Pre-Operative Assessment and Post-Operative Care

Pre-Operative Assessment and Post-Operative Care

Adam Eslick

Staff Specialist

Department of Anaesthetics and Perioperative Medicine

Learning Objectives

• Pre-Operative Assessment: What are we trying to achieve?

• What really matters for pre-operative patients?

• Referring patients to Anaesthetics

• What is the role of specialty consults peri-operatively?

• What do Anaesthetists care about?

• What really matters post-operatively?

Perioperative Medicine is a big topic…

Goals of Pre-Operative Assessment

• Patient Safety

• Facilitate Operating Theatre/Hospital Efficiency

• Early Planning for Post-Operative Rehabilitation

• Advanced Care Directives/Goals of Treatment

Pre-Operative Care: What really matters

• Optimisation of important, unstable disease• Cardiovascular

• Respiratory

• Endocrine

• Neurology

• Renal

• Haematological


• Optimisation of unstable, important disease

• Tests


• Optimisation of important, unstable disease

• Tests• Common Sense: Why are we doing this?

• Tests to facilitate surgery: • Group and Screen, Imaging etc…

• Screening Tests: • ECG, CXR, Spirometry, Sickle Cell, (?? Troponin)

• Tests to facilitate pre-op optimisation and risk stratification:• FBC, Electrolytes, Albumin, Coags, beta-hCG, Echocardiography, PFTs, HbA1c….



• Tests

• Fluids• This really matters

• Fasting is bad for you

• Inpatient management so much harder than outpatient management

Pre-Operative Fluid Management: A Diversion

• Fluids• Euvolaeamia is the goal

• Heart Failure, Renal Failure, Bowel Prep

• Electrolytes• Na+ = 1mmol/kg/day

• K+ = 0.5 – 1mmol/kg/day

• Mg++ = 10-15mmol/day

• Glucose = 50-100g/day

• Nutrition• Major Cavity Surgery

Fasting???

• Historical• Dehydration is bad• Aspiration is very, very bad…• Fasting Times

• 6 hours solids• 4 hours breast milk• 2 hours clear fluids

• Delayed Gastric Emptying• Diabetes, Autonomic dysfunction• Renal Failure• Head Injury• Opioids• Trauma, Pain• Raised Intra-Abdominal Pressure



• Tests

• Fluids

• Management of Diabetes• This really matters

• Common problem

Diabetes Mellitus: Another Diversion

• Common: • 10-15% of surgical population.

• Up to 30% of emergency surgery population.

• Significant: • Perioperative mortality up to 50% higher than non-diabetic population.

• Hyperglycaemia is an independent risk factor for surgical site infection.

• Evidence for SSI in Spinal, Vascular, Colorectal, Cardiac, Breast, Trauma, Orthopaedic, Neurosurgery, Upper GI.

• Increased risk of AMI (100% increase)

• Increased risk of AKI (100% increase)

• Increased risk of UTI, Pneumonia (> 100% increase)

Perioperative Management of Insulin

• Listen to the patient

• Ultra-Long Acting Insulin (once daily)• Lantus, Levemir• Reduce dose by 20% Day -1 and Day 0. • Continue with Insulin Infusion (80%)

• Twice Daily Insulin• Novomix 30, Humalog Mix, Levemir or Lantus used BD• Leave unchanged on Day -1• Halve the usual morning dose on Day 0

• Short and Intermediate Acting• Actrapid, Novorapid, Humulin, Apidra, Isophane• Leave Unchanged on Day -1• Calculate total morning dose, give half

Perioperative Management of Oral Hypoglycaemics – Practical Guide

• Drugs that can cause hypoglycaemia when fasting• Sulphonylureas – Gliclazide, Glipizide, Glibenclamide• Meglitinides – Repaglinide, Nateglinide

• Continue Day -1, Withhold Day 0, Restart when eating normally

• Drugs that can cause ketoacidosis when fasting• SGLT-2 Inhibitors – Dapaglifozin, Canaglifozin

• Continue Day -1, Halve Morning Dose on Day 0, Restart when eating normally

Perioperative Management of Oral Hypoglycaemics – Practical Guide• Drugs that may be continued when fasting

• DPP-IV Inhibitors – Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin• GLP-1 analogues – Exenatide, Lixisenatide• Glitazones – Pioglitazone, Rosigllitazone• Acarbose• Continue Day -1 and Day 0• Restart post-operatively when eating normally

• Metformin• Controversial• Contrast, Renal Impairment: Withhold on Day 0 and for 48 hours thereafter

Insulin Infusions

• Poor Control

• Complex medical regimes (eg Insulin + 2 oral hypoglycaemics)

• Repeated Surgery

• Major Surgery

• Emergency Bookings

• Use 10% Dextrose 40mL/hr if volume is a problem



• Tests

• Fluids

• Management of Diabetes

• Drugs

• Insulin Management

• Anticoagulants and Antiplatelet agents

• ACE inhibitors and Angiotensin II Receptor Blockers (…pril, …artan)

• MAO-A Inhibitors• Tranylcypromine, phenelzine, isocarboxacid, moclobemide + LINEZOLID



• Tests

• Fluids

• Management of Diabetes

• Drugs

• Pain Management• This really matters• Aggressive management of pain perioperatively is one of

the few interventions shown to reduce the risk of persistent post-surgical pain

• Acute Pain Service can help• Long-Term analgesic therapy should NOT be stopped.


• Patient and Carer Expectations

• Consent

• Advanced Medical Directives

• Goals of Treatment

Refer to Anaesthetics…

• What is the goal of the referral?• Courtesy• Assist with pre-operative optimisation• Collaborative assessment of fitness for surgery• Participation in multi-disciplinary planning and assessment

• What are the goals of the anaesthetist when seeing patient pre-operatively?• Maximise patient safety, pre-operative optimisation• Facilitate OT efficiency• Provide information to the patient and family about anaesthetic plan• Expectations, Consent, Advanced Directives

What is the role of Specialty Consults?

• Pre-Operative Optimisation

• Answer Specific Questions

What is the role of Specialty Consults?

• Pre-Operative Optimisation

• Answer Specific Questions

• NOT to Assess Fitness for Surgery

What makes up an Anaesthetic Assessment?

Surgical Factors

AnaestheticFactors

Patient Factors

Anaesthetic Assessment: Patient Factors

• Age

• Focused Medical History

• General Medical History

• Functional Status

• Medications

• Allergies

• Smoking, Alcohol, Other Drugs

• Airway Assessment

Anaesthetic Assessment: Patient Factors

• Age• < 2 or > 70…75…80 years

• Focused Medical History• Cardiorespiratory (inc OSA)• Endocrine/Diabetes/Obesity• Renal Disease• Major Haematological Disease• Major Neurological Disease

• General Medical History

• Functional Status

• Medications

• Allergies

• Smoking, Alcohol, Other Drugs

• Airway Assessment

• Disease Processes with direct implications for Anaesthesia Practice• Myaesthenia Gravis• Muscular Dystrophy• Myotonica dystrophica• Multiple Sclerosis• Major Burns• Phaeochromocytoma• Carcinoid Syndrome• Rheumatoid Arthritis (involving neck/jaw)• Ankylosing Spondylitis• Mastocytosis• Malignant Hyperthermia (or family Hx)• Suxamethonium Apnoea• Halothane Hepatitis• Structural Airway disease

ASA Score

• Designed to compare workload of hospitals

• Never intended to serve as a prognostic marker

• ASA 1 – A healthy individual

• ASA 2 – Minor disease only (eg well controlled asthma, hypertension on a single agent)

• ASA 3 – Significant co-morbidities which impact on a patient’s daily life (egMorbid Obesity + DM + Coronary Artery Disease)

• ASA 4 – Significant co-morbidities which pose a constant threat to life (egIschaemic Heart Disease complicated by ischaemic cardiomyopathy with intermittent VT).

• ASA 5 – A moribund patient, not expected to survive 24 hours without surgery

ASA Score - Modifiers

• ASA 6 – A patient undergoing organ donation

• E – Emergency Surgery

• T – Trauma Surgery

Cardiac and Respiratory Investigations

• Impressive shift to minimise investigations

• ACC/AHA Guidelines almost universally adopted

• Respiratory Guidelines being developed• Often need an anatomical and physiological approach

• 3 legged-stool.

Airway Assessment

• History• Medical conditions• Previous Anaesthetics• Anaesthetic Charts, Letters

• Examination• Mallampatti Score• Thyromental Disease• Neck circumference• Teeth• Mouth Opening• Mandibular advancement• Macroglossia• Facial structure, beard

• Investigations• Lateral Neck X-Ray• CT Neck• Nasoendoscopy

Obligatory Ridiculous Photo

Post-Operative Care: The Big Issues

• Where to physically care for patients

• Pain

• Fluids, Electrolytes and Nutrition

• Diabetes Management

• Mobilisation, Physiotherapy, DVT Prophylaxis

• Nausea and Vomiting

• Post-Op Investigations

• Returning to baseline function, medications etc….

Pain Management: Issues• Oral analgesia vs Parenteral analgesia

• Who needs a PCA? For how long?

• What adjunct analgesics are available:• Paracetamol• NSAIDs• Tramadol• Amitriptylline, Pregabalin, Gabapentin, Duloxetine, others….• Ketamine

• How do I manage Local Anaesthetic techniques:• Epidurals• Nerve/Sheath infusions• Wound infusions

Resources• Oxford Handbook of Anaesthesia

• Pre-Procedure Preparation Toolkit, NSW Health 2007

• Perioperative Diabetes Management Guidelines, Australian Diabetes Society, 2012

• Peri-Operative Management of the surgical patient with diabetes 2015. Anaesthesia 70: 1427-1440.

• Preoperative Assessment A Cardiologists perspective. Australian Prescriber 2014: 37: 188-91.

Thank you!

Adam Eslick

[email protected]

0401863900

Pre-Operative Assessment and Post-Operative Care

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