Assessment of the surgical patient

CHAPTER 19 Assessment of the surgical patient



I. Reilly



Chapter contents



1. Introduction


2. Pre-operative assessment


3. Post-operative assessment


4. Summary


5. Further reading



Introduction


The process of surgery can be broken down into three distinct phases: the pre-operative, intra-operative and post-operative phases. These phases are collectively known as the peri-operative period and may overlap and vary in relative importance, depending on the individual patient and the nature of the planned surgical procedure. The overall results of surgery depend on the effective assessment and management of each phase. Box 19.1 lists the key issues in the assessment process. Corrective surgery can help resolve many chronic foot conditions that have traditionally been treated with conservative or palliative care. For example, the treatment of ingrown toe nails in the UK has been transformed by the phenol-alcohol nail surgery technique. Hammer toes and hallux abductovalgus are other common forefoot complaints that can be corrected with surgery.



Box 19.1 The pre-operative assessment process



Information from the primary patient assessment




• What is the diagnosis?


• What are the important facets of the history?


• Is surgery indicated?


• What further investigations are required?



Health status and fitness for surgery




• Is the patient fit for the planned surgery?


• Are there any concomitant diseases that increase the peri-operative risk?


• Is the patient on any drugs that could influence the surgical outcome?


• What medical management is required?



The anaesthetic




• Local, regional or general anaesthetic?


• If local – which technique will be used – field, digital, ankle, popliteal, other?



The operation




• What is the aim of surgery?


• What is the surgical plan?


• Does the surgery itself pose any special problems?


• Has informed consent been obtained?



After the operation




• Can any problems be anticipated?


• What home support is required/available?


• Have re-dressing appointments been arranged?


• What other factors will affect the post-operative recovery?


• Is the patient able to use crutches?


Pre-surgical assessment should be tailored to the individual patient with regard to their medical history, their expectations and their choice of anaesthesia. The majority of surgical procedures on the foot performed by podiatrists and podiatric surgeons in the UK are undertaken on an elective day-case basis under local or regional anaesthesia. Procedures on the hindfoot and the ankle and other operations that require prolonged periods of anaesthesia or immobility are more likely to be performed under general anaesthesia (GA). The option to perform regional anaesthesia was traditionally reserved for the medically compromised patient, but now it has become the first choice for many consultant anaesthetists. Published studies have demonstrated safer practice, reduced costs and high patient satisfaction to validate its place in modern anaesthesia. The most important advances in anaesthetic techniques include the development of new general anaesthetic agents of short duration and advanced techniques in the administration of spinal, epidural and regional nerve blockade. It is predicted that the number, variety and complexity of surgical procedures performed in an outpatient setting will continue to expand.



Pre-operative assessment


It is the responsibility of the practitioner to determine the most likely diagnosis of the presenting problem based on a detailed history taking and physical examination. Appropriate laboratory investigations and diagnostic imaging support and confirm the provisional diagnosis. Clear communication between the practitioner and the patient is vital and forms the basis of informed consent, which is a prerequisite to any invasive procedure. The decision to recommend surgery to the patient is taken in light of the presenting problem and usually after non-surgical treatment options have been tried (or at least considered) and when the potential risks and benefits of invasive techniques have been calculated in the surgeon’s mind and discussed with the patient as part of the consent process.



Purpose of the pre-operative assessment


The purpose of the pre-operative assessment is to:



• review the history of the presenting illness or complaint


• review the major systems of the body and ascertain whether these systems are functioning within normal limits and, if not, to facilitate the management of this


• arrive at an informed position regarding the medical appropriateness of the planned surgical procedure


• identify any factors that may contraindicate surgery or place the patient ‘at risk’.


At the end of the assessment the practitioner will have formed an opinion as to whether the patient is fit for surgery and thus will be able to proceed with the management with the knowledge that the risk of encountering an intra-operative or post-operative complication has been reduced to a minimum. An inadequate assessment of the patient’s health status may have serious consequences for the surgical patient:



1. The patient is placed at risk – inappropriate or unsafe surgery is performed because of an inadequate surgical assessment. Surgery carried out on patients with certain systemic pathologies carries an increased risk of post-operative morbidity. Medical disorders can complicate surgical practice in various ways, e.g. a patient with rheumatoid arthritis on steroid therapy is prone to impaired healing and infection. Invasive treatment in a patient with haemophilia or a patient taking anticoagulants requires special consideration because of the likelihood of very slow blood clotting and haemorrhage. The use of postoperative analgesia, especially if obtained on patient group directions, requires that the practitioner is familiar with the indications, contraindications, interactions and side effects of the analgesic medication.


2. The surgeon is placed at risk – the practitioner will inevitably encounter blood and tissue fluids. Inadequate history taking with regard to identifying known or potential blood-borne diseases such as hepatitis B places the practitioner and their assistant(s) at risk.


3. An increased risk of clinical emergencies – a number of intra-operative emergencies, such as hypertensive crises, can arise. A detailed pre-operative assessment should identify those at greatest risk. An occult condition may manifest under the stress of surgery, e.g. a cerebrovascular insult may occur intra-operatively or post-operatively in patients with undiagnosed or uncontrolled hypertension.


4. Poor treatment outcomes – a combination of any of the above factors can lead to a poor treatment outcome. Without a thorough assessment and a judicious use of laboratory investigations, certain disease states can be overlooked. Assessment of pre-operative radiographs is often essential if the practitioner is to effectively plan the appropriate surgical procedure.


N.B. These factors have implications for the litigation risk and overall cost if not adequately discussed.


A systematic approach to the assessment process will ensure that the practitioner covers all relevant areas in the enquiry process. The use of questionnaires give the patient time to consider their answers, reduces the amount of time spent during the consultation and ensures that the patient’s answers relate to their current and past health status (see Ch. 5). Health status can be classified using the American Society of Anesthesiologists (ASA) classification (Table 19.1). Patients who fall into either class 1 or 2 are the most suitable for elective procedures.


Table 19.1 American Society of Anesthesiologists (ASA) surgical risk classification
























Class Symptoms
P1 The patient has no organic, physiological, biochemical or psychiatric disturbance. The pathological process for which the operation is to be performed is localised and does not entail systemic disturbance
P2 Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiological processes
P3 Severe systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality
P4 Severe systemic disorders that are already life-threatening, not always correctable by operation
P5 The moribund patient who has little chance of survival but is submitted to operation in desperation
P6 A declared brain-dead patient whose organs are being removed for donor purposes

As already noted in the introduction it is assumed that the practitioner has undertaken a full medical and social history as detailed in Chapter 5. However, there are specific issues that need to be taken into consideration when assessing a patient for elective surgery under local anaesthesia. These are considered below.



Determining surgical need


American podiatrists favour the NLDOCAT system for primary patient evaluation (see Box 19.2). The key component in determining the need for surgery is the treatment received to date and its outcome. Before recommending surgery to a patient, due consideration must be given to non-surgical treatment options. Surgery is indicated either when non-surgical options have been tried but have been unsuccessful, or when conservative treatment is not indicated.



Box 19.2 NLDOCAT system for primary patient evaluation




• N – Nature of the presenting problem


• L – Location


• D – Duration


• O – Onset


• C – Cause of the problem


• A – Aggravating and alleviating factors


• T – Treatment used and its effect


An operation causes physiological stress to the patient. The magnitude of the stress increases with the invasiveness of the procedure. The National Institute of Health and Clinical Excellence (NICE) has suggested a simple grading system for surgery-related stress in the absence of an accepted validated system:



• Grade 1 (minor) – e.g. nail surgery


• Grade 2 (intermediate) – e.g. knee arthroscopy


• Grade 3 (major) – e.g. hysterectomy


• Grade 4 (major +) – e.g. total hip replacement


The author would classify most forefoot surgery as grade 2 and most rearfoot surgery as grade 3.



Current health status



General health


In general, patients who are unwell are not good candidates for elective surgical procedures or treatments which are likely to demand close compliance.



Nutrition


Obesity is a condition that may be more complicated than simple overeating. Obesity is associated with various endocrine diseases, such as type 2 diabetes mellitus, peripheral vascular disease, hypertension and cardiac disease, anaemia, deep vein thrombosis (DVT), cholecystitis and nutritional imbalances. Obese patients have an increased risk of post-operative DVT and wound complications such as infection and dehiscence.


It is commonly assumed that malnutrition is rare in Western societies. However, the malnutrition status among elderly people is alarmingly high. A percentage weight loss of 20% or greater is associated with a 10-fold increase in operative mortality following major surgery, and a threefold increase in post-operative infection. Vitamin B1 (thiamine) and B12 deficiencies are associated with peripheral neuropathy. Vitamin C and serum zinc deficiencies may impair wound healing. Seriously underweight patients may be suffering from a range of systemic conditions or they could be poorly nourished due to alcoholism, drug misuse or anorexia nervosa. Fatigue and weight changes are symptoms of many systemic illnesses and are always worthy of note, especially if weight change appears to be rapid.



Pregnancy


Elective surgery is rarely indicated in a pregnant woman. An exception might be for an infected ingrown toe nail not responsive to conservative care. The practitioner should weigh up the relative risk of a small dose of anaesthetic to treat an ingrown toenail versus a protracted period of antibiotic therapy.



Past and current medication


Information about the patient’s past and current drug therapy can provide useful information about the patient’s health status. Patients should be asked if they are currently taking, or have taken in the past, any medicines or used any ointments or creams that have been prescribed by their doctor or bought over the counter. The practitioner should refer to the British National Formulary (BNF) or other pharmacological text if they unfamiliar with any drug the patient is taking. In particular, details of adverse reactions, either by the patient or any member of the patient’s family, to previous local anaesthetic injections and other drugs (e.g. antibiotics, analgesics, etc.) should be sought.


Steroids such as prednisolone are commonly used in the treatment of asthma, obstructive airway disease and rheumatoid arthritis. They have three main effects, which can be of importance during the peri-operative period:



• suppression of the hypothalamus–pituitary–adrenal (HPA) axis


• poor wound healing


• predisposition to infection.


There will be a suppression of the HPA axis if the patient has taken more than 7.5 mg/day of prednisolone for more than 1 week. In such instances, consideration must be given to the administration of exogenous steroids to prevent hypotension or cardiovascular collapse. For minor procedures, no supplementary therapy is usually required; for more extensive (grade 3) procedures a typical regimen would be 15 mg PO (by mouth) at 6 a.m. on the day of surgery; and the same dose 12 hours and 24 hours later.


Anticoagulants are used in ischaemic heart disease, mitral stenosis, atrial fibrillation and in the prevention of post-operative thrombosis formation. Heparin inhibits the intrinsic clotting pathway and is used in the short-term prophylaxis of DVT. Warfarin inhibits the extrinsic clotting pathway and is used in long-term therapy. The use of an oral anticoagulant has obvious implications if surgical treatment is planned (Case history 19.1). Adjustment of the dosing regimen can be undertaken to allow surgery to proceed with relative safety. Current NICE guidelines recommend that with warfarin the international normalised ratio (INR) should be below 1.5 for elective surgical procedures. Drugs that alter platelet function include aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), steroids and antihistamines. In patients regularly taking aspirin it may be necessary to stop its use because of delayed clotting after surgery. This should be done 1 week before surgery – with the consent of the patient’s GP or drug prescriber. Women taking oral contraception have a slightly increased risk of post-operative DVT and consideration must be given to stopping contraceptive use during the peri-operative period, depending on the grade of surgery and post-operative immobility. Counselling must therefore also be given on alternative forms of contraception.



19.1 Case history


A 54-year-old woman presented with an interdigital corn that failed to respond to many years of palliative treatment. The history and physical examination revealed that she had atrial fibrillation for which she took warfarin (to prevent ventricular thrombosis).


Outcome: Surgery was indicated. At first assessment the patient’s INR was 4.1. In consultation with her GP and in accordance with current NICE guidelines, her dosage was adjusted to reduce the INR to below 1.5. Surgery was carried out with INR 1.4 on the day. The post-operative course was unremarkable and the patient was discharged after the 12-week follow-up visit.


The use of all recreational drugs should be recorded. Patients who use injectable drugs are at a higher risk of hepatitis and human immunodeficiency virus (HIV). Long-term or heavy use of tobacco can affect wound and bone healing due to the immediate vasoconstrictive effect of nicotine as well as the long-term effect of increased platelet adhesiveness and atherosclerosis. Tobacco smokers are also at greater risk of bronchitis, asthma and lung cancer. Heavy alcohol consumption can affect peripheral sensation, immune response, post-operative healing and the metabolism of local anaesthetics, as well as having implications for treatment compliance.



Past medical history


The past medical history consists of information about previous lower-limb problems and the treatment received, as well as details about any problems that have affected the patient’s general health. The nature of previous treatment, the name of the practitioner, details of relevant investigations such as X-rays and the patient’s view of the treatment success should be recorded. This information may prevent the repetition of tests or treatments which have previously been ineffective (Case history 19.2). Of particular interest is the operative history of the patient. In an audit of the author’s National Health Service (NHS) surgical caseload, 10% of patients were referred for revision surgery.



19.2 Case history


A 32-year-old woman presented with a hammered second toe on her right foot. After pre-surgical assessment she was listed for a proximal interphalangeal joint arthrodesis with percutaneous Kirschner (K) wire. It was planned that the wire would remain in situ for 4–6 weeks, until osseous fusion had been achieved. At the first post-operative visit she presented with a painful, swollen toe and mentioned (for the first time) that she could not wear cheap jewellery.


Diagnosis: Nickel allergy, a component of stainless steel K wires. The wire was removed 2 weeks after the surgery. The toe went on to form a painful pseudo-arthrosis that required revision surgery with a titanium K wire.



Home circumstances


It is important to assess the patient’s home situation. In the case of surgical treatment, the practitioner must establish who is going to transport the patient to and from surgery and who is going to assist them through the immediate post-operative recovery period. Lack of home support may rule out surgical intervention (Case history 19.3). Stairs, either outside or within the house are also important factors to be aware of and can have implications for postoperative recovery.



19.3 Case history


A 59-year-old widow was referred for treatment for a tailor’s bunion. Palliative treatment did not control the symptoms. A pre-operative assessment was undertaken with a view to performing an osteotomy of the fifth metatarsal head. The typical post-operative course involves complete rest for 2 days and performing ‘light duties’ for between 2 and 4 weeks. Patients are asked not to perform any household duties and to have someone stay with them for the first 2 days in case of an emergency.


The present patient lived alone and had no children. The only home support she was able to organise was from neighbours. This support was not very reliable as the neighbours were out at work all day.


Outcome: In view of the lack of home support, surgery was not offered to the patient.



Occupation


A patient’s occupation may be contributing to the lower-limb problem and may influence the decision as to whether surgery could or should be offered. Some patients may have difficulty taking time off work to attend for treatment and need to be aware of the variable amount of time needed to recuperate from surgery (Case history 19.4). The patient who cannot commit to devoting the time required for healing after surgery is not a good surgical candidate.



19.4 Case history


A 47-year-old publican attended for a surgical opinion for a complex digital deformity. The pre-operative assessment indicated that he required extensive digital and soft-tissue reconstruction. While discussing his occupation as a landlord, the patient expressed his intention to return to bar work the evening following surgery. He equated the surgery he was to receive with tooth extraction under local anaesthesia. Clear (and written) advice was given regarding the need to rest in the post-operative period.


Outcome: The patient did not comply with the advice given. He presented at his first re-dressing appointment with marked forefoot swelling and pain – more than was expected from the procedure performed. The final result was a less than satisfactory ‘sausage toe’ because of failure to take appropriate advice. This example highlights the need to document the advice given to patients during the peri-operative period to protect the surgeon from litigious action.

Related posts:

The presenting problem Assessment of the sports patient Laboratory tests The painful foot Neurological assessment Diagnostic imaging

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Aug 10, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Assessment of the surgical patient

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