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Dr Michael Tronson's notes on Perioperative patient care








Disclaimer




These notes have been produced to assist the junior surgical staff at Box Hill Hospital Melbourne when caring for surgical patients throughout their perioperative course. They could be applied to all surgical disciplines. They are the thoughts and insights of an experienced anaethetist. They are not meant to replace standard textbooks, or local hospital policy. They are not specifically authorised by Box Hill Hospital or any other organisation. They have been prepared as a guide, not as an authorative text - and should be used as such.






Is health care a risky business?

Sipping a cup of coffee and seemingly unaware of the irony of what he was about to say, the registrar said; “The operation was a success, but he died two days later”.  According to a report from the Australian Patient Safety Foundation, one in ten surgical patients coming to an acute care hospital suffers harm because something predictable or preventable goes wrong during their stay. About three-quarters of all preventable deaths occur in patients over 65 years old.

Our job in Preadmission clinic is to prevent calamities. Our goal is to predict and prevent nasty surprises during the patient’s hospital stay and after they leave hospital.  To achieve this we need to evaluate our patients’ medical, physical and emotional states, optimize known diseases, identify occult diseases, predict likely postoperative problems, and take steps to prevent or manage them. Patient’s medication is frequently harming them. Other troubles occur because we fail to use effective treatments, and worse, give treatments that damage patients. Hospitals that follow guidelines save more lives. This is the reason for this book – to suggest some guidelines.

 

“First do no harm” – Hippocrates (460 –335 BC)

Important stuff

If you don’t diagnose it, you can’t fix it.

If you don’t predict it, you can’t prevent it.

Who is not suitable for elective anaesthesia?

· 

· 

·  Upper respiratory tract infection, chest infection or purulent sputum — wait 3 weeks.

·  Suboptimally controlled cardiac failure = can’t talk while walking down the corridor.

·  Untreated, unstable or suboptimally controlled diabetics (HbA1C >8.0%).

·  Unstable angina; meaning angina worse in the past 3 months, or occurring at rest.

·  Coronary stent within past 3 months (better to defer for at least 6 months).          + 50

·  TIA or stroke within previous 3 months (better to defer for at least 6 months).

·  Any infection where foreign material is to be implanted: hips, knees, vascular grafts.

What harms patients postoperatively

The majority of postoperative deaths occur in elderly patients with pre-existing cardiac or pulmonary disease who have undergone major surgery.

·  PACE = perioperative adverse cardiac events

o   Cardiac failure

o   Cardiac ischaemia

o   Sepsis

o   Renal failure

o   Haemorrhage

o   Pneumonia

o   Pulmonary emboli

 

Our aim is to get patients back

to their usual life as quickly as possible

 

An aside

Take nothing you see or hear for granted. Accept nothing you see or hear at face value. The most important clinical question you can ask yourself is  “Why did that happen?”  If you can’t find an answer then look it up, or ask someone. So much is known – so little is used. The most spectacular advance yet to be made in medicine will be to fully use existing knowledge.

Jargon

PACE  =  Perioperative Adverse Cardiac Event 

·  Arrhythmias.

·  Cardiac failure.

·  Acute pulmonary oedema.

·  Myocardial ischaemia.

·  Infarction.

·  Death.

ASA grading

ASA (American Society of Anesthesiologists) classification.  Anaesthetists use this shorthand to describe patient’s fitness.  Despite being written more than 50 years ago, the ASA grading is brilliant at predicting problems.

ASA I               Fit and well for age.

ASA II              Mild disease that does not hamper the patient enjoying daily activities.

ASA III             Severe disease restricting the patient’s daily activities.

ASA IV             Life threatening disease.

ASA V              Not expected to live another 24 hours without intervention.

ASA VI             Brain dead – organ donor

Major procedure (highly invasive surgery)

·  Expected to take more than 60 minutes.

·  Involves extensive tissue mass or  trauma.

·  Major disruption to body physiology persists after 24 hours.

·  Needs blood transfusion.

·  Involves a patient of ASA III grade or more.

·  All vascular surgery.

·  Major joint replacement.

·  Open abdomen or thorax including major laparoscopic surgery.

·  Intracranial or spinal operations.

·  Is an emergency.

Examples: aortic aneurysm repair, bowel resection, thoractomy, major joint replacement.

Minor surgery (moderately invasive surgery)

·  Procedure

·  expected to take from 30 - 60 minutes

·  Some tissue trauma.

·  Minor disruption to body physiology persists after 24 hours.

·  Patient is intubated.

·  No blood transfusion.

·  Laparoscopy.

Examples: inguinal hernia repair, laparoscopic cholecystectomy, prostatectomy.

 

“Wotcha mean minor surgery; it’s major surgery to me.”

Minimal procedure (minimally invasive surgery)

·  Expected to take less than 30 minutes.

·  Minimal tissue trauma.

·  No disruption to body physiology persisting after 24 hours.

·  Examples arthroscopy, D&C, cystoscopy.

Get the side and site of the surgery correct

Although it is rare a for surgeon to operate on the wrong side or the wrong site, mistakes are harrowing, heartbreaking and expensive.  Always PRINT the side of surgery in full, do not use abbreviations eg. don’t simply scrawl L.THR; print left total hip replacement.

Good 5 step regime

1.        On admission to hospital, ask the patient to mark YES on the site of the surgery with an indelible pen, and if on an extremity write no on the other limb.

2.        The ward nurse checks the patient’s pen mark before transfer to the OR.

3.        Check the pen mark again on arrival and admission to the operating theatre suite.

4.        The surgeon checks the patient's mark and confirms the site with an indelible marker.

5.        Don't induce anaesthesia until all these steps have been taken.

When to admit your patient

Admit on the day of surgery

·  As far as possible, admit all patients on the day of surgery.

·  Routine admission times are 06.30 for morning surgery or 10.30 for afternoon surgery.

·  Admit those with mental impairment on the day of surgery.  Organise for a person they trust to stay with them. 

· 

Admit the day before

Admit the following patients at 14.30 hrs the day before surgery:

·  Elective abdominal aortic aneurysms that require angiography or other investigations.

·  Insulin dependent diabetics for major bowel surgery with severe intercurrent disease.

·  Patient who require bowel prep the day before their procedure and who are:

o   Frail and live alone, and those >80 years;

o   Those likely to get postural hypotension if they become dehydrated;

o   Patients with CCF or IHD with METs score of 2 or less.

How to postpone a patient

Check category of patient on MR4 form.  Catergory 1 patients are urgent, and have to have their procedure within 28 days. Before postponing Category 1 patients discuss it with your consultant surgeon.  BHH is fined up to $30 000 if Cat 1 surgery is postponed unnecessarily. Inform the registrar, anaesthetist, and booking office.

Consent

Box Hill Hospital's policy on consent

The policy is set out in a document: "Box Hill Hospital Medical Services Policy Manual 2002".  If you have doubts about what you are doing then seek help from the head of your unit, or if not available then contact Clinical Services Administration.  There is always someone on call. Don’t get yourself into the situation where “Hizonor” might ask from the bench  “Oh I see doctor, and just how many pancreactoduodenctomies have you done?”

The minimum the patient needs to know

·  Diagnosis and prognosis.

·  Why the procedure is being done.

·  What will happen if nothing is done.

·  Options for anaesthetic and surgery.

·  Chances of success.

·  What tests are recommended and why.

·  Risk of the anaesthetic/operation.

·  Risks and benefits of blood transfusion.

·  How pain will be controlled.

·  How long the patient will be confined to bed.

·  How long is the stay in hospital.

Valid consent involves

For the consent to be valid and effective, the patient's consent must:

·  Be freely and voluntarily given.

·  Cover the procedure to be performed.

·  Cover the person who is to perform the procedure.

·  Be given by a competent patient capable of consenting.

·  Be sufficient to satisfy the patient while ensuring that no material risks are withheld.

This means that you must inform the patients of known risks when either a risk is rare but the outcome is severe, or the risk is common but the outcome slight.

Hints

·  Don’t consent a patient for surgery unless you are aware of the consequences of the surgery and the anaesthetic, and all the material risks. [Rogers vs. Whittaker 1992]

·  If you aren’t sure about all the material risks then refer difficulties to a more experienced senior colleague (that’s what they’re paid for).

·  Note in the record whether the patient appears to understand what you have said.

·  Ask your patient “Do you understand everything I have said to you?” 

·  Ask yourself:  “Do I know enough to stand in a witness box to defend my career?” 

·  Ask your patient to write down any further questions that arise when they get home. They can then resolve these queries when they are admitted for their operation.

b     Little gem

Never deprive someone of hope; it may be all they have.

 

·  Don’t say, “Good luck!” to your patients as they leave your office because some get really upset by this.  If you want to say anything say something like:”I hope it all goes well for you.”

Jehovah’s Witnesses and other sects

Jehovah’s Witnesses may consent to surgery and anaesthesia, but refuse a blood transfusion.  They have a sincere and deep religious objection to blood transfusion or receiving any blood products.  Fill-out the special consent forms for those who refuse blood, or blood products.  However, Jehovah’s Witnesses cannot refuse to consent for blood transfusion for relatives, minors, or friends.  It is futile to argue with the patient or their associates; refer difficulties to Medical Administration.

Minders

Some religious sects send 'minders' to accompany patients through the preadmission process.  Interview patients for at least part of the time, without their 'minders' being present.   Out of the earshot of their minder, the patient’s views may differ.  You can always invite their 'minder' to come in later.

Relatives

A similar problem occurs with relatives and friends.  If the patient asks: "Can my husband come in too?" usually means she is happy to have him present.   However if the husband asks, "Do you mind if I come in too?” then it is wise to seek the wife's consent out of her partner's earshot.  This particularly applies to older teenagers, and young adults accompanied by their parents. 

Interpreters

Box Hill Management Executive Committee Policy rules

·  Book interpreters well in advance.  This is best done from the waiting list when patients are first booked for their outpatients appointments.

·  Patients have a right to interpreters at all times.

·  The biggest risk of litigation or harm occurs if the health care worker fails to:

o   comply with the patient’s wishes;

o   obtain informed consent; 

o   to ensure patients understands what they have been told.

·  Where possible, use accredited medical interpreters. Do not use the patient’s friends or family, or any member of the hospital staff who is not a doctor or a nurse.

·  Make sure there is an orange coloured Interpreter Alert Sticker on the patient’s file.

·  Book an appropriate interpreter through the Eastern Health Transculural Services Unit. They have a good intranet site.

·  There are a number of telephone interpreting services. Box Hill Hospital uses Victorian Interpeting Telephone Service (VITS) – see the Eastern health Intranet for details.

Specific surgery

General surgery

Bowel resection

Colon and rectal cancer affects about 1:18 males, 1:24 females usually when elderly, with 9000 new cases each year in Australia.  Familial predisposition is about 1%.

Preoperative

Problems include: anaemia from occult blood loss, poor nutrition. Useful to start preoperative vitamin supplement, and consider nutritional supplements.  Check for pernicious anaemia. May need preop iron supplements.

Overall postoperative mortality is a 6.9 - 8.1%.  Independent predictors of death are age, ASA >II, Duke’s stage, urgency of operation. 

Operation

1.5 -  3 hours

Anaesthesia

G+A ± epidural

Cross-match

2 units

Pain

+++ if no epidural.

Nasogastric tube

Not usually

Urinary catheter

Yes

Hospital stay

6 -  8 days

Mortality

8 -  10% at BHH

Big risks

Postop hyponatraemia, postop hypoxia, sepsis, with ensuing cardiac problems.

 

Postoperative

Better to avoid blood transfusions with colorectal cancer because transfusion is an independent predictor of recurrence, or rapid progression of cancer.

6 – 8 litres of isotonic fluid transudates into the bowel resolving with diuresis on the 4th day.  Use at least 3 or more litres of Hartmann’s solution on the first and second day. 5% dextrose causes hyponatraemia. Check electrolytes the morning after surgery. Add 13.4 mmol potassium to alternate litres.

Sepsis on day 1 or 2 revealed by gradually rising respiratory rate, poor perfusion status, and possibly mild confusion. Patients over 70 years may not get febrile, or mount a white cell response.

On days 3 + hiccups are a sign of a blood or pus collection under the diaphragm (usually on the left side). Look for partial basal lung collapse in the left lower lobe (fuzzing out the medial few centimeters of the diaphragm), and fluid collecting in the pleural space obliterating the lateral angle of the diaphragm on the affected side.

Oesophagectomy – open

Preoperatively

·  A suboptimal nutritional status increases mortality and morbidity.

·  Chemotherapy causes further immunosuppression.

·  Get respiratory function tests, and arrange an elective admission to ICU. 

·  In patients > 45 years get an echocardiogram + EF

·  Make sure the patient brings all CT scans and X-rays with them.   

 

Operation

4 - 7 hours, long and often bloody.

Indication

Usually carcinoma, but occasionally stricture.

Anaesthesia

GA with mid thoracic epidural.  Needs one lung anaesthesia. 

Cross match

6 units

Lines

Pulmonary artery catheter, arterial line. thoracic and abdominal drains.

Nasogastric tube

Essential.  Crosses anastomoses. Must be stitched to nasal frenulum,. A disaster if this becomes dislodged in first few days.

Pain

++++

Urinary catheter

Yes

Intensive care

Yes, for at least 4 - 5 days

Hospital stay

12 - 14 nights

Mortality

< 6% in skilled hands, up to 50% in occasional operators

Big risks

Intraoperative hypothermia. High risk of aspiration About 25% get major complications especially PACE.  2/3 of deaths are from anastomotic breakdown leading to sepsis. 

Laparoscopic cholecystectomy 

10% of the adult Western population get gallstones, and 1-4% a year cause problems.

Operation

1 -  1.5 hours

Anaesthesia

G+A

Cross-match

G+H

Pain

++  particularly radiated to shoulder tips

Urinary catheter

No

Hospital stay

2  - 3 nights

Mortality

<0.1%

Big risks

Gas embolism, conversion to open operation, DVT, right lower lobe collapse, bile leakage causing peritonitis, bleeding.

 

Conversion to open surgery is more likely if  body mass index >35, previous abdominal surgery; gall bladder wall thickness >0.4 cm; ASA III or more; acute cholecystitis.

Insufflated gas irritates the under surface of the diaphragm (innervated by C3, 4, 5). Shoulder tip pain may feel as though “somebody has tried to rip my arms out” and responds to NSAIDs, or small dose of opioid.

High gastric reduction

Operation

1.5  - 2 hours

Anaesthesia

G+A

Cross-match

G+H

Pain

+++

Urinary catheter

Yes

Hospital stay

4 – 5 nights

Mortality

<1% but it depends on the mass of the patient. 

Big risks

DVT, aspiration, basal lung collapse, wound infection, abdominal hernia, anastomotic leak, failure,

From Jan 2007 add the following investigations: Zinc, chromium, homocysteine, fasting lipids, fasting glucose, fasting insulin, HbA1C, iron studies, B12, folate, TFTs.

Gastric banding - laparoscopic

Operation

1 – 1.5 hours

Anaesthesia

G+A

Cross-match

G+H

Pain

++

Urinary catheter

No

Hospital stay

1 night

Mortality

<0.1% but it depends on the mass of the patient. 

Big risks

DVT, aspiration, basal lung collapse, organ perforation, failure,

From Jan 2007 order the following additional investigations: Zinc, chromium, homocysteine, fasting lipids, fasting glucose, fasting insulin, HbA1C, iron studies, B12, folate, TFTs.


Haemorrhoids

Operation

15 - 45 minutes

Anaesthesia

GA or spinal

Cross match

Nil

Pain

++++ if no caudal anaesthetic is given

Urinary catheter

No

Hospital stay

2 - 3 nights

Mortality

Negligible

Abdominoplasty (apronectomy)

Indication

Flabbing abdominal fat apron

Surgery

1.5 -  2 hours

Anaesthesia

G+A

Cross-match

G+H - may need up to 2 units

Pain

+++

Urinary catheter

Yes,  usually - depends on weight of patient

Hospital stay

5 – 7 nights

Mortality

<1% but it depends on the mass of the patient. 

Big risks

DVT, aspiration, basal lung collapse, wound infection,

 

Splenectomy

Indication

ITP, Felty’s syndrome, trauma 

Operating time

60 - 90 minutes

Preop tests

platelet count.  Consult the haematologists, and the blood bank.

Anaesthetic

GA supplemented by epidural or intercostal blocks depending on the platelet count.

Blood transfusion

Cross-match 2 units for small spleens, up to 6 units for large spleens. Have 6 units of group specific platelets at hand.

Urinary catheter

No

Pain

+++++  without local blocks or epidural

Hospital stay

7 - 10 days

Special problems

postoperative chest infection, haemorrhage pain.

Postoperative:

Patient needs life time penicillin cover and you need to organise vaccination against pneumococcus, and meningiococcus.

Platelet transfusion

Order 6 units of platelets, because it may be necessary to top-up the patient’s platelets up once the spleen is clamped during surgery . The spleen gobbles platelets lightning fast.

Thoracic surgery

Sternal split

Surgery

1 - 1.5 hours

Anaesthesia

General anaesthesia

Cross-match

2 units of blood are needed for a large sternal split

Blood loss

600 - 800 ml

Drains

Possible thoracic drain if pleura breached

Pain

+++

Urinary catheter

No

Hospital stay

5 days

Mortality

<0.1%

Big risks

Airway obstruction, vocal cord paralysis, laryngeal incompetence and nausea and vomiting.

 


Lung resection

Preop need

·  Physiotherapy referral

·  Those with major symptomatic cardiac disease, reduced pulmonary functions who are dyspnoeic when walking on the level, are likely to die after operation.

·  Patients with < 4 METs are at high risk of postoperative complications.

 

Surgery

1.5  - 2 hours

Preop needs

·  Minimum preoperative FEV1/VC (age corrected) are:

Pneumonectomy                        >55%

Lobectomy                               >40%

            Wedge resection                       >35%

Anaesthesia

General anaesthesia + thoracic epidural

Cross-match

2 units of blood are needed for a large sternal split

Blood loss

600 - 800 ml

Drains

Thoracic drain

Pain

++++ controlled with thoracic epidural

Urinary catheter

Yes

Hospital stay

7 – 10 days

Mortality

1 %

Big risks

postoperative chest infection, pain, dermatomal neuralgia.

VATs Pleurodesis 

Involves stripping of parietal pleura from inside chest and instillation of talcum powder to ensure lung stays inflated.  Used for repeated pneumothorax in young asthmatics, and elderly with recurrent pleural effusions.  If pleural effusion >50% then drain first.  Patients with < 3 METs are at high risk of postoperative complications.

 

Surgery

1.5 hours 

Preop needs

Physio referral, recent chest X-ray. Discuss analgesic options

Anaesthesia

General anaesthesia +/- thoracic epidural

Cross-match

2 units of blood are needed for a large sternal split

Blood loss

600 - 800 ml

Drains

Thoracic drain

Pain

+++++   controlled with either pleural catheter or thoracic epidural

Urinary catheter

Yes

Hospital stay

3–4 days

Mortality

<1 %

Big risks

postoperative chest infection, pain, dermatomal neuralgia.

Needs chest X-ray in recovery room to check that lung is fully expanded.

Vascular surgery

Abdominal aortic aneurysms (AAA)

Operation

2.5 – 4 hours

Anaesthesia

general + epidural

Cross-match

4 units

Pain

+++   controlled with with epidural. 

Urinary catheter

Yes

Hospital stay

10 –12 days

Mortality

1%

Big risks

postoperative hypoxia with MI on day 2

Medication

Consider preoperative beta-blocker

Without operation risk of rupture increases with aneurysm diameter:

·  4 - 7 cm   = 25% risk.

·  7 - 10 cm = 45% risk.

·  >10 cm 60% risk.

·  Mortality rate for ruptured aneurysm at Box Hill Hospital is about 50%. 

Risks

Risks of myocardial infarction postoperatively is about 5%, with a 50% mortality.  Coronary artery plaque rupture is a major cause, but also the heart needs to increase its output considerably in the first few days after surgery. and this in itself may cause ischaemia.

Infra-inguinal vascular surgery

Operation

2.5 - 4 hours

Anaesthesia

general or spinal/epidural

Cross-match

2 units

Pain

++

Urinary catheter

Yes

Hospital stay

10 days

Mortality

2+%

Big risks

postoperative hypoxia. At least 6% risk of MI on day 1 or 2

Medication

preop beta-blockers

Carotid endarterectomy (CEA)

Usually performed on patients with > 70% stenosis of internal carotid artery with symptoms.  Once artery is totally blocked, operation is not required.

Operation

2 – 2.5 hours

Anaesthesia

usually general anaesthesia

DO NOT STOP ASPIRIN

Cross-match

G+H

Pain

+1

Urinary catheter

No

Hospital stay

4 days, and then to rehabilitation

Mortality

1%

Big risks

Postoperative stroke, and hypoxia at night with MI on day 2

Urology

Cystoscopy

Day case.  Diagnostic flexible cystoscopy under local. 

Rigid cystoscopy spinal or GA. 

Operation 5 - 10 minutes. 

Cystoscopy and resection of bladder tumour (TURBT)

·  Overnight stay.

·  Anaesthetic: general.

·  Operation 15 - 25 minutes.

·  Catheter if tissue resected.

Radical prostatectomy

·  Urine micro and culture, FBE, U+Es, liver function tests, ECG, CXR. 

·  Cross-match either 2 units of autologous blood, or 3 units of homologous blood.

·  Reinforce preop pelvic floor contractions held for 14 seconds 10 times per day.

·  Fit venous compression stockings. 

·  Arrange Hospital-in-the-Home after operation: continuation of pelvic floor exercises,

 

Operation                      1 - 1.5 hours

Anaesthesia                  general supplemented with continuous epidural

Cross-match                 4 units of blood

Blood loss                     1500+ ml

Pain                             ++       

Urinary catheter yes

Hospital stay                  5 days

Mortality                        2%

Big risks                       Postoperative hypoxia especially at night, urinary obstruction, DVT,                                              incontinence.

Total cystectomy ± ileal conduit

Preoperatively:

·  Note any previous chemo or radiotherapy.

·  Make sure current CT scans available and that the patient brings them to hospital.

·  Check tissue biopsy is confirmed.

·  Tests include FBE, U+Es, LFTs and MSU

 

Operation                      4 - 7 hours

Anaesthesia                  general supplemented with continuous epidural

Cross-match                 4 units of blood

Blood loss                     1500+ ml

Pain                             ++        usually controlled with epidural   

Urinary catheter yes

Hospital stay                  7 - 10 days

Mortality                        2%

Big risks                       Postoperative hypoxia especially at night, urinary obstruction.

                                    DVT

Extracorporeal shock wave lithotripsy (ESWL)

·  Plain X-ray to show position of stone.  ECG.  U+Es, FBE, LFT.

·  Give patient to take withthem: photocopy of relevant outpatient notes, container for stone debris, “Stone diet” instructions, BHH review appointment for 3/52 with prior kidney U/Sound.  Completed consent form, unreported current X-ray of stone.

·  Patient to fast from midnight the night before and present to St.  Vincent’s Hospital at 7.00 am on the day of procedure, with all their results.

 

Operation

1 hour

Anaesthesia

epidural or sometimes general anaesthetic

Cross-match

G+H

Blood loss

Minimal

Pain

++

Urinary catheter

Yes

Hospital stay

Day case, done at St.  Vincent’s Hospital

Mortality

Rare

Big risks

urinary obstruction from debris, bleeding, failure, systemic sepsis.

If the procedure is complicated they will be admitted to BHH Urology Ward on that afternoon.  If stents need later removal then book for this procedure at BHH. 

TURP = transurethal resection of the prostate. 

·  The aim is to resect the prostate tissue, but spare the prostatic capsule. 

·  Use prostate ultrasound to find the size and uniformity of the prostate. 

·  Prostates >100 gm usually need an open (Miller’s) prostatectomy.

Preoperative

·  Tests: Urine micro and culture because incidence of bacturia about 40%. 

·  FBE, U+Es, liver function tests,

·  ECG.  CXR. 

·  If haematuria then get a renal ultrasound. 

·  Stop aspirin 7 days prop and recommence 5 days postop

Operation

20 - 40 minutes

Anaesthesia

Spinal

Cross-match

G+H

Blood loss

200+ ml

Pain

+

Urinary catheter

Yes

Hospital stay

4 nights

Mortality

1%

Big risks

Postoperative hypoxia especially at night, urinary obstruction, TURP syndrome, glycine toxicity, sepsis

Postoperative

·  Patients may absorb large amounts of irrigation fluid during the procedure. 

·  If they already have peripheral oedema this will exacerbate their fluid overload and they may develop pulmonary oedema. 

·  Make sure hat peripheral oedema is as well controlled as possible before TURPs, even if it means postponing the procedure for a couple of weeks.

Risks

Bleeding needing transfusion, re-operation, conversion to open operation, permanent stress or urge incontinence 15%, long term catheter, impotence 5%.  Retrograde ejaculation 100%, sex feels different 100%. Mortality <1%, success rate 85+%, recurrence <15%.  Hypothermia, clot-retention with 3-way catheter for 24 - 36 hours.  The operation is done under spinal anaesthesia with minimal sedation so that TURP syndrome 1% can be diagnosed early.  Transient blindness secondary to glycine absorption.

Orthopaedic surgery

Hip replacement (THR)

Preop.

Need to achieve a MET score of 3.

 

Operation

2.5 – 4 hours

Anaesthesia

Usually spinal + sedation. Redo needs GA

Cross-match

3 units

Pain

++    (little if they have PCA)

Urinary catheter

No

Hospital stay

4 – 6 days and then up to 1 month in rehab

Mortality

1%

Big risks

DVT /PE, postoperative hypoxia with MI on day 2,

Bone dust and trash emboli ends up in the lungs after joint replacement. This causes episodic hypoxaemia at night for upt to 8 days. The SaO2 may dip below  “safe” limits of 92%. Order mandatory oxygen supplement, especially in those receiving opioids. It only takes a few minutes of hypoxaemia to scramble an older persons brain - permanently.

 

Oxygen is cheaper than nursing home care.

Total knee replacement (TKR)

Preop.

Need to achieve a MET score of 3.

 

Operation

2.5 – 4 hours

Anaesthesia

Usually spinal + sedation. Redo needs GA

Cross-match

1 unit if patient weighs < 55 Kg

Pain

++    (little if they have PCA)

Urinary catheter

No

Hospital stay

4 – 6 days and then up to 1 month in rehab

Mortality

1%

Big risks

DVT /PE, postoperative hypoxia with MI on day 2,

Bone dust and trash emboli ends up in the lungs after joint replacement. This causes episodic hypoxaemia at night for upt to 8 days. The SaO2 may dip below  “safe” limits of 92%. Order mandatory oxygen supplement, especially in those receiving opioids. It only takes a few minutes of hypoxaemia to scramble an older persons brain - permanently.

 


Investigations

We waste staggering amounts of money on unnecessary investigations. A routine CXR, FBE, U+Es + LFTs cost >$100. Of the 4000 patients a year we review in preadmission clinic less than 1% of otherwise well people return worrying results.  Nevertheless, chronic kidney disease (CKD) is under diagnosed, and this causes unnecessary misery. Those most at risk of CKD have hypertension, diabetics, or other vascular disease.

Use your clinical acumen to select investigations.

Nursing observations

The nursing staff in Preadmission Clinic routinely record height, weight, oxygen saturation, peak flow, blood pressure, urine analysis, and in diabetics a blood glucose (finger-prick).

Routine preoperative investigations              

·  FBE, in patients older than 65 years unless done recently.

·  U+Es if patient has diabetes, hypertension (treated r untreated), cardiac failure, or has known renal disease. Allso those taking drugs excreted by the kidney (digoxin) or those that could damage the kidney (NSAIDS, COX,

· 

·  Add LFTs if the patient:

·  has intercurrent disease that might affect the liver,

·  is on medication affecting the liver including statins, antimetabolics (methotrexate), herbal remedies

·  drinks > 3 – 4 units of alcohol daily

·  surgery is expected to take >60 minutes,

·  or was born or have lived outside developed countries (Hep B, & C).

·  Hypothyroidism is common in the elderly.  They feel the cold – “something awful”. Consider TSH in female patients over 60 years;

 

Test

ASA I

ASA II

ASA III

ASA IV

FBE

 

+

+

+

U + E

 

+

+

+

Creatinine

 

+

+

+

LFT

 

+ (if on medication)

+

+

ECG

 

+

+

+

CXR

 

 

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ECG

Write helpful stuff on the ECG form especially blood pressure, any cardiac, or psychotropic drugs, IHD or CCF. 

Order ECGs for anyone with:

·  History of actual or possible heart disease,.

·  Hypertension.

·  Diabetes.

·  Vascular disease.

·  Obesity BMI > 30.

·  Men > 40 years.

·  Women > 45 years unless ECG in previous 2 months.

·  All smokers aged 35 years or more. 

CXR

Be kind to a radiologist:

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·  Radiologists aren’t mind readers, so write useful things on their forms too.

·  Don’t annoy them by writing “routine preop CXR”, or infuriate them by writing nothing.  

·  Don't double radiation radiation dose with lateral CXR unless there is a good reason.

·  Don’t order routine chest X-rays in asymptomatic patients:

·  who are under the age of 70 years;

·  who are undergoing minor surgery;

·  who are life long non-smokers;

·  with a previously normal chest X-ray in the past 5 years;

·  asthmatics (unless you think they have pneumothorax);

·  fertile women.

·  Do order a CXR in patients who have:

·  smoked for 5+ years at any time and are now >55 years of age;

·  a history of cardiac failure;

·  cancer anywhere. 

Other indications for CXR include: deviated trachea, recent onset of hoarse voice, haemoptysis, hacking dry cough, suspected mediastinal masses, persistent crackles in lung bases, cardiac enlargement, or dextrocardia.

Liver function tests

Order LFTs if there is evidence of previous or current liver disease, the patient is taking medication that potentially can damage livers, or if major surgery is planned.  Consider LFTs if patients were born or have lived outside developed countries and may have Hep B or C.

`                Physiological foundations

·  Liver function tests do not test liver function; they test liver damage (“transaminitis”).

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