Preoperative preparation!!

Dr.Syed Alam Zeb

Role of Surgeon during preoperative preparations:

Gathering & recording information; Minimizing risk, maximizing

success; Contingency plans for adverse

events; Communications

Steps of P.O.P’s :

History Examinations Investigations Preoperative treatments Communications Informed consent Operating lists On arrival to OT table

Types of patients:

Out-Patient Department

Usually seen 1-2 weeks before surgery at preadmission clinic

Emergency department

Need initial assessment & immediate resuscitation

History:

A- listen to ur patient complains B- clarify his problem by questions C- try to reach to a diagnosis by

confirming & excluding. D- determine the fitness of ur

patient for a surgery physically & psychologically.

Examinations:

General medical examinations Specific surgical examinations Specific medical examinations

General Medical Ex:

To check fitness for anesthesia & surgery.

GPE Systemic: - CVS- CNS- GIT- Respiratory system

Specific Surgical Ex:

Its 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 Medical Ex:

Its aim: to evaluates the presence & severity of other problems.

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

Investigations:

I. Routine Investigation 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

Investigations: II. Targeted Surgical Tests:

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

Creatinine & Electrolytes: state of dehydration & renal insufficiency.

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

Investigations: 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- human chorionic gonadotrophin )

HBsAg, HCV Antibodies & HIV testing.

Communication: Information for the patient : He should be aware of his surgeon,

procedure, stuff & what is going on. Information for stuff : Team work is the main key for success. Recording : All important information should be

recorded clearly in patient notes because it is the reference database.

Preoperative Treatments:

Antibiotics : should be at peak level when surgery starts.

Transfusion : sort anemia well in advance.

Nutrition : improve situation whatever possible.

Thromboprophylaxis : needs for high risk patient only.

Prophylactic Antibiotics: The commonest infective organism is

Staphylococcus aureus. Some surgeon use flucloxacillin , but

most used broad spectrum antibiotics which cover S. aureus, streptococci & anaerobes.

In GIT surgery combination of cephalosporin & metronidazole.

Prophylactic antibiotic best administered just prior to induction.

Anemia & Blood Transfusion:

Preoperative transfusion should be considered if major blood loss is anticipated during surgery or if Hb% < 8 g/dl.

Malnutrition : Malnourished patient is at high risk of

morbidity & mortality following surgery.

Nutritional support is required for a minimum of 2 weeks prior to surgery.

Malabsorption overcome by vitamins & enzymes while obstructive conditions N/G feed, I/V fluids, surgical bypass & formal enterostomy.

Thromboprophylaxis:

Methods of anticoagulation : I. Pharmaceutical : Aspirin is the best choice. II. Mechanical : Foot & calf pumps believed to prevent

stasis. III. Physical : Early mobilization & minimizing length of

stay in hospital reduce stasis & DVT.

Preoperative Tx for special cases:

Diabetes:- If controlled orally: omit morning

dose of oral hypoglycemic- Insulin-dependent: managed on I/V

infusion of dextrose & insulin- Extra K needed

Preoperative Tx for Special cases:

Respiratory disease: - Blood gases & pulmonary function tests

needed to assess severity.- Stop smoking & continue inhalers- Involve physiotherapists & anesthetists.- Avoid respiratory suppressants (narcotics)- Mobilize early- Give O2

Preoperative Tx for special cases:

Hypertension :- BP > 160 systolic or > 95 diastolic their

surgery postpone till controlling of BP.- Plasma Potassium (K) checking is

necessary in Pt. with diuretics. Routine Medication: - Most can be given as usual- Stop aspirin if bleeding is suspected- Discuss ACE inhibitors or unusual drugs

with anesthetists.

Informed Consent:

STAGES OF INFORMED CONSENT:- I. Preparation- II. Explanation- III. Competence- IV. Closure

I. Preparation: A. Introduction: - Ur name- Pt name- Explain what are u doing & by which

authority B. Background:- Check what pt knows- Explore how much he/she actually want

to know.

II. Explanation: A. What is wrong: Explain the diagnosis is

simple language.

B. Action : what is the proposed action? Is it differ from national or other guidelines ? justify

C. Outcome: describe the likely short & long outcome

D. Choices: describe all viable choices, including doing nothing

II. Explanation: E. Complications:- Explain in clear language all serious

complications & those with a risk > 1%- Describe actions that will be taken to

prevent each- Explain how they will managed them if

they do occur F. Right of Refusal:- Make it clear that the final decision is the

patient’s alone- Give the patient time to think about the

decision

III. Competence:

Check the ability of patient to take in, retain & consider the information provided & articulate the decision.

Can be achieved by recording the patient’s answer to the questions “ Tell me what you have understood”.

IV. Closure:

A. Open question : e.g. “ Is there anything else you

would like to discuss?”. B. Record: Record & write every thing was

discussed & what was agreed.

Operating List: Diabetic patients first. Day cases early Major cases before minor “ Dirty” cases last Operating lists final check:- Patients: name, number & location correct- Side written & marked- Radiographs & results available- Blood cross-matched & ready- Consent is taken- Nurses informed of timing- Theatres informed of special needs

On Arrival for Surgery:

The patient:- Confirm identity, notes, problem, tests

result & blood if ordered. The operating theatre & team:- Good communication with stuff- All required instruments is ready- Surgeon not usually the leader

References:

Bailey & Love’s Short Practice of Surgery 24th edition.

Internet websites.