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Preop preparation
- 2. OUTLINE Introduction History and physical examination Investigations Organ Systemic approach References 8/31/2019Preop care Jemal 2
- 3. Introduction Preop care Jemal 3 The preoperative assessment is a vital part of the care given to patients scheduled for both routine and emergency surgery. The clinical assessment: Standard format of history Physical examination Investigations Main systems under evaluation are CVS and Pulmonary. 8/31/2019
- 4. Thorough History and P.E Preop care Jemal 4 Focus on operative, anaesthetic and patient healing factors. Cardiovascular and Respiratory Fitness Pre-existing Medical Conditions which influence wound healing: Drug therapy and allergies Previous Medical and Surgical/ Anaesthetic History 8/31/2019
- 5. Key points 8/31/2019Preop care Jemal 5 Individualize preop preparation! Don’t rely on the examination of others! Acquire the habit of performing a complete examination in exactly the same sequence. No step is omitted and added, advantage of familiarizing what is normal so that abnormalities can be more recognized. Discuss all the risks and advantages each and every intervention,drugs!
- 6. Preoperative plan 8/31/2019Preop care Jemal 6 Preoperative plan for the best patient outcome • Gather & record all relevant information • Optimize patient conditions • Choose surgery that offers minimal risk & maximum benefit • Anticipate & plan for adverse events • Inform everyone concerned.
- 7. Preoperative Care And Evaluation Preop care Jemal 7 Aims: to identify undiagnosed comorbidity,Undertreated medical problem or exacerbation of underlying comorbidity which may affect operative outcome. Psychological: Patient information, obtaining written consent, allaying fears. Physical: Ensure diagnosis is correct and symptoms have not changed. 8/31/2019
- 8. Cont… 8/31/2019Preop care Jemal 8 The extent of pre-operative preparation will depend on the: Situation( Emergency/Urgency/Elective) Patient & surgical factors (Large anticipated blood loss,DM,Poor exercise tolerance) Nature of surgery(Major/minor) Facilities available( ICU…)
- 9. Relevant Preoperative Tests Preop care Jemal 9 General Tests carried out in most patients: Full Blood Count(ANC) Group, Cross match and Save Chest X Ray and ECG Urinalysis,Urine HCG Urea, Creatinine and Electrolytes 8/31/2019
- 10. Specific Blood Tests: where indicated10 Liver Function Tests in jaundice, malignancy Amylase in acute abdominal pain Blood Glucose in established or suspected Diabetics Clotting Studies in liver disease, or if on anticoagulants Thyroid Function Tests in thyroid disease 8/31/2019Preop care Jemal
- 11. Cont’d 8/31/2019Preop care Jemal 11 Hematologic Parameters Platelets >/= 50,000. . .impose no risk even in major surgeries except in CNS and Cardiac surgeries in which >80,000 Spontaneous bleeding </= 10-20,000 Performed according to requirement CXR ECG- All men>40 ,women>50, all patients with history cardiovascular disease, arrhythmia, DM, HTN Ultrasound CT Scan MRI
- 12. Cont’d 8/31/2019Preop care Jemal 12 Serum electrolyte Na++ = 135-145 mmol/L K+= 3.5-4.5mmol/L Cl- = 98-108mmol/L Ca++= 2.2-2.6mmol/L Mg++=0.62-0.95mmol/L Lactate= 0.5-2.2mmol/L T3=1.5-3.5 nmol/L T4=55-150 nmol/L TSH= 0.3-3.3m mol/L(0.5-5 uU/mL) BP : Systolic </=160 mmhg diastolic </= 110mmhg Blood glucose : 200-250 mg/dl
- 13. Anaesthetic Risk Assessment (ASA Classification Preop care Jemal 13 Class Physical Status ASA1: A normal, healthy patient ASA2: A patient with mild systemic disease ASA3: A patient with severe systemic disease that limits activity but is not life threatening ASA4: A patient with severe systemic disease that is a constant threat to life ASA5: Moribund; Not expected to survive but is submitted to operation in desperation E: Indicates Emergency surgery “ E ” used on addition to the above “ ASA” classification. 8/31/2019
- 14. Pre-operative Preparation (a day before) Preop care Jemal 14 Obtain consent for the procedure. Discuss with patient and the family about the risks, benefits and alternatives. Keep NPO after mid-night for morning surgery. Commence IV hydration with fasting. Optimize patient medically, treat infection and Stabilize diabetes(Earlier). 8/31/2019
- 15. CONT’D Preop care Jemal 15 Preoperative incentive spirometry. Schedule anesthetic evaluation or consultations. Discontinue or maintain medications. Skin preparation/Marking for ostomies. Bowel preparation as necessary. 8/31/2019
- 16. Pre-operative Preparation Preop care Jemal 16 DVT prophylaxis where indicated. Catheterize or insert NG tube as indicated. Arrange intra-operative X/Rays or Frozen section as required. Blood availability. Wound infection prophylaxis. 8/31/2019
- 17. Cardiovascular System CVD is the leading cause of death in developed countries and its perioperative mortality in noncardiac surgery is significant. Signs and symptoms of unstable angina,MI, congestive heart failure, arrhythmia,HTN. Chest pain,heart failure and arrhythmia should be treated before elective surgery. Interval between MI time and surgery less than 6 month is more likely with reinfarction. 8/31/2019Preop care Jemal 17
- 18. CVS… Preop care Jemal 18 Workup should start with history, physical exam, and ECG to determine the existence of cardiac pathology. TE echocardiography is the best modality for diagnosing cause of cardiac murmur. According to AHA/ACC,initial preoperative risk can be assessed by clinical calculator RCRI. Overall functional ability is the best clinical measure of cardiac fitness. 8/31/2019
- 19. Revised cardiac Risk Index(RCRI) Components,Hx of: o IHD o CHF o CVD(Stroke or TIA ) o DM requiring insulin use o CKD(Cr > 2mg/dl) o Planned high risk procedure Advanced testing needed if ≥2 of these risks present. 8/31/2019Preop care Jemal 19
- 21. The Goldman’s index Preop care Jemal 21 Risk factor Score Third heart sound / gallop rhythm 11 MI within 6 months 10 >5 Ventricular ectopics per min 7 Rhythm other than sinus 7 Age > 70 years 5 Emergency surgery 4 Aortic stenosis 3 Abdominal or thoracic operation 3 Poor general condition 3 8/31/2019 Cardiac Complication 0-5 pts= 1% 6-12 pts= 7% 13-25 pts=14% >26 pts= 78%
- 22. Hypertension and Surgery Preop care Jemal 22 Patients with a history of hypertension, even medically controlled hypertension, are more likely to be hypertensive preoperatively. Pre-existing hypertension is the most common medical reason for postponing surgery. Poorly controlled hypertension is indicated by diastolic blood pressure > 110 or systolic pressure > 160. 8/31/2019
- 23. Cont… Preop care Jemal 23 Severe untreated hypertension may lead to serious complications myocardial infarction left ventricular failure cerebral hemorrhage hypertensive encephalopathy renal failure. develop marked swings in blood pressure cardiac dysrhythmias and ischemia bleed more during surgery 8/31/2019
- 24. Emergency Surgery Preop care Jemal 24 Efforts should be made to control the blood pressure before induction. Treat pain and anxiety with appropriate medication. Acute use of anti-hypertensive drugs can cause unexpected hypotension which may result in stroke, blindness and myocardial ischemia. Note that a moderately low blood pressure in a normal patient (eg 90-100 systolic) may reflect more serious hypotension in the hypertensive. 8/31/2019
- 25. Elective surgery Preop care Jemal 25 The blood pressure should be assessed well before operation. Examine for cardiac, renal or neurological complications. Electrolytes estimation, ECG and a chest X-ray are useful to help assess cardiac and renal function. Patients with significant hypertension (diastolic pressures >110mmHg) should not undergo elective surgery until their hypertension has been adequately controlled. 8/31/2019
- 26. Cont… Preop care Jemal 26 Patients with well-controlled hypertension should normally continue their medication up to, and including, the day of surgery. Premedication with benzodiazepines (eg diazepam 10- 20mg, temazepam 20-30mg, or lorazepam 2-4mg) two hours prior to surgery will help to allay anxiety. Atropine should be avoided if possible, because of its tendency to cause tachycardia 8/31/2019
- 27. Ischemic Heart Disease (including recent MI) 8/31/2019Preop care Jemal 27 Postoperative MI is associated with hospital mortality rates of 15% to 25%. Recent MI is a strong contraindication to elective anaesthesia. Rx - BETA-BLOCKER THERAPY -NITRATES -ASPIRIN - ACE inhibitor General recommendation wait for 4-6 wks after acute MI?
- 28. Congestive Heart Failure and Arrythmias CHF is A definite risk factor for perioperative cardiac morbidity/mortality. RX-Diuretics,ACEI,B-blockers New and fast atrial fibrillation must be controlled before surgery. RX-Regular Serum K+ measurement -Rate control(B-blockers,CCB,Digoxin). -Rhythm control(amiodarone). 8/31/2019Preop care Jemal 28
- 29. The Respiratory System Preop care Jemal 29 Postoperative pulmonary complications are common and contribute considerably to overall morbidity and mortality. The presence of a productive cough is associated with an increase in postoperative chest complications. Recent onset warrants postponement of surgery and the commencement of appropriate treatment with antibiotics and chest physiotherapy. 8/31/2019
- 30. Respiratory Cont’d Preop care Jemal 30 If the patient has a chronic productive cough, then elective surgery should be postponed only if the patient has additional signs suggesting an infection. Postpone elective surgeries in URTI The functional ability questions: "how far can you walk before you get short of breath”? "what activities make you short of breath”? 8/31/2019
- 31. The Risk factors for Pulmonary Complications Known pulmonary disease Abnormal pulmonary function tests (FEV1/FVC < 60%) Current Smoking Age > 60 years CHF,Serum albumin<3mg/dl Serum Cr >1.5mg/dl Impaired sensorium,sepsis Pneumonia Obstructive sleep apnea Upper abdominal and thoracic surgery Long operation time(>3 hrs General anesthesia Emergency operation 8/31/2019Preop care Jemal 31
- 32. Preoperative steps Preop care Jemal 32 Usual history CXR if over age of 40 years. Preoperative Spirometry and arterial blood gases if necessary. FEV1 and FVC ABG Decrease or stop smoking and increase or optimize bronchodilator therapy. 8/31/2019
- 33. Ways to Decrease Complications Preop care Jemal 33 Education of lung expansion maneuver and deep breath exercise(incentive spirometry) Postural drainage Humidified oxygen Cessation of smoking Bronchodilator therapy Antibiotics when necessary 8/31/2019
- 34. Cont’d 8/31/2019Preop care Jemal 34 COPD/Asthma 1.Bronchodilator therapy 2.Inhaled steroids should be continued Oral/IV steroid therapy for either prophylaxis or active COPD/Asthma 3.Oral theophylline therapy if the patient uses it chronically. 4.Anibiotics
- 35. Respiratory cont’d 8/31/2019Preop care Jemal 35 INFECTIONS-should be treated appropriately. SMOKING Counsel patient to stop smoking 4 to 8 weeks before surgery Smoking cessation 24 hr: decrease carboxyhemoglobin 2-3 day: increase ciliary function but increase secretion 1-2 wk: decrease secretion 4-8 wks: decrease postop pulmonary complication.
- 36. Gastrointestinal Tract 8/31/2019Preop care Jemal 36 Regurgitation/Aspiration risk; NPO for 08 hrs after solid meals,06 hrs for light meals,02 hrs for clear fluids before surgery. Children-solid diet(08hrs),infant formula(06hrs),breast milk(04hrs),clear liquid(02hrs). Special group-pregnant,elderly,obese,stomach disorders. Routine use of antisecretory medications in elective surgery is under question currently. Bowel preparation(mechanical,antibiotics)
- 37. GIT cont’d… 8/31/2019Preop care Jemal 37 Bowel preparation Aim is to minimizes the titers of GI microbiota and facilitates bowel manipulation by reducing stool bulk. Contradictory but better to continue until well studied in our country. Mechanical preparation Antibiotics adminstration
- 38. Hepato-Biliary 8/31/2019Preop care Jemal 38 Evidences of Hepatic dysfunction(Hx,PE,Ix) Preoperative preparation of jaundeiced Vitamin K 10mg IM for 5 days FFP(>6),Adequate hydration,Transfuse if anemic,Enteral nutritional supplementation. Mannitol 100-200ml IV BID(For HRS prevention) Ceftriaxone Oral neomycin,lactulose Umblical/inguinal hernia,cholecystitis
- 40. Renal System Preop care Jemal 40 Renal dysfunction-in 5% of general population serum urea, creatinine >2 mg/dl Electrolyte abnormality-hyperkalemia,hypocalcemia,. Timing of dialysis-within 24 hrs of elective surgery. Chronic anemia-Rx by EPO or Carbepoitin Medications : Gentamicin, Meperidine, NSAIDS Maintain euvolemia and avoid nephrotoxic agents. 8/31/2019
- 41. Diabetes and Surgery41 An estimated that nearly 50% of individuals with diabetes undergo surgery in their lifetime. Evaluation for surgery aims at: Adequacy of glycemic control(FBS-<140,RBS-<180mg/dl) Identification of complications which affect perioperative patient care. Preoperative assessment of the diabetic pt. -Hx -P/E -Ix-RFT,ECG,U/A,FBS/RBS,Hg A1c 8/31/2019Preop care Jemal
- 42. Cont… 8/31/2019Preop care Jemal 42 TYPE-II DM 1)On oral hypoglycemics PRE-OP : hold all oral agents starting from morning dose. INTRA-OP : 5% dextrose infusion(75-125cc/hr) is used with short-acting insulin. POST-OP : Regular insulin q6 hrs until taking PO's then resume OGA
- 43. Cont… 8/31/2019Preop care Jemal 43 2) On Insulin Preop-NPH and long-acting insulin administered at 2/3 of pm dose the night before surgery &1/2 of am dose the morning of surgery. Intra-op-5% dextrose infusion is used with short-acting insulin. Post-op standing dose of regular insulin q6 hrs additional correctional dose regular insulin q6 hrs until oral taking po.
- 44. Cont’d 8/31/2019Preop care Jemal 44 Type-I DM Preop: ½ of total morning insulin dose to be given only as NPH on the morning of surgery. Intraop : 5% dextrose infusion is used with short-acting insulin. Postop: standing dose of regular insulin q6 hrs additional regular insulin q6 hrs until sliding scale.
- 45. Thyroid Disorders 8/31/2019Preop care Jemal 45 HYPERTHYROIDISM To decrease Perioperative thyroid storm. Rx 1) Beta-blockers(long acting) 2) Anti-thyroid agents-PTU or methimazole(preferred) 3) Iodide-start 10 days before surgery. 4) Fluid management and arrythmias CONTINUE MORNING DOSE **** HYPOTHYROIDISM Rx: 1) Thyroid replacement: thyroxine (Very low level or free) 2) steroids: Hydrocortisone
- 46. Adrenocortical Problems 8/31/2019Preop care Jemal 46 Patients who have taken more than 5 mg of prednisone (or equivalent) per day for more than 3 weeks within the past year are considered at risk when undergoing major surgery. Rx: Stress dose steroids o Hydrocortisone 100mg IV at/prior to surgery followed by 100mg IV q8 hours postop continued at least for 24hrs then taper the dose and discontinue. o For minor surgery single dose of hydrocortisone 50 to 100mg IV at / prior to surgery will suffice.
- 48. Immune System Preop care Jemal 48 Hx &P.E-on chemotherapy,drugs,any focus of infection… Ix-CBC(with differentials),OFT,CXR, Drugs: steroids, immune suppressing (transplant) AIDS-HAART don’t affect wound healing or increase infection rates. 8/31/2019
- 49. Coagulation Disorders 8/31/2019Preop care Jemal 49 Asses risks of bleeding and risks of thrombosis. Management of factor deficiencies(known factor Dos). Warfarin****STOP 4-5 DAYS BEFORE SURGERY Target INR should be <1.5
- 51. Anemia & Transfusion 8/31/2019Preop care Jemal 51 Consider transfusion if hemoglobin is less than 8g/ dl.
- 52. Acutely bleeding and transfusion 8/31/2019Preop care Jemal 52
- 53. Nutrition 8/31/2019Preop care Jemal 53 Malnutrition: • BMI <18Kg/m2,Serum albumin<3mg/dl,rRecent significant wt loss Treatment with nutritional support for minimum of 2 weeks before surgery. Obesity: for patient BMI >30kg/m2 , are at risk for: DVT & PE, Difficulty intubating, Aspiration, Wound infection, Dehiscence and poor wound healing, Pressure sores, Mechanical difficulty, MI & Cerebrovascular accident
- 55. Others 8/31/2019Preop care Jemal 55 Prophylactic Antibiotics Potential causes of intraoperative instablity Herbal medicines Postop depression and delirium Alcohol and substance abuse
- 56. References 1.Sabiston textbook of surgery 20th edition 2.Maingot abdominal operations 13 th edition 3.Uptodate 21.6 4.Internet 8/31/2019Preop care Jemal 56
Hinweis der Redaktion
- y to understand the patient’s risk and to optimize the outcome. These components of risk assessment take into account the perioperative (intraoperative period through 48 hours postoperatively) and later postoperative (up to 30 days) period and seek to identify factors that may contribute to patient morbidity during these periods. The main systems under evaluation are the respiratory and cardiovascular systems.
- Relevant advice: Lose weight, stop smoking, reduce alcohol
- ). Ideally, the preoperative evaluation should be individualized on the basis of age, history, physical examination findings, and the surgical procedure to be performed.
- The aim of preoperative evaluation is not to screen broadly for undiagnosed disease but the goal of presurgical testing is to identify an undiagnosed comorbidity, an undertreated medical problem, or a significant exacerbation of existing comorbid illness that may affect the operative outcome(is to avoid surgery is successful,but the patient died!) Aim=Psychological and Physical preparation of the patient for surgery.
- Eg1 pt with perf PUD or bowel perforation(no time for bowel preparation but insert NGT,Cimetidine,suck out gastric secretion by suction,start abcs right away,insert drainage for gross spillage but colonic malignancies Eg U can’t do majority of neurosurgical procedures in ARTH despite having qualified physician.
- Any woman of childbearing age, unless the ovaries or uterus have been previously surgically removed, must undergo a urine pregnancy test on the morning of surgery,preferably on the morning before surgery. hemoglobin, renal function tests, and albumin, which are indicated for all geriatric surgical patients. WBC ANC= Total WBC * functional neutrophil % ANC >/= 1000. . .associated with no risk of infection < 1000 . . . Risk increases < 500 . . . Marked increase of risk, GCSF is recommended 500-1000 . . .GCSF is recommended for procedures of non sterile sites (bowel. . ) Don’t screen all 1.costy n unnecessary as 60% of positive results are disregarded 2.Unneccessary tension by unhiding dses which don’t alter surgery
- ECG-some group say not predictive,while others find it very useful. Screening with chest radiographs and ECG is required for men over 40 and women over 55.
- Ser El done in pts with loss,CKD,Prolonged starvation, RBS <=180 mg /dl
- Catheterize or NGT insertion in emergency usually.
- A retrospective study in gynecologic patients found that hypertension and previous MI were major predictors of postoperative cardiac events, as opposed to the ACC/AHA guidelines, which indicate that they are minor and intermediate criteria, respectively General recommendations are to wait 4 to 6 weeks after MI to perform elective surgery. Any patient can be evaluated as a surgical candidate after an acute MI (within 7 days of evaluation) or a recent MI (within 7-30 days of evaluation). The infarction event is considered a major clinical predictor in the context of ongoing risk for ischemia Perioperative risk for cardiovascular morbidity and mortality was decreased by 67% and 55%, respectively, in ACC/AHA-defined medium- to high-risk patients receiving β-blockers in the perioperative period versus those receiving placebo. Obtain historical information concerning previous MI, angina, cardiac medications and arrhythmias. Examine patient to assess the rate and rhythm of the pulse, origin of any murmur, crackles, peripheral edema, or CHF. The most accurate method of diagnosing the cause of a cardiac murmur is Echocardiography
- RCRI-Revised cardiac risk index In general all diastolic murmurs and loud systolic murmurs which are accompanied by a thrill are abnormal and indicate underlying structural heart disease. Screening with chest radiographs and ECG is required for men over 40 and women over 55 Patients who can exercise without limitations can generally tolerate the stress of major surgery.35 Limited exercise capacity may indicate poor cardiopulmonary reserve and the inability to withstand the stress of surgery. Poor functional status is the inability to perform activities such as driving, cooking, or walking less than 5 km/h. Exercise testing demonstrates a propensity for ischemia and arrhythmias under conditions that increase myocardial oxygen consumption. Numerous studies have shown that performance during exercise testing is predictive of perioperative mortality in noncardiac surgery. ST-segment changes during exercise including horizontal depression greater than 2 mm, changes with low workload, and persistent changes after 5 minutes of exercise are seen in severe multivessel disease. Other findings include dysrhythmias at a low heart rate, an inability to raise the heart rate to 70% of predicted, and sustained decrease in systolic pressure during exercise
- High risk procedure-Undergoing suprainguinal vascular, intraperitoneal, or intrathoracic surgery Exercise tolerance Walk at 6 km/hr, run short distance, heavy work around house, golf, bowling, dancing
- Out of 53 Previously it is no 1 to predict but currently funtional status then followed by RCRI
- Why---Anxiety, Twenty-five percent of patients will exhibit hypertension during laryngoscopy. Sympathetic activation during the induction of anesthesia can cause the blood pressure to rise by 20 to 30 mmHg and the heart rate to increase by 15 to 20 beats per minute in normotensive individuals [ 5 ]. These responses may be more pronounced in patients with untreated hypertension in whom the systolic blood pressure can increase by 90 mmHg and heart rate by 40 beats per minute. Patients with chronic hypertension may not necessarily benefit from lower blood pressure during the preoperative period because they may depend on higher pressures for cerebral perfusion. Those receiving antihypertensive medications should continue them up until the time of surgery. Patients taking β-blockers are at risk of withdrawal and rebound ischemia. Prior to elective surgery blood pressure should be controlled to near 160/100 mmHg. If a new antihypertensive agent is introduced, a stabilisation period of at least 2 weeks should be allowed. Continue medication until day of surgery. ACEI and diuretic may be discontinued In DM patients keep the DBP < 90mmHg.
- Hydralazine,nifedipine P.O,Nitrogycemics nitropurusside,metoprolol Pethidine n diazepam
- general we recommend continuing ACE inhibitors or ARBs in patients who are taking them for the management of hypertension or heart failure.
- eta blocker therapy should not be started on the day of surgery. In patients in whom beta blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers far enough in advance to assess safety and tolerability, preferably 2 to 7 days before surgery. Perioperative morbidity may be decreased with beta blocker Continue medication except anticoagulant or antifibrinolytic: aspirin,warfarin,ticlopidine etc. Digitalis : discontinue except in severe arrhythmia Angiotensin-converting enzyme (ACE) inhibitors and receptor blockers are often omitted 24 hours prior to surgery and reintroduced gradually in the postoperative period.
- Diuretics miss morning dose,cont after liberal fluid intake started postop ACEI/ARB-Dc 24 hrs before surgery,Start postop Digoxin dc except in severe arrythmia New and fast atrial fibrillation must be controlled before surgery. The intervention necessary depends on the physiological state of the patient and the urgency of the surgery required. Regular measurement of serum potassium. Rate-control(beta-blockers, calcium-channel blockers, or digoxin). Rhythm control (amiodarone). If prosthetic valve is functioning well and LV function is preserved then, -Antibiotics -Anticoagulation In patients with atrial fibrillation, β-blockers, digoxin or calcium channel blockers should be started preoperatively (or continued if the patient is already on such medication) in order to control rate and possibly rhythm. Cardiac output can increase by 15% if sinus rhythm is restored in general we recommend diuretics be held on the morning of surgery, and resumed when the patient is taking oral fluids.
- Pulm Complications can prolong hospital stay by 1-2 weeks. It is prudent to consider assessment of pulmonary function for all lung resection cases, for thoracic procedures requiring singlelung ventilation, and for major abdominal and thoracic cases in patients who are older than 60 years, have significant underlying medical disease, smoke, or have overt pulmonary symptoms Symptoms like cough, shortness of breath and hemoptysis, purulent sputum and the presence of wheeze may also indicate underlying lung disease.
- Restrictive pulmonary disease fare better than those with obstructive pulmonary disease because the former group maintains an adequate maximal expiratory flow rate, which allows for a more effective cough with less sputum production Smoking should be current,preop sputum production Not Risk Factors Obesity Well-controlled asthma Diabetes Unitentional wt loss>10-15% over the past 6 months Patients with an FEV1 of less than 0.8 L/sec or 30% of predicted are at high risk for complications Upper and transverse incision got bhigh risk of complication
- It has been shown that smokers have a fourfold increased risk for postoperative pulmonary morbidity and as high as a 10-fold higher mortality rate.
- POSTOP PULM Cxs Adult respiratory distress syndrome Pulmonary edema Fat embolism Atelectasis Pneumonia Aspiration A reasonable recommendation would be to encourage patients to walk 3(5 km) miles in less than 1 hour several times weekly. Incentive spirometry and pulmonary toilet are pulmonary expansion maneuvers, which reduce the relative risk of pulmonary complications by 50%.
- In many asthmatic patients, treatment with systemic corticosteroids and bronchodilators is indicated to prevent the inflammation and bronchoconstriction associated with endotracheal intubation. In emergency surgery give Iv hydrocosrtisone n cont Elective-Asthmatic pts should hv their personal best or FEV1 >80%,Acute exacerbation of COPD should be Rxed n surgery should be postponed.
- Smoking n pulm Cxs-sudden cessation exacerbate Smoking Vs SSI-dec with sudden cessation as well. T1/2 of nicotine(1hr),carboxyhemoglobin(4hrs). Patients with active pulmonary infections should have surgery delayed if possible Initial choice of antibiotic will depend on whether the infection was acquired at home or from hospital, and on the severity of the infection. NPO 6-8 hr. before surgery Clear liquid diet for 2 hr. Children Clear liquid 2 hr Breast milk 4 hr Infant formula 6 hr solid diet 8 hr. Guideline used for patient with no proble with gastric emptying time
- The standard order of “NPO past midnight” for preoperative patients is based on the theory of reduction of volume and acidity of the stomach contents during surgery. The most critical factor in the development of erosive ulceration now appears to be mucosal ischemia. Once the rich blood supply of the mucosa is compromised, the protective mechanisms are impaired, and gastric acid causes erosion, bleeding, and perforation. In addition, the routine use of antisecretory medication, in particular in the elective setting, may lead to increased risk of pneumonia and pseudomembranous colitis. elines have been established by the ASA for preoperative fasting. Recommendations are 8 hours or more fasting after intake of fried or fatty foods or meat and 6 hours or more fasting after ingestion of a light meal, nonhuman milk, or infant formula. The ASA recommends fasting at least 2 hours from clear liquid intake, including medicines NPO 6-8 hr. before surgery Clear liquid diet for 2 hr. Children Clear liquid 2 hr Breast milk 4 hr Infant formula 6 hr solid diet 8 hr. Guideline used for patient with no proble with gastric emptying time. Although not reported in all the trials, there appeared to be no increased risk for aspiration or regurgitation with a shortened period of fasting. Very few trials have investigated the fasting routine in patients at higher risk for regurgitation or aspiration (pregnant patients, older patients, obese patients, or patients with stomach disorders).
- OJ-Check serum albumin,PT,LFT(ALT,AST,Serum bilirubin sepecially direct) Why malnutrition-impaired prot synthesis,dec glycogen store,poor intake. Hx-of blood product exposure,easy fatiguablity,jaundice, P.E--- Ix-Viral markers,LFT,Child pugh classification In the event of an emergency situation requiring surgery, such an investigation may be impossible. A patient with acute hepatitis and elevated transaminase levels is managed nonoperatively, when feasible, until several weeks after normalization of laboratory values. Urgent or emergency procedures in these patients are associated with increased morbidity and mortality. A patient with evidence of chronic hepatitis may often safely undergo surgery. Child’s Pugh criteria (INR, bilirubin, albumin, ascites, encephalopathy). A: low-10% B: moderate-31% C: high (Less than 1 yr survival)-76% Data generated more than 25 years ago showed that patients with Child class A, B, and C cirrhosis had mortality rates of 10%, 31%, and 76% during abdominal operations; Two common problems requiring surgical evaluation in a cirrhotic patient are hernia (umbilical and groin) and cholecystitis. Patients with cirrhosis and ascites have a 20% risk of developing an umbilical hernia. Hence U.Hernia can repaired in pts A n B,but C Cholecystitis…done in all Emergency in CP C???
- Refractory ascites did not increase operative risk and recurrence rate.
- Approximately 5% of the adult population has some degree of renal dysfunction that can affect the physiology of multiple organ systems and cause additional morbidity in the perioperative period. A preoperative creatinine level of 2.0 mg/dL or greater is an independent risk factor for cardiac complications Urinalysis and urinary electrolyte studies are not often helpful in the setting of established renal insufficiency, although they may be diagnostic in patients with newonset renal dysfunction. Anemia-usually mil n asxtic,but if sxtic Rx with EPO PLT no usually normal but may have plt dysfunction hence communicate El abnormality Rx hyperkalemia,hypocalcemia,hyperphosphatemiaPharmacologic manipulation of hyperkalemia, replacement of calcium for symptomatic hypocalcemia, and use of phosphatebinding antacids for hyperphosphatemia are often required. Sodium bicarbonate is used in the setting of metabolic acidosis not caused by hypoperfusion when serum bicarbonate levels are less than 15 mEq/liter. It can be administered in intravenous fluid as 1 to 2 ampules in 1 liter of a 5% dextrose solution. Hyponatremia is treated by volume Patients with chronic endstage renal disease undergo dialysis before surgery to optimize their volume status and control the potassium level. Intraoperative hyperkalemia can result from surgical manipulation of tissue or transfusion of blood. These patients often undergo dialysis on the day after surgery as well. In the acute setting, patients who have a stable volume status can undergo surgery without preoperative dialysis, provided that no other indication exists for emergency dialysis.1
- Hyperglycemia is a risk factor for postoperative infection and perioperative mortality. Our current recommendation for glucose control in noncardiac surgery patients is to maintain blood glucose less than 180 mg/dL The patient’s history and physical examination document evidence of diabetic complications including cardiac disease; circulatory abnormalities; and the presence of retinopathy, neuropathy, or nephropathy. Preoperative testing may include fasting and postprandial glucose and hemoglobin A1c levels. Serum electrolyte, blood urea nitrogen, and creatinine levels are determined to identify metabolic disturbances and renal involvemen Ix-CBC,U/A,RFT,ECG,Ophthalmometery
- Balance Hyperglycemia(ketosis,HHS) Vs Hypoglycemia 1Type 2 diabetes treated with diet alone — Generally, patients with type 2 diabetes managed by diet alone do not require any therapy perioperatively. Supplemental short-acting insulin (eg, regular, lispro, aspart or glulisine) may be given as a subcutaneous sliding scale in patients whose glucose levels rise over the desired target. Patients who take oral hypoglycemic agents (sulfonylureas, such as chlorpropamide and glyburide) typically withhold their normal dose the day of surgery. Patients can resume their oral agent when diet is resumed. An exception is metformin. If the patient has altered renal function, this agent needs to be discontinued until renal function normalizes or stabilizes to avoid potential lactic acidosis.1 Coverage for hyperglycemia is with a shortacting insulin preparation based on blood glucose monitoring. Omit any short-acting insulin on the morning of surgery. For patients who take insulin only in the morning, give between one-half to two-thirds of their usual total morning insulin dose (both intermediate and short-acting insulin) as intermediate or long-acting insulin to provide basal insulin during the procedure and prevent ketosis. For patients who take insulin two or more times per day, give between one-third to one-half of the total morning dose (both intermediate and short-acting insulin) as intermediate acting insulin only. Patients on continuous insulin infusion may continue with their usual basal infusion rate. Start dextrose containing intravenous solution (either dextrose with water or one-half isotonic saline) at a rate of 75 to 125 cc/hour to provide 3.75 to 6.25 g glucose/hour to avoid the metabolic changes of starvation
- Rapid acting and short acting insulin preparations are usually withheld when the patient stops oral intake and are used for acute management of hyperglycemia during the NPO period. Intermediateacting and longacting insulin preparations are administered at two thirds the normal evening dose the night before surgery and half the normal morning dose the day of surgery, with frequent bedside glucose determinations and treatment with shortacting insulin as needed. An infusion of 5% dextrose is initiated the morning of surgery. On the day of surgery, the patient continues with the basal insulin infusion. The pump is used to correct the glucose level as it is measured. P
- TYPE OF INSULIN ONSET OF ACTION PEAK EFFECT DURATION OF ACTION Rapid-acting (lispro, NovoLog, Apidra) 10-30 min 30-90 min 3-4 hr Short-acting (regular, Humulin, Novolin) 30-60 min 2-5 hr 6-10 hr Intermediate-acting (NPH, Lente) 1-4 hr 4-12 hr 12-24 hr Long-acting (glargine [Lantus]) 1-2 hr 3-20 hr 24-30 hr
- There are no published studies evaluating the risks of nonthyroid surgery in hyperthyroid patients. Despite the relatively high prevalence of thyroid disease in the general population, we believe there is no need to screen for thyroid disease during the preoperative medical consultation. While thionamides alone are sufficient to achieve euthyroidism in approximately three to eight weeks, we suggest adding iodine ( potassium iodidesolution, SSKI, one to five drops three times daily) at least one hour after thionamides are administered, if hyperthyroidism is severe and the need for surgery is urgent. Iodine blocks release of T4 and T3 from the gland and thereby shortens the time to achieving a euthyroid state. This effect, however, may be transient, and the use of iodine to block release of hormone beyond 10 days is not generally recommended; it can be started 10 days preoperatively for urgent procedures that are scheduled more than 10 days in the future, but which cannot be delayed until the patient is chemically euthyroid following a thionamide. Very Low level <1 mic gm/dl,free < 0.5 ng/dl(thyroxine) Long acting –atenolol 25-50mg po one hr before surgery.
- Chronic glucocorticoid therapy can suppress the hypothalamic-pituitary-adrenal (HPA) axis and, during times of stress such as surgery, the adrenal glands may not respond appropriately. In addition to suppression of the hypothalamic-pituitary-adrenal (HPA) axis, chronic glucocorticoid therapy may cause a number of other problems in the perioperative period: Impaired wound healing [ 16 ] Increased friability of skin, superficial blood vessels, and other tissues (eg, mild pressure may cause hematoma or skin ulceration, removing adhesive tape may tear the skin, and sutures may tear the gut wall) Increased risk of fracture, infections, gastrointestinal hemorrhage, or ulcer [ 17,18 ] One important reason to avoid supraphysiologic administration of glucocorticoids perioperatively, unless absolutely necessary, is that they have acute side effects that can influence surgical outcomes [ 7,19 ]. These include: Hyperglycemia Hypertension Fluid retention Increased risk of infection. In general, the duration of use and dosing of glucocorticoids should identify appropriate management: Patients who have taken glucocorticoids for less than three weeks, or who have taken chronic alternate day therapy, are unlikely to have a suppressed hypothalamic-pituitary-adrenal (HPA) axis and should continue usual doses of glucocorticoids perioperatively. Patients taking prednisone at a dose greater than 20 mg/day for three weeks or more, and patients with a Cushingoid appearance should be assumed to have HPA axis suppression and may need an increased dose of corticosteroids perioperatively. Patients who have been taking glucocorticoids in a dose equivalent to prednisone 5 to 20 mg daily for more than three weeks may have HPA axis suppression, and either should undergo testing or receive empiric glucocorticoid coverage. Prednisone doses of less than 5 mg/day given in the morning do not suppress the HPA axis. The equivalent morning doses of other glucocorticoids (eg, 4 mg/day of methylprednisolone , 0.5 mg/day of dexamethasone , or 20 mg/day of hydrocortisone ) will have a similar effect ( table 1 )
- A lowdose (1 µg) adrenocorticotropic hormone stimulation test may demonstrate abnormal response to adrenal stimulation and suggest the need for perioperative steroid supplementation. Minor operations such as hernia repair nder local anesthesia may not require any additional steroid. Moderate operations such as open cholecystectomy or lower extremity revascularization require 50 mg bolus and 75 mg/day of hydrocortisone equivalent for 1 or 2 days. Major operations such as colectomy or cardiac surgery are covered with 100 mg bolus and 150 mg/day of hydrocortisone equivalent for 2 to 3 days. Inadequacy of the hypothalamicpituitaryadrenal axis in the perioperative period can lead to unexplained hypotension.
- atient or is the result of advanced disease in a patient with AIDS. The goal is to optimize immunologic function before surgery and to minimize the risk for infection and wound breakdown. Discontinue steroids within 3 days of surgery
- For patients on long-term anticoagulation therapy, the INR should be 1.5 or lower before elective surgery. After warfarin is discontinued, it takes about 4 days for an INR in the range of 2.0 to 3.0 to spontaneously reach 1.5, and about 3 days for the INR to reach 2.0 after it is restarted. This bridging may be achieved by therapeutic dose lowmolecularweight heparin (LMWH) or perioperative intravenous heparinization. For patients taking LMWH, it is recommended to give the last dose 24 hours before surgery and restart approximately 48 to 72 hours postoperatively. For patients requiring systemic heparinization, it should be stopped within 6 hours of surgery and restarted within 12 to 24 hours postoperatively Aspirin continuation may still be reasonable in patients with highrisk coronary artery disease or cerebrovascular disease, in which the risks of potential cardiovascular events outweigh the risks of perioperative bleeding. For patients taking a vitamin K antagonist (VKA) (e.g., warfarin), it takes several days to reduce the anticoagulant effect and then to reestablish it postoperatively. The newer targetspecific oral anticoagulants (e.g., direct thrombin inhibitor dabigatran and factor Xa inhibitors rivaroxaban, edoxaban, apixaban) have shorter halflives and are easier to discontinue and resume rapidly preoperatively. However, they lack a specific antidote or reversal strateg
- The decision to cont or discontinue aspirin depends on clinical conditions 1.Continue in pts with maintenance Rx of Coronary stents,Recent CABG,Pheripheral artery surgery 2.discontinue(7-10 days before intracranial surgeries, intracranial, middle ear, posterior chamber of the eye, and intramedullary spine surgery9devastating effect of bleeding),prostate(urokinase0,local fibrinolysis. Warfarin in patients with atrial fibrillation (AF) should be stopped 5 days preoperatively to achieve an international normalised ratio (INR) of 1.5 or less, which is safe for most surgery. The newer anticoagulants such as dabigatran (direct thrombin inhibitor) or rivaroxaban, apixaban and edoxaban (direct factor Xa inhibitors) do not have antagonists and must be stopped preoperatively, generally for 2–3 days in patients with normal renal function and longer when renal function is impaired. Alternative anticoagulation is not required in the perioperative period unless the risk of stroke is high (high CHA2DS2- VACs score). Bridging therapy with unfractionated heparin or low molecular weight heparin (LMWH) is recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin. Decisions on bridging therapy should balance the risks of stroke and bleeding. latelet agents or anticoagulants. If it is felt that the neurological and cardiovascular thrombotic risks are low, antiplatelet agents should be withdrawn (7 days for aspirin, 10 days for clopidogrel). If the thrombotic risks are perceived to be high and the patient is undergoing surgery with a high risk of bleeding, aspirin alone should be continued. In general, oral contraceptives should be discontinued four to six weeks prior to surgery in patients with increased risk. Other forms of contraception must be used to prevent unwanted pregnancy during
- Hematologic assessment may lead to the identification of disorders such as anemia, inherited or acquired coagulopathy, or a hypercoagulable state. Substantial morbidity may result from failure to identify these abnormalities preoperatively. The need for perioperative prophylaxis for VTE must be carefully reviewed in every surgical patient. Anemia is the most common laboratory abnormality encountered in preoperative patients. In general, transfusion is not indicated in a hemodynamically stable patient with hemoglobin greater than 10 g/dL and no signs of active bleeding. However, the lower threshold for transfusion varies from 6 g/dL to 8 g/dL. A platelet count of 20,000 or greater is usually adequate for normal clotting. Aspirin causes irreversible impairment of platelet aggregation and is commonly prescribed in patients at risk of cardiovascular and cerebrovascular disease. The clinical effect of aspirin lasts 10 days, and it is for this reason that patients are asked to stop taking aspirin 1 week before elective surgery
- BMI less than 18.5 kg/m2, serum albumin less than 3 g/dL, and unintentional weight loss greater than 10% to 15% over a 6month period are significant findings. Albumin (longest halflife, 18 to 20 days), transferrin (intermediate halflife, 8 to 9 days), and prealbumin (transthyretin; shortest halflife, 2 to 3 days) levels can be determined on a regular basis in hospitalized patients. Low serum albumin (<2.2 g/dL) is a marker of a negative catabolic state and is a predictor of poor outco
- Potential causes of intraoperative instability-MI,PE,PNEUMOTHORAX,latex Allergy n anaphylaxis,malignant hyperthermia It is recommended that patients with alcohol use disorder receive perioperative daily multivitamins (with folic acid) and highdose oral or parenteral thiamine (100 mg). Generally, the use of herbal medications is stopped preoperatively, but this needs to be done with caution in patients who report the use of valerian, which may be associated with a benzodiazepinelike withdrawal syndrome. NSAIDs stopped 1-3 days before OR.