Pre & post oprative prepration

Preoperative
peroration
(15/7/2020)

 PREPERED BY
Dr.Amani Abd Alazimnn 18
Dr.Alaa Abd Elsamee 19
DR.Esraa Suliman 18
Dr. Salameh Aburizq
DR. Attia Fadul Attia 19
DR. Khlood Osman 18
 Presented By
Dr. Amar Yahia Ibrahim
Registrar of General Surgery
SURGICAL CLUB RED SEA UNIVERSITY SC (RSU)

preoperative preparation
The purpose of preoperative evaluation is
to identify the problems that may increase
the operative risk and predispose to
postoperative problem .

A consultant surgeon leads a large team of
people involved in safely seeing a patient
through their individual operative
experience.
Even at an early stage in surgical training a
trainee is a key member of that team.

Important aspects of the trainee’s role in
this process are:
1-Gathering and recording concisely all relevant
information.
Notes on the history, examination, investigation,
conclusions and treatment plan should be clearly
written, concise and yet comprehensive

2-Planning to minimize risk and maximize benefit for the
patient.
Patients have to be medically fit before surgery is
undertaken.

3-Being prepared for adverse events and how to deal
with them.
4-Communicating with the patient and all other
members of the team

Principles of history-taking
■Listen: what does the patient see as the problem? (Open
questions)
■ Clarify: what does the patient expect? (Closed questions)
■ Narrow the differential diagnosis. (Focused questions)
■ Fitness: what other comorbidities exist? (Fixed questions)
1- History :
Assessment is done by :

a) review when taking the past medical history
Cardiovascular;-
Ischemic heart disease – angina,-myocardial infarction-
Hypertension-Heart failure -Dysrhythmias -Peripheral vascular
disease- Deep vein thrombosis and pulmonary embolism -
Anemia

Respiratory:-
Chronic obstructive pulmonary disease- Asthma- a Fibrotic lung
conditions -Respiratory infections- Malignancy
Gastrointestinal:-
Peptic ulcer disease and gastro- oesophageal reflux Bowel habit –
bleeding per rectum, obstruction Malignancy Liver disease –
jaundice, alcohol, coagulopathy

Genitourinary tract :-
Urinary tract infection- Prostatism - Renal dysfunction
Neurological:-
Epilepsy -Cerebrovascular accidents and transient ischemic attacks -
Psychiatric -disorders Cognitive function
Endocrine/metabolic:-
■ Diabetes
■ Thyroid dysfunction
■ Pheochromocytoma
■ Porphyria

Locomotor system
■ Osteoarthritis
■ Inflammatory arthropathy such as rheumatoid arthritis, including
neck instability
Infectious diseases
■ Human immunodeficiency virus
■ Hepatitis
■ Tuberculosis

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

b) Drugs & allergic Hx :
- Interaction with anesthesia (MAOI) .
- Related with sudden withdrawal (steroids) .
- Drug for HTN – IHD to be continued over .
- Anticoagulant drugs (aspirin , warfarin) .
- HRT .
c) Family Hx :
- bleeding disorder

History of emergence : ( A M P L E )
Allergies .
Medication .
Past medical Hx .
Last meal .
Event preceding the surgery .

d) Social Hx :
-Smoking . (stop before 1 month preoperative)

2 – Examination
1. General Ex. Including vitals ( BP , Pulse , RP , Temp. )
2. Cardiac Ex ( JVP , HS )
3. Respiratory Ex.
4. Abdominal Ex.
5. CNS Ex.
6. Musculoskeletal Ex.
7. Back examination

the general medical examination
General
■ Anemia, jaundice, cyanosis, nutritional status, teeth,
feet, leg ulcers (sources of infection)
Cardiovascular
■ Pulse, blood pressure, heart sounds, bruits, peripheral
pulses, peripheral edema

Respiratory
■ Respiratory rate and effort, chest expansion and percussion note,
breath sounds, oxygen saturation
Gastrointestinal
■ Abdominal masses, ascites, bowel sounds, bruits, hernia, genitalia
Neurological
■ Conscious level, any pre-existing cognitive impairment or confusion,
deafness, neurological status of limbs

B. Emergency examination :
1. the routine examination must be altered to fit the
circumstance .
2. A,B,C,D,E,F .
3. Secondary survey (head-to-toe).

3- Investigation :
Laboratory test : to all
patient undergoing general
anathesia:
1-CBC.
2-urine general.
3-FBG.
4- Blood grouping /
Crossmatch.
5-LFT.
6-TFT.
7-RFT.
8- Clotting screening.
9- bleeding tendence.

Special test in high RISK PATIANT :
- In cardiac disease: CXR / ECHO / ECG / Cardio enzyme .
- In respiratory disease : CXR / Pulmonary function test .

Hematologic teats indicated in:-
- Women of child-bearing age
- Men > 60 yrs.
- Baseline where blood loss is likely to be significant e.g. moderate
(abdominal hysterectomy, major vascular or abdominal surgery)
- Significant CVS/RS disease
- Thalassemia/Sickle Cell/ Hematological disease, Clinical signs
of anemia

- Bowel disease (including Ulcerative Colitis/Crohn’s)
- Liver/Renal Disease (including alcohol abuse)
- Rheumatoid/Connective tissue disease, Diabetes
- Known malignancy
- Long-term NSAID’S
- Short of breath on minimal exertion or orthopnea

N.B. Repeat Hb if there is likely to have been a significant
change since last result e.g. bleeding
FBC Not necessary for minor surgery in otherwise fit
patients

Clotting
• Not necessary for minor, intermediate or major surgery in
otherwise fit patients
• For all patients for major + (Grade 4) surgery such as hepatobiliary
and vascular surgery
• Liver disease (include. suspected alcohol abuse) , Jaundice
• Coagulopathy known or suspected (e.g. recent blood transfusion,
family history, Signs or symptoms of excessive bleeding, Anticoagulant
therapy

Blood grouping and cross matching
• All operations where blood loss may be significant
• Hemoglobin Electrophoresis in case of Family History of
haemoglobinopathy

BIOCHEMICAL TESTS
1-Urea & Electrolytes, Creatinine
• Patients > 60 yrs
• Baseline for all operations likely to require large
amounts of fluid/blood replacement
• Significant CVS/RS disease including hypertension
• Bowel disease, Liver/Renal Disease

 Rheumatoid/Connective tissue disease, Diabetes,
malignancy
 Diuretics/ACE inhibitors/B-blockers/Digoxin/ Steroids
 All patients on iv fluids
 Clinical signs of anemia, short of breath on minimal
exertion, orthopnea

2-Blood Sugar
• Not necessary for minor surgery in otherwise healthy patients
• All patients > 40 yrs presenting for intermediate, major and
major+ surgery
• Patients with abnormal urinalysis
• Liver and pancreatic disease (incl. suspected alcohol abuse)

 Diabetes (immediately before surgery)
 All vascular patients B-blockers, Steroids History of
dizziness or collapse
 Large or unusual abscesses
HbA1C – for major surgery, patients with poor control

3- Liver Function Tests & Consider Bone Profile
(serum calcium, magnesium & phosphates)
- Hepato-biliary surgery, Liver disease, Jaundice
- Known or suspected excessive alcohol intake
- Known Hep B/ C

 Thyroid Surgery (baseline Ca2+)
 Malignancy with risk of metastases
 Malnourishment
 Renal failure
 Significant heart failure Methotrexate, Anti-fungals (i.v.
only)

4- Thyroid Function Tests
- Thyroid surgery
- Thyroid disease – unless clinically euthyroid AND with normal
TFTs within last 6 months
-Signs or symptoms of hypo- or hyperthyroidism
5-Fasting Lipids
- Vascular Surgery
- Signs of hyperlipidemia in patients < 50 yrs old e.g. Xanthelasma

Principles of preoperative preparation
1. Correct any abnormalities and management of high risk patient.
2. obtain informed consent .
3- detail of preparation :-
nil by mouth for 4-16h preoperatively
i.v fluid and two large bore canula
 nasogastric aspiration
bowel perpetration
medication planning

4- cross match of blood if major operation with expected blood loss
5. DVT prophylaxis, e.g. graded compression stocking
(thromboembolic deterrent – TED) , subcutaneous low weight
heparin, e.g. Clexane .
6. Assessment of nutritional status.

Stages in the consent process
■ Ensure competence (ensure that the patient can take
in, analyze 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

7-Preoperative preparation anesthesia;-
Types of anesthesia
■ Local anesthetic – suitable for day cases;
contraindicated in infection
■ Regional block – useful in an emergency when the
patient is not starved; gives good postoperative pain
relief

■ Spinal and epidural anesthetic –
1. only to be used by an anesthetist under full sterile
conditions
2. epidural anesthesia allows on-going postoperative
pain relief
■ General anesthetics are now safer and more
controllable.

1-GENERAL ANAESTHESIA
Intraoperatively, the anesthetist should provide the general
anaesthetic triad of
1. unconsciousness,
2. pain relief and
3. muscular relaxation,
while ensuring maintenance of tissue perfusion and
oxygenation.

General anesthesia is most frequently induced
intravenously and maintained by inhaled vapor such as
halothane, enflurane or the more recent desflurane or
sevoflurane.
Propofol has replaced thiopentone as the commonest
intravenous agent.
It can also be used for maintenance in total
intravenous anesthesia (TIVA)

Analgesic agents are also frequently injected at the
time of anesthetic induction, to reduce the
cardiovascular response to tracheal intubation and to
be effective by the time of surgical incision.
Although the use of nitrous oxide contributes analgesic
and weak anesthetic effects

Techniques for maintaining an airway:-
■ Jaw thrust – only suitable for short term
■ Guedel airway – holds tongue forwards but does not
prevent aspiration
■ Laryngeal mask – simple to insert, allows ventilation
■ Endotracheal intubation – very secure protection of the
airway
■ Tracheostomy – used when airway needs protecting for
prolonged periods

A fibreoptic intubating laryngoscope.

Tasks of the anesthetist during anesthesia;-
■ Muscle relaxation – to allow ventilation and opening of
wounds
■ Pain control and unconsciousness – to minimize distress to
patient
■ Minimize blood loss – careful control of blood pressure
■ Temperature – avoid hypothermia
■ Monitoring – patient safety

8. management of high risk patient
a- patient with cardiac disease :
1-Ischaemic heart disease
Recent myocardial infarction is a strong contraindication to
elective anesthesia.
 elective procedures should ideally be delayed until at least 6
months have elapsed.

2- Dysrhythmias
Fast atrial fibrillation must be controlled before surgery
Regular measurement of serum potassium is essential,
particularly if digoxin is being used.

3-Anaemia and blood transfusion
Preoperative anemia may result from bleeding or as a
result of a chronic disease state.
 Preoperative transfusion should be considered if the
preoperative hemoglobin concentration is low

Preoperative transfusions
■ Consider transfusion if hemoglobin level is less than 8 g
dl–1
■ Consider carefully which products to use
■ Order and write up blood products clearly
■ Give the blood at a sensible time of day
■ Consider co-administration of a loop diuretic
Be prepared to treat any reactions rapidly

4-hypertetion:-
Patients with systolic pressures of 160 mmHg or above and
diastolic pressures of 95 mmHg or above should have elective
surgery deferred until their blood pressure is under control

Respiratory disease
1-Infection
Significant lower respiratory tract infections should be treated
before surgery except when the surgery is life-saving.
2-Asthma
The patient’s usual inhalers should be continued. Brittle asthmatics
may need oral steroid cover.

4-Chronic obstructive pulmonary disease
The anesthetist must be informed if the chronic obstructive
pulmonary disease (COPD) is significant, as regional anaesthetic
techniques may need to be considered.
5-Pulmonary fibrosis
the anesthetist will appreciate being warned about any cases in
which gaseous exchange is significantly impaired.

Gastrointestinal disease
1-Malnutrition
In the malnourished patient, treatment with nutritional
support for a minimum of 2 weeks before surgery is
required to have any impact on subsequent morbidity.

Metabolic response to starvation
 Low plasma insulin
 High plasma glucagon
 Hepatic glycogenolysis
 Protein catabolism

Hepatic gluconeogenesis
 Lipolysis: mobilization of fat stores
 Adaptive ketogenesis
 Reduction in resting energy expenditure (15–20 kcal
kg/day–1)

Effect of malnutrition on out come of surgery
 Impairment wound healing
 Suppression of immune response
 sense of mental and physical exhaustion
 reduced tolerance of radiotherapy and chemotherapy

Perioperative feeding in Children (0 to 16 years)
Preoperative fasting in children undergoing elective
surgery – ‘The 2-4-6 rule’
• ‘2’ - Intake of water and other clear fluid* up to 2 h
before induction of anesthesia
• ‘4’ - Breast milk up to 4 h before induction
• ‘6’ - Formula milk, cows’ milk or solids (Food, including
sweets) up to 6 h

The anesthetic team should consider further
interventions for children at higher risk of regurgitation
and aspiration
Regular medication should be continued, unless
contraindicated; premedication (benzodiazepines)
acceptable; taken with clear fluid up to 0.5 ml/kg

Obesity
Obesity is defined as a BMI of more than 30.
In some cases it might be better for the patient to
delay surgery until they have lost weight

Problems of surgery in the obese
 Difficulty intubating
 Aspiration
 Myocardial infarction
 Cerebrovascular
accident
 Deep vein thrombosis and
pulmonary embolism
 Respiratory compromise
 Poor wound
healing/infection
 Pressure sores
 Mechanical problems

Renal impairment
1-Prerenal
If the renal impairment appears to be a new finding, suspect a
perennial cause such as volume depletion.
Make comparison If previous tests of renal function are available
for rise in urea concentrations compared with those of creatinine.
Consider other causes of poor perfusion, particularly impairment of
cardiac output

2-Renal:
Acute – volume depletion, platelet function, immunosuppression
Chronic – fluid balance, ?dialysis, ?transplantation
3-Postrenal:
Obstruction – calculi, prostate, blocked catheter

patient with preexisting liver disease
operative risk increase steadily with increase of child grade
the three main risk to such patient including :
1. Bleeding : maybe necessary vit k and fresh frozen plasma .
2. hepatocellular failure : avoid massive bleeding , sever
dehydration Or sepsis , hepatotoxic drug .
3. sepsis : should be treated before surgery

Surgery in the jaundiced patient:-
If the cause of jaundice is obstruction to the biliary tree it
is important to ascertain whether there is associated
sepsis (cholangitis)

Causes of jaundice:
Pre-hepatic – hemolysis
Hepatic – hepatitis, cholangitis, alcohol
Post-hepatic – biliary obstruction, drugs

Secondary complications of surgery:
Clotting disorders
Hepatorenal syndrome
Infection

Preoperative preparation of patient obstructive
jaundice:-
Proper diagnosis and assessment
 Injection vitamin K IM 10 mg for 5 days
 Fresh Frozen plasma—often requires 6 bottles or
more
 Adequate hydration is most important 5/10%
dextrose

 Blood transfusion in case of anemia
 Oral neomycin, lactulose
Mannitol 100-200 ml BD IV to prevent hepatorenal syndrome

1. Preoperative Prevention of SSI
(surgical site infection):-
Preoperative cleaning and antiseptic scrub of surgical
site.
Skin is colonized by various bacteria mainly
Staphylococcus aureus (50%). Preoperative skin wash
using chlorhexidine decreases bacterial colonization by
80% and so wound contamination.

Surgical site to be shaved or clipped in the operation
theatre.
Shaving should be done in the theatre itself or within 2
hours of beginning of the surgery.
selective shaving is definitely needed in area like scalp,
axilla, groin, and perineum.

Surgery should be avoided or postponed if fingers or
hand of surgeon has open wounds or infection.
 Obvious infection in patient if exists should be treated.
 Prolonged preoperative admission should be avoided
for an elective surgery.

Preoperative preparation of Transplantation:-
1- General evaluation: Pulmonary, cardiac, GIT, renal status
and cancer screening.
2-Immunologic evaluation: Serology for hepatitis, HIV,
cytomegalovirus.
3-Placing the organ in the same position is called as
orthotopic transplantation, e.g. liver.
4- Placing the organ in new position is called as heterotopic
transplantation.

Metabolic disorders
Diabetes
These patients are at high risk of complications.
A careful preoperative assessment of their
cardiovascular, peripheral vascular and neurological
status should always be made.

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

Minor surgery in the non-insulin-dependent diabetic can be
managed by simply omitting their morning dose of
medication, listing them for early surgery and restarting
treatment when they start eating postoperatively.
For more significant surgery, and in the insulin-dependent
diabetic, an intravenous insulin infusion will be required.
This should be started when the patient first omits a meal and
continued until they have recovered from the surgery.

The plasma potassium level must be closely monitored .
There is a risk of life-threatening lactic acidosis in
patients taking metformin who are to have contrast
angiography.
This drug should be discontinued 24 hours before the
test and restarted 24–48 hours afterwards

Management of diabetic patient:
- check recent valve of HbA1c available .
- capillary blood glucose .
- Fasting rule to apply : normal dinner on the previous day.
- Clear fluid on the morning of surgery : 2 h. before induction.
- Usual doses of insulin on the evening of the preoperative day
with dinner.

Coagulation disorders
Patients taking drugs that interfere with the clotting
cascades.
Warfarin is the commonest drug in this category.
The reasons for the therapy should be established and the
associated risks of stopping the treatment assessed .
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 normalized ratio (INR) has
dropped to 1.5 or lower before surgery Alternative
perioperative anticoagulation is not required

the international
normalized ratio (INR)
Uses INR
Deep vein thrombosis 2-2.5
Pulmonary embolus 2.5-3.0
Chronic atrial fibrillation 2.5-3.0
Dilated cardiomyopathy 2.5-3.0
Mural thrombus 2.5-3.0
Rheumatic mitral valve disease 2.5-3.0
Recurrent deep vein thrombosis 3.5
Pulmonary embolus 3.5
Mechanical heart valve 3.5

Risk groups for thrombosis
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 orthopedic 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 orthopedic, 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 mobilization
■ Neuraxial anesthesia
■ Leg compression stockings
■ Calf and foot pumps

Pharmacological
■ Heparin and low molecular weight heparin
■ Warfarin
■ Aspirin
■ Pent saccharides (e.g. fondaparinux – inhibits activated
factor X)
■ Direct thrombin inhibitors (e.g. melagatran and
ximelagatran)

PREPARATION OF LARGE BOWEL FOR SURGERY
Principle Behind Bowel Preparation
Colon contains large amount of bacteria up to 109 / ml of
feces.
Most common anaerobe is Bacteroides.
commonest aerobe is Escherichia coli; Pseudomonas,
Enterococcus, Proteus, Klebsiella, Streptococcus are other
organisms.
Bowel preparation is done to clear this bacterial load to reduce
postoperative complications.

1. Mechanical bowel preparation
1. Polyethylene glycol (PEG)
is a non absorbed sodium sulphate solution,
2-3 litres of which is asked to drink by the patient along
with plenty of additional fluids orally.
It cleans the bowel by passing loose stool for 10-15
times in 12 hours.
It acts by its hygroscopic action.

Side effects are—nausea, vomiting, and abdominal
cramps. Antiemetic's are often needed.
It is ideal in renal failure, ascites, cirrhosis, CCF.
 Sodium phosphate is an alternative to PEG as smaller
volume is sufficient to take. But it causes electrolyte
imbalance. Its efficacy is similar to PEG. But patient

2. Antibiotics—parenteral and as bowel antiseptics
Oral neomycin (gentamycin, streptomycin were used
in olden days) 1 gram, erythromycin 1 gram, is used 3
days prior to surgery.
Alternatively ciprofloxacillin and metronidazole are
used

IV fluids should be given in addition to these patients to
maintain adequate hydration.
IV antibiotics 4 hours before making incision, reduces
the incidence of sepsis.
Usually cephalosporins are given.

Indications for Large Bowel Preparation
1. Carcinoma colon (especially left sided).
2. Anorectal malformations.
3. Megacolon.
4. Carcinoma rectum.
5. Surgery for ulcerative colitis.
6. FAP.
7. Diverticulitis.
8. High pelvirectal fistulas.
9. Before colonoscopy.

In operation room
No operating room can be kept completely free of
bacteria and, therefore, the risk of a wound becoming
infected from contamination is always present

the risk can be minimized by Scrub technique
1 Preparation before scrubbing:
You should not scrub if you have an open wound or an
infection.
Uninfected cuts or abrasions can be covered after a routine
scrub-up process by applying a sterile clear dressing before
gloving.
All jewelry on the hands should be removed.

2- A theatre hat, mask and eye protection should be fitted so
that no hair is exposed and you are protected from splash
back.
3- A sterile scrubbing brush and nail cleaner are used for 1–2
min to remove dirt from under the nails and from deep
creases in the skin.
4- The hands are then washed systematically, paying special
attention to the clefts between the fingerstick theatre
discipline.

5 Following the final rinse the hands and arms should be raised to
face level
6-The hands and arms should be dried using a sterile towel for
each side
7 The first scrub up of the day, therefore, should take about 5min
from start to drying.
8 If the surgeon stays within the theatre suite and there are no
significant external contacts or contamination, subsequent scrub
up will be shorter, with no need for the use of the nail cleaner or
brush.

Theatre staff preparation
■ Operating list (order of patients)
■ Special needs (implants and equipment)
■ Cross-matched blood, imaging and investigations
■ Extra staff (radiology, pathology)

Positioning in operation on the table:-
■ The diathermy plate must be secure and well positioned
■ The patient must be securely held on the table in the
correct position
■ There should be no contact between the patient and any
metal surface
■ All pressure areas should be protected

Tourniquets:
The majority of limb tourniquets in use in contemporary
practice are pneumatic tourniquets.
A tourniquet can and should be sized for the surgery to be
undertaken.
Small tourniquets can be used for digits

■ Note the distal neurovascular status before
application
■ Care with position and padding
■ Exsanguinate the limb before inflation
■ Note the time of inflation
■ Deflate after 1 hour
■ Check return of circulation and sensation after
deflation

Tourniquet complications
1. Excessive tourniquet time cause:
local pressure
Distal ischemic effects
nerve damage
compartment syndrome.

2. If the tourniquet pressure is inadvertently set too high,
nerve And muscle damage beneath the cuff itself will
occur
3. Chemical burn or blistering from skin preparation
leaking under the tourniquet.
4. Tourniquet failure.

Precautions when gloving/ degloving
■ Do not allow your skin to touch the outer surface of the
glove
■ Keep your fingers inside the sleeve of the gown until the
glove is on
■ If contamination occurs, both gown and gloves must be
replaced
■ Gloves are removed after the gown using a glove-to-glove,
then skin-to-skin technique

Factors that predispose a patient to
hypothermia include:
• long preoperative fasting (lowered patient
metabolism);
• prolonged immobility on the operating table
• the effects of anaesthetic agents, e.g. peripheral
vasodilatation.

evaporative heat loss from exposed viscera;
emergency surgery on shocked patients who are
already
Hypothermia in children, the large surface area-to-
weight ratio means that they lose heat quickly.

A waterproof under drape is applied with adhesive
edges.
A sterile waterproof stockinette is about to be applied by
the scrub nurse, initially onto the forefoot with the
uncurbed assistant supporting the heel.
The unsterile assistant will then move away carefully
from the operating table.
 All of these drapes are disposable

c) The final drapes are placed over the stockinette’s,
the operation sites are covered with clear adhesive and
a sterile bandage is used to secure the stockingettes.
Note also the hand position of the surgeon

Preparing the patient’s skin (‘prepping’)
■ Performed by staff who are scrubbed up
■ Use aqueous solutions for open wounds, alcohol for intact
skin
■ Work from the incision site outwards
■ Repeat at least twice
■ Clean heavily contaminated areas last and then discard the
prep sponge
■ Remove excessive prep solution with a dry swab

Post-operative care
SC (RSU)
(15/7/2020)

Introduction to operative care :
● Operative care is care that clients receive before ,
during and after surgery.

Post-operative care :
● To enable a successful and faster recovery of the
patient post operatively
● To reduce post operative mortality rate
● To reduce the length of hospital stay of the patient
● To provide quality care device
● To reduce hospital and patient cost during post
operative period

Immediate post-operative period
● Airway patency
● Effectiveness of respiration
● Presence of artificial airways
● Mechanical ventilation or supplemental oxygen
● Circulatory status and vital sings

● Wound condition including dressing and drain
● Fluid balance
● Level of consciousness
● Pain control
● General appearance

Post-operative orders :
IV fluids :-
● Daily requirements
● Losses from GIT and UT
● Losses from stomas and drain
● Insensible losses
● Care of renal patient
● care of drainage tubes

 Medication :-
● Antibiotics
● Pain killers
● H2 blockers ( esp ICU)
● Anticoagulant
● Antidiabetics
● Antihypertensive

Post-operative Fluids and electrolytes
management :
● Maintenance requirements
● Extra need resulting from systemic Factors" e.g. fever
,burn ,diarrhoea ,vomiting "
● Losses from drain and fistula
● Tissue edema

● The daily maintenance requirements in adult for
sensible and insensible losses are 1500_2500mls
depending on age , sex weight and body surface area
● Rough estimation of need is by body weight × 30/ day
● Requirements is increased with fever, hyperventilation
and increase catabolic states

General operative problem :
Pain
IV nutrition
Nausea and vomiting
Bleeding
DVT – PE - Fat embolism
Hypothermia and shivering
Fever
Prophylaxis against infection SURGICAL CLUB RED SEA UNIVERSITY SC (RSU)

Pressure sores
Confessional states
Drain
Wound care
Wound dehiscence
Enhanced recovery
Discharge of patient
Follow up in clinic

References :
❑ MRCS Part A_ Essential Revision Notes_ Book 1.
❑ BRS General Surgery 1st edition
surgical club red sea university SC(RSU)

Pre & post oprative prepration

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