Preoperative investigations and significance

Dr. Moyukh Chowdhury

Indoor Medical Officer, Department of Surgery Sylhet Women’s Medical College Hospital

Sylhet Bangladesh.

19th centuryThe Victorian era

• Evolution of revolution when barbers stopped doing surgeries &

• concept of antisepsis started to take place.

Strabismus correcting operation in 19th century .

Compressing the arteries of arms and legs

to reduce blood loss

Renowned Scottish surgeon Robert Liston with anesthetic support

Experience without anesthesia or Poor anesthesia

Poorly controlled blood loss .

Gazillions of microbe .

80-90 % Mortality

Surgery or

DEATH sentence ?

Welcome to the21st century

According toWHO … • The reported crude mortality rate after major

surgery is 0.5-5% .• complications after inpatient operations

occur in up to 25% of patients;• In industrialized countries, nearly half of all

adverse events in hospitalized patients are related to surgical care.

• At least half of the cases in which surgery led to harm are considered preventable .

Surgical management

Peroperativ

e

Post operative

Preoperati

ve

History

Examination

Investigation

PREOPERATIVE ASSESSMENT

Key points

Type of surgery:

• Major surgery can lead to organ system dysfunction so needs most investigations .

Patient: • For example, sickle cell test for patient with Afro- Caribbean origin .

Comorbidities:

• Peak flow rates for severe asthmatics .

PREOPERATIVE INVESTIGATION CRITERIA

PREOPERATIVE INVESTIGATION

S

Complete blood count (CBC)

• Needed for major operations, in the elderly and in those with anaemia or

pathology with ongoing blood loss.

• A sickle cell test is needed in any patient of Afro-Caribbean origin.

Serum creatinine, Urea and electrolytes.

• Needed before all major operations, in most patients over 60 years of age especially with cardiovascular, renal and endocrine disease or if significant blood loss is anticipated.

• It is also needed in those on medications which affect electrolyte levels, e.g. steroids, diuretics, digoxin, NSAIDs , intravenous fluid or nutrition therapy.

Electrocardiography (ECG) & Echocardiogram

• Required for those patients aged over 60 years or cardiovascular, renal and cerebrovascular involvement, diabetes and in those with severe respiratory problems.

Clotting screening If a patient has a history suggestive of • bleeding diathesis, • liver disease, • eclampsia, • cholestasis , • family history of bleeding disorder, or• on antithrombotic or anticoagulant agents, then coagulation screening will be needed. However, the

effects of antiplatelet agents, low molecular weight heparins and newer agents affecting factor “Xa” cannot be measured by routine laboratory tests.

Chest radiography

• A chest x-ray is not required unless the patient has a significant cardiac history, cardiac failure, severe chronic obstructive pulmonary disease (COPD), acute respiratory symptoms, pulmonary cancer, metastasis or effusions, or is at risk of tuberculosis.

Urinalysis • Dipstick testing of urine should be performed on all patients

to detect urinary infection, biliuria, glycosuria and inappropriate osmolality.

Human chorionic gonadotrophin:• Pregnancy needs to be ruled out in all women of childbearing

age.

Blood glucose and HbA1c :• These should be performed in patients with

diabetes mellitus and endocrine problems. HbAlc indicates how well diabetes has been controlled over a longer duration.

Arterial blood gases : • This test allows detailed assessment of severe

respiratory conditions and acid-base disturbances.

Liver function tests :• These are indicated in patients with jaundice, known or

suspected hepatitis, cirrhosis, malignancy or patients with poor nutritional reserves.

Other investigations:• Further relevant investigations should be undertaken to

assess capacity of specific organ system and risks associated. Specialist radiological views and recent imaging are sometimes required. If imaging is going to be needed during surgery then this needs to be planned in advance. Blood grouping and Viral markers.

Specific medical problems encountered during preoperative assessment should be corrected to the best possible level.

Many patients with severe disease will be needed to be referred to specialists; the referral letter should include all the details including history, examination and investigation results .

• Neuromuscular Diseases (Muscular Dystrophies, Myotonias, Amyotrophic Lateral Sclerosis, Myasthenia Gravis)

Patients with muscular dystrophy, myotonia, or amyotrophic lateral sclerosis (ALS) undergoing surgery have an increased risk for respiratory and cardiac complications. The risk of life-threatening cardiac dysrhythmia and depression of cardiac contractility should be carefully considered, and cardiac function should be evaluated by specialist.

• It’s a system for assessing the fitness of cases before surgery .

• In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system; a sixth category was later added.

ASA PHYSICAL STATUS CLASSIFICATION SYSTEM

Thank you all…

Reference :

• Bailey and Loves Short practise of Surgery ( 26th Edition )

• www.who.int/patientsafety/safesurgery

• www.elitereaders.com/crucial-interventions-reveal-surgery-victorian-era