Pre- and Post-operative care

Assessments Pre-theatre
- Pre-operative assessment (pre-op)
- Consent
- Bloods (including groups and save / crossmatch)
- Fasting
- Medication changes
- Venous thromboembolism assessment

Pre-Operative Assessment
- This involves exploring their co-morbidities, risk from anaesthesia, their frailty status and
their cardiorespiratory fitness.
o Past medical problems
o Previous surgery
o Previous adverse responses to anaesthesia
o Medications
o Allergies
o Smoking
o Alcohol use
- Pregnancy needs to be considered
- Patients with a low BMI (< 18.5) may need nutritional support prior to surgery.

ASA Grade: classifies the physical status of patient for anaesthesia

- ASA I – normal healthy patient
- ASA II – mild systemic disease
- ASA III – severe systemic disease
- ASA IV – severe systemic disease that constantly threatens life
- ASA V – “moribund” and expected to die without the operation
- ASA VI – declared brain-dead and undergoing an organ donation operation
- E – this is used for emergency operations

Pre-Operative Investigations
- ECG if there is known or possible cardiovascular disease
- Echocardiogram if there are heart murmurs, cardiac symptoms or heart failure
- Lung function tests may be required if there is known or possible respiratory disease
- Arterial blood gas testing may be required if there is known or possible respiratory disease
- HbA1C (within the last 3 months) for people with known diabetes
- U&Es for patients at risk of developing an acute kidney injury or electrolyte abnormalities
(e.g., taking diuretics)
- FBC may be required if there is possible anaemia, cardiovascular or kidney disease
- Clotting testing may be required if there is known or possible liver disease
Further Investigations
- Group and save refers to sending off a sample of the patient’s blood to establish their blood
group. The sample is saved in case they require blood to be matched to them for a blood
transfusion. A group and save is done routinely where there is a lower probability that they
will require blood products. No blood is assigned to the patient at this stage. A group and
save sample will only be valid for a certain period (e.g., 7 days) depending on the local trust
policy, after which a repeat sample is required.
- Crossmatching involves the process of actually taking a unit or more of blood off the shelf
and assigning it to the patient in case they need it quickly. This is done where there is a
higher probability that they will require blood products, so that the blood is ready to go if
required.
- MRSA screening is routinely performed on all patients being admitted to hospital. This is
usually arranged automatically by the nursing staff, so you don’t need to think about this.

Fasting
- The aim is to reduce the risk of reflux of food around the time of surgery (particularly during
intubation and extubation), which subsequently can result in the patient aspirating their
stomach contents into their lungs.
- Fasting for an operation typically involves:
o 6 hours of no food or feeds before operation
o 2 hours no clear fluids (fully “nil by mouth”)

Medications
- Follow local guidelines for medication alterations before and after an operation.
- Anticoagulants need to be stopped before major surgery. Monitor the INR to ensure that it
returns to normal before surgery.
o Treatment dose low molecular weight heparin or an unfractionated heparin
infusion may be used to bridge the gap between stopping warfarin and surgery in
higher-risk patients (e.g., mechanical heart valves or recent VTE), and stopped
shortly before surgery depending on the risk of bleeding and thrombosis.
o In acute scenarios, Warfarin can be rapidly reversed with Vitamin K
o DOACs (e.g., apixaban, rivaroxaban or dabigatran) are stopped 24-72 hours before
surgery depending on the half-life, procedure and kidney function.
- Oestrogen-containing contraception (e.g., the combined contraceptive pill) or hormone
replacement therapy (e.g., in perimenopausal women) need to be stopped 4 weeks before
surgery to reduce the risk of venous thromboembolism
- Long-term corticosteroids, equivalent to more than 5mg of oral prednisolone, require
additional management around the time of surgery. Surgery adds additional stress to the
body, which normally increases steroid production. In patients on long-term steroids, there
is adrenal suppression that prevents them from creating the extra steroids required to deal
with this stress. Management involves:
 o Additional IV hydrocortisone at induction and for the immediate postoperative
period (e.g., first 24 hours)
o Doubling of their normal dose once they are eating and drinking for 24 – 72 hours
depending on the operation
- Diabetes: The stress of surgery increases blood sugar levels. However, fasting may lead to
hypoglycaemia. In general, the risk of hypoglycaemia is greater than hyperglycaemia.
o Sulfonylureas (e.g., gliclazide) can cause hypoglycaemia and are omitted until the
patient is eating and drinking
o Metformin is associated with lactic acidosis, particularly in patients with renal
impairment
o SGLT2 inhibitors (e.g., dapagliflozin) can cause diabetic ketoacidosis in dehydrated
or acutely unwell patients
- Insulin
o Continue a lower dose (BNF recommends 80%) of their long-acting insulin
o Stop short-acting insulin whilst fasting or not eating, until eating and drinking again
o Have a variable rate insulin infusion alongside a glucose, sodium chloride and
potassium infusion (“sliding-scale”) to carefully control their insulin, glucose and
potassium balance

VTE Risk Assessment

- All surgical and trauma patients must be assessed for risk of venous thromboembolism
(VTE) and bleeding, using a suitable tool. (See DoH tool below)
- Balance the person's individual risk of VTE against their risk of bleeding when deciding
whether to offer pharmacological thromboprophylaxis
VTE Prophylaxis
- Mechanical:
o Correctly fitted anti-embolism (aka compression) stockings (thigh or knee height)
 Do not use in PAD, PABG, peripheral neuropathy, oedema, allergy etc.
o An intermittent pneumatic compression device
 Used in acute stroke patients
- Pharmacological
o 1st Line: LMWH: e.g. enoxaparin
 Reduced doses should be used in patients with severe renal impairment
o Unfractionated heparin (UFH)
 Used as an alternative to LWMH in CKD patients
o Fondaparinux sodium (SC injection)
o NB: People receiving anticoagulants as part of ACS treatment (e.g., DOACs) do not
usually need VTE prophylaxis
- General Management
o All medical patients where risk of VTE > bleeding risk are started on pharmacological
VTE prophylaxis. In severe cases, anti-embolic stockings are offered.
o For surgical patients at low risk of VTE first-line treatment is anti-embolism
stockings. If a patient is at high risk these stockings are used in conjunction with
pharmacological prophylaxis.

Patient Advice:
- Pre-surgical interventions:
o Advise women to stop taking their combined oral contraceptive pill/hormone
replacement therapy 4 weeks before surgery
- Post-surgical interventions:
o Try to mobilise patients as soon as possible after surgery
o Ensure the patient is hydrated

Post Procedure Prophylaxis

- For certain surgical procedures (hip and knee replacements) pharmacological VTE
prophylaxis is recommended for all patients to reduce the risk of a VTE developing post-
surgery

Procedure Prophylaxis
LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28
days, or

Elective hip LMWH for 28 days combined with anti-embolism stockings until
discharge, or

Rivaroxaban
Elective knee Aspirin (75 or 150 mg) for 14 days, or
 Procedure Prophylaxis

LMWH for 14 days combined with anti-embolism stockings until

discharge, or

Rivaroxaban
The NICE guidance states the following (our bolding):
Offer VTE prophylaxis for a month to people with fragility fractures of
Fragility fractures of the pelvis, hip or proximal
the pelvis, hip and femur if the risk of VTE outweighs the risk of bleeding. Choose either:
proximal femur  LMWH , starting 6–12 hours after surgery or
 fondaparinux sodium, starting 6 hours after surgery, providing
there is low risk of bleeding.

Surgical Site Infection

- This occurs following a breach in tissue surfaces, which allows normal commensals to enter
and initiate infection.
- Measures which increase SSI risk:
o Shaving the wound using a razor (disposable clipper preferred)
o Using a non-iodine impregnated incise drape if one is deemed to be necessary
o Tissue hypoxia
o Delayed administration of prophylactic antibiotics in tourniquet surgery
- Preoperatively
o Don't remove body hair routinely
o If hair needs removal, use electrical clippers with a single-use head (razors increase
infection risk)
o Antibiotic prophylaxis
- Intraoperatively
o Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
o Cover surgical site with dressing
- Postoperatively
o Tissue viability advice for management of surgical wounds healing by secondary
intention

Antibiotic Prophylaxis
- Given when:
o Clean surgery involving placement of prosthesis or valve
o Clean-contaminated surgery
o Contaminated surgery
- Use the local antibiotic formulary and always take into account the potential adverse
effects when choosing specific antibiotics for prophylaxis
- Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia.
However, give prophylaxis earlier for operations in which a tourniquet is used
- Before giving antibiotic prophylaxis, take into account the timing and pharmacokinetics (for
example, the serum half-life) and necessary infusion time of the antibiotic. Give a repeat
dose of antibiotic prophylaxis when the operation is longer than the half-life of the
antibiotic given.
- Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or
infected wound.

Post Operative Care

Post-Operation
- Immediately after the operation, the patient will go to the recovery room to be monitored
closely whilst they regain consciousness. Once they are conscious and stable, they can
return to the ward. Patients may be transferred to HDU or ICU depending on their condition
and the monitoring requirements post-operatively.

Enhanced Recovery
- Enhanced recovery aims to get patients back to their pre-operative condition as quickly as
possible, by encouraging independence, early mobility and appropriate diet
o Good preparation for surgery (e.g., healthy diet and exercise)
o Minimally invasive surgery (keyhole or local anaesthetic where possible)
o Adequate analgesia
o Good nutritional support around surgery
o Early return to oral diet and fluid intake
o Early mobilisation
o Avoiding drains and NG tubes where possible, early catheter removal
o Early discharge

Analgesia
- Adequate analgesia in the post-operative period is important to encourage the patient to:
o Mobilise
o Ventilate their lungs fully (reducing the risk of chest infections and atelectasis)
o Have an adequate oral intake
- Analgesia is usually started in theatre by the anaesthetist, with regular paracetamol,
NSAIDs and opiates if required (e.g., regular modified-release oxycodone with immediate-
release oxycodone as required for breakthrough pain). The surgeon may put local
anaesthetic into the wound to help with the initial pain after the procedure. Analgesia
should be reduced and stopped as symptoms improve.
- Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naproxen and
diclofenac may be inappropriate or contraindicated in patients with:
o Asthma
o Renal impairment
 o Heart disease
o Stomach ulcers
- Patient Controlled Analgesia
- Patient-controlled analgesia (PCA) involves an intravenous infusion of a strong opiate (e.g.,
morphine, oxycodone or fentanyl) attached to a patient-controlled pump. This involves the
patient pressing a button as pain starts to develop, for example during a contraction in
labour, to administer a bolus of this short-acting opiate medication. The button will stop
responding for a set time after administering a bolus to prevent over-use. Only the patient
should press the button (not a nurse or doctor).
- Patient-controlled analgesia requires careful monitoring. There needs to be input from an
anaesthetist, and facilities in place if adverse events occur. This includes access
to naloxone for respiratory depression, antiemetics for nausea, and atropine for
bradycardia. The anaesthetist may prescribe background opiates (e.g., patches) in addition
to a PCA, but avoid other “as required” opiates whilst a PCA is in use. The machine is locked
to prevent tampering.

Post Operative Nausea and Vomiting

- Nausea and vomiting are common in the 24 hours after an operation and is called post-
operative nausea and vomiting (PONV). There are many causes, including the surgical
procedure, anaesthetic, pain and opiates. Risk factors include:
o Female
o History of motion sickness or previous PONV
o Non-smoker
o Use of postoperative opiates
o Younger age
o Use of volatile anaesthetics
- Prophylactic antiemetics are often given at the end of the procedure by the anaesthetist to
prevent PONV from occurring. Common options for prophylaxis given at the end of the
operation are:
o Ondansetron (5HT3 receptor antagonist) – avoided in patients at risk of prolonged
QT interval
o Dexamethasone (corticosteroid) – used with caution in diabetic or
immunocompromised patients
o Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and
elderly patient
- Examples of “rescue” antiemetics used in the post-operative period if nausea or vomiting
occur are:
o Ondansetron
o Prochlorperazine (dopamine (D2) receptor antagonist) – avoid in patients with
Parkinson’s disease
o Cyclizine
Tubes
- Post-operative patients may have a catheter, drains or nasogastric tube, and these will be
monitored and removed when appropriate.
o Drains are usually removed once they are draining minimal or no blood or fluid
o Nasogastric tubes are removed when they are no longer required for intake or
drainage of gas or fluid
o Catheters are removed when the patient can mobilise to the toilet
- Removal of a catheter is called a trial without catheter (TWOC). It is called this as there is a
risk the patient will find it difficult to pass urine normally and go into urinary retention, and
the catheter may need to be reinserted for a period before removal can be tried again. This
is quite common, more so in male patients.

Nutritional Support
- Good nutrition is important for healthy wound healing and overall recovery from surgery. A
dietician may be involved. Where possible, patients should get their nutrition via their
gastrointestinal tract. Having nutrition via the gastrointestinal tract is called enteral feeding.
This could be by:
o Mouth
o NG tube
o Percutaneous endoscopic gastrostomy (PEG) – a tube from the surface of the
abdomen to the stomach
- Total parenteral nutrition (TPN) involves meeting the full ongoing nutritional requirements
of the patient using an intravenous infusion of a solution of carbohydrates, fats, proteins,
vitamins and minerals. This is used where it is not possible to use the gastrointestinal tract
for nutrition. It is prescribed under the guidance of a dietician. TPN is very irritant to veins
and can cause thrombophlebitis, so is normally given through a central line rather than a
peripheral cannula.

Post-Operative Complications
- Anaemia
- Atelectasis is where a portion of the lung collapses due to under-ventilation
- Infections (e.g., chest, urinary tract or wound site)
- Wound dehiscence is where there is separation of the surgical wound, particularly after
abdominal surgery
- Ileus is where peristalsis in the bowel is reduced (typically after abdominal surgery)
- Haemorrhage with bleeding into a drain, inside the body creating a haematoma or from the
wound
- Deep vein thrombosis and pulmonary embolism
- Shock due to hypovolaemia (blood loss), sepsis or heart failure
- Arrhythmias (e.g., atrial fibrillation)
- Acute coronary syndrome (myocardial infarction) and cerebrovascular accident (stroke)
- Acute kidney injury
- Urinary retention requiring catheterisation
- Delirium refers to fluctuating confusion and is more common in elderly and frail patients