Preoperative assessment

Published on 11/04/2015 by admin

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Preoperative assessment

Principles of preoperative assessment

ESSENTIALS OF PREOPERATIVE ASSESSMENT

PREPARATION FOR MAJOR OPERATION

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

• (Provisional) diagnosis; how confident is it?

• Are any further investigations needed to confirm the primary diagnosis?

• Important aspects of the history?

• Findings on examination?

• Results of investigations already performed?

• If appropriate, have tissue diagnoses been obtained before admission to hospital?

• What operation or procedure is planned?

• Have any circumstances changed relating to the planned operation?

• Has the patient got better or worse?

• Has any new diagnostic information appeared? (e.g. pulmonary metastases on a chest X-ray)

• Is the planned operation still appropriate?

• Any special risks attending this particular operation, intraoperative or postoperative? (e.g. risk of DVT after pelvic surgery)

• Any standard procedures needing to be performed for this operation? (e.g. ordering blood if heavy blood loss anticipated)

• Any operation-specific actions needing to be performed? (e.g. examining vocal cord movement before thyroid surgery, arranging perioperative radiology)

• What type of anaesthesia is to be employed?

• Can any anaesthetic complications be anticipated? (e.g. risk of postoperative chest infection after thoracotomy or upper abdominal surgery, risk of a patient with bowel obstruction inhaling vomitus during anaesthetic induction)

4 Fitness for operation

• Any intercurrent diseases and are they being appropriately treated, e.g. insulin-dependent diabetes, or any that might pose special problems? e.g. rheumatoid arthritis with cervical spine involvement

• Are any preoperative investigations or treatments needed for intercurrent disease? (e.g. lung function tests and physiotherapy for chronic bronchitis, cervical spine radiology for rheumatoid arthritis)

• Does the surgical condition pose special problems? (e.g. fluid or electrolyte disturbances from vomiting)

• Is the patient taking any drugs which might cause problems with anaesthesia or operation? (e.g. monoamine oxidase inhibitors or corticosteroids)

• Is the patient fit for the planned anaesthetic and operation?

• Is this patient particularly predisposed to anaesthetic or surgical complications (Table 7.1)?

6 After the operation

• Can any special problems be anticipated during the postoperative period and after discharge? (e.g. elderly patients living alone)

• Any problems specific to this anaesthetic or operation regarding recovery and rehabilitation, and is any special planning required? (e.g. prostheses after mastectomy, stoma care, limb fitting and rehabilitation following amputation)

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 loss Heat loss in operating theatre	Careful measurement and replacement of fluids and electrolytes Warming 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	Confusion Hyponatraemia Immobility	Multifactorial—see Chapter 8 Preoperative electrolyte estimations and correction Good nursing and rehabilitation
Smokers	Postoperative chest infection and atelectasis Increased risk of myocardial infarction	Stop smoking before operation—ideally at least 4 weeks beforehand Preoperative chest X-ray Preoperative and postoperative physiotherapy Preoperative ECG; avoid hypoxia during and after operation; postoperative oxygen therapy
Obese patients	Increased risk of DVT Increased risk of wound infection Reduced mobility	DVT prophylaxis—see Chapter 12 Preoperative counselling during consent process Early mobilisation with assistance Encourage patients to lose weight prior to surgery
Patients with intercurrent medical disease	Depends on medical condition	Early referral to anaesthetist and/or medical specialist

Essentials of preoperative assessment

Standard preoperative procedures vary in different hospitals but basic steps ensure the greatest patient safety (see Box 7.2). The nature and urgency of the operation and the state of the patient determine what is needed.

Box 7.2 Essential steps in preoperative assessment and preparation

• History taking

• Physical examination

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