Preoperative Assessment and Management of Postoperative Problems

Explanations to the Patient, Informed Consent and Shared Decision Making

See Ch. 1 for the legal framework and further detail.

To make informed choices, patients need to understand their condition as far as possible, and the range of treatments available with their attendant risks and benefits. Patients often absorb little of what is said initially. They are often anxious and overwhelmed by the surgical clinic visit and so cannot take in the full implications of what has been said, so discussions often need to be repeated.

For elective operations , consent should be in two stages: first an initial explanation, with the range of options and pros and cons of each procedure discussed well in advance, and without pressure of an imminent operation. Patient information leaflets and guidance about accurate internet sites should also be given. Second, before surgery, the patient’s understanding is checked and consent confirmed. In general, complications should be discussed if there is a 1% or greater risk, or if there are rarer but serious procedure-specific risks, such as recurrent laryngeal nerve injury in thyroid surgery. In addition, the Montgomery court ruling of 2015 ( https:// www.bmj.com/content/357/bmj.j2224 ) demands that patients are informed of all material risks of all the treatment options that might adversely impact on them as an individual, such as the inability to perform a certain task or outcomes which might compromise their ability to continue to work. Important questions the patient should consider during the surgical consent process are:

• What are my options?

• What are the risks and benefits of those options to me?

• How do I get further information that will help me make a decision?

For some diagnoses, the UK National Health Service has developed decision support tools to help patients. For most settings and conditions, however, it is up to the perioperative care team—surgeons, anaesthetists and specialist nurses—to support the patient with the best available information and individual risk assessment.

Methods of Evaluating Patient Risk

These fall into three broad categories

• Clinical judgment

• Risk scores or models

• Evaluation of functional capacity

In practice, a combination is likely to provide the best estimate of a patient’s risk of complications, death or other poor outcomes. However, no risk prediction tool can be entirely accurate because of the complexity of patients and procedures, and the risk of unexpected events occurring (e.g., anaphylaxis to a drug in the perioperative period).

There are numerous individual risk scores and models designed to help predict risk. In general, the most accurate risk estimates come from using a procedure specific tool (e.g., the Nottingham Hip Fracture Score, or the National Emergency Laparotomy Audit model for emergency laparotomy) or one which has been tested and validated in the same type of healthcare system (e.g., the Surgical Outcome Risk Tool for the United Kingdom, www.sortsurgery.com , or the American College of Surgeons National Surgical Quality Improvement Program risk calculator for the United States, www.riskcalculator.facs.org ).

There is a direct and clear link between reduced functional capacity (cardiorespiratory fitness) and adverse perioperative outcomes, and sedentary lifestyles are a risk factor for this. Functional capacity can be undertaken using a self-assessment tool, such as the Duke Activity Status Index, or through face-to-face evaluation of exercise capacity (such as, a 6-minute shuttle walk test or a cardiopulmonary exercise test on a bicycle ergometer). For older patients, frailty evaluation (e.g., by Frailty-VIG Index, https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-018-0718-2 )can provide a holistic assessment of a patient’s health and function. The purpose of preoperative risk assessment is for clinical teams to use it to tailor a perioperative plan so as to obtain the best possible result from the operation and to reduce the risk of adverse outcomes.

For emergency surgery , there may not be time for a two-stage consent process but the risks are often substantially higher than for elective surgery. Quality improvement programmes have shown that senior input into risk assessment and decision-making can improve outcomes, for example, the UK’s National Emergency Laparotomy Audit, https://www.nela.org.uk .

Planning the Perioperative Period

For elective surgery, it may be in the patient’s best interest to defer operation until any detected comorbidities can be optimised, although the option to delay does depend on the underlying diagnosis. A good example of this might be chronic iron deficiency anaemia in a patient awaiting elective orthopaedic surgery. Correction of haemoglobin preoperatively using iron supplements may reduce the need for blood transfusion perioperatively, and thus the risks of transfusion—increased length of stay and poorer oncological outcomes, for example. Similarly, there is increasing interest in the concept of prehabilitation , where a patient might be placed on a structured exercise programme to improve their functional capacity (general fitness) before undergoing a major procedure. Innovative approaches, such as ‘surgery schools’ are also being evaluated, where patients are brought together with each other and surgeons, anaesthetists, physiotherapists and specialist nurses to have explained in detail what to expect during their recovery period and how they can help themselves prepare for operation and recovery more quickly.

Enhanced recovery pathways (see Ch. 2 ) encourage a protocol-driven but individualised approach to patient care, guided by the principle of trying to return patients to their optimal physiological state as quickly as possible. Enhanced recovery means using minimally invasive surgical approaches, precise fluid management using oesophageal Doppler, avoiding tubes and drains where possible, encouraging drinking, eating and mobilising as soon as possible after surgery and supporting all of this with multimodal analgesia.

Planned admission to a critical care unit after surgery is an intervention recommended for high-risk patients. For some types of elective surgery (e.g., open cardiac) this is a normal standard of care, and patients should be counselled on this as part of the consent process. Patients admitted to normal wards after surgery can be closely monitored with help from critical care outreach teams, or through continued monitoring via acute pain teams, intensivists and anaesthetists.

Plans for rehabilitation and convalescence should be discussed with the patient and relatives, including the likely rate of recovery and levels of activity likely to be possible on discharge, allowing social, business and domestic arrangements to be made early. If necessary, domestic or home nursing help can be arranged. Uncertainty about these matters often causes anxiety and may prolong hospital stay.

Marking the Operation Site

When obtaining final consent, the surgeon should mark the operation site on the patient’s skin with an indelible pen. This is particularly important if the operation could be performed on either side, for example, an inguinal hernia repair or limb amputation. It is even more important if the patient is likely to be turned prone (face down) in theatre as this can cause confusion. Failure to mark the site represents a never event in-waiting (and there is no legal defence). Checking processes for identity, type of operation, side and marking must be in place at several stages during the patient’s journey to the operating theatre. The World Health Organization checklist (see Ch. 1 , Box 1.8 ) is now used in most environments where surgical procedures are undertaken and has been shown to reduce morbidity and mortality.

Immediate Preoperative Starvation and Fluid Restriction

General anaesthesia depresses the protective airway reflexes of gag and cough. To minimise the risk of aspiration of gastric contents into the lungs at induction of anaesthesia or in the early recovery period, the patient must be adequately fasted. Patients can usually eat until 6 hours before surgery and drink clear fluids up to 2 hours before. They must be allowed to have a small amount of water to take their regular medication. As part of an Enhanced Recovery After Surgery programme, clear nonparticulate carbohydrate drinks have been shown to reduce postoperative insulin resistance and inflammatory responses, thereby contributing to improving surgical outcome after major surgery. These drinks are specially formulated complex carbohydrates with low osmolality facilitating a fast transit time through the stomach. They are given up to 2 hours before surgery (provided gastric emptying is not impaired).

For patients at higher risk of aspiration, for example, gastro-oesophageal reflux, intestinal obstruction and pregnancy, the anaesthetist may prescribe antacid medication. In all patients for operation, starvation and hydration need to be checked carefully.

Liaison With Anaesthetist

For elective cases, the anaesthetist will know in advance of the proposed operation or list of operations. For emergency cases, the anaesthetist needs to know which patient is having which operation, how urgent the procedure is and the condition of the patient. The anaesthetist visits to evaluate the patient, advise on patient preoperative management and discuss the anaesthetic. The anaesthetist is responsible for ensuring that the patient is fit for surgery and often assists in resuscitation if needed.

Operating Theatre Arrangements

For any operation, the junior surgeon (intern) is usually responsible for informing the operating department about the operation(s) and any special arrangements needed. A formal operating list should be prepared, giving name, age, sex, ward and proposed operation for each patient. The side of the body to be operated on should be clearly noted. Any special instruments, intraoperative radiography or patient positioning must be listed. The presence of transmissible infections for example, methicillin-resistant Staphylococcus aureus (MRSA) or hepatitis C, should be recorded, as well as any allergies, for example, to latex or iodine. In some hospitals, the amount of bank blood ordered for a patient is also noted. If changes are made, a completely new list must replace the old to avoid error and harm.

Planning the Order of an Operating List

For elective cases, the following order can normally be recommended:

• 1.

  Latex allergy —remove all latex containing products from theatre and pressure ventilate for several hours beforehand.

• 2.

  Paediatric cases —to minimise the period of starvation and reduce anxiety.

• 3.

  Diabetic patients —to make perioperative diabetes management as smooth as possible, minimise the period of starvation and return rapidly to normal diet and treatment.

• 4.

  Adult day cases —to maximise the amount of available recovery time before discharge.

• 5.

  Inpatients with no special theatre requirements.

• 6.

  Contaminated, infected cases, colorectal cases, gangrenous limbs —so as not to infect later cases.

• 7.

  Patients with transmissible infections , for example, MRSA, hepatitis C. Preparation includes all nonessential equipment and personnel being removed from theatre; disposable items replace recyclable items of linen, and theatre must be cleaned before next list.