The surgical

patient

APPROACH TO THE SURGICAL

PATIENT
A skilled surgeon can make diagnosis appear very easy, almost
intuitive.
The process of problem analysis and decision making may be
faster, but it is the same for every practitioner, whatever his or
her experience.
It consists of:

History
Physical examination
Differential diagnosis
Investigations, if required, to confirm your diagnosis
Treatment
Observation of the effects of treatment
Re-evaluation of the situation, the diagnosis and the treatment.

APPROACH TO THE SURGICAL

PATIENT
If you make the diagnosis too early, you may
miss the opportunity to collect important
information.
Do not jump to conclusions.
A diagnostic algorithm can be helpful, but
cannot replace active thinking about the case.
Talk to, examine and think about the patient.

The History
A full medical history includes the following:

Patient identification: name, sex, address and date of birth

Presenting complaint
History of the present symptoms/illness
Past medical history, especially previous surgery and any
complications, including:

Allergies
Medications, including non-prescription and locally obtained drugs
Immunizations
Use of tobacco and alcohol

Family history
Social history
Functional inquiry which reviews all systems

Investigations: general principles

Use laboratory and diagnostic imaging
investigations to confirm a clinical hypothesis;
they will not make the diagnosis in isolation.
Remember to inform the patient of the results of
any tests.
Take time and care if the results are unexpected
or are likely to cause emotional trauma.
Do not delay an urgent procedure if laboratory
services or diagnostic imaging are not available.

Investigations: general
principles
The decision to operate must often be made on
purely clinical grounds,
even
though
investigations provide additional information
and further support for the diagnosis and
management plan
Only ask for an investigation if:
You know why you want it and can interpret the
result
Your management plan depends on the result.

Decision making
Your clinical assessment of the patient may
indicate that surgery is required.
If so, consider the following important issues.
Can we do the procedure here?
Is the operating room safe and fit for use?
Are the necessary equipment and drugs available?
Are all members of the team available?
Do I have the knowledge and skill to perform the
necessary procedure?

Decision making.
Can we manage this patient?
Is there back up or extra support available, if required?
Can we manage the potential complications if problems
arise?
Do we have nursing facilities for good postoperative care?

If the answer to any of these questions is No, it is

inadvisable to proceed with surgery.
If transfer is not possible or the patient could not
withstand such a stress, then be aware of, and
communicate, the increased risk of the procedure and
proceed with great caution.

Preoperative note
The preoperative note should:
Document:

The history and physical examination

Results of laboratory and other investigations
Diagnosis
Proposed surgery
Document your discussion with the patient and family and their
consent to proceed

Demonstrate:
The thought process leading to the decision to operate
That you have considered possible alternatives and the risks and
benefits of each.

Preparation for surgery

On operative day
Intraoperative

Operative Note
After an operation, an operative note must be
written in the patients clinical notes.
It should include at least:
Names of persons in attendance during the
procedure
Pre- and postoperative diagnoses
Procedure carried out
Findings and unusual occurrences
Length of procedure
Estimated blood loss

Operative Note
Anaesthesia record (normally a separate sheet)
Fluids administered (may also be on anaesthesia record)
Specimens removed or taken
Complications, including contamination or potential for
infection
Method of closure or other information that will be
important to know before operating again (for example,
the type of incision on the uterus after Caesarean
section)
Postoperative expectations and management plan
Presence of any tubes or drains.

Postoperative note and orders

The patient should be discharged to the ward
with comprehensive orders for the following:
Vital signs
Pain control
Rate and type of intravenous fluid
Urine and gastrointestinal fluid output
Other medications
Laboratory investigations.

Postoperative note and

The patients progress should be monitored
and should include at least:
A comment on medical and nursing observations
A specific comment on the wound or operation site
Any complications
Any changes made in treatment

Aftercare
Prevention of complications
Encourage early mobilization:

Deep breathing and coughing

Active daily exercise
Joint range of motion
Muscular strengthening
Make walking aids such as canes, crutches and walkers available and
provide instructions for their use

Ensure adequate nutrition

Prevent skin breakdown and pressure sores:
Turn the patient frequently
Keep urine and faeces off skin

Provide adequate pain control.

Discharge note
On discharging the patient from the ward,
record in the notes:
Diagnosis on admission and discharge
Summary of course in hospital
Instructions about further management, including
drugs prescribed.

Ensure that a copy of this information is given

to the patient, together with details of any
follow-up appointment.

THE PAEDIATRIC PATIENT

Infants and children under 10 years of age
have important physiological differences that
influence the way in which they should be cared
for before, during and after surgery.
The pattern of surgical disease is also
different; congenital disorders must be
considered in all children, but especially in
neonates.
Children are not just little adults

PHYSIOLOGICAL CONSIDERATIONS
Vital signs
Infants and children have a more rapid metabolic
rate than adults.
This is reflected in their normal vital signs.

Vital signs (normal and at rest)

Compensatory mechanisms for

shock
Children compensate for shock differently
from adults, mainly by increasing their heart
rate.
A rapid heart rate in a child may be a sign of
impending circulatory collapse.
Do not ignore a decreased blood pressure.
A slow heart rate in a child is hypoxia until
proven otherwise.

Blood volume
Children have smaller blood volumes than adults:
Even small amounts of blood loss can be life
threatening
Intravenous fluid replacement is needed when blood
loss exceeds 10% of the total blood volume
Chronic anaemia should be slowly corrected before
elective operations with iron, folic acid or other
supplements, as appropriate
Make sure that safe blood will be available in the
operating room if blood loss is anticipated during
surgical procedures

Blood volume.
Paediatric blood volumes
Blood volume ml/kg body weight
Neonates : 85 90
Children: 80
Adults : 70

Fluid and electrolytes

Baseline fluid and electrolyte requirements are
related to the childs weight.
However, the actual fluid requirements may
vary markedly, depending on the surgical
condition
Total daily maintenance fluid requirements
<10 kg :
10 19 kg :
>20 kg :

100 120ml/day
90 120ml/day
5090ml/day

Fluid and electrolytes

Hourly maintenance fluid requirements can be
calculated using the 4:2:1 rule.
Hourly maintenance fluid requirements
Body weight (kg) Fluid (ml/hour)
First 10 kg

Plus
Second 10 kg

Plus
Thereafter

Fluid and electrolytes

Fluid requirements in surgical patients commonly
exceed maintenance requirements.
Children with abdominal operations typically require
up to 50% more than baseline requirements and even
larger amounts if peritonitis is present.
Special care is needed with fluid therapy in children;
pay close attention to ongoing losses (e.g. nasogastric
drainage) and monitor urine output.
In the case of fever, add 12% to total maintenance
requirements per 1C rise above 37.5C temperature
measured rectally.

Fluid and electrolytes

The most sensitive indicator of fluid status in a child
is urine output.
If urinary retention is suspected, pass a Foley
catheter.
A catheter also allows hourly measurements of urine
output that can prove invaluable in the severely ill
patient.
Normal urine output:
Infants 12 ml/kg/hour
Children 1 ml/kg/hour

Pain Mgt
Children suffer from pain as much as adults, but
may show it in different ways.
Make surgical procedures as painless as possible:
Oral paracetamol can be given several hours prior to
operation
Local anaesthetics (bupivacaine 0.25%, not to
exceed 1 ml/kg) administered in the operating room
can decrease incisional pain

Pain Mgt
Paracetamol (1015 mg/kg every 46 hours)
administered by mouth or rectally is a safe and
effective method for controlling postoperative pain
Intravenous narcotics
morphine sulfate 0.05 0.1 mg/kg IV) every 2 4 hours.
For more severe pain,

Ibuprofen 10 mg/kg can be administered by mouth

every 68 hours
Codeine suspension 0.51 mg/kg can be
administered by mouth every 6 hours, as needed

Pre- and postoperative care

The pre- and postoperative care of children with
surgical problems is often as important as the
procedure itself.
For this reason, surgical care of children does not
begin or end in the operating room.
Good care requires teamwork, with doctors,
nurses and parents all having important roles to
play:

Pre- and postoperative

care
Prepare the patient and family for the procedure
Ensure that the needed paediatric supplies
(such as intravenous catheters, endotracheal tubes
and Foley catheters) are available in the operating
room to complete the procedure
Monitor the patients vital signs during the critical
period of recovery
Encourage a parent to stay with the child in the
hospital and to be involved in his/her care

Surgical Problems In Neonates

Intestinal obstruction
Hypertrophic pyloric stenosis
Esophageal atresia
Abdominal wall defects
Anorectal anomalies
NTD/ spina bifida
Cleft lip and palate
Club foot/ talipus equinovarus
Hip dislocation

Surgical Problems In Young Children

Injury
Burn
Surgical infection
Acute abdomen
Abdominal pain
Bowel obstruction
Appendicitis
Hernia