PRE OP ASSESSMENT PRE OP ASSESSMENT OF THE SURGICAL OF THE SURGICAL PATIENTPATIENT

Who goes to PAC?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

Why have Pre op Why have Pre op assessment?assessment?Chance to be assessed by all

teams involved in the care of the surgical patient◦Surgical resident/intern◦Anaesthetics◦Nursing staff

What is included in the Pre What is included in the Pre Op assessment?Op assessment?HistoryExaminationBlood testsRadiologyConsentTissue bank (if required)

Important Questions to Important Questions to askaskWhat surgery they are havingNatural history of the disease

process, and any worsening since last seen in clinic◦E.g., further obstruction in a patient

having a thyroidectomy

Important Questions to Important Questions to askask• 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.

Important Questions to Important Questions to askask• Medications–Anticoagulation• Clopidogrel vs warfarin vs aspirin

–Diabetic meds• Insulin vs metformin

– Immunosuppressants/steroids–Thyroxine–Parkinsons medications–etc

ExaminationExaminationUsually heart, lungs depending

on historyThen specific examination for

particular system being operated on

Bloods and radiologyBloods and radiologyFBC, UEC, coagsLFT/CMP if you are concerned.Extended G+H if surgery is more

than 3 days awayCXR

◦Only if indicatedLimb/pelvis for orthopedic

patients

Consent/tissue bank Consent/tissue bank If unsure call registrarOften 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

CASE STUDIESCASE STUDIES

OrthopedicsOrthopedics70 F for right total knee

replacementHx

◦On aspirin for TIAs◦HTN, COPD, OSA on CPAP

Radiology is over 1 year oldWhat do we need to think about

for this patient?

OrthopedicsOrthopedicsAspirin

◦ 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.

Colorectal surgeryColorectal surgery25 F for colonoscopyHx

◦Type 1 DM◦Nil other medical history

What do we have to think about for this patient?

Colorectal surgeryColorectal surgeryType 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

PlasticsPlastics80 M LLC NH resident for excision

3 x lower leg SCCsHx

◦St Judes MVR on warfarin◦CAD, no recent AMIs◦HTN, CRF Creat 120◦What do we need to think about for

this patient?

PlasticsPlasticsWarfarin

◦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.

NeurosurgeryNeurosurgery52 M ASAP PAC for symptomatic

meningiomaOtherwise healthyWhat do we need to think about

for this patient?

NeurosurgeryNeurosurgeryUsually special set of rules for

neurosurgBloods including coags, G+HUsually you do consent in

emergency PAC situationsWill need CT/MRI with fiducials if

using brainlab technology will need to organise

Tissue bank very important

SummarySummaryPre operative assessment

extremely importantAny 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