The Case Of A Patient Undergoing Surgery

5.2.07

Preoperative anaesthetic visit
• Explain all details of perioperative period.
• Allay anxiety.
• Answer queries.
• Check appropriate investigations have been done.
• Prescribe premedication.
• Explain procedure.
• Detail possible methods of postoperative analgesia e.g. PCA, epidural, spinal.
• Explain risks.
• Explain post-operative procedure.

Preoperative anaesthetic assessment
• Any previous anaesthetic?
• Allergic reaction?
• Awareness.
• Anxiety.

Drug therapies
• Should they be continued?
• Is it optimal?
• Any drug allergies?

Anatomy of airway
• Is it abnormal?
• Any pathology?
• Can patient open mouth?
• Any airway infection?
• Check teeth.

Preoperative preparation - indications for:
• Physiotherapy.
• Anti-embolism stockings.
• Heparin.

Preoperative investigations
• Which of these does she need?
• FBC, U+Es, Ca, glucose.
• Cross-match.
• CXR.
• ECG.
• Lung function tests.
• Blood gas analysis.

Premedication
• Allay anxiety.
• Relieve pain.
• Anti-sialogogue.
• Appropriate for surgery e.g. drying agent for surgery on airway.

Premedicants
• Anxiolytics: benzodiazepines, trimeprazine.
• Analgesics: oral e.g. NSAIDs, paracetemol; parenteral e.g. opiates, NSAIDs.
• Anticholinergics: atropine.
• Antiemetics.

Preparation for theatre
• Starve:
-4 hours: no fluid.
-6 hours: no solid food.
• Consent, correct side.
• No artificial teeth, hairgrips, jewellery, make-up.
• Empty bowel and bladder.

Immediate postoperative care recovery room
• Adequate oxygenation (any facial deformities?).
• Adequate pain relief.
• Adequate fluid therapy.

Postoperative pain
• Minor surgery, day case.
-Simple oral analgesia e.g. paracetemol, Dihydrocodeine.
• Intermediate surgery.
-NSAIDs, IM opiates.

Major surgery: postoperative pain
• IV opiates: continuous infusion patient-controlled analgesia (PCA).
• Epidural analgesics: local anaesthetic agents e.g. lignocaine, bupivicaine; opioids analgesics e.g. diamorphine, morphine, fentanyl - must be preservative-free.
• Local nerve blocks e.g. intercostals nerve blocks for thoracic surgery, 3-in-1 block for hip surgery.
• Spinal analgesia for lower abdominal and lower limb surgery.

Postoperative care - risks of:
• Chest infection (is she a smoker?).
• Appropriate antibiotic cover.
• DVT, PE (any risk factors?).
• MI.

Postoperative chest infection
• Which is most common organism to cause it?
• Is there risk of transmission?
• Other therapies.
• Physiotherapy.
• Nebulisation.