Chapter 16: Perioperative care
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Pre‐operative theatre checklist
Related theory
The pre‐operative theatre checklist (Figure 16.13) is the final check after a patient has been moved from the ward to the operating theatre. It should be completed clearly and in full, in order to reduce the possibility of any complications during the period that the patient is put under anaesthetic or during the surgical procedure.
Figure 16.13 Example of a pre‐operative and theatre checklist.
These checks include ensuring that blood results and X‐rays or imaging accompany the patient. The blood results are important for assessing the patient's haemoglobin levels, which in turn help the body to transport oxygen and electrolytes to identify any imbalances, such as low sodium or potassium. Such deficiencies can interfere with anaesthetic agents and cause cardiovascular disturbances such as arrhythmias (Higgins and Higgins [79]) (Table 16.9).
Table 16.9 Haematology values
| Test | Reference range | Functions and additional information |
|---|---|---|
| Red blood cells (RBC) |
Men: 4.5–6.5 × 1012/L
Women: 3.9–5.6 × 1012/L | The main function of the RBC is the transport of oxygen and carbon dioxide. |
| Haemoglobin (Hb) |
Men: 130–170 g/dL
Women: 120–150 g/dL | Hb is a protein pigment found within the RBC that carries oxygen. Anaemia (deficiency in the number of RBC or in the Hb content) may occur for many reasons. Changes to cell production, deficient dietary intake or blood loss may be relevant and need to be investigated further. |
| White blood cells (WBC) |
Men: 3.7–9.5 × 109/L
Women: 3.9–11.1 × 109/L | The function of the WBC is defence against infection. There are different kinds of WBC: neutrophils, lymphocytes, monocytes, eosinophils and basophils. Leucopenia is a WBC count lower than 3.7 and is usually associated with the use of cytotoxic drugs. Leucocytosis (high levels of neutrophils and lymphocytes) occurs as the body's normal response to infection and after surgery. Leukaemia involves an increased WBC count caused by changes in cell production in the bone marrow. The leukaemic cells enter the blood in increased numbers in an immature state. |
| Platelets | 150–400 × 109/L | Clot formation occurs when platelets and the blood protein fibrin combine. A patient may be thrombocytopenic (low platelet count) due to drugs or poor production, or have a raised count (thrombocytosis) with infection or autoimmune disease. |
| Coagulation/international normalized ratio (INR) | INR range 2–3 (in some cases a range of 3–4.5 is acceptable) | Coagulation occurs to prevent excessive blood loss by the formation of a clot (thrombus). However, a clot that forms in an artery may block the vessel and cause an infarction or ischaemia, which can be fatal. Aspirin, warfarin and heparin are three drugs used for the prevention and/or treatment of thrombosis. It is imperative that patients on warfarin therapy receive regular monitoring to ensure a balance of slowing the clot‐forming process and maintaining the ability of the blood to clot. |
| Sodium | 135–145 mmol/L | The main function of sodium is to maintain extracellular volume (water stored outside the cells), acid‐base balance and the transmitting of nerve impulses. Hypernatraemia (serum sodium >145 mmol/L) may be an indication of dehydration due to fluid loss from diarrhoea, excessive sweating, increased urinary output or a poor oral intake of fluid. An increased salt intake may also cause an elevation. Hyponatraemia (serum sodium <135 mmol/L) may be indicated in fluid retention (oedema). |
| Potassium | 3.5–5.2 mmol/L | Potassium plays a major role in nerve conduction, muscle function, acid‐base balance and osmotic pressure. It has a direct effect on cardiac muscle, influencing cardiac output by helping to control the rate and force of each contraction. The most common cause of hyperkalaemia (serum potassium >5.2 mmol/L) is chronic renal failure, in which the kidneys are unable to excrete potassium. The level may be elevated due to an increased intake of potassium supplements during treatment. Tissue cell destruction caused by trauma or cytotoxic therapy may cause a release of potassium from the cells and an elevation in the potassium plasma level. It may also be observed in untreated diabetic ketoacidosis. Urgent treatment is required as hyperkalaemia may lead to changes in cardiac muscle contraction and cause subsequent cardiac arrest. The main cause of hypokalaemia (serum potassium <3.5 mmol/L) is the loss of potassium via the kidneys during treatment with thiazide diuretics. Excessive or chronic diarrhoea may also cause a decreased potassium level. |
| Urea | 2.5–6.5 mmol/L | Urea is a waste product of metabolism that is transported to the kidneys and excreted as urine. Elevated levels of urea may indicate poor kidney function. |
| Creatinine | 55–105 μmol/L | Creatinine is a waste product of metabolism that is transported to the kidneys and excreted as urine. Elevated levels of creatinine may indicate poor kidney function. |
| Calcium | 2.20–2.60 mmol/L | Most of the calcium in the body is stored in the bone but ionized calcium, which circulates in the blood plasma, plays an important role in the transmission of nerve impulses and the functioning of cardiac and skeletal muscle. It is also vital for blood coagulation. High calcium levels, or hypercalcaemia (>2.6 mmol/L), can be caused by hyperthyroidism, hyperparathyroidism or malignancy. Elevation in calcium levels may cause cardiac arrhythmia, potentially leading to cardiac arrest. Tumour cells can cause excessive production of a protein called parathormone‐related polypeptide (PTHrP), which causes loss of calcium from the bone and an increase in blood calcium levels. This is a major reason for hypercalcaemia in cancer patients ( Higgins and Higgins [79]). Hypocalcaemia (<2.20 mmol/L) is often associated with vitamin D deficiency due to inadequate intake or increased loss due to gastrointestinal disease. Mild hypocalcaemia may be symptomless but severe disease may cause increased neuromuscular excitability and cardiac arrhythmias. It is also a common feature of chronic renal failure (Higgins and Higgins [79]). |
| C‐reactive protein (CRP) | <10 mg/L | Elevation in the CRP level can be a useful indication of bacterial infection. CRP is monitored after surgery and for patients who have a high risk of infection. The CRP level can help to monitor the severity of inflammation and assist in the diagnosis of conditions such as systemic lupus erythematosus, ulcerative colitis and Crohn's disease ( Higgins and Higgins [79]). |
| Albumin | 35–50 g/L | Albumin is a protein found in blood plasma that assists in the transport of water‐soluble substances and the maintenance of blood plasma volume. |
| Bilirubin | (total) <13 μmol/L | Bilirubin is produced from the breakdown of haemoglobin; it is transported to the liver for excretion in bile. Elevated levels of bilirubin may cause jaundice. |
Patients should not be given routine pre‐operative medication before being asked for their consent to proceed with the treatment (NMC [152]) (see ‘Consent’ above).
Procedure guideline 16.2
