As a junior doctor, you will frequently look after patients prior to and after their operation. You may be asked to clerk patients who are admitted to hospital the night before their operations. Here are some things to consider during your clerking & whilst you’re considering pre & post-operative issues.

Pre-Operative Clerking

• Before you see the patient
  • What operation will they be having & when? Which consultant will be completing it? Read their last surgical & anaesthetic clinic letters as they often give important instructions about pre-operative care
• Confirm with the patient which operation they are expecting to have. Take a brief history.
• Take a brief pre-op assessment
  • Any previous surgery? Any pre or post-operative complications e.g. nausea/vomiting, complications with anaesthetic
  • Drug history – allergies! Holding nephrotoxic agents (e.g. NSAIDs, ACE inhibitors), sliding scale for diabetics, holding of blood thinners. Drugs that must not be stopped: antiepileptics, Parkinson’s medication or increased e.g. steroids
  • Family history – any issues with anaesthetic previously (e.g. pseudocholinesterase deficiency, malignant hyperpyrexia)
  • Social history – baseline mobility & exercise tolerance. What do they do for work & will they need time off?
• Arrangements to go home (will someone be taking them?) for day case procedures
• Aim to write a clear pre-operative plan for patients in the notes

Pre-Operative Considerations

• Ensure patients are reviewed by the anaesthetist & surgeon. The surgeon will often need to mark the site & consent the patient. F1s cannot mark the site of an operation. 
• Bloods
  • Baseline bloods (renal function, haemoglobin, LFTs & clotting)
  • Unless very low risk, patients will need a valid group & save. Usually, this requires 2 samples  which need to be taken by 2 people on different occasions
  • Blood may need to be cross-matched if you’re expecting blood loss (i.e. for a major operation) so it is ready in an emergency. Do ask your seniors. 
• MRSA swab
• Pregnancy test
• Fasting (usually only if general anaesthetic):  Starved usually 6 hours prior to operation for food with clear fluids up to 2 hours before
• Drug chart
  • Allergies
  • Prescribe VTE prophylaxis (usually TEDs only)
  • Prescribe medications that need to continue peri-operatively
  • Prescribe maintenance IV fluids, antiemetics & analgesia
  • Consider a sliding scale in diabetic patients
• Any special requirements e.g. bowel preparation

Post-Operative Considerations

• Drug chart
  • Review VTE prophylaxis. Never initiate LMW heparin without checking with a senior.
  • Restart routine medications appropriately
  • Optimise fluids & analgesia. Be careful about fluid overload in patients at risk (elderly, heart failure)
  • Laxatives (as necessary) – caution in abdominal surgery
  • Antibiotics (if necessary)
• Review bowels & when a patient can start eating & drinking
  • Monitor for ileus
  • Consider when to stop sliding scale
  • In GI surgery patients may slowly be escalated on to a normal diet: small sips → clear fluids (if you can read a newspaper through it) → free fluids → soft diet → normal diet
• Blood: monitor haemoglobin, renal function & inflammatory markers
• Review any special post-op requirements (surgical & anaesthetic notes)
• Monitor for complications
  • Ileus (look for abdominal distension, hiccups, nausea/vomiting)
  • Nausea & vomiting
    • Can cause electrolyte disturbance & aspiration pneumonia
  • Electrolyte disturbances (hyponatraemia is common post-operatively and if very mild usually self resolves, hypokalaemia can be iatrogenic from too much 0.9% sodium chloride)
  • Bleeding or hypotension (urgently escalate these patients)
  • Wound dehiscence (monitor dressings for serosanguinous discharge (blood & serum)
    • Usually occurs within a week. Can get cellulitis of the skin.
  • Thromboembolism
  • Acute kidney injury
  • Peritonism
  • Hospital-acquired pneumonia (particularly if insufficient analgesia to breathe properly or cough)
  • Constipation (particularly if immobile)
• Consider discharge planning
  • Physiotherapy to mobilise ideally within 24 hours
  • TWOC (trial without catheter)
  • Discharge advice e.g. when to return to work, carry out usual activities
  • Follow up
  • How to care for the wound & dressing
  • Removal of sutures

References

• https://www.uptodate.com/contents/perioperative-medication-management
• https://www.nhs.uk/conditions/having-surgery/recovery/
• https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/how-should-i-care-for-my-stitches/
• https://teachmesurgery.com/perioperative/preoperative/assessment/

Written by Dr Jaskiran Sodhi & Dr Ella Botzenhardt (FY2)

Edits by Dr Akash Doshi CT2