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Perioperative assessment

SARAH Al-Ghanim

ORL-HNS Resident ( R1)

+The goals of perioperative assessment

1• Identify the patient’s medical problems

2• Determine if further information is needed to

characterize the patient’s medical status

3

• Establish if the patient’s condition is medically optimized

4• Confirm the appropriateness of the planned procdure.

+ 3

Scenario

Dr.Hessa ( GS- R1 ) has been called form ward

8 for an elective admission under the care of

Dr.Alsalman :

A 50 year old non insulin dependant diabetic is

planned for a right inguinal hernia repair. He is

on warfarine for past hx of DVT.

Outline the steps needed to assess and prepare this man for the planned surgery

+Perioperative Evaluation & Management

General

Evaluation

Specific Consideration

+

General Evaluation of the

Surgical Patient

+General Evaluation of the Surgical

Patient

History & physical Examination

Routine Diagnostic testing

Preoperative medications

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Preexisting medical conditions

Prior operation

Operative complication

Medication allergy

Use of tobacco , alcohol , or drugs

History & physical Examination

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Routine Diagnostic testing

CBC

Serum electrolytes , Cr, BUN

Coag. profile

Biochemical & profiles

(e.g. liver enzyme )

Pregnancy test

CXR

ECG

Type & screen

Urine analysis

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In general patients should continue their medications in the

immediate perioperative period.

Exceptions to this rule include;

diabetic medications

Anticoagulants

Antiplatelet

Preoperative medications

+Specific Consideration

In preoperative management

Cerebrovascular

Cardiovascular

Pulmonary

Renal

Infectious

Diabetes mellitus

Adrenal insufficiency

Anticoagulation

+Cerebrovascular

disease

Risk factors:

Previous CVA, age, hypertension, CAD, DM, tobacco use

Special consideration :

The Asymptomatic carotid bruit ?

Recent transient ischemic attack?

Elective surgery for patient with recent CVA ?

+The Asymptomatic carotid bruit ?

In 14% of surgical patients older than 55 years

50% of bruits reflect hemodynamically significant disease.

No increased in risk of stroke has been demonstrated during no

cardiac surgery

Cerebrovascular disease

+Recent transient ischemic attacks

Patients with Recent transient ischemic attack (TIAs)are at

increased risk for perioperative stroke

They should have perioperative neurological evaluation ;

Patients with symptomatic carotid artery stenosis should have

an endarterectomy or carotid stenting before elective surgery

Cerebrovascular disease

+Elective surgery for patient with

recent CVA ?

Elective surgery for patient with recent CVA should be delayed

for :

A Minimum of 2 weeks

Ideally for 6 weeks

Cerebrovascular disease

+Cardiovascular

Cardiovascular disease is one of the leading cause of death

after non cardiac surgery .

Patients who experience a myocardial infarction after non

cardiac surgery have a hospital mortality rate of 15% to 25%.

Risk factors :

The patient’s age , unstable angina , Recent MI , Untreated

CHF, DM, valvular heart disease, Arrhythmia, peripheral

vascular disease , type of procedure , functional impairment .

+Perioperative Testing :

1• ECG

2

• Non invasive testing

• Exercise stress testing , Dipyridamole thallium, Dobutamine stress echo

3

• Invasive testing

• angiography

• Definitive tx ( CBAG – angioplasty )

• Turned to the uninhibited mode before surgery.

• Bipolar cautery should be used

• Monopole if necessary the pad should be placed away from the heart

Patients with Pacemaker

• The device should turned off during surgery

Internal defibrillators

• Delay noncardiac surgery at least 6 weeks

Recent angiography or stenting

+Pulmonary disease

Risk factors :

Chronic obstructive pulmonary disease (COPD), smoking , advanced age , obesity , type of surgery, acute respiratory infections, functional status .

Diagnostic evaluation :

CXR acute symptoms related to pulmonary disease

ABG hx of lung disease

preoperative pulmonary function testing ?

+Preoperative prophylaxis &

management

Pulmonary toilet: incentive spirometry

Antibiotics:

elective procedure should be postponed,

if emergent surgery ;IV antibiotics

Cessation of smoking

Bronchodilators

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Risk factors:

Additional underlying medical disease , metabolic & physiologic

derangements of CRI , type of operative procedure.

Management :

Timing of dialysis within 24 hr of the planned procedure

Intravascular volume status hypovolemia & volume overload

are both poorly tolerated

Renal

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Assessment of risk :

Procedure specific risk factors :

type of operation , the degree of wound contamination ,& duration

& urgency of the operation

Patient specific risk factors:

Age , DM, obesity , immunosuppression, malnutrition

,preexisting infection, & other chronic illness.

Infectious

+Prophylaxis

1- non antimicrobial strategies:

Strict sterile technique ,maintain normal body

temperature & normal blood glucose , hyper

oxygenation

2- surgical wound infection: AB prophylaxis

3-Preop skin antisepsis

4- respiratory infections

5- genitourinary infections

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Diet controlled

Can maintain safely without

food or glucose infusion

Oral hypoglycemic

agent Stop medications Sliding scale

On insulin Sliding scale

Insulin pumps should be

inactivated in the morning of

surgery

Diabetes mellitus

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Preoperative stress dose steroid are indicated for patients undergoing major surgery who have :

Chronic steroid replacement or

Immunosuppressive steroid therapy within the preceding year.

Dosage Recommendations :

A regimen of hydrocortisone sodium succinate 100 mg IV;

on the evening before major surgery

At the beginning of surgery,

& every every 8 hours on the day of surgery.

Patients who undergoing minor surgery or diagnostic procedures usually do not required stress dose steroid

Adrenal insufficiency

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Preoperative anticoagulation :

It is safe to perform surgery when INR below 1,5

Patient who is INR = 2-3 require withholding of medication

for 4 days before surgery

If the INR value is greater than 3 withholding the medication

for a longer period

The INR should be measured the day before surgery

Anticoagulation

+Post operative anticoagulation :

High risk of thromboembolism :

Resume warfarin + bridged with therapeutically dosed SC LW

heparin or IV UFH

Moderate risk :

warfarin + bridged with therapeutically or prophylactic dosed

SC LW heparin or IV UFH

Low risk :

no need to be bridged

Anticoagulation

+Reference

THANKyou