UBC Objectives: Surgical + Procedural Skills

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Manage routine pre-operative and post-operative care

While I am currently on my Obstetrics & Gynecology rotation, there isn't often a lot that needs to be done in terms of pre-operative and post-operative medical care. This is because women undergoing OB/GYN surgery are often otherwise healthy young to middle aged women. However, next up will be my General Surgery rotation, so I need to be prepared to assess for and manage perioperative complications in patients who have a bit more going on. 

Management of surgical patients begins in the preoperative period, ideally well in advance of any surgery they are going to have so as to best optimise their health pre-surgery. Optimising their health means to do 2 things:

1. Screen for diseases the patient it as risk for, which if left unnoticed and untreated could lead to complications during or after surgery (ex: cardiopulmonary disease, anesthesia risk factors, and others)
2. Optimize the control of any medical conditions that have already been diagnosed

It is important to start the pre-operative assessment with complete history. Elements that are particularly important to include in the pre-op history include:

1. Patient's functional status 
   1. Basically what matters for surgery is if the patient has exercise capacity  ≥4 METs (metabolic equivalents). 4 METs is equivalent to climbing up a flight of stairs, walking up a hill, walking at ground level at a brisk pace, or performing heavy work around the house. If the patient can do these things without stopping to rest, they may have less capacity than 4 METs and may warrant further assessment by stress testing (to look for evidence of coronary artery disease).
2. Patient's baseline risk of having a bad reaction under anesthesia
   1. Has the patient ever had general anesthesia, and if so, have they ever had any complications? Having had general anaesthesia without any prior complications means the risk of future complications is extremely low. If the patient has not had general anesthesia, asking if a family member has had a bad reaction to anesthesia is the next best thing. A rare genetic (autosomal dominant) phenomenon called malignant hyperthermia can occur with some patients, and it can be life-threatening. If a patient has had a family member with a scary reaction to anesthesia, the patient needs further assessment prior to receiving general anesthesia.
   2. Obstructive sleep apnea (OSA) is a common problem that is under-diagnosed, but that can lead to problems upon recovery from anesthesia. If a patient has OSA, it is important to optimize management of this pre-operatively. If the patient is not known to have OSA, the best screening tool out there to look for it is the STOP-Bang questionnaire (see below). Patients who screen positive should have further assessment with a polysomnography (seep study), which is the gold standard way of diagnosing OSA.
3. Complete record of the patient's past medical and surgical history, specifically looking for the presence or absence of the following diseases:
   1. Heart attack, irregular heartbeat, of heart failure
   2. Bleeding disorders or a family history of bleeding disorders
   3. Asthma, COPD, or other chronic lung disease
   4. Stroke or seizure
   5. Arthritis, pain, or stiffness of the neck and/or jaw
   6. Thyroid disease
   7. Diabetes mellitus (clarify whether the patient is insulin-dependent or not)
   8. Liver disease
   9. Kidney disease
4. Gather an accurate medication record, including anything taken over-the-counter, and any complementary or alternative medications. It is equally important to ask if the patient "self-medicates" with any other substances, and get down to the nitty gritty specifics (knowing the details can really make a difference to risk stratifying them).

Credit to the UpToDate article, "Preoperative medical evaluation of the adult healthy patient."

After you've gathered the above history, doing a focused physical exam is next. This includes the following elements: 

1. General inspection 
2. Vital signs (in full, including BMI*) *Note that while obesity is not a risk factor for surgical complications per se, it is a risk factor for postoperative venous thromboembolism and poor wound healing.
3. Cardiovascular assessment
4. Pulmonary assessment
5. Abdominal exam
6. Peripheral vascular exam

After the clinical assessment is complete, consider using this nifty risk calculator to stratify the patient's likelihood of having a perioperative complication.

After clinical assessment, you can move on to informed investigations based on the assessment. Consider ordering (if you know an indication, not by default) any of the following investigations:

1. Laboratory measurements: Hemoglobin, platelet count, electrolytes, blood glucose or HbA1c, LFTs, renal function, hemostasis testing, urinalysis, pregnancy testing.
2. 12-lead ECG
3. CXR
4. Echo
5. C-spine xray
6. Others, depending on the medical conditions and risk factors an individual has

After the full clinical assessment, with the results of any necessary investigations, you can develop your management plan to optimize any medical issues as previously known or as detected based on your pre-operative assessment (ex: getting blood glucose levels better controlled in a patient with diabetes). Next on the to-do list is to communicate any perioperative risk factors to the patient, surgery team, and any other relevant care providers. This will help the patient and care team decide whether or not to proceed with the surgery given the risks, benefits, values, and specific circumstances of the individual patient. If the patient is to proceed with the operation, a detailed care plan will need to be outlined to optimize patient outcomes before and after the surgery. Common issues to work out will be when to stop and start certain medications such as anticoagulants, and what the strategy will be after surgery to try to prevent them from developing a clot (a common post-op complication, we think about this in everyone who undergoes any surgery that keeps them bed-bound for a little while)

Post-operatively care consists of monitoring the patient as they recover, checking for any signs of complication, and encouraging a quick return to their usual functioning, because this leads to better outcomes. 

There is a well-known mnemonic for the medications you want to think about providing to the post-op patient if indicated: the 5 Ps. I've added a couple of extra Ps to include make it a completely useful mnemonic for me to remember not only some basic drugs to think about ordering to improve patients' comfort in the discomfort that is the post-op period, but also to remind myself of the most common concerns I want to check in about as the patient is recovering.

1. Pain/dyspnea
2. Prophylaxis (DVT)
3. Puke (nausea)
4. Poop (constipation)
5. Pass out (insomnia)
6. Physical exam (vital signs, ins&outs, labs)
7. Preexisting medical conditions

And then, on the surgical ward, they get sent home faster than you can say "no bedside manners."