1

• History of the presenting complaint

• Past medical history
• Drug history
• Social history

1-History of Cardiovascular

■ Ischaemic heart disease – angina, myocardial infarctiona
■ Hypertension
■ Heart failure
■ Dysrhythmias
■ Peripheral vascular disease
■ Deep vein thrombosis and pulmonary embolisma
■ Anaemia


2-Respiratory

■ Chronic obstructive pulmonary disease

■ Asthmaa
■ Fibrotic lung conditions
■ Respiratory infections
■ Malignancy

3-Gastrointestinal

■ Peptic ulcer disease and gastro-oesophageal reflux
■ Bowel habit – bleeding per rectum, obstruction
■ Malignancy
■ Liver disease – jaundice, alcohol, coagulopathy

4-Genitourinary tract

■ Urinary tract infection
■ Prostatism
■ Renal dysfunction

5-Neurological

■ Epilepsy
■ Cerebrovascular accidents and transient ischemic
attacks
6-■ Psychiatric disorder


7-Endocrine/metabolic
■ Diabetes
■ Thyroid dysfunction
■ Phaeochromocytoma
■ Porphyria

8- Locomotor system

■ Osteoarthritis
■ Inflammatory arthropathy such as rheumatoid arthritis,
including neck instability

9-Infectious diseases

■ Human immunodeficiency virus
■ Hepatitis
■ Tuberculosis

10-Previous surgery

■ Types of anesthetic and any problems encountered
■ Have any members of the patient’s family had particular problems with anesthesia?

Examination

General
■ Anaemia, jaundice, cyanosis, nutritional status, teeth, feet,
leg ulcers (sources of infection)


Cardiovascular
■ Pulse, blood pressure, heart sounds, bruits, peripheral
pulses, peripheral oedema

Respiratory

■ Respiratory rate and effort, chest expansion and
percussion note, breath sounds, oxygen saturation

Gastrointestinal

■ Abdominal masses, ascites, bowel sounds, bruits, herniae,
Genitalia

Neurological

■ Conscious level, any pre-existing cognitive impairment or
confusion, deafness, neurological status of limbs

Investigations

1-Full blood count
- young woman with menorrhagia
- older patient
2-Urea and electrolytes
- in cases of the age over of 65 year
- lose a significant amount of blood in theatre
- history of cardiovascular, pulmonary or renal problems.
- diuretic taking patients


3- Liver function testsThese are indicated in patients with jaundicehepatitis, cirrhosis, malignancy, portal hypertension, poor nutritional reserves or clotting problems

4-Clotting screen

- any patient on anticoagulants, with compromised liver function tests
- evidence of a bleeding diathesis.
.
5-Arterial blood gases
assessment of some respiratory conditions,

6-Electrocardiography

-anyone over the age of 65 ???, 40year?
- in all patients in whom significant blood loss is possible
- All patent with a history of cardiovascular, pulmonary or anesthetic problems.

7-Chest radiography

This is not usually required unless the patient has a significant
cardiac history (including hypertension) or respiratory problems.
in IRAQ is different due to TB.

8- Human chorionic gonadotrophin

- in blood or urine and used to confirm pregnancy. It is essential in all female patients of childbearing age with abdominal pain to exclude an ectopic pregnancy and in any
unconscious female patient of childbearing age.
9-Sickle cell test
Usually the patient with sickle cell disease will know that they have this and inform the surgical team
10-Hepatitis/human immunodeficiency virus serology
Testing should be undertaken in any patient with a past history of high-risk exposure to infected body fluids, hepatitis or disorders associated with acquired immunodeficiency syndrome. .


.
12-Further cardiac evaluation
discussion with the anesthetist and/or a cardiologist is advisable if there are cardiac problems. A resting ECG does not reliably predict ischemic perioperative events.
ECHO, A ventricular ejection fraction of less than 35%, however, indicates a high risk of cardiac complications.

13- Further respiratory evaluation

-Thoracic surgery usually requires a thorough respiratory work-up preoperatively.
Otherwise, this is only indicated in patients with severe chronic obstructive airways disease [forced expiratory volume in 1 s (FEV1) of < 40%] or poorly controlled asthma in which preoperative optimization might be possible

14-Temperature
Patients with a pyrexia should not be operated on until the cause
has been identified and corrected if possible.
15-Urinalysis
Dipstick testing of urine is usually carried out preoperatively. It can detect urinary infection, biliuria, glycosuria and inappropriate osmolality. More detailed microscopic or biochemical analysis is indicated if the patient has a history of urinary tract problems or

SPECIFIC PREOPERATIVE PROBLEMS

1-Cardiovascular disease
- Hypertension
- ischaemic heart disease
- heart failure
- dysarrythmia
- anaemia
.
.


2-Respiratory disease

Infection..

Asthma
.
Chronic obstructive pulmonary diseas
.
Pulmonary fibrosis

3-Gastrointestinal disease

Malnutrition
.
Obesity
.

Problems of surgery in the obese

Increased risk of:
■ Difficulty intubating
■ Aspiration
■ Myocardial infarction
■ Cerebrovascular accident
■ Deep vein thrombosis and pulmonary embolism
■ Respiratory compromise
■ Poor wound healing/infection
■ Pressure sores
■ Mechanical problems – lifting, transferring, operating table


3-Surgery in the jaundiced patient

1-Clotting disorders need vitamin k

2-Hepatorenal syndrome need hydration
3- Infection need antiboitic

4-Renal impairment

■ Prerenal:
Dehydration
Poor perfusion

■ Renal:

Acute – volume depletion, platelet function,
immunosuppression
Chronic – fluid balance, ?dialysis, ?transplantation

■ Postrenal:

Obstruction – calculi, prostate, blocked
Catheter


Urinary tract infection

5- Metabolic disorders

Diabetus
Surgical risks for the diabetic patient
■ Increased risk of sepsis – local and general
■ Neuropathic complications – pressure care
■ Vascular complications – cardiovascular, cerebrovascular,
peripheral
■ Renal complications
■ Fluid and electrolyte disturbances

6-Adrenocortical suppression

Patients receiving oral adrenocortical steroids regularly (including up to 2 months before surgery) will have a degree of adrenocortical suppression. They will require extra doses of steroids around the time of surgery to avoid an Addisonian crisis

7-Coagulation disorders

Patients taking drugs that interfere with the clotting Cascades
For simple atrial fibrillation, warfarin can usually be stopped 3–4 days before surgery and then restarted at the normal dosage level on the evening after surgery.
Check that the international normalised ratio (INR) has dropped to 1.5 or lower before surgery

DVT

Deep vein trombosis
Risk factors for thrombosis
■ Increasing age
■ Significant medical comorbidities (particularly malignancy)
■ Trauma or surgery (especially of the abdomen, pelvis and
lower limbs)
■ Pregnancy/puerperium
■ Immobility (including a lower limb plaster)
■ Obesity
■ Family/personal history of thrombosis
■ Drugs, e.g. oestrogen, smoking


Risk groups for thrombosis according to surgery
Low risk
■ Minor surgery (less than 30 min), no risk factors, any age
■ Major surgery (more than 30 min), no risk factors, less
than age 40
■ Minor trauma or medical illness
Moderate risk
■ Major surgery (not orthopaedic or abdominal cancer), age
40+ or other risk factor
■ Major medical illness, trauma or burns
■ Minor surgery, trauma or illness in patient with a
family/personal history
High risk
■ Major surgery (elective or trauma orthopaedic, cancer) of
the pelvis, hip or lower limb
■ Major surgery, trauma or illness in a patient with a
family/personal history
■ Lower limb paralysis/amputation

Prophylaxis against thrombosis

Mechanical
■ Early mobilisation
■ Neuraxial anaesthesia
■ Leg compression stockings
■ Calf and foot pumps
Pharmacological
■ Heparin and low molecular weight heparin
■ Warfarin
■ Aspirin
■)


Neurological and psychiatric disorders
Peripheral neuropathies and myopathiesmay require prolonged
ventilation postoperatively and this should be anticipated.

Anticonvulsants need to be continued perioperatively and

may need to be changed to intravenous forms if starvation is prolonged.

Psychiatrically disturbed patients may require general rather

than regional anaesthesia.

Locomotor disorders

Specific complications of the inflammatory arthropathies should
be identified preoperatively.
The commonest, and potentially most catastrophic, of these is the unstable cervical spine in the patient with rheumatoid arthritis
If not handled carefully during intubation these patients can sustain
significant spinal cord damage

CONSENT

Stages in the consent process
■ Ensure competence (ensure that the patient can take in,
analyse and express their view)
■ Check details (correct patient)
■ Make sure that the patient understands who you are and
what your role is
■ Discuss the treatment plan and sensible alternatives
■ Discuss possible risks and complications (especially those
specific to the patient)
■ Discuss the type of anaesthetic proposed
■ Give the patient time and space to make the final decision
■ Check that the patient understands and has no more
questions
■ Record clearly and comprehensively what has been agreed

Peri-Operative Care

Monitoring Allows:

Adequate anesthesia.

Adequate analgesia

Adequate immobilization

Early notice of trends which may develop into life-threatening conditions

Parameters to Monitor(every 10-15minutes)

1-ECG

pulse rate ,arrhythmia, ischaemia
2- Peripheral Perfusion
oxygen saturation by oximeter normally 90-100%
3- Pulmonary Monitoring
ventilation Po2 Pco2 PH
4- Temperature
5- Blood Pressure
Hypotension , hypertension

Pulse Oximetry

Sensor beams infrared light through tissue and records the absorption either of light passing through the tissue to a receiver on the other side (transmission) or reflected back to the sensor (reflectance)

Reflector sensor Transmission sensor

post operative care

The aim of postoperative care is to provide the patient with as quick, painless and safe a recovery from surgery as possible

Patient recovery

Once patients are fully conscious and comfortable and their vital functions are stable they are transferred to the general ward;
however, patients who are at high risk may be transferred to a high-dependency or intensive care unit.

POSTOPERATIVE CARE OF THE PATIENT

After the operation the patient should be safely transferred to the
bed from the operating table, under the supervision of the anaesthetist
and surgeon.
A clear operative note should be written immediately.and should be included in the operative note
1 Patient’s details – full name, date of birth, hospital number,
address, ward.
2 Date (and start/finish time) of operation.
3 Operating room.
4 Name of operation.
5 Surgeon, assistant, anaesthetist.
6 Anaesthetic type.
7 Patient positioning and set-up.
8 Was a tourniquet used, were antibiotics given, was the patient catheterised, type of skin preparation, method of draping.
9 Tourniquet time, if applicable.


10- Operative details including:
• incision;
• approach;
• findings;
• procedure (appropriate illustration, if appropriate);
• complications, untoward events;
• implants used;
• closure, including suture material used;
• dressing;
• postoperative state (e.g. distal neurovascular status);
• type of dressing used.

11- Postoperative instructions relevant to surgery:

• observations required and frequency, e.g. 4-hourly pulse
and blood pressure measurements for 24 hours;
• possible complications and action to be taken if complications occur, e.g. if blood loss exceeds 500 ml in a drain
call the surgeon;
• treatment, e.g. intravenous fluids .antibiotic
• time lines for patient recovery, e.g. when to mobilise,
when to resume normal oral intake, the need for physiotherapy,
allowable movements, dressing changes.


12- Discharge and follow-up details; instruction for sutures,splints, casts

Post Check the patient’s charts for temperature, pulse and respiration

(TPR), fluid balance
Specific examinations also need to be recorded, such as
- Bowel sounds after abdominal surgery
- Distal neurovascular status after orthopaedic procedures.
- Regularly review nutritional status in those patients who may
be in negative nitrogen balance.
- Review all laboratory results and investigations.
- Review the drug chart to ensure that drugs are not being continued unnecessarily.
- Record all relevant findings (both negative and positive) clearly in the notes

Pain management

Optimal management of acute postoperative pain requires planning,
patient and staff education and tailoring of the regimen to
the type of surgery and the needs of the individual patient.


Patients vary greatly (up to eightfold) in their requirement for analgesia, even after identical surgical procedures.
Under treatment results in unacceptable levels of pain with tachycardia
hypertension, vasoconstriction .
Painful abdominal and thoracic wounds restrict inspiration, leading
to tachypnoea, small tidal volumes and inhibition of effective
coughing and mobilisation. This predisposes to chest infection
delayed mobilisation, deep venous thrombosis, muscle wasting
and pressure sores
Pain,the fifth vital sign’
requires regular pain measurement, with staff to be alerted in the
event of high scores .
The joint working party report also encouraged
the use of combined ‘multimodal’ analgesia comprising local anaesthesia and simple analgesics such as paracetamol (acetaminophen)and non-steroidal anti-inflammatory drugs (NSAIDs)
with opioid drugs

Simple analgesic agents

In minor surgery and when the patient is able to eat after surgery,
NSAIDs and paracetamol may be sufficient
- Codeine phosphate is commonly favoured after intracranial surgery
because of its intermediate respiratory depressant effect; however,
it should not be given intravenously as it can then cause profound
hypotension. Constipation is also not uncommon with codeine
- Rectal and intravenous diclofenac or intravenous
ketorolac are commonly used NSAIDs in the perioperative
period.
Stronger analgesic agents
With adjuvant analgesics in combination, regular intramuscular
morphine injection can provide effective treatment for the majority
of surgical patients

Techniques for postoperative pain relief

■ Regular intramuscular injections – may get pain
breakthrough
■ - Local anaesthetic block – ideal if it works
■ Indwelling epidural – good pain control
-opioids may depress respiration
■ Continuous infusions – reduce oscillations in pain relief
but risk overdose
■ Patient-controlled analgesia – pain relief titrated to
patient’s needs

Fluid ,electrolyte management

1- give daily requirement
2- add fluid lost by
bleeding,
NGT,
drains

Cardiovascular complications

Hypotension
Whatever the cause of hypotension, the emergency treatment
requires an increase in the fluid input with administration of high-flow oxygen
Low blood pressure postoperatively
■ dehydration
■ anaesthetic
■ blood loss
■ morphine
■ myocardial infarct