Preoperative assessment

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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7

Preoperative assessment

Introduction

When a patient is admitted for surgical investigation or treatment, a detailed history and examination (clerking) should be done and recorded. These patient notes are essential to make information available to other clinicians and also form a permanent record for medico-legal purposes if things go wrong. Notes must be accurate and legible, entries dated and signed, and the doctor’s name identifiable.

For elective treatment, clerking is often performed at a pre-assessment visit by a junior doctor or a surgical or anaesthetic assistant. This is to anticipate potential medical and social complications, and take preventive action (Box 7.1). In patients with significant co-morbidity, a senior anaesthetist (anaesthesiologist) should also make an assessment. This is often performed in specialised clinics, which increasingly have direct access to advanced assessment tools such as cardiopulmonary exercise testing and pulmonary function analysis.

Box 7.1   Preoperative assessment and planning

For emergency admissions, review is often a layered process, with junior doctors performing initial assessment and then reporting to seniors. The prime purpose is to diagnose the primary disorder, but co-morbidity and complicating factors are also sought. For major trauma, senior staff are usually mobilised by phone before the ambulance arrives.

Principles of preoperative assessment

The essence is careful questioning and examining to foresee anaesthetic and surgical problems, plus any social aspects relevant to the admission. Most surgical cases are uncomplicated but preventable disasters occur unless the approach is systematic. The patient’s condition may need optimising, taking the urgency of surgery into account. The assessor aims to answer the questions in Box 7.1. The review may disclose the need for tests or other actions and also identifies patients with medical co-morbidity who have risks of particular perioperative problems. Current treatment of co-morbidity (e.g. diabetes, hypertension) also needs review. Investigations provide baseline information against which later changes can be measured, e.g. echocardiography in heart failure. Common problems of high-risk groups are summarised in Table 7.1.

Table 7.1

High-risk groups for perioperative complications

Group Particular risks Management
Premature or tiny babies, neonates and infants Fluid and electrolyte lossHeat loss in operating theatre Careful measurement and replacement of fluids and electrolytesWarming blanket, temperature monitoring
Patients over 60 Cardiovascular disease Chest X-ray and ECG preoperatively if indicated by guidelines, and monitoring during operation
Very elderly patients ConfusionHyponatraemiaImmobility Multifactorial—see Chapter 8Preoperative electrolyte estimations and correctionGood nursing and rehabilitation
Smokers Postoperative chest infection and atelectasisIncreased risk of myocardial infarction Stop smoking before operation—ideally at least 4 weeks beforehandPreoperative chest X-rayPreoperative and postoperative physiotherapyPreoperative ECG; avoid hypoxia during and after operation; postoperative oxygen therapy
Obese patients Increased risk of DVTIncreased risk of wound infectionReduced mobility DVT prophylaxis—see Chapter 12Preoperative counselling during consent processEarly mobilisation with assistanceEncourage patients to lose weight prior to surgery
Patients with intercurrent medical disease Depends on medical condition Early referral to anaesthetist and/or medical specialist