Pre-op care

Habari Yako, Daktari Mtarajiwa! Setting the Stage for Surgical Success

Welcome to your surgical rotation! You've probably seen the consultants and registrars looking cool and composed as they head into theatre. But let me tell you a secret: the real magic, the foundation of a successful operation, happens long before the first incision is made. It happens in the ward, at the bedside, with you. This is Pre-operative Care. Think of it as a pilot's pre-flight check. You wouldn't want your pilot to just jump in and take off, would you? Likewise, a surgeon needs to know the "flight plan" for their patient is safe. Let's get you ready to be an expert co-pilot!

The 'Why': Goals of Pre-operative Care

Before we dive into the "how," let's understand the "why." What are we trying to achieve?

• Full Patient Picture: To identify and assess all medical conditions, not just the surgical one. Does your patient with a hernia also have unchecked hypertension?
• Risk Assessment: To predict potential complications. Is this patient likely to bleed? Do they have a difficult airway for the anaesthetist?
• Optimization: To get the patient in the best possible shape for surgery. This could mean controlling their blood sugar, improving their nutrition, or starting chest physiotherapy.
• Education & Consent: To ensure the patient and their family understand the procedure, risks, benefits, and alternatives. This reduces anxiety and is a crucial ethical and legal step.
• Planning: To create a clear plan for the surgery and the care needed afterwards (post-op).

The Pre-Op Clerkship: Your Step-by-Step Guide

This is your bread and butter as a junior clerk. When a consultant says, "Clerk this patient for theatre," this is your time to shine. You follow the same principles you know: History, Examination, and Investigations, but with a surgical lens.

1. The Surgical History (Listening for Clues)

Beyond the history of presenting illness, you need to be a detective looking for surgical risks:

• Past Surgical/Anaesthetic History: "Have you ever had an operation before?" Ask about their experience. Any issues with waking up? Nausea? Did a family member ever have a bad reaction to anaesthesia (ask about high fevers or muscle problems - you're screening for Malignant Hyperthermia!).
• Medication History: This is critical! Ask specifically for:
  • Blood thinners: Aspirin (Disprin), Clopidogrel, Warfarin. These MUST be noted and often stopped days before surgery.
  • Diabetes meds: Metformin, Insulin. The plan for these will change around the time of surgery.
  • Herbal medications: Many patients in Kenya use traditional medicine. Always ask! Some can affect bleeding or interact with drugs. "Kuna dawa yoyote ya kienyeji unatumia?" (Are you using any traditional medicines?)
• Allergies: Don't just ask about drugs. Ask about plasters (latex allergy) and food. Remember to document 'No Known Drug Allergies' (NKDA) if they have none.
• Social History: Smoking and alcohol use are major risk factors. Smoking impairs wound healing and lung function. Chronic alcohol use can lead to withdrawal post-op and affects liver function.

Real-World Scenario:

You are clerking Mr. Otieno, a 65-year-old man for a prostatectomy. He tells you he takes "a small white pill for his heart." You probe further and discover he's on daily Aspirin 75mg. By flagging this to your registrar, you've potentially prevented a major intra-operative bleed. That's a clinical win!

2. The Focused Physical Exam (Looking for Trouble)

Your exam should confirm the surgical diagnosis and screen for other problems.

• General Exam: Check for nutrition status (is he cachexic?), pallor (anaemia), jaundice (liver issues), and hydration status.
• The Airway Exam: This is for your anaesthetist colleague! A difficult airway can be a catastrophe. The Mallampati Score is a quick and vital assessment.

    // ASCII Diagram: The Mallampati Classification

    You ask the patient to sit up, open their mouth, and stick out their tongue WITHOUT saying "Ahh".

    Class I:                Class II:               Class III:              Class IV:
    +---------------+       +---------------+       +---------------+       +---------------+
    |   Soft Palate |       |   Soft Palate |       |   Soft Palate |       | Hard Palate   |
    |   Uvula       |       |   Uvula       |       |   Base of     |       |   Only        |
    |   Fauces      |       |   Fauces      |       |   Uvula       |       |               |
    |   Pillars     |       |   (partially  |       |               |       |               |
    |   Visible     |       |    obscured)  |       |   Visible     |       |   Visible     |
    +---------------+       +---------------+       +---------------+       +---------------+
       (Easy Airway)          (Easy Airway)         (Moderate Diff)        (High Diff)

3. Investigations (Gathering the Data)

Investigations are guided by the patient's age, comorbidities, and the magnitude of the surgery.

• The Basics (for most major surgeries):
  • Full Haemogram (FBC): To check for anaemia (low Hb) or infection (high WCC).
  • Urea, Electrolytes, Creatinine (U/E/Cs): To assess kidney function. Poor kidney function affects drug clearance.
  • Group & Crossmatch: To have blood ready if needed. For a major operation like a Whipple, you might need 4-6 units crossmatched. For a simple hernia repair, a 'Group & Save' might suffice.
• The Extras (based on history/exam):
  • ECG: For patients over 45-50 years or with a history of heart disease.
  • Chest X-ray: For heavy smokers, patients with chronic lung disease, or suspected metastases.
  • Coagulation Profile (PT/INR, APTT): For patients on anticoagulants or with liver disease.

Risk Stratification: The ASA Score

Once you have all your data, you need to classify the patient's overall risk. The American Society of Anesthesiologists (ASA) Classification is a simple and universal tool for this.

Image Suggestion:

A simple, clean infographic chart showing five stick figures, each progressively looking more unwell. Below each figure is the ASA class number (1-5) and a one-sentence description. For example, the ASA 1 figure is jogging, while the ASA 5 figure is in a hospital bed with multiple monitors, looking very sick. Style: minimalist, educational, with clear labels.

• ASA 1: A normal, healthy patient. (e.g., A healthy 22-year-old for an appendectomy).
• ASA 2: A patient with mild systemic disease. (e.g., A 50-year-old with well-controlled hypertension on medication, for a hernia repair).
• ASA 3: A patient with severe systemic disease that is a constant threat to life. (e.g., A patient with poorly controlled diabetes and a previous heart attack, now needing a leg amputation).
• ASA 4: A patient with severe systemic disease that is a constant threat to life. (e.g., A patient with recent MI or sepsis needing emergency surgery).
• ASA 5: A moribund patient who is not expected to survive without the operation. (e.g., A patient with a ruptured abdominal aortic aneurysm).
• ASA 6: A declared brain-dead patient whose organs are being removed for donor purposes.

The Final Checklist: Pre-Op Orders

This is where everything comes together in a clear, actionable plan. These are the orders you will see written in the patient's file the night before surgery.

1. Informed Consent: It's a process, not just a signature! You, the junior clerk, have a vital role. After the surgeon has explained the procedure, you can sit with the patient and ensure they understood everything. Use simple language. Check for understanding. "Bwana Juma, unaweza nielezea kwa maneno yako operesheni gani daktari amesema utafanyiwa kesho?" (Mr. Juma, can you explain to me in your own words what operation the doctor said you will have tomorrow?).

2. NPO (Nil Per Os) Status: This means "Nothing by Mouth." It's crucial to prevent aspiration of stomach contents into the lungs during anaesthesia.

• Standard Rule: 6 hours for solid food, 2 hours for clear fluids (water, black tea).
• So, for a morning surgery at 8 AM: "Patient to be NPO from midnight. Can have sips of water until 6 AM."

3. Prophylaxis (Preventative Measures):

• Antibiotics: To prevent surgical site infection. Usually given one hour before the first incision. e.g., "IV Ceftriaxone 1g at induction of anaesthesia."
• Thromboprophylaxis (DVT Prevention): For patients at high risk of blood clots (e.g., major cancer surgery, long procedures, immobility). This can be mechanical (TED stockings) or pharmacological (e.g., "Enoxaparin 40mg subcutaneously at 6 PM").

4. Special Considerations for Paediatrics: Children are not small adults! Their fluid requirements are very specific.

The 4/2/1 Rule for calculating maintenance fluids is your best friend:

    // Formula: Calculating Hourly Maintenance IV Fluid Rate for Children

    1. For the first 10 kg of body weight: 4 mL/kg/hr
    2. For the next 10 kg of body weight (11-20 kg): 2 mL/kg/hr
    3. For every kg above 20 kg: 1 mL/kg/hr

    // Example: A 25 kg child
    - First 10 kg:  10 kg * 4 mL/kg/hr = 40 mL/hr
    - Next 10 kg:   10 kg * 2 mL/kg/hr = 20 mL/hr
    - Remaining 5 kg: 5 kg * 1 mL/kg/hr =  5 mL/hr
    ---------------------------------------------------
    Total Hourly Rate = 40 + 20 + 5 = 65 mL/hr

Your Final Act: The Pre-Theatre Checklist

Just before the patient is wheeled to theatre, a final check is done, often with the ward nurse. This is your last chance to catch any issues.

    // Flowchart: The Final Countdown

    [Start] --> [Is Informed Consent Signed?] --Yes--> [Is the Surgical Site Marked?]
       | No                                                    | No
       V                                                       V
    [ALERT SURGEON]                                       [ALERT SURGEON]
       | Yes                                                   | Yes
       V                                                       V
    [Is patient NPO?] --Yes--> [IV Access Secured?] --Yes--> [Prosthetics/Jewelry Removed?]
       | No                                                    | No                           | No
       V                                                       V                           V
    [ALERT ANAESTHETIST]                               [FIX IT]                    [FIX IT]
       | Yes                                                   | Yes                       | Yes
       V                                                       V                           V
    [Pre-meds Given?] --Yes--> [All Documents Ready?] --Yes--> [TO THEATRE!] --> [End]
                                  (File, X-rays)

Image Suggestion:

A warm, realistic photo of a Kenyan student doctor (in a green KNH-style scrub top) and a nurse at a patient's bedside in a public hospital ward. They are smiling and looking at a clipboard together, pointing to a checklist. The patient, an elderly woman, is sitting up in bed and looks reassured. The lighting is soft and natural, emphasizing a collaborative and caring environment.

And that's it! You've successfully prepared a patient for surgery. You haven't just ticked boxes; you've actively contributed to patient safety and surgical success. You've acted as a meticulous co-pilot, ensuring the journey to the operating room and back is as smooth as possible. Now go out there and clerk your patients with confidence. You've got this, daktari!