Preoperative Preparations
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Transcript of Preoperative Preparations
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