Preparations Prior to Surgery Essay
Preparations Prior to Surgery Essay
Table 6. Common adverse reactions during administration of local anaesthetics and their management 34
| Signs and symptoms | Cause | Corrective measures |
| CNS excitation: headache, anxiety, tingling of lips and tongue, twitching,,slurred speech, metallic taste in mouth,light headedness, tinnitus, seizures
Cardiac depression: hypotension Respiratory depression |
Lignocaine toxicity | Stop further administration of local anaesthetics
Airway, breathing and circulation management Diazepam for convulsion, ephedrine for hypotension, atropine for bradycardia |
| Tachycardia, palpitations, apprehension, anxiety, hypotension | Epinephrine | Stop further administration, observe for 10-15 mins, reassure patient
Esmolol, soatlol may be used for hypertension Phentolamine may be needed |
| Bradychardia, hypotension, nausea, pallor, dizziness/fainting | Vasovagal syncope | Lower the head end
Elevate the leg and monitor vitals and intervene accordingly |
| Edema, erythema, dyspnea
Bronchospasm, tachycardia, hypotension |
Anaphylaxis | Intravenous hydrocortisone, adrenaline subcutaneously, bronchodilator (nasal or oral spray)
Be prepared for emergency tracheotomy or cricothyroidotomy Lignocaine sensitivity to be performed to prevent such an occurrence |
Box 2: Useful guidelines while administering local anesthesia 33
| 1. The commonest cause of LA toxicity is not excessive dose but inadvertent intravascular injection of the anaesthetic. Preparations Prior to Surgery Essay. Hence, aspirate before injecting LA,. Use incremental injections with intermittent test aspiration in highly vascular areas.
2. Patients having hypertension, perivascular disease, vasospasm, history of Raynaud’s phenomenon, thromboembolism, thromboangitis obliterans should be given lignocaine alone, without adrenaline. 3. While administering anesthesia in the oral cavity, the swallowing mechanism is hindered, hence, patients must be advised not to eat for one hour. 4. Use the lowest effective dose of local anesthetic to prevent the risk of toxicity. 5. Observe the patient for half an hour post administration for any signs of toxicity ( toxicity is usually rapid in onset, <5 min, however maybe delayed up to half an hour) |
Box 3: Local anaesthesia in special situations: 30,31,32
| Children :
The dose of anaesthetic needs to be adjusted according to the weight of the children, duration and amount of topical anaesthetic also reduced Pregnancy: Adrenaline generally avoided as may cause inadvertent uterine spasm. Topical EMLA is pregnancy category B, can be used in pregnant females Lactation: Lignocaine is excreted through breast milk, hence caution to be exercised Geriatrics : No difference in safety in geriatrics, however concomitant morbidities to be kept in mind Hepatic disease: Decreased metabolism of LA, increased chances of LA toxicity |
Intradermal test dose is done to check for hypersensitivity to local anaesthesia. 0.5 to 1.0mL of test solution undiluted and containing no epinephrine is injected subcutaneously. Preparations Prior to Surgery Essay.The test is negative if no reaction occurs during the 30 minutes following the injection. However, regular use of test dose remains controversial as allergy to LA has been found to be exceptionally low (0.7%). (43) Many cases of reported allergy to LA have been attributed to sensitivity to preservatives used in the solution, such as sodium metabisulfite, rather than an allergy to the anaesthetic agent itself. (33)
In some dermatologic procedures, often patients are averse to use of local injections for anaesthesia while use of topical anaesthesia may not be sufficient to alleviate their discomfort.. In these patients, vibration can be used to reduce the pain of injections. It may even be used as a substitute for anaesthesia by pharmacological agents in certain dermatological procedures like botulinum toxin injection, laser therapy, cautery of facial warts, incision and drainage of abcesses, etc.
Their action is defined by the gate control theory of pain. The A -β nerve fibers which transmit mechanoreceptor signals like touch, vibration, stimulate the inhibitory interneurons in the spinal cord which in turn reduce the amount of pain signal l transmitted by A-δ and C fibers from thes kin. Thus, counter stimulation, akin to stroking or pinching the skin, can alleviate pain sensation. (44)
Cold temperature in the form of ice packs or ethyl chloride sprays has also been used for these purposes (cryo analgesia)
The accountability of a dermatosurgeon towards his patient who requires surgery, not only lies in performing the procedure well but, actually begins from collecting all the medical information about him, counselling him and chalking out a plan that has his best interest in mind.(45)
It is prerogative to work up the patient completely before he is taken up for surgery to avoid any adverse events.
The workup should include a complete history and clinical examination, relevant investigations, counseling, and documentation. 46
A detailed history of co-morbidities and concomitant medication is taken. Concurrent conditions like diabetes mellitus, cardiovascular disease, infectious diseases should be inquired upon. History regarding bleeding tendencies should also be taken. Wound healing is delayed in diabetes due to associated vasculopathy, decrease in the peripheral blood supply and increased risk of infections, hence the blood sugar levels should be monitored and brought under control before surgery. Also, these patient should be given a broad spectrum antibiotic prophylactically. 47,48
For patients with cardiovascular disease, a sublingual nitroglycerin is kept handy in case of a possible precipitation of angina. Adrenaline maybe avoided in cases of hypertension or peripheral vascular disease.49, 50 Electrosurgical procedures are avoided in patients with pacemakers.51
In pregnancy, local anaesthesia is used without adrenaline to avoid chances of uterine artery spasm. Safer antibiotics are prescribed and salicylates and NASIDS are avoided as they can interfere with the growth of the foetus. 39
A detailed drug history is imperative as certain drugs meddle with the haemostatic, inflammatory and wound healing processes. Hence, these drugs need to be stopped for a certain period, after the advice of the physician. 52History of allergy to any drugs, ingested or applied, allergy to adhesive tapes, history of keloid formation, scarring tendencies should be asked in detail. Box 4 gives the important drugs to be taken into consideration while planning a surgery. Preparations Prior to Surgery Essay.
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Box 4: Important drug history that need to be asked for prior to a dermatosurgery
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Local examination of the site to be operated should be done to check the condition of the overlying skin, and to rule out any infection. The dermatosurgeon should have a thorough knowledge of the underlying vital structures so as to avoid any trauma while performing the procedure. Thorough examination also provides signs of keloidal tendency, for e.g in pre existing scars.
If the lesion to be operated upon is suspected to be premalignant or malignant, then it is prudent to perform a biopsy first to confirm the findings on histopathology and then decide the next line of treatment.
To prevent post –operative infections check for damaged ,infected skin, diabetes, debilitation, hypogammaglobulinaemia, severe malnutrition, long –term antibiotic therapy, corticosteroids, immunocompromised states, emotional stress, poor hygiene, etc.
Counselling is an important constituent of the management of any dermatosurgical procedure. The problems and needs of the patient are assessed, and all the options are put forward for him to decide. Patients need to have a thorough knowledge of the procedure, the complications, the follow-up, post-operative care, outcome of the surgery, must be given to the patient. All queries about the procedures duly addressed. Expected results should be explained. Any unrealistic expectations need to be put to rest then and there. Patients with unrealistic expectations should be counselled against the procedure
Baseline investigations that should be done before a dermatosurgical procedure are listed in box 5. It is, however, not necessary to do the whole list of investigation prior to a minor dermatosurgical procedure.Preparations Prior to Surgery Essay. The investigations that need to be carried out should be based on the results of the clinical examination.
Box 5: Investigations to be carried out prior to a dermatosurgical procedure.
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Complete documentation of the case is a very important part of preoperative preparation. All the relevant clinical notes, photographs should be kept as record for medicolegal reasons. A written informed consent is of paramount importance. Drugs that are prescribed before a major dermatosurgery are mentioned in box 6. However, this is again not mandatory and is based on the patient profile, nature of the surgery and surgeon’s experience
Box 6: Preoperative drugs prior to a dermatosurgery
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Dermatosurgeon must undertake strict safety measures in order to prevent hazardous infections. As mentioned earlier hand hygiene plays a major role in preventing iatrogenic infections. Right technique of hand washing reduces contamination and prevents the transfer of infection from one man to another. Preparations Prior to Surgery Essay.
Personal protective equipment (PPE) is a protective gear that comprises of mask, gloves, gowns, goggles and shoes. A high quality PPE is the only barricade between the surgeon and the infectious material. 23.
All the instruments required for the surgery should be kept ready in the instruments trolley before the surgery. The surgical trolley should also have surgical drapes, adequate amount of gauze pads, cotton swabs and surgical disinfectants in place. The order of keeping the instruments on the trolley should be predetermined and kept uniform for a particular surgery so as to maintain a smooth flow of operation.
Also, the emergency tray should always be ready in order to deal with any critical situation.
The area to be operated upon has to be cleaned and shaved if required. Preparations Prior to Surgery Essay. Disinfection of the surgical area is done by using disinfectants like povidone iodine and methylated spirit. The cleaning of the area should always be started from the centre extending into the periphery in order to ensure minimum possible risk of contamination of the site of operation. Sterile drapes must then be used to isolate the surgical area.
Excision means cutting out a tissue, an organ or a tumour. The ellipse (fusiform excision) is the mainstay and workhorse of cutaneous excisional surgery and reconstructive surgery.
Proper planning of the incision should be done before the surgery is started. This results in a least noticeable and well healed scar.
A well planned incision line should run parallel to the favourable lines of closure i.e. the relaxed skin tension lines (RSTL) or the lines of minimal skin tension (natural skin creases or wrinkles). [Illustration 31.4] These lines can be made obvious by pinching the skin in all direction. Preparations Prior to Surgery Essay. They can also be judged by asking the patient to smile or grimace.57,58 The incision line so planned not only makes the scar inconspicuous but it heals faster and has a higher tensile strength. Lines of maximal extensibility are typically at right angles to the RSTL. These lines are important when performing a flap grafting from an adjacent area. Incisions can also be taken along the wrinkle lines, skin folds. Another option is to make a circular incision and wait for some time to allow it to turn into an oval shape after undermining the edges. Before final closure the oval shape can be converted into an ellipse. Always respect the cosmetic units of the face. The cosmetic units of the face are chin, perioral region, cheek, periorbital region, nose, forehead, glabella, and temple. Scars restricted to single cosmetic unit hide well, than the scar crossing multiple units.58 [Illustration 31.5]
Nature of the lesion removed is also an important factor. For benign lesions the surrounding normal skin excised is minimal, on the other hand for malignant lesion two factors are very important, complete excision of the tumour and to include sufficient surrounding normal looking tissue in the excision to prevent recurrences. ( 59,60)
The shape of the lesion also plays important role in deciding the excision line. For oval shaped lesion the long axis of the incision line must run parallel the long axis of the lesion. This will shorten the length of the scar.[61].
When taking incisions near lips or eyes, functional considerations are very important to prevent lip retraction and ectropion respectively.
Pre-operative assessment is required prior to the majority of elective surgical procedures, primarily to ensure that the patient is fit to undergo surgery, whilst identifying issues that may need to be dealt with by the surgical or anaesthetic teams. The post-operative management of elective surgical patients begins during the peri-operative period and involves several health professionals. Appropriate monitoring and repeated clinical assessments are required in order for the signs of surgical complications to be recognised swiftly and adequately. Preparations Prior to Surgery Essay.
This article examines the literature regarding pre-operative assessment in elective orthopaedic surgery and shoulder surgery, whilst also reviewing the essentials of peri- and post-operative care. The need to recognise common post-operative complications early and promptly is also evaluated, along with discussing thromboprophylaxis and post-operative analgesia following shoulder surgery.
INTRODUCTION
Pre-operative assessment is necessary prior to the majority of elective surgical procedures, in order to ensure that the patient is fit to undergo surgery, to highlight issues that the surgical or anaesthetic team need to be aware of during the peri-operative period, and to ensure patients’ safety during their journey of care. In addition, unnecessary cancellations or complications due to inappropriate surgery may be avoided, in addition to costs both to the patient and health service [1]. The post-operative management of elective surgical patients begins during the peri-operative period and involves the surgical team, anaesthetic staff, and allied health professionals. Appropriate monitoring and repeated clinical assessment are required, along with support for all major organ systems, including cardiorespiratory function, renal function and fluid and electrolyte balance, and awareness for signs of early surgical complications such as bleeding and infection [2].
This article examines the literature regarding pre-operative assessment in elective orthopaedic surgery and shoulder surgery, whilst also reviewing the essentials of peri- and post-operative care. The need to recognise common post-operative complications early and promptly is also evaluated.
PRE-OPERATIVE ASSESSMENT
Most patients undergoing elective surgery are subjected to routine history checks and clinical examinations by medical staff at the time that a decision is taken by both clinician and patient to undergo surgery. Preparations Prior to Surgery Essay. For most procedures other than those which are very minor, a formal pre-operative assessment consultation is usually led by a specialist nurse or a member of medical staff, and generally includes a review of the patient’s case notes, a detailed history and clinical examination, and additional tests and investigations.
History
Salient points in the history in patients who are presumed to be healthy is to identify any as-yet undetected illnesses which could have an adverse affect on the forthcoming surgery and peri-operative care. The history should focus on the indication for surgical procedures, allergies, and undesirable side-effects to medications or other agents, known medical problems, surgical history, major trauma, and current medications.
Common conditions which can affect peri-operative care include ischaemic heart disease, congestive cardiac failure, chronic respiratory disease, diabetes mellitus and liver or renal dysfunction [3]. As anaesthetic drugs can have pronounced adverse effects on cardiovascular and respiratory systems, it is worthwhile enquiring about chest pain, dyspnoea, ankle swelling and palpitations. The presence of a cough, sputum production and any indication of airway obstruction will provide invaluable information. An excellent indicator of cardiorespiratory function is tolerance of exercise [4]. A smoking history should also be taken as smokers are difficult to anaesthetise due to their upper airways being sensitive to the dry gases used during anaesthesia, and their risk of hypoxia is greater. Assessment and documentation of alcohol intake is required, as induction of liver enzymes by alcohol may shorten the action of anaesthetic drugs and may identify the risk of potential alcohol withdrawal. The use of recreational drugs such as intravenous opiates should also be recognised, as such patients may have poor venous access, may be at risk of septicaemia, and may pose a risk to the surgical team. Patients on long term steroids require adequate cover intra-operatively in order to avoid a hypotensive crisis [4].
In elective shoulder surgery, a detailed history is important not only in arriving at the correct diagnosis, but also in decision-making between the clinician and patient.Preparations Prior to Surgery Essay. The history may be considered one of the most valuable yet least effectively used tools in clinical medicine [5]; and poor history taking and physical examination may lead to both inappropriate diagnostic testing and surgery. Patients with shoulder pathology usually present with pain and/or loss of function, which should be explored along with the patient’s premorbid status and demands, and the likely functional demands aimed for in the future. A comprehensive interview regarding the patient’s pain and functional deficit is required, exploring components such as site, onset, duration, character and radiation of the pain, including features of neural irritation. The degree of dysfunction should also be clarified and how this impacts on the patient and their activities of daily living (ADL), especially as lower pre-operative ADL measurements have been associated with higher post-operative mortality in patients undergoing elective orthopaedic surgery [6]. Table 11 below displays how shoulder function can be assessed [5].
Table 1.
Assessment of Shoulder Dysfunction
| Which movements are limited? This can help isolate the structure |
| Consider the following if movements are limited by: |
| ▪ pain: tendinopathy, impingement, sprain/strain, labral pathology |
| ▪ mechanical block: labral pathology, frozen shoulder |
| ▪ night pain (lying on affected shoulder): rotator cuff pathology, anterior shoulder instability, ACJ injury, neoplasm (particularly unremitting pain) |
| ▪ sensation of ‘clicking or clunking’: labral pathology, unstable shoulder (either anterior or multidirectional instability) |
| ▪ sensation of stiffness or instability: frozen shoulder, anterior or multidirectional instability |
Physical Examination
A general systems examination is performed to identify abnormalities of the cardiorespiratory system which would require further assessment. In particular, cardiac murmurs, additional heart sounds, and abnormal chest signs in patients with no previously documented pathology require investigation and/or referral to an appropriate specialist. Review of the gastrointestinal (GI) system identifies any abdominal masses and previous surgical scars. Skeletal malformations such as kyphoscoliosis can be detected on examining the musculoskeletal system. Local skin abnormalities should be documented and any issues should be highlighted to the surgical team. Preparations Prior to Surgery Essay.
Observations including heart rate and blood pressure are recorded. Brief examination of the airway provides valuable information regarding the feasibility of intubation. Several factors must be considered when assessing the airway. These include whether the patient is obese, has a short neck and small mouth, or whether or not there is any soft tissue swelling at the back of the mouth or if there are any constraints to neck flexion or extension. Cervical spine stiffness should be followed up with a plain radiograph to aid the anaesthetic team in decision-making regarding intubation.
Specific examination of the shoulder involves inspection, palpation, movement and special tests which may be able to narrow down the diagnosis. Previous scars, skin abnormalities, erythema, bruising and shoulder symmetry are to be noted on inspection [5]. Palpation of the shoulder should reveal any specific tenderness around the joint, in addition to crepitus, especially with movement. Passive and active range of movement should then be assessed, comparing both sides.
Special tests of shoulder joint function involve Hawkins test for subacromial impingement, with the humerus abducted to 90 degrees and 30 degrees anteriorly in the line of the scapula. The elbow is then flexed to 90 degrees and the glenohumeral joint internally rotated. Pain constitutes a positive test. This test has a sensitivity of 91–92% and specificity of 25–43% [7]. The empty can test can also be used for detecting a torn rotator cuff, specifically for a supraspinatus tear. Pain and/or weakness signify a positive test when the patient resists a downward pressure with the arm in 90 degrees of abduction in the plane of the scapula. Sensitivity for this test is 18.7% with specificity being 100% [7]. The apprehension test can be used to test for anterior shoulder instability, following anterior shoulder dislocation and subluxation, with a sensitivity of 91.9% and specificity of 88.9%. The active compression test (O’Brien’s test) for acromioclavicular joint (ACJ) arthritis and labral pathology can also be utilised. With the arm flexed to 90 degrees and the elbow fully extended, the arm is then adducted about 15 degrees medially. The arm is internally rotated so that the thumb points to the floor, the patient then resists the downward force applied by the clinician. The arm is then supinated so the palm is facing upward and resisting another downward force. The test is positive and diagnostic of ACJ pathology if pain is elicited over the ACJ or on top of the shoulder in the thumb down position and reduced or eliminated in the palm up position. Sensitivity for this test is 100% with specificity of 96.6% [7].
Investigations
Most patients admitted for elective surgery undergo a range of routine pre-operative tests. Some of these tests are guided by the patient’s clinical needs, whilst others are done as a matter of routine. The purposes of routine pre-operative tests are to assess whether the patient may have any pre-existing health problems, to identify any medical conditions unknown to the patient, the prediction of post-operative complications and the establishment of a reference for comparisons [8] if tests need to repeated at a later date.
Chest Radiographs
Overuse of pre-operative chest x-rays (CXR) has in the past led to inappropriate wastage of resources [9]. Unexpected abnormalities are rare and seldom lead to changes in further management [10].Preparations Prior to Surgery Essay. In many cases, the radiologist’s report of the pre-operative chest radiograph is not available until after surgery [11], and the absence of achest radiograph pre-operatively has not been shown to be associated with an increase in post-operative morbidity or mortality [12].
Little evidence exists advocating the use of pre-operative chest X-rays prior to elective orthopaedic surgery. Radiographs should be sought when clinically indicated, or as requested by an anaesthetist. Chest x-rays should, however, be included in routine pre-operative tests for patients with a hip fracture [13]. The National Institute for Clinical Excellence (NICE) does not recommend routine pre-operative chest X-rays for otherwise healthy patients unless cardiac surgery is to be performed, but states that the decision depends upon the clinical history (e.g. chronic obstructive pulmonary disease (COPD), asthma) and the pathology requiring surgery [8, 14].
Electrocardiograms (ECGs)
ECGs can identify, amongst other things, underlying ischaemic heart disease, previous infarction, and abnormalities in heart rhythm. No clear consensus exists whether pre-operative ECGs should be performed. ECGs may provide the major, and perhaps only, indication as to whether the patient has previously suffered an unrecognised myocardial infarction, which within the preceding 6 months is a risk factor for life-threatening cardiac complications in the peri-operative period [15].
Barnard et al. [16] recommend pre-operative ECGs in those over 60 years of age undergoing major surgery and in those displaying signs and symptoms of cardiovascular (ischaemic heart disease/hypertension) or respiratory disease. In patients with known or suspected coronary artery disease, ECGs should be performed pre-operatively, immediately post-surgery and on the first two days after surgery. In addition, patients with unstable coronary syndromes, significant arrythmias or severe valvular heart disease scheduled for elective non-cardiac surgery should have surgery cancelled or delayed until the cardiac issue has been clarified and treated [17]. NICE guidelines for pre-operative tests and investigations in otherwise healthy patients state that pre-operative ECGs should be performed in patients younger than 60 years of age if they are asthmatic or a smoker, and in all those patients above the age of 80 years [14].
Full Blood Count
For those patients in whom anaemia is suspected, a full blood count (FBC) is recommended. Whether or not a patient requires a pre-operative FBC also depends on the complexity of the surgery to be performed. For those patients attending only for minor surgery it can be argued that an FBC is not required [16]. It is required however if the proposed operation is expected to cause anything greater than minor blood loss [4] and also in those patients over the age of sixty who will be undergoing major surgery [14]. Pre-operative FBC also acts as a baseline for comparison with post-operative testing. Preparations Prior to Surgery Essay.
Biochemistry
Pre-operative serum biochemistry testing generally includes assessment of urea & creatinine and electrolytes. Abnormalities of serum potassium concentrations should be highlighted to anaesthetic staff pre-operatively and corrected where possible, due to a risk of cardiac arrest with agents such as suxamethonium [16]. NICE recommends pre-operative renal function in patients older than 40 years undergoing major surgery [14]. In addition to NICE, Barnard [16] recommends a dipstick urine test in those older than 16 years to screen for evidence of diabetes. Pre-operative liver function tests should be performed in those with established cirrhosis or a history of liver disease, or excessive alcohol intake [18].
Coagulation Screening
Coagulation testing is often routinely undertaken in anticoagulated patients or patients to be started on anticoagulants. The activated partial thromboplastin time (APTT) is used to monitor unfractionated heparin, whereas the International Normalised Ratio (INR) is used for the monitoring of coumarin anticoagulants such as warfarin. Rohrer et al‘s study from 1988 suggested that blanket use of routine coagulation testing in the pre-operative setting is unnecessary [19], and may result in needless further testing and perhaps a delay in surgery. This is also the viewpoint of NICE [14]. Thus pre-operative clotting screens should only be performed in selective groups, namely those with a history of a bleeding disorder, liver disease, or malnutrition, or patients on anticoagulants (warfarin, heparin) [18].
Pre-operative care specific to shoulder arthroplasty includes the features mentioned above, but in addition shoulder X-rays are necessary and essential. Such radiographs may include a true anterior/posterior (AP) and an axillary view [20]. These allow for careful consideration regarding which prosthesis is to be used.
POST-OPERATIVE CARE WITH RECOGNITION OF COMPLICATIONS
The mainstays of post-operative care in general are regular assessment, selective monitoring and timely documentation [2]. Further principles of post-operative care involve reviews of the major body systems, namely respiratory, cardiovascular and renal systems. Furthermore, sepsis must be controlled and sufficient pain relief must be provided. Specific post-operative neurovascular assessment following shoulder surgery is also of vital importance. In order for a patient to be discharged from the post-operative recovery room and back to the ward, certain criteria need to be met [21] (see Table 22).
Table 2.
Criteria for Patients to be Discharged from the Post-Operative Recovery Room
| • The patient is fully conscious, responding to voice or light touch, able to maintain a clear airway and has a normal cough reflex |
| • Respiration and oxygen saturation are satisfactory (10-20 breaths/minute and SpO2>92%) |
| • The cardiovascular system is stable with no unexplained cardiac irregularity or persistent bleeding |
| • The patient’s pulse and blood pressure should compare with normal pre-operative values or should be at a level corresponding to planned post-operative care |
| • There should be adequate control of pain and vomiting with suitable analgesic and anti-emetic regimens prescribed |
| • Temperature should be within acceptable limits (>36°C) |
| • Oxygen and fluid therapy should be prescribed when required |
The first post-operative assessment should take place following a patient’s return from theatre. This acts as a baseline against which the patient’s condition can be assessed at a later date and identifies any problems that may have occurred on transfer from the operating department. Preparations Prior to Surgery Essay. This assessment should include the intraoperative history and post-operative instructions, circulatory volume status, respiratory status and cognitive state. Common causes of confusion in the postoperative period include infection, hypoxia, sedatives and other medications such as anticholinergics [22].
Monitoring
Monitoring of patients allows routine data to be collated and trends established, therefore making it more straightforward to detect any clinical deterioration. It also allows a patient’s response to treatment to be evaluated. Common parameters include temperature, pulse rate, blood pressure, respiratory rate, urine output, peripheral oxygen saturation and pain scores [2].
These variables should be measured multiple times during the day, depending on the type of surgery involved. Other examples of monitoring include ECGs, arterial blood gas analysis (ABGs) and central venous pressure (CVP) monitoring [23]. In addition, assessment of drainage and bleeding should also be performed routinely [24].
Cardiovascular Monitoring
As the main significant post-operative complications in general surgical patients are cardiovascular and respiratory in nature, it is sensible that cardiorespiratory monitoring be made a priority [25]. In general, maintaining a patient’s heart rate and blood pressure within normal limits will result in a satisfactory outcome. However, there are no clinical studies to indicate what is normal with respect to heart rate and blood pressure for individual patients in the post-operative period [2].
Hypertension is common post-operatively and can be due to various causes including pain, anxiety and discontinuing antihypertensive medication. Guidelines by The American College of Cardiology/American Heart Association [26] recommend deferring surgery if the diastolic pressure is above 110 mm Hg and systolic is above 180 mm Hg. No such guidelines exist in the UK however.
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Hypotension is also common post-operatively and has been defined as a systolic blood pressure below 90 mmHg [27]. Causes include hypovolaemia due to bleeding or dehydration, or drug therapy.
Myocardial ischaemia in the first 48 hours after an operation is the single most important predictor of serious cardiac events, including cardiac death, myocardial infarction, unstable angina, congestive heart failure and serious arrhythmias [2]. High risk procedures with a risk of cardiac event greater than 5% include cardiac and vascular surgery, or major pelvic/GI surgery in the presence of pre-existing vascular disease. Preparations Prior to Surgery Essay. The majority of elective orthopaedic surgery is classed as intermediate risk, with a cardiac risk of less than 5% [28].
Respiratory Monitoring
Pulmonary complications are an important and common cause of post-operative morbidity and mortality and are particularly common after major abdominal and thoracic surgery. Risk factors for the development of post-operative pulmonary complications include high body mass index (BMI), smoking status and the presence of COPD [29]. Others include pre-operative respiratory illnesses, Intensive Care Unit (ICU) stay and mechanical ventilation in the post-operative period [30]. In order to adequately observe respiratory function and to identify post-operative respiratory complications the respiratory rate, heart rate and conscious level should be monitored routinely. Indicators of respiratory complications include respiratory rate <10 or >25 breaths per minute; pulse rate >100 beats per minute and reduced conscious level.
Patients in whom there is a suspicion of post-operative pulmonary complications should have an arterial blood gas analysis, a sputum culture and ECG. A CXR should be performed on suspicion of major collapse, effusions, pneumothorax or haemothorax. Generally accepted diagnostic criteria for respiratory failure, pulmonary infections and acute respiratory distress syndrome (ARDS) are summarised in Table 33 [2]. Preparations Prior to Surgery Essay.
