PRE-OPERATIVE ASSESSMENT

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PRE-OPERATIVE ASSESSMENT BEFORE THR

STEM - A 62-year-old man came for his preoperative assessment in Orthopaedic OPD for his scheduled THR in one week, He was diagnosed with OA & months ago, and his operation was cancelled due to his reluctance. Now, his wife has managed him and taken him to Orthopaedic OPD to get a schedule soon as they are going to arrange their daughter's wedding in 2 weeks.
Now that you are an orthopaedic SHO, considering this a history-taking station, go through his preoperative assessment to inform your consultant.

(This station is deviated largely from the usual history format. Here patient is already diagnosed and has done all the relevant investigations and came to SOPD to get his schedule for THR with his wife who actually convinced him for operation. There's no need to ask about pain, similarly no need ask questions for differentials. This station largely focuses on pre-operative fitness status, co-morbidities, medications, PMH, PSH that are most concerned issues before operation which need to be optimized).

1. Introduce yourself

• Hello, good morning, I’m Dr. Z, one of your surgical doctors.

2. Confirm patient's ID and verbal consent

• = Just for documentation purposes, could you please confirm me your name and age please?
• = Nice to meet you! Good to see you again Mr. X.
• =I do believe that today you are here to get schedule for your upcoming hip surgery. Before that, I've been told to ask you few questions regarding your health condition and to assess how fit you are for your surgery and anaesthesia so that we can take appropriate measure accordingly. Are you okay with that?

3. Assess respective concern

• Mr. X, how’re you feeling today? Is your leg hurting much?
• I'm so sorry to hear that. I understand you are passing through a difficult situation right now.

4. Past medical history & medication history

• May I know, Mr. X, whether you have been diagnosed with some medical conditions or not? Do you have any chronic illness?

(The patient will bring his prescription and drug list & will tell you to check this. Don't take it; instead, assure him you will check his file once your conversation is finished).
(Now ask elaborately about those conditions that the patient says one by one)

• Diabetes

• How long has it been? Is it under control?

• Which medication do you take? Dose? How long?

• Do you have any problems with your feet and hand? Any numbness?

• Anything wrong with your Vision?

• Asthma / COPD

• How long has it been? Is it under control?

• Which medication do you take? Dose? How long? (ask specially for steroids and inhalers)

• Cardiac issues, Hypertension

• How long has it been? Is your HTN under control?

• Which medication do you take? Dose? How long?

• Do you have any issues with your heart?

• Are you attending your cardiology doctor and warfarin clinic regularly?

5. Past surgical history

• Have you undergone any surgeries before? (H/O CABG 2 years back, pacemaker insertion 4+ years ago, left nephrectomy 7 years ago)
• Was there any problem with surgeries or anaesthesia? If yes, what was that?

6. Personal history

• Who do you live with?
• Do you smoke? If yes, how many cigarettes & how long?
• Do you take alcohol? If yes, how many units & how long?

6. General fitness & systemic review

• How far can you walk normally before breathlessness stops you?

• Is it for pain or are there any other issues?

• Do you take physiotherapy?

• Ask for constitutional questions as part of systemic review.

• Now patient may ask you some questions, for example, “Doctor, when will | be scheduled for my hip surgery? My daughter's wedding is in 2 weeks, Please get me scheduled.as soon as possible”.

• Your answer would be, “Mr. X. I completely appreciate your concern. Please pardon me, but I can’t tell you my thoughts right now, As you have several medical & surgical conditions and you're on various medications, to ensure a safe surgery and safe anaesthesia for you, we must optimize your health condition and medications first.
  Considering these, I think you're not fit for this major surgery at this moment. Mr. X, I assure you that I will discuss about your surgery with my consultant as soon as possible,

We need to discuss and seek opinions from endocrinologists, pulmonologists, cardiologists, physiotherapists, and urologists (depending on the history) about optimizing your health condition before surgery. Only after the opinion from MDT, we can schedule the date for your hip surgery.”

PRESENTATION

Mr. X, a 62-year-old man, came to SOPD for the awaiting THR. On preoperative assessment, he is noted to have DM/HTN/COPD/CAD. He has a past surgical history of CAG and pacemaker insertion 2 years back, CABG 4 years back and right nephrectomy 4 years back. In addition, he is commenced on warfarin and oral prednisolone,

Considering his past medical and surgical history, he is not fit for surgery this week as he needs an opinion from MDT, and his warfarin and steroid which need to be optimized along with his comorbidities.

Is the patient fit for surgery? Why do you think like that?

I don’t think Mr. X is fit for surgery and anaesthesia. Because of having Significant cardiac history (CABG, Pacemaker)
HTN
COPD
Diabetes
Patient is on warfarin that must be bridged
Patient is on steroids which should be optimized to prevent Addisonian crisis

What are your differentials for hip pain at this age?
I would consider
OA
RA
AVN
Paget's disease of bone
Neoplasm
Septic arthritis

How will you optimize his conditions before operation? What are your considerations pre-operatively for this patient?
I will discuss with MDT

• Diabetes control (see OR listing station)
  HTN control with opinion from cardiologist
  Pre-op pacemaker setup control (sce OR listing station)
  Reversal of warfarin (see OR listing station)
  Asthma’ COPD optimization (see OR listing station)
  Steroid optimization (see ASSCC steroid station)
  Optimize pre-op fluid and electrolyte imbalance as he has only one kidney
  Pre- and post-operatively under supervision of physiotherapist
  Pre-op thromboembolic prophylaxis (risk factors include orthopaedic operation, patient may have
  polycythemia due to COPD)