PREOPERATIVE PREPARATION AND POSTOPERATIVE CARE

PREOPERATIVE PREPARATION

HAZMAN NORMAN 012013051891

OVERVIEW

• PATIENT ASSESSMENT

• RISK ASSESSMENT AND CONSENT

• ARRANGING THE THEATRE LIST

PATIENT ASSESSMENT

• Aims:– look actively at risks

– proper management of risks

– enabling safe surgery

• Usually done by surgical team, nursing team and anaesthetic team

• Standard history taking

• Proper physical examination

• Investigations needed (NICE guidelines)

• Airway assessment and evaluation

RISK ASSESSMENT AND CONSENT

• ASA classification

• Explain on the advantages, side effects and, and prognosis

• Taking comprehensive valid consent – given voluntarily by a competent and informed person

ARRANGING THE THEATRE LIST

• Confirm it is the right date, time, and place of operation

• Personnel availability

• Appropriate equipment and instruments should be made available

• Operating list should be distributed early

• Priorities to children, diabetic patients, cancer patients, and life threatening patients

BEFORE THEATRE• Must be seen by anaesthetist and operating surgeon

in charge

• Keep in view for specific requirement

• Arrange the theatre list appropriately

SURGICAL SAFETY CHECKLISTIntroduced by WHO in 2008, a guideline recommended practices to reduce rate of preventable surgical complications and death

worldwide.

• Prelist briefing

• Sign in

• Antibiotic

• Monitoring

• Operating theatre environment

• Diathermy

• Torniquets

• Time outs

• Temperature control

• Hair removal

• Glycaemic control

• Infection control

SCRUBBING UP

• Process of washing of hands and arms and putting on gloves and gown

• 2 standard scrub solutions include

-2% chlorhexidine

-7.5% povidone-iodine

-alcohol

• Hat, mask and eye protection should be worn andjewellery should be removed

• Nails and deep skin crease should be clean for 1-2 minsusing brush

• Hands and forearms wash systematically 3 times

• Hands and arms are dried from distal to proximal usingsterile towel

• Folded gown lifted away from trolley, allowed to unfold

• Arms inserted into armholes, hands remain inside gownsuntil gloves are donned, secure the gown

• Gloves are put on, hands remain above waist level at alltimes.

REFERENCES

• BAILEY AND LOVE’S 26TH EDITION

• OXFORD HANDBOOK OF CLINICAL MEDICINE 8TH EDITION

SPECIFIC PREOPERATIVE PROBLEMS , REFERRALS

AND MANAGEMENT

SURENTHIRAN

012010090079

INTRODUCTION

OPreoperative problems – certain specificmedical conditions encountered duringpreoperative assessment

OShould be corrected to the best possible levelto eliminate serious complications

OPatients with severe disease will need to bereferred to specialists and the referral lettershould include all the details

( history , examination and investigationresults ).

Preoperative management of patients with systemic

disease

CAPACITY : baseline organ function capacity

should be assessed

OPTIMISATION : Medication, lifestyle changes,

specialist referral will improve organ capacity

ALTERNATIVE : Minimally impacting procedure ,

appropriate postoperative care will improve

outcomes

THEATRE PREPARATIONS : Timing, teamwork ,

special instruments and equipment

OCARDIOVASCULAR DISEASE

OHYPERTENSION, IHD AND STENTS

ODYSRHYTHMIAS

OVALVULAR HEART DISEASE

OANAEMIA AND BLOOD TRANSFUSION

ORESPIRATORY DISEASE

OGASTROINTESTINAL DISEASE

CARDIOVASCULAR DISEASE

O Identify patients who have a high

preoperative risk of MI and make

arrangements to reduce the risk

O Include those who have suffered coronary

artery disease, CCF , arrhythmias , severe

peripheral vascular disease , CVD or renal

failure

OPatients with IHD – left ventricular status can

be evaluated using a stress test

OPatients with symptomatic valvular heart disease

or poor left ventricular function – an echo should

be performed

(ejection fraction less than 30% - poor

outcomes)

OReferred to cardiologist if :

- murmur heard and patient is symptomatic

- poor left ventricular function or cardiomegaly

- ischaemic changes on ECG even if patient is

not

symptomatic (silent MI)

- abnormal rhythm on ECG , tachy/bradycardia

or

a heart block

HYPERTENSION , IHD AND STENTS

OPrior to surgery blood pressure should be

controlled to 160/90 mmHg

OStabilisation period of 2 weeks if new

antihypertensive is introduced

OPatients with angina

– investigated further by a cardiologist if not

well controlled

- some may need thrombolysis , stents or

bypass surgery prior to non-cardiac surgery

OPatients who have had stents inserted for

IHD, should be asked for the effectiveness of

the treatment and concurrent antiplatelet

medication (clopidogrel and/or aspirin)

ORisk of stent thrombosis with consequences

of MI and death is reduced if elective surgery

is postponed until after dual antiplatelet

therapy is stopped

O If cannot be postponed and risk of

perioperative bleeding is low – dual

antiplatelet therapy can be continued during

surgery

DYSRHYTHMIAS

OPatients with atrial fibrillation

-B-blockers, digoxin and CCB started

preoperatively

- warfarin stopped 5 days preoperatively

O Implanted pacemaker and cardiac

defibrillator checks and appropriate

reprogramming done

OSymptomatic heart blocks and asymptomatic

second and third degree heart blocks need

cardiology consultation

VALVULAR HEART DISEASE

OPatients with severe mitral and aortic stenosis

may benefit from valvuloplasty before elective

non-cardiac surgery

OPatients with mechanical heart valves-

- warfarin stopped 5 days prior to surgery and

infusion of unfractionated heparin ( INR <1.5)

- APTT kept at 1.5 times normal and stopped 2

hours before surgery

- Heparin and warfarin postoperatively and

heparin

stopped once full effect of warfarin realised

ANAEMIA AND BLOOD TRANSFUSION

OAnaemic at preoperative assessment treated

with iron and vitamin supplements

OChronic anaemia well tolerated in the

perioperative period

O if major procedure, preoperative

transfusion if Hb below 8g/dL

RESPIRATORY DISEASE

OCurrent respiratory status should be compared

with their normal state

ORegular treatment, PEFR , steroids use ,

CPAP should be taken note of

OEncourage patients to be compliant with

medications, exercise , consume balanced diet

and stop smoking

REFER TO RESPIRATORY PHYSICIANS IF :

- Severe disease or significant deterioration from

usual condition

- Major surgery is planned in a patient with

significant respiratory comorbidities

- Right heart failure is present

- Patient is young with COPD

O Smoking : provide information regarding

perioperative risks associated with smoking

O Asthma : establish severity of asthma, PEFR ,

precipitating causes, frequency of steroid and

bronchodilator use and any previous intensive care

unit admission. Use regular inhalers until the start

of anaesthesia

O COPD : Patients with significant COPD who are

undergoing major surgery will need to be referred

to physicians to optimise their condition. ABG also

useful

O Infections : elective surgery postponed if chest

infection. Treated with antibiotics and operation

rescheduled after 4-6 weeks.

GASTROINTESTINAL DISEASE

Nil by mouth and regular medications

- Not to take solids within 6 hours and fluids

within 2 hours before anaesthetic

- Infants allowed a clear drink up to 2 hours ,

mother’s milk up to 3 hours and cow or

formula milk up to 6 hours before anaes

- If surgery delayed, oral (until 2 hours of

surgery) or IV fluids started in the vulnerable

group of patients

Regurgitation risk

- High risk of pulmonary aspiration if patients with

hiatus hernia, obesity, pregnancy and diabetes

- Antacids, H2-receptor blockers or PPI given

Liver disease

- Cause of the disease , clotting problems, renal

involvement and encephalopathy should be

known

- LFT, coagulation , blood glucose, urea and

electrolyte levels

- Ascitis, hypoalbuminaemia, sodium and water

retention should be noted

THANK

YOU…..(but to be continue…)

SPECIFIC

PREOPERATIVE

PROBLEMS ,

REFERRALS AND

MANAGEMENT (2)BY :

M.Krishnavaathi

012011100086

Genitourinary disease

1) Renal disease

- Diabetes mellitus, hypertension and ischemia heart disease

should be stabilised

( leading to chronic renal failure )

- Apporiate measures to treat acidosis, hypocalcemia and

hyperkalemia > 6mmol/L

- Continue peritoneal or hemodialysis until a few hours before

surgery

- Blood sample sent for FBC and U & E ( after final dialysis before

surgery )

- Chronic renal failure patients often suffer chronic microcytic

anemia that is well tolerated

- Acute renal failure can present with acute surgical problems ; eg

bowel obstruction needing emergency surgery ( simultaneous

medical , surgery treatments and critical care unit )

2) Urinary tract infection

- Uncomplicated urinary infections are common in female

- Outflow uropathy with chronically infected urine is common in

men

- For elective surgery * infection should be treated because it

carries dire consequences eg joint replacements

- For emergency surgery * give antibiotics, ensure good urine

output before, during and after surgery

Endocrine and metabolic disorders

1 ) Malnutrition

- BMI < 18.5 kg/m2 ( nutritional impairment )

- BMI < 15 kg/m2 ( significant hospital mortality )

- Nutritional support for 2 weeks before surgery

2) Obesity

- Advice on healthy eating and taking regular exercise

- Use CPAP device for obstructive sleep apnea and cholesterol

reducing agents

- If possible, delay surgery until patients more active and lost

weight.

- Preventative measures for acid aspiration , DVT and associated

risks explained prior to surgery

3) Diabetes mellitus

- Check HbA1c level

- Start lipid lowering medication in high risk group of

cardiovascular complications of diabetes

- Morning operation { advice to omit morning dose medication

and breakfast, tight control of blood sugar not needed }, check

blood sugar for every 2 hrs

- Afternoon operation { breakfast + half regular dose of insulin or

full dose of oral anti – diabetics, check blood sugar for every 2

hrs

- Intravenous insulin sliding for insulin dependent diabetes

mellitus undergoing major surgery or if blood sugar difficult to

control for other reason

4 ) Adrenocortical suppression

- Ask oral adrenocortical steroid dose and duration to avoid

Addisonian crisis

Coagulation disorders

1) Thrombophilia

- Thrombophylaxis needed if present of risk factors

Risk factors for thrombosis

- Increasing age

- Significant medical comorbidities (particularly malignancy)

- Trauma or surgery (especially of the abdomen, pelvis and lower

limbs)

- Pregnancy/puerperium

- Immobility (including a lower limb plaster)

- Obesity

- Family/personal history of thrombosis

- Drugs (e.g. oestrogen, smoking)

- Hormone replacement therapy ( HRT ) should be stopped 6 weeks

prior to surgery

- Low risk patients can be given thromboembolism deterrent stockings

- Give warfarin for patients with high risk patients with history of

recurrent DVT, pulmonary embolism and arterial thrombosis

- Stop warfarin before surgery and replaced with low molecular weight

heparin or factor Xa inhibitor

Neurological and psychiatry disorders

- History of stroke, pre existing neurological deficit patients may be on

antiplatelet or anticoagulants.

- Low risk of cardiovascular thrombosis, antiplatelet withdrawn ( 7days

for aspirin, 10 days for clopidogrel )

- High risk patients, use aspirin alone

- Anticonvulsant and antiparkinson continued to help early mobilization

- Stop lithium 24 hours prior to surgery, measure blood level to avoid

toxicity

- Inform anaesthetist if psychiatric medications such tricyclic

antidepressants or monoamine oxidase inhibitors to avoid drug

interactions.

Musculoskeletal and other disorders

- Rheumoid arthritis , flexion and extension lateral cervical spine x ray

should be taken. ( lead to unstable cervical spine with spinal cord

injurt during intubation )

- Rheumatologist will advice on steroids and disease modifying drugs so

as to balance immunosuppression against need to stabilise disease

preoperatively

- In ankylosing spondylitis, technique of spinal or epidural anaesthesia

often challenging

- Patients with systemic lupus erthematosis may exhibit

hypercoagulable state along with airway difficult

Airway assessment

Samsoon and Young modified Mallampati test

Fauces, pillars, soft palate and uvula seen Grade 1

Fauces, soft palate with some part of uvula seen Grade 2

Soft palate seen Grade 3

Hard palate only seen Grade 4

- Patient’s mouth open and tongue protruding

- Higher the grade, higher the risk in obtaining and securing

airways

- Look for loose teeth, obvious tumors, scars, infections,

obesity, thickness of neck which will indicate difficulty in

obtaining airway

- Modified Mallampati class

- Jaw protrusion, neck movement and thyromental distance

Preoperative assessment in emergency surgery

- Start similar principle to that for elective surgery

- Constraints : time, facilities available

- Consent : may be not be possible in life saving emergencies

- Organisational efforts : for example, local/ national algorithms

for treatment of multi-trauma patients

GENERAL MANAGEMENT

AND

SYSTEM SPECIFIC

POST-OPE

COMPLICATION

SABRINA TAMILMANY

PURPOSES

To enable a successful and faster recovery of the patient post operatively.

To reduce post operative mortality rate.

To reduce the length of hospital stay of the patient.

To provide quality care service.

To reduce hospital and patient cost during post operative period.

GENERAL

MANAGEMENT

WHAT IS NEEDED?

the immediate recovery and requires to detect early signs of complication.

Receive a complete patient record from the operating room which to plan post operative care.

Patient’s name

•Age

•Surgical procedure

•Existing medical problem

•Allergies

•Aneasthetic & analgesics given

•Fluid replacement

•Blood loss

•Urine output

•Any surgical/ anaesthetic problems

encountered

Assessing the patient

Monitor vitals-pulse volume

and regularity, depth and

nature of respiration.

Assessment of patient’s O2

saturation.

KEEP MONITORING VITALS

• Check the level of consciousness.

Ability to respond to commands.

MAINTAIN INTAKE AND OUTPUT

PROTECT

AIRWAY

By proper positioning of patient’s head.

By clearing airway.

Oxygen therapy.

Maintaining IV Stability

Hypovolemic shock: can be avoided by timely administration of IV Fluids, blood and blood products and medication.

Replacement of fluids.[colloids and crystalloids]

Keep the patient warm.

Monitor intake and output balance.

Monitor the vitals continuously with the patient condition.

ASSESSMENT OF THE SURGICAL SITE

Haemorrhage

It is a serious complication of surgery that resulting death.

It can occur in immediate post operatively or upto several days after surgery.

If left untreated,cardiac output decreases and blood pressure and Hb level will fall rapidly.

• Blood transfusion if necessary.

• The surgical site+incision should always be inspected.

• If bleeding,pressure dressing are placed.

• If the bleeding is concealed,the patient is taken in OR for emergency exploration of concealed haemorrhage in body cavity.

RELIEVING PAIN +ANXIETY

Administer opioid analgesia as

per Doctor’s order.

Epidural analgesia.

NSAIDS.

Psychological support to

relieve fear+To give support.

CONTROLLING NAUSEA+VOMITTING

These are common problem in post operative period.

Medication can be administered as per doctor’s order.

Example:

Inj Metaclopramide

Inj Ondansetron

( Emeset )

WHEN TO BE DISCHARGED

FROM RR?

• When patient fulfill following criterias,

Fully concious

Respiration and oxygenation are satisfactory

Not in pain or nausea

CVS parameters are stable

Oxygen, fluids and analgesics prescribed

No conceren related to surgical procedure

SYSTEM SPECIFIC

COMPLICATION

RESPIRATORY COMPLICATION

• most common are

hypoxaemia

hypercapnia

aspiration

• late complication

Pneumonia

pulmonary embolism

POSTOPERATIVE HYPOXIA

• Present as shortness of breath, or agitated due

to upper airway obstruction

• Signs

Absence of air movements

Seesaw movement of chest

Suprasternal recession

cyanosis

Causes of hypoxia

Upper airway obstruction due

to residual effect of

anaesthesia

Laryngeal edema due to

tracheal intubation or

palsy

hypoventillation

Atelectasis or pneuomia

Pulmonary edema of cardiac

origin

Pulmonary embolism with

sudden chest pain

TREATMENT

• Should be treated urgently

• Administer oxygen at 15L/min using a non-rebreathing mask + head tilt, chin lift and jaw thrust

• Suctioning of any blood or secretions

• Tracheal intubation and manual ventillation

• If pneumonia : antibiotics, chest physiotherapy and bronchodillators

• If pulmonary edema : start on diuretics and cardiology opinion sought

CARDIOVASCULAR

COMPLICATION

• Hypotension is common due to inadequate

fluid replacement, vasodilatation from

anesthesia

• Other causes Surgical bleeding

Sepsis

Arrythmias

Myocardial infarction

Cardiac failure

Tension pneumothorax

Pulmonary embolism

• Signs

Cold clammy extremities

Tachycardia

Low urine output ( < 0.5 ml/kg )

Low CVP

MYOCARDIAL ISCHEMIA /

INFARCTION

• Patient with previous cardiac problems are at

risk of ACS

• Present with retrosternal pain radiating to jaw,

neck or arms, may have nausea, dyspnoea or

syncope

• ST elevation seen in 2 continous leads on ECG

and serum troponin level will be high in both

conditions

TREATMENT

• Start with oxygen, glyceryl trinitrate, morphine

and aspirin

• Beta blockers or calcium antagonist may be

started

• Cardiologist should be involved.

ARRYTHMIA

• Cause hypotension and ischemia

• Need continuous monitoring

• Treated according to Resuscitation Council

peri-arrest guideline,

Correct the cause including acid-base and

electrolyte imbalance, hypoxia, and

hypercapnia

RENAL AND URINARY

COMPLICATIONS

ACUTE RENAL FAILURE

• Any perioperative events like sepsis, bleeding,

hypovolaemia, rhabdomyolysis and abdominal

compartment syndrome precipitates

• Treatment, If urine output < 0.5ml/kg for 6 hrs, check the catheter if its

blocked

Correct hypovolaemia, metabolic and electrolyte disturbance

and stop nephrotoxic dugs

URINARY RETENTION

• Common in pelvic and perineal operations

• Catheterisation should be performed if an ope

expected to last more than 3 hours or longer or

when large volumes are administered

URINARY INFECTION

• Patient present with dysuria or pyrexia

• Immunocompromised, diabetis and patient

with h/o urinary retention are at higher risk

• Treatments

Adequate hydration

Proper bladder drainage

antibiotics

Complicatons Related

to Specific Surgical

Specialities

Anna Alisha Mathew Simon

Abdominal Surgery

• The abdomen should be examined for

distension, tenderness, drainage

• Sites/wounds :

– Paralytic illeus

• following surgery, bowel movements may

reduce temporarily

• adequate hydration and electrolytes

– Localised infection

– Anastomotic leakage

Orthopeadic Surgery

• Neurovascular status of limbs must be checked

regularly

• External fixator-pin site should be checked

• Compartment syndrome-remove circumferential

dressings-fasciotomy

Neck Surgery

• Accumulation of blood = asphyxia

• Recurrent laryngeal nerve damage-pre

and post op

Thoracic Surgery

• Regular review of chest drain

• Continous ECG monitoring

• Bronchopleural fistula

• Heamothorax

• Pleural effusion

Neurosurgery

• Raised intracranial pressure-monitored

closely

Vascular Surgery

• Regular clinical assessment and Doppler

ultrasound post op

Plastic Surgery

• Viability of flaps and perfusion needs to be

monitored regularly

Urology

• Catheter patency must be check regularly

• TURP-continous bladder irrigation-

pulmonary oedema

GENERAL POSTOPERATIVE PROBLEMS AND MANAGEMENT

NUR NABILAH ISZA BT ISMAIL JA’FAR

• Pain

• Nausea and vomiting

• Bleeding

• Deep vein thrombosis

• Hypothermia and shivering

• Fever

• Prophylaxis against infection

• Confusional state

• Drains

• Wound care

• Wound dehiscence

• Enhanced recovery

Pain

• Most feared problem among patients

• More than 80% of patients experience post operative pain

Nausea & Vomiting

• Postoperative nausea and vomiting (PONV) can precipitate bleeding and

dehiscence of wounds by dislodging the clots and bursting suture lines.

• In neurosurgical patients raised intracranial pressure

• Risk factors:

– Women

– Non smoker

– Past h/o PONV, motion sickness, migraine

– Use of volatile anesthetic agents, opioids & NO

– Duration and type of surgery

• Management

– Adequate treatment for pain, anxiety, hypotension & dehydration

– Antiemetic (eg. Ondansetron, dexamethasone)

Bleeding

• Primary hemorrhage:

– either starting during surgery or following postoperative increase in blood pressure - replace blood loss and may require return to theatre to re-explore the wound

• Secondary hemorrhage:

– often as a result of infection.

Deep Vein Thrombosis

• Presentation:

– Calf pain

– Swelling

– Warmth

– Redness

– Engorged veins

• Venography or duplex Doppler ultrasound is used to assess flow and the presence of thromboses

• Management :

– Use of stockings, calf pumps

– Low molecular weight warfarin

Stratification of risk of DVT

Low Medium High

Maxillofacial surgery Inguinal hernia repair Pelvic elective and trauma surgery

Neurosurgery Abdominal surgery Total knee and hipreplacement

Cardiothoracic surgery Gynecological surgery

Urological surgery

Hypothermia and shivering

• Anesthesia induces loss of thermoregulatory control.

• Exposure of skin and organs to a cold operating environment, volatile skin preparation, infusion of cold IV fluids

• Leads to increased cardiac morbidity, a hypocoagulable state, shivering with imbalance of O2

supply and demand, immune function impairment with possibility of wound infection.

• Management active warming devices

Fever

• Causes of a raised temperature postopertivelyinclude:

– Day 2-5 : atelectesis of lung

– Day 3-5 : superficial & deep wound infection

– Day 5 : chest infection, UTI and thrombophlebitis

– > 5 days : wound infection, anastomotic leakage, abscess

• Management : treat possible causes

Prophylaxis against infection

• Patients who had foreign material insertion :

– Hip or knee prosthesis

– Aortic valve

• Bacteria can be incorporated into the biofilm that forms on the surface of the implant.

• Management :

– Prophylactic antibiotic should be administered, usually one dose 30 mins before ‘knife to skin’ and two postoperatively.

Confusional state

• Acute confusional states occur on recovery from anesth or few days after surgery.

• Higher in elderly with hip fractures & is associated with increased morbidity and mortality.

• Present as :– Anxiety

– Incoherent speech

– Clouding of consciousness

– Destructive behavior (eg. pulling off cannula)

CauseRenal Renal failure

Hyponatraemia UTI Urinary retention

Respiratory Hypoxia Atelectesis

Cardiocvascular Pulmonary embolism Dehydration Septic shock Myocardial infarction Chronic heart failure Arrhythmia

Drugs Opiates Hypnotics Cocaine Alcohol withdrawal Hypoglycemia

Neurological Epilepsy Encephalopathy Head injury Cerebrovascular accident

Idiopathic (rare) Hypothyroidism Hyperthyroidism Addison’s disease

• Risk factors:

– Pre-existing cognitive impairment

– Use of narcotics, benzodiazepines, alcohol

– Renal impairment

– Depression

• Precipitating factors

– Physical restraints

– Addition of new medications

– Electrolyte & fluid abnormalities

– Intraoperativeblood loss

– Admission to ICU

• Management

– Treat underlying medical problems

– Involve relative, friends

– Pain control

Drains

• Used to prevent

– Accumulation of blood, serosanguinous or purulent fluid

– To allow the early diagnosis of a leaking surgical anastomosis

• Quantity & character of drain fluid can be used to identify any abdominal complication such as fluid leakage (eg. bile or pancreatic fluid) or bleeding

– Additional IV fluids with same electrolyte contents

• Removed if drainage stopped or become less than 25 ml/day

Wound care

• Within hours, dead space cells fills up with an inflammatory exudate.

• Within 48 hours, a layer of epidermal cells from wound edge bridges the gap.

• Inspect wound only if there is any concern or the dressing needs changing (under sterile condition)

• Inflamed wound swab and sent for Gram staining & culture

• Infected wound & hematoma treat with antibiotics

• Contaminated/nonviable tissue remains packed & return to theater every 24-48 hours for cleaning

• Skin sutures/clips are usually removed between 6-10 days after surgery.

• Delayed wound healing patients who are malnourished, or have vitamin A & C deficiency

• Causes of inhibition of wound healing :

– Steroids

– Diabetes (uncontrolled)

Wound dehiscence

• Is a disruption of any or all of the layers in a wound

• Commonly occurred from 5th to the 8th postoperative day when the strength of the wound is at the weakest.

• It may herald an underlying abscess & usually presents with serosanguinous discharge.

• Management

Return to theater & resuturing

Leave wound open & treat with dressings or vacuum

assisted closure (VAC) pumps

Risk factors

General Local

Malnourishment Inadequate or poor closure of wound

Diabetes Poor local wound healing

Obesity Increased intra-abdominal pressure

Renal failure

Jaundice

Sepsis

Enhanced recovery

• An approach to the perioperative care of patients undergoing surgery.

• Designed to speed clinical recovery of patient, reduce the cost and length of stay in the hospital.

• Strategies include :

– Early planned physiotherapy & mobilisation (reduce risks of DVT, urinary retention, pressure sores)

– Early oral hydration & nourishment

– Good pain control NSAIDs

– Discharge planning (support from stoma care nurses, physiotherapists)

DISCHARGE OF PATIENTS

Discharge Letter

• Do include:

– Diagnosis

– Treatment

– Laboratory results

– Complications

– Discharge plan

– Support needed (eg: physiotherapy)

– Follow up

Follow Up in Clinic

• Reviewed in clinic when a key decision on management needs to be made

• Letter to patient’s GP:

– Care plan agreed with patient

– Advise on recognizing the onset of complications

• Discharge patient from clinic