Preoperative

Learning objectives

• To be able to organize preoperative care and the operating list

• To understand surgical, medical, and anaestheticaspects of assessment

• How to optimize the patient’s condition

• How to take consent

• How to organize an operating list

The preoperative period runs from the time

the patient is admitted to the hospital or

surgicenter to the time that the surgery begins.

4

DEFINITION

PRE-OPERATIVE PLAN

• Gathering & recording concisely all relevant information

• Planning to minimise risk & maximise benefit for the patient

• Prepared for adverse events & how to deal with them

• Communicate with patient & all members of the team

PATIENT ASSESSMENT

o History taking

o Examination

o Investigations

o Preoperative treatment

o Documentation

o Communication

o Principles of History taking

• Listen: What is the problem? (Open questions)

• Clarify: What does the patient expect?

(Closed questions)

• Narrow: Differential diagnosis

(Focused questions)

• Fitness: Comorbidities (Fixed questions)

• IHD, HTN, heart failure, dysrhythmias, PVD, DVT, anemia

Cardiovascular Respiratory

• COPD, asthma, fibrotic lung conditions, respiratory infection, malignancy

Gastrointestinal

• Peptic ulcer disease, GERD, bowel habits, malignancy, liver disease

Genitourinary tract

• UTI, renal dysfunction

Neurological

• Epilepsy, CVA, psychiatric disorder, cognitive function

Endocrine / metabolic

• Diabetes, thyroid dysfunction, phaeochromocytoma

Locomotor system

• Osteoarthritis, inflammatory arthropathy

Infectious

• Tuberculosis, hepatitis, HIV

Past medical history

Examination

• General: + findings even if not related to the proposed procedure should be explored

• Surgery related: Type and site of surgery, complications which have occurred due to underlying pathology

• Systemic: Comorbidities and their severity

• Specific: For example, suitability for positioning during surgery.

o Examination

General Physical Ex:Aim: to check fitness for anesthesia & surgery.

• GPE

• Systemic:

- CVS

- CNS

- GIT

- Respiratory system

Aim: to confirm previous findings & diagnosis, to determine severity & to gauge extent.

• E.g. in inguinal hernia confirm it’s inguinal not femoral, reducible or not & whether there are any signs of bowel obstruction.

Specific Surgical Ex:

Aim: to evaluates the presence & severity of other problems.

• E.g. Diabetic patient undergoing surgery need careful examination for sepsis , neuropathy or microvascular disease

Specific Medical Ex:

Investigations – Routine

• Every unit and ward has its own protocol.

• The tests which normally performed on most patient coming to surgery:

* Full Blood Count

* Basic Biochemistry

* Chest Radiography

o Investigations - routine

Investigations – Targeted tests

• Hematology : to exclude anemia, for platelets count & to assess the amount of blood may be needed during or after operation.

• Urea, Creatinine & Electrolytes: state of dehydration & renal insufficiency.

• Liver Function Tests: Alb & Protein guide to nutritional status & shows any clotting problems.

o Investigations – targeted tests

Investigations – Others

• ECG : It’s recommended in all patient >65years, pt. with blood loss & cardiovascular/pulmonary problems.

• Urinalysis: used for determination of renal function, inflammation, infection & metabolic disorders.

• Pregnancy Test: ( B- HCG )

• HBsAg & HIV testing.

• RBS & HbA1c : Diabetes

• Blood gas analysis: Occ. required

o Investigations - others

PREOPERATIVE PROBLEMS

HypertensionPreoperative blood pressure should not exceed 160/90 mmHg

Newly diagnose HTN may need further evaluation

Acute admission require urgent surgery, BP should be controlled more rapidly

Ischemic heart disease / MI - Recent MI is strong contraindication to elective anaesthesia- Postpone surgery 3-6 months after proven MI

Dysrhythmias• Fast atrial fibrillation must be controlled before surgery –

warfarin should be stopped 3-4 days before surgery

• Regular measurement of serum potassium essential

• Some conduction disorders may require pacing preoperatively, 2nd & 3rd degree heart block

Anemia & blood transfusion

• Preoperative transfusion considered if Hb < 8g dl

Respiratory system• Infection - to be treated

before surgery

• Asthma • Establish the severity and

the course of illness• Patient usual inhalers

should be continued

• COPD• Preoperative chest x-ray • Significant COPD who need

major surgery, refer respiratory physician

• ABG analysis

Gastrointestinal disease

• Nil by mouth before surgery: - solid (6 hours) - fluids (2 hours)

Regurgitation risk

• H2 receptor blockade/PPI, NG tube to empty distended stomach

Jaundice

• Secondarycomplications:Impaired clotting,risk of renal failure

• Prophylacticantibiotics needed

• Determine nutritional status of patient, nutritional assessment

• Malnourished patient: nutritional support minimum of 2 weeks

• Clinically obese patient (BMI >30) • Increased risk of

postoperative complication

• Some case might better delay the elective surgery until they lost some weight

Genitourinary disease

Renal impairment• Categorize pre-renal, renal,

post-renal

• Appropriate measure for acidosis, hypocalcemia, hyperkalemia

• Continue peritoneal or haemodialysis until few hours before surgery

Urinary tract infection• Treat such infection before

high risk elective surgery

• Urgent procedure, antibiotics should be started and ensure patient maintains good urine output

Metabolic disorder

Diabetes • Check HbA1c level

• Preoperative risk-reduction strategies (lipid-lowering agent, diabetic control)

• Minor surgery in non-insulin dependent diabetic – omitting morning dose, listing early surgery, restarting treatment

• Significant surgery in insulin dependent –intravenous insulin infusion require

Adrenocortical suppression

• Occur in patient receiving oral adrenocortical steroids regularly

• Require extra dose of steroids around the time of the surgery – avoid Addisonian crisis

Coagulation disorder

Thrombophilia • Identify the risk factor for thrombosis

Age

Obesity

Trauma or surgery (abdomen, pelvis, lower limb)

Reduced mobility > 3days

Pregnancy

Drugs ; estrogen, HRT

Family history of thrombosis

• Prophylaxis in perioperative period (mechanical/pharmacological)

• HRT should be stopped 6 weeks prior to surgery

Other disorders

Neurologic • H/o stroke, neurological

deficit

• Withdraw antiplatelet agents • Aspirin (7 days)• Clopidogrel (10 days)

• Neuropathies / myopathies –need prolonged ventilation

Psychiatric • Need GA

• Certain medication ( TCA & monoamine MAOi) have unwanted interactions with anaesthetic medication

Locomotor

• Inflammatory arthropathies to be identified

MANAGEMENT PLAN – KEY POINTS

Provide all information necessary for the patient to make an informed decision

Use common language

Discuss the options rather than telling the patient what will be done

Give the patient time to think things over

Encourage to discuss things – trusted person

RISK ASSESSMENT AND CONSENT

• All life- or limb-threatening complications and all complications with an incidence of 1% or > should be discussed with the patient

• Risks: related to comorbidities, anaesthesia, and surgery

• Explain: advantages, side effects, prognosis

• Language: simple, use daily life comparisons to explain risks

• Consents: valid consent is necessary except in life-saving circumstances

• Patient mouth is open and tongue protruding

• Look for loose teeth, scars, infections, thickness of neck, which indicate difficulty in obtaining airways

• Neck movement, thyromental distance and mallampati score

Taking a comprehensive consentLead in Introduce yourself and identify the patient

Explore How much does the patient know

Diagnosis Why the operation is being proposed

Treatment Explain wether the treatment proposed is in accordance to protocols

Options Discuss all the options including that of doing nothing

Results Explain likely outcome (pain, mobility, work, diet, and return to normal activities)

Eventualities For example, the needing to remove the testicle in a hernia operation

Adverse events Myocardial infarction, stroke, embolus, bleeding and specific damage

Sound mind Ask if they have understood

Open question Check if further clarification is needed

Notes Document everything discussed and agreed

(acronym: LED TO REASON)

ARRANGING THE THEATRE LIST

• Date, place, and time of operation should be matched with availability of the personnel.

• Appropriate equipment and instruments should be made available.

• Operating list should be distributed as early as possible to all staff who are involved.

• Prioritized patients.• Children and diabetic patients • Life- and limb- threatening surgery• Cancer patients

REFERENCES

• Bailey and Love’s Short Practice of Surgery, 26th

Edition

THANK YOU