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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
