Intraoperative, Postoperative, Perioperative, Preoperative Assessment & Management
A 72-year-old man is awaiting a left total knee replacement. He has hypertension that is
controlled with amlodipine and takes warfarin for atrial fibrillation. He takes no other regular
medications.
This patient is ASA 2
This patient is going for a major operation and takes warfarin. He would need his clotting checked before proceeding with
surgery although this may not take place until the day of surgery after the warfarin has been stopped.
All patients undergoing a major operation that are either ASA 1 and over the age of 65 or ASA 2 and above should have an
ECG performed.
In addition, lung function tests would not routinely be arranged for patients like this without a history of respiratory disorder.
U+E) blood tests
Patients over 60 years, those with cardiovascular and renal disease, diabetes and those on steroids/ACE-I or diuretics should
have U+Es monitored pre-operatively.
Blood thinners and Surgery
Aspirin is an antiplatelet medication with irreversible action. Therefore, the effects of aspirin last for the duration of the life of
the platelet which is up to 10 days. Although most surgeons will stop aspirin 7 days before surgery. => Effects of aspirin last
10 days but usually it is stopped 7 days pre-op
Unfractionated heparin should be discontinued 6 h before surgery to reduce risk of bleeding. Unfractionated heparin can be
used intraoperatively for high risk patients normally on anticoagulation to ensure they continue to receive appropriate
anticoagulation during the perioperative phase.
Low-molecular-weight heparins often given prophylactically in hospital should typically be stopped 12 h before surgery,
although some surgeons will proceed with surgery provided it was prophylactic not treatment dose, depending on the type of
procedure.
Warfarin is typically stopped 5 days pre-operatively with the International Normalised Ratio (INR) checked before surgery to
ensure it is at an adequate level. INR < 1.5 is usually acceptable to proceed with surgery but some surgeons prefer an INR <
1.3.
The non-vitamin K antagonist oral anticoagulants (NOACs) including Apixaban (direct factor Xa inhibitor) and
Rivaroxaban are typically stopped 2 days before surgery depending on the patient’s renal function and bleeding risk.
laparoscopic cholecystectomy
On average, patients go home on the same day as the procedure. There is an NHS initiative to ensure that 60% of laparoscopic
cholecystectomies are performed as day case procedures.
Cirrhosis is not a contraindication for laparoscopic cholecystectomy, however there is increased risk of bleeding and
postoperative infection.
,Cholangiography is only required in the presence of common bile duct (CBD) stones. These can be detected by preoperative
MRCP and if this is negative there is no need for intra-operative cholangiography.
Previous abdominal surgery can make the procedure more challenging due to the presence of adhesions but is not a
contraindication.
Around 5% of laparoscopic cholecystectomies require conversion to open procedures.
Rates of bile duct injury are comparable between open and laparoscopic cholecystectomy procedures, with current studies
reporting an incidence of between 0.2–0.5%. Due diligence is required when identifying the cystic duct to ensure the CBD is
not damaged as this can have a lasting, and distressing, impact on the patient. Major duct transection is obvious early because
of abdominal pain. It is difficult to treat and may require hepaticojejunostomy. Minor injury with a stricture causes biliary
cirrhosis and malabsorption, in this situation balloon dilatation of the stricture may be of value. Bile duct injury does not seem
to be prevented by routine cholangiography.
Mortality rates following laparoscopic cholecystectomy are around 0.22–0.4%
Risk of deep vein thrombosis (DVT) (without prophylaxis) is around 1–2%
Haemorrhage is the commonest complication of laparoscopic cholecystectomy. Treatment is with good surgical haemostasis
and appropriate fluid resuscitation, including blood transfusion as required. As such, patients should also be consented for
blood transfusion.
Incisional hernia would be a long-term complication of a laparoscopic cholecystectomy and may require surgical treatment. The
risk of an incisional hernia is low due to the small size of the port incisions.
Diathermy injury may cause a enterocutaneous fistula, however, insufflation of the abdominal cavity with carbon dioxide during
laparoscopic surgery thus reduces the risk of damage to adjacent structures as the surgical working space is increased.
Pneumothorax may occur as a result of a diaphragmatic injury using from the diathermy hook. This is an uncommon
complication.
Obstruction occurs due to adhesions or port site hernia and is considered a long-term complication and uncommon.
Consent Forms
Consent form 1 would only be suitable if the patient had capacity to make a decision regarding the proposed treatment.
Consent form 1 is used for adult patients with capacity who are agreeing to an investigation or treatment in which their
consciousness will be impaired as is the case in any procedure performed under general anaesthetic.
Consent form 2 is used when parental consent is also required for a child up to age of 16. Although, if the child is deemed to
have capacity (can comprehend and retain information relating to the decision, weigh it up and then communicate their
decision) they may also sign the consent form.
Consent form 3 is used for patients who have capacity and when their consciousness will not be impaired during the
procedure.
Consent form 4 This is used for patients who lack capacity and it should be checked whether the patient has a lasting power of
attorney or advanced directive before proceeding with this. It must be deemed that a procedure cannot be delayed until the
patient regains capacity and is in the patient’s best interests.
,Verbal consent is not enough for patients undergoing this type of procedure. Verbal consent would be suitable for example for
a patient who is going to have a CT scan and agrees that they are happy to have it performed.
recent MI
Major elective surgery is not recommended within 6 months of a myocardial infarction.
The patient has had a recent MI and is on dual antiplatelet therapy. She would, therefore, be a high anaesthetic risk and would
be high risk for bleeding. She has had recent cardiac stents and therefore these medications cannot be stopped at present.
Clopidogrel is typically stopped after the first year and given that this is an elective procedure it would be sensible to postpone
the surgery until the risk of bleeding and anaesthetic can be reduced.
Recent myocardial infarction is a significant risk factor for a further perioperative re-infarction for patients undergoing surgery.
Optimisation of medical co-morbidities, such as hypertension, diabetes and hypercholestrolaemia, is paramount in reducing risk
of re-infarction. Furthermore, delaying non-emergency procedures until at least 8–12 weeks post infarction is pragmatic.
The risk of a perioperative re-infarction is approximately
37% within 30 days
16% at 3–6 months
5% after 1 year
A patient in extremis, or requiring an extensive surgical procedure, will have a higher risk of re-infarction due to increased
cardiovascular stress.
The most important indicator of ischaemic heart disease is in the patient’s history. Risk factors in the history include smoking,
diabetes or hypercholesterolaemia. They should lead one to suspect myocardial disease. An electrocardiogram is more helpful
in aiding the diagnosis of an acute myocardial event.
Well controlled hypertension does not appear to be an adverse risk factor.
ASA grade
Patients with an ASA grade of 1 are fit and well.
ASA 2 describes a patient with mild systemic disease and this patient would fit into that category. He has well controlled
diabetes and there is nothing to suggest from the history that the hypertension is uncontrolled.
ASA 3 describes a patient with severe systemic disease. In this case if the patient’s hypertension was not well controlled (need
for two antihypertensives) or he was a poorly controlled diabetic then he would fit into the ASA 3 category.
ASA 4 describes a patient with severe systemic disease that is a constant threat to life. For example a patient with severe
chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy.
ASA 5 describes a moribund patient that is not expected to survive without the operation. For example, a patient with a
ruptured abdominal aortic aneurysm having an emergency open repair.
ASA grade Definition Mortality %
I Normal healthy individual 0.06
II Mild systemic disease that does not limit activity 0.4
III Severe systemic disease that limits activity but is not incapacitating 4.5
IV Incapacitating systemic disease which is constantly life threatening 23
V Moribund, not expected to survive 24 h with or without surgery 51
, VI A declared brain-dead person whose organs are being removed for donor purposes N/A
TURP
Procedure-specific complications for a TURP include: retrograde ejaculation, erectile dysfunction, incontinence, haematuria,
UTI, urethral stricture and bladder perforation. Systemic complications include: DVT, PE and there is a small risk of death (which
occurs in 0.5–1% of cases). In addition there is a risk of TURP syndrome.
TURP syndrome is an uncommon, but important complication of a TURP. It occurs due to excessive absorption of hypotonic
irrigation fluids used during the operation. It is most common in larger resections that are difficult with heavy bleeding. The
main problems that result include electrolyte disturbances – in particular hyponatraemia, fluid overload and cerebral oedema.
This can result in confusion, impaired consciousness and seizures. The management consists of fluid restriction, the use of
diuretics as required and supportive management, usually in an high dependency unit (HDU) setting.
obesity
A BMI is a simple measure for estimating obesity using the patient’s weight and height measurements.
A normal BMI lies between 20–25, while a BMI of between 25–30 is classed as being 'overweight'. A BMI of between >30–40 is
obese; and a BMI of over 40 is 'morbidly obese'. BMI is equal to weight (kg)/height (m) 2. Obese patients encounter significantly
greater complications, both intra- and post-operatively. ITU care must be considered and beds booked before admission. BMI is
calculated as weight (kg)/height2 (m2)
Obesity increases the risk of requiring mechanical ventilation, tracheostomy placement and stays on critical care.
Obesity is a risk factor for venous thromboembolism, however the mainstay of prophylaxis is pharmacological and mechanical
(TED stockings and/or calf pumps). The routine use of vena caval filters is not currently recommended by NICE
MRSA
Barrier nursing with apron and gloves is the current accepted infection control procedure.
Face masks are unnecessary when seeing patients with MRSA.
Most hospitals do not place patients with one MRSA positive swab in an exclusive bay. If a single side-room is not available
patients may be able to be nursed in a bay alongside other MRSA patients. Some hospitals have made arrangements for
patients with multiple MRSA infections to stay in one ward.
Reversed barrier nursing
Reversed barrier nursing is implemented to protect patients (such as neutropenic individuals) who are at high risk of
contracting infection from common organisms carried by other people.
Diabetes and Surgery
Diabetics should ideally be placed first on the list to prevent prolonged starvation. Often other factors may change this, but in
an ideal scenario this would be the case.
There is no need for the patient to be solely on long-acting insulin as he will be starved. If he becomes hyperglycaemic, this can
be controlled with a Glucose/potassium/insulin (GKI) infusions (sliding scale), which usually employs short acting insulin.
Sliding scale should remain up until the patient is eating and drinking normally. He should go back to his usual insulin regime
once the surgery is complete and he is eating and drinking.
Insulin increases cellular update of potassium and commencing an insulin sliding scale poses the risk of hypokalaemia.
A 72-year-old man is awaiting a left total knee replacement. He has hypertension that is
controlled with amlodipine and takes warfarin for atrial fibrillation. He takes no other regular
medications.
This patient is ASA 2
This patient is going for a major operation and takes warfarin. He would need his clotting checked before proceeding with
surgery although this may not take place until the day of surgery after the warfarin has been stopped.
All patients undergoing a major operation that are either ASA 1 and over the age of 65 or ASA 2 and above should have an
ECG performed.
In addition, lung function tests would not routinely be arranged for patients like this without a history of respiratory disorder.
U+E) blood tests
Patients over 60 years, those with cardiovascular and renal disease, diabetes and those on steroids/ACE-I or diuretics should
have U+Es monitored pre-operatively.
Blood thinners and Surgery
Aspirin is an antiplatelet medication with irreversible action. Therefore, the effects of aspirin last for the duration of the life of
the platelet which is up to 10 days. Although most surgeons will stop aspirin 7 days before surgery. => Effects of aspirin last
10 days but usually it is stopped 7 days pre-op
Unfractionated heparin should be discontinued 6 h before surgery to reduce risk of bleeding. Unfractionated heparin can be
used intraoperatively for high risk patients normally on anticoagulation to ensure they continue to receive appropriate
anticoagulation during the perioperative phase.
Low-molecular-weight heparins often given prophylactically in hospital should typically be stopped 12 h before surgery,
although some surgeons will proceed with surgery provided it was prophylactic not treatment dose, depending on the type of
procedure.
Warfarin is typically stopped 5 days pre-operatively with the International Normalised Ratio (INR) checked before surgery to
ensure it is at an adequate level. INR < 1.5 is usually acceptable to proceed with surgery but some surgeons prefer an INR <
1.3.
The non-vitamin K antagonist oral anticoagulants (NOACs) including Apixaban (direct factor Xa inhibitor) and
Rivaroxaban are typically stopped 2 days before surgery depending on the patient’s renal function and bleeding risk.
laparoscopic cholecystectomy
On average, patients go home on the same day as the procedure. There is an NHS initiative to ensure that 60% of laparoscopic
cholecystectomies are performed as day case procedures.
Cirrhosis is not a contraindication for laparoscopic cholecystectomy, however there is increased risk of bleeding and
postoperative infection.
,Cholangiography is only required in the presence of common bile duct (CBD) stones. These can be detected by preoperative
MRCP and if this is negative there is no need for intra-operative cholangiography.
Previous abdominal surgery can make the procedure more challenging due to the presence of adhesions but is not a
contraindication.
Around 5% of laparoscopic cholecystectomies require conversion to open procedures.
Rates of bile duct injury are comparable between open and laparoscopic cholecystectomy procedures, with current studies
reporting an incidence of between 0.2–0.5%. Due diligence is required when identifying the cystic duct to ensure the CBD is
not damaged as this can have a lasting, and distressing, impact on the patient. Major duct transection is obvious early because
of abdominal pain. It is difficult to treat and may require hepaticojejunostomy. Minor injury with a stricture causes biliary
cirrhosis and malabsorption, in this situation balloon dilatation of the stricture may be of value. Bile duct injury does not seem
to be prevented by routine cholangiography.
Mortality rates following laparoscopic cholecystectomy are around 0.22–0.4%
Risk of deep vein thrombosis (DVT) (without prophylaxis) is around 1–2%
Haemorrhage is the commonest complication of laparoscopic cholecystectomy. Treatment is with good surgical haemostasis
and appropriate fluid resuscitation, including blood transfusion as required. As such, patients should also be consented for
blood transfusion.
Incisional hernia would be a long-term complication of a laparoscopic cholecystectomy and may require surgical treatment. The
risk of an incisional hernia is low due to the small size of the port incisions.
Diathermy injury may cause a enterocutaneous fistula, however, insufflation of the abdominal cavity with carbon dioxide during
laparoscopic surgery thus reduces the risk of damage to adjacent structures as the surgical working space is increased.
Pneumothorax may occur as a result of a diaphragmatic injury using from the diathermy hook. This is an uncommon
complication.
Obstruction occurs due to adhesions or port site hernia and is considered a long-term complication and uncommon.
Consent Forms
Consent form 1 would only be suitable if the patient had capacity to make a decision regarding the proposed treatment.
Consent form 1 is used for adult patients with capacity who are agreeing to an investigation or treatment in which their
consciousness will be impaired as is the case in any procedure performed under general anaesthetic.
Consent form 2 is used when parental consent is also required for a child up to age of 16. Although, if the child is deemed to
have capacity (can comprehend and retain information relating to the decision, weigh it up and then communicate their
decision) they may also sign the consent form.
Consent form 3 is used for patients who have capacity and when their consciousness will not be impaired during the
procedure.
Consent form 4 This is used for patients who lack capacity and it should be checked whether the patient has a lasting power of
attorney or advanced directive before proceeding with this. It must be deemed that a procedure cannot be delayed until the
patient regains capacity and is in the patient’s best interests.
,Verbal consent is not enough for patients undergoing this type of procedure. Verbal consent would be suitable for example for
a patient who is going to have a CT scan and agrees that they are happy to have it performed.
recent MI
Major elective surgery is not recommended within 6 months of a myocardial infarction.
The patient has had a recent MI and is on dual antiplatelet therapy. She would, therefore, be a high anaesthetic risk and would
be high risk for bleeding. She has had recent cardiac stents and therefore these medications cannot be stopped at present.
Clopidogrel is typically stopped after the first year and given that this is an elective procedure it would be sensible to postpone
the surgery until the risk of bleeding and anaesthetic can be reduced.
Recent myocardial infarction is a significant risk factor for a further perioperative re-infarction for patients undergoing surgery.
Optimisation of medical co-morbidities, such as hypertension, diabetes and hypercholestrolaemia, is paramount in reducing risk
of re-infarction. Furthermore, delaying non-emergency procedures until at least 8–12 weeks post infarction is pragmatic.
The risk of a perioperative re-infarction is approximately
37% within 30 days
16% at 3–6 months
5% after 1 year
A patient in extremis, or requiring an extensive surgical procedure, will have a higher risk of re-infarction due to increased
cardiovascular stress.
The most important indicator of ischaemic heart disease is in the patient’s history. Risk factors in the history include smoking,
diabetes or hypercholesterolaemia. They should lead one to suspect myocardial disease. An electrocardiogram is more helpful
in aiding the diagnosis of an acute myocardial event.
Well controlled hypertension does not appear to be an adverse risk factor.
ASA grade
Patients with an ASA grade of 1 are fit and well.
ASA 2 describes a patient with mild systemic disease and this patient would fit into that category. He has well controlled
diabetes and there is nothing to suggest from the history that the hypertension is uncontrolled.
ASA 3 describes a patient with severe systemic disease. In this case if the patient’s hypertension was not well controlled (need
for two antihypertensives) or he was a poorly controlled diabetic then he would fit into the ASA 3 category.
ASA 4 describes a patient with severe systemic disease that is a constant threat to life. For example a patient with severe
chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy.
ASA 5 describes a moribund patient that is not expected to survive without the operation. For example, a patient with a
ruptured abdominal aortic aneurysm having an emergency open repair.
ASA grade Definition Mortality %
I Normal healthy individual 0.06
II Mild systemic disease that does not limit activity 0.4
III Severe systemic disease that limits activity but is not incapacitating 4.5
IV Incapacitating systemic disease which is constantly life threatening 23
V Moribund, not expected to survive 24 h with or without surgery 51
, VI A declared brain-dead person whose organs are being removed for donor purposes N/A
TURP
Procedure-specific complications for a TURP include: retrograde ejaculation, erectile dysfunction, incontinence, haematuria,
UTI, urethral stricture and bladder perforation. Systemic complications include: DVT, PE and there is a small risk of death (which
occurs in 0.5–1% of cases). In addition there is a risk of TURP syndrome.
TURP syndrome is an uncommon, but important complication of a TURP. It occurs due to excessive absorption of hypotonic
irrigation fluids used during the operation. It is most common in larger resections that are difficult with heavy bleeding. The
main problems that result include electrolyte disturbances – in particular hyponatraemia, fluid overload and cerebral oedema.
This can result in confusion, impaired consciousness and seizures. The management consists of fluid restriction, the use of
diuretics as required and supportive management, usually in an high dependency unit (HDU) setting.
obesity
A BMI is a simple measure for estimating obesity using the patient’s weight and height measurements.
A normal BMI lies between 20–25, while a BMI of between 25–30 is classed as being 'overweight'. A BMI of between >30–40 is
obese; and a BMI of over 40 is 'morbidly obese'. BMI is equal to weight (kg)/height (m) 2. Obese patients encounter significantly
greater complications, both intra- and post-operatively. ITU care must be considered and beds booked before admission. BMI is
calculated as weight (kg)/height2 (m2)
Obesity increases the risk of requiring mechanical ventilation, tracheostomy placement and stays on critical care.
Obesity is a risk factor for venous thromboembolism, however the mainstay of prophylaxis is pharmacological and mechanical
(TED stockings and/or calf pumps). The routine use of vena caval filters is not currently recommended by NICE
MRSA
Barrier nursing with apron and gloves is the current accepted infection control procedure.
Face masks are unnecessary when seeing patients with MRSA.
Most hospitals do not place patients with one MRSA positive swab in an exclusive bay. If a single side-room is not available
patients may be able to be nursed in a bay alongside other MRSA patients. Some hospitals have made arrangements for
patients with multiple MRSA infections to stay in one ward.
Reversed barrier nursing
Reversed barrier nursing is implemented to protect patients (such as neutropenic individuals) who are at high risk of
contracting infection from common organisms carried by other people.
Diabetes and Surgery
Diabetics should ideally be placed first on the list to prevent prolonged starvation. Often other factors may change this, but in
an ideal scenario this would be the case.
There is no need for the patient to be solely on long-acting insulin as he will be starved. If he becomes hyperglycaemic, this can
be controlled with a Glucose/potassium/insulin (GKI) infusions (sliding scale), which usually employs short acting insulin.
Sliding scale should remain up until the patient is eating and drinking normally. He should go back to his usual insulin regime
once the surgery is complete and he is eating and drinking.
Insulin increases cellular update of potassium and commencing an insulin sliding scale poses the risk of hypokalaemia.
