : Anemia , Clotting abnormalities , Thromboprophylaxis .

• Musculoskeletal Disease : Rheumatoid Arthritis .• Renal Disease : Renal Failure , Patients on Dialysis

. • CNS Disease: Seizures , TIA , Stroke, Raise ICP.• GI: Liver Disease , hepatitis, vomiting , diarrhea• Endocrine Disease: Diabetes Mellitus

A history of previous anaesthesia .

• Allergy to drugs .• Sore throat and headache • Post-operative nausea or vomiting.• Expose to Halothane within 3 months prior to

Surgery • DVT or Respiratory problems.• Difficulties with tracheal intubation.

History Taking

• Allergy to drugs, food, antibiotics, anesthetic agent, latex allergy and atopic patient

• HBV,HCV,HIV carriers have additional risk on staff.

• Taking a special method with infected patient:

Pregnancy

• If it’s elective surgery then postpone it till delivery.

• Many anaesthetic are teratogenic especially in early stage.

• They my induct spontaneous abortion.

Smoking

• Smoking indicate: CVS problems , chronic bronchitis or Lung CA.

• It cause tachycardia, increase peripheral resistance, decrease the availability of O2 by 25%, and the Respiratory complication will increase by 6 folds.

• It must be stopped 1 month to operation Or at least 6 hours before anesthesia .

Alcohol

• Alcohol: it cause induction of liver enzyme, hepatic & cardiac damage, delirium tremors post-operatively as result of drug withdrawal.

• Drug history: many drugs interact with the anaesthesia

• Drugs must be stooped before surgery and anesthesia (contraceptive tablets .warfarin and MAOI )

Drug History

• CVS medication: ACE Inhibitors, Diuretics, B-Blockers, Calcium channel blockers

• Antibiotics: Aminoglycosides,Sulphonamides.• Anticoagulant: Warfarin, Aspirin,

contraceptive, hormone replacement therapy• Lithium and Insulin .

Physical Examination

• Full examination must be done even if it’s a minor surgery.

• General: color, activity, weight, dehydrated, & type of breathing.

• CVS: pulse volume, rate, and pressure, heart sounds, & BP.

• RS: Breathing sound, chest , airway and trachea.• Assessment of the ease of tracheal intubation.

Physical Examination

• Mouth opening – Flexion of cervical spine & extension of Atlanto-occipital joint.

• CNS : cranial nerve examination , Eye Examination , Peripheral sensory & Motor Dysfunction

Investigation

• Routine investigation : urine analysis & CBC• Medically fit pt less than 40 yr old ( Hb & sugar

in urine )• Medically fit pt more than 50 yr old ( Hb &

sugar in urine + chest X-ray & ECG )• More investigation, if the pt has any medical

diseases.

Risk Assessment

• Overall mortality rate from surgery is 0.6% while from anaesthesia 1/1000.

• The information gathered is used to predict the patient absolute mortality

Grade status absolute mortality 1 a normal healthy patient 0.1 2 mild systemic disease 0.2 3 severe systemic disease 1.8 4 incapacitating systemic disease 7.8 5 a moribund patient 9.8

Causes of death due to anaesthesia

• Inadequate preoperative assessment.

• Inadequate supervision & monitoring inter-operative period.

• Inadequate post-operative care.

Common causes for postponing surgery

• Acute upper respiratory tract infection.• Untreated medical diseases.• Inadequate resuscitates pt in emergency( 1/3

of fluid lost ) in dehydrated pt & 100 BP in shock pt.

• Recent ingestion of food.• Failure to obtain informed consent.• MI : wait 6 months

Pre-operative preparationfor surgery & anaesthesia

• History , physical examination & investigation• Preoperative fasting• Providing information to the patient & gaining

a consent• Collect or Prepare of the blood product • Organize appropriate staff and equipment in

the theater

Pre-operative preparationfor surgery & anaesthesia

• BP should not be more than 100-105 mmhg diastolic.

• Control cardiac diseases, • FBS = 130-180 mg/100cc bld.• Bld preparation for major surgery.• Drugs which may be given in the day of

operation: steroid, aminophyline, heparin, antibiotic, & insulin.

Pre-MedicationThe objective of pre-medication

• Allay anxiety and fear.• Reduce secretions.• Enhance the hypotonic effect of anaesthetic agents.• Reduce postoperative nausea & vomiting.• Produce amnesia.• Reduce the volume & increase pH of gastric

contents.• Reduce vagal reflexes.• Limitation of sympathoadrenal response

Anti cholinergic

• They are used to : 1- antisialagogue effect ( reduce secretion )2- sedative and amnesic effect3- prevention of reflex bradycardia : as

prophylactic and treatment of bradycardia

Anti cholinergic • Atropine:• given IM in a dose 0.6 mg for adult & 0.01 mg/kg.• It reduce the oral and respiratory secretion.• It’s highly indicated in anal surgery, eye surgery,

bronchoscope, suxamethonium single dose, and Ketamine.

• It should not be used for pt with high tem, thyrotoxicosis, heart failure controlled by digoxin.

Anti cholinergic

• Scopolamine:• Given IM,IV, or SC in a dose 0.4.• It produce amnesia, hallocination, and reduce

salivation.• It should not be given to a pt below 6 yr and

above 60 yr.

Anti cholinergic• Side effects : 1 - CNS toxicity : restlessness , agitation ,

somnolence , convulsion & coma2 - reduction in lower esophageal sphincter tone 3 - tachycardia 4 – visual impairment5 – pyrexia 6 – excessive drying

Benzodiazepines

• They are used to :1 – relief anxiety 2 – sedation 3 – anterograde amnesia 4 – muscle relaxants

Benzodiazepines

• Diazepam: 0.2 mg/kg. long acting, night before the operation.. It produce light anaesthesia.

• Midazolam: 0.1 mg/kg. shorter in action. Hepatic & non-hepatic elimination and doesn’t cause thrombosis.

Narcotic

• They are used to : 1 – production sedation2 – relieve pain 3 – when using opioids ,lower concentration of

anesthetic agent is required for maintenance of anesthesia because of its synergistic effects with anesthetics .

Narcotic• Pethidine: 1.5 mg/kg with mild atropine like

action. Moderate to sever pain.

• Morphine: 0.15 mg/kg. It’s more potent with incidence of vomiting.

• Omnapone: it’s extract of opiate. 50% morphine, 25% morphine like action, and 25% papaverine.

Narcotic

• Side effect : 1 – depression of ventilation and delay

resumption of spontaneous ventilation at the end of anesthesia .

2 – nausea and vomiting3 – Rt upper quadrant pain

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