...

1. Dr. Belal Mansoor
Al-thowra Hospital
Medical faculty ,Taiz University
Taiz , Yemen
12/4/2018

2. OverviewOverview

4. The aim of preoperative evaluation
 The aim of preoperative evaluation is
not to screen broadly for
undiagnosed disease
but
to identify and quantify any
comorbidity that may affect the
operative outcome.

5. The purpose of preoperative evaluation is not to give :
medical clearance but rather to:
To perform an evaluation of the patient’s current medical
status.
To make recommendations concerning the evaluation,
management, and risk of (cardiac) problems over the entire
perioperative period.
.
Purpose of the preoperative medical evaluation

6. PREOPERATIVE
EVALUATION AND
MANAGEMENT

7. Preoperative management
 preoperative evaluation:
1) History and physical examination
2) Surgical Risk Factors
3) Preoperative investigations:
4) Perioperative Management of medications
 preoperative preparation.
1) General preoperative preparation.
2) Special preoperative preparation
 Depending on the type of the operation
 depending on the (organ) system

8. Steps to preoperative Evaluation
1
Surgical Risk Factors2
3
Perioperative Management
of medications4
History and physical examination.
Preoperative Testing

9. History and physical examination.
 Key elements of the history should include
preexisting medical conditions known to
increase operative risk, such as:
 ischemic heart disease,
 congestive heart failure (CHF),
 renal insufficiency,
 prior cerebrovascular accident (CVA),
 diabetes mellitus.
 Prior operations, operative complications,
 medication allergies,
 the patient's use of tobacco, alcohol, and/or drugs
should also be noted.

10. History and physical examination.
 Standardized preoperative
screening questionnaires
have been developed for
the purpose of identifying
patients at intermediate or
high risk who would benefit
from a more detailed
clinical evaluation.

11. SABISTON TEXTBOOK of SURGERY 20th
edition-2017

12. Surgical Risk
Factors

13. Type of Procedure
-Acc/AHA Guidelines (American College of Cardiology and the American Heart
Association(
High
<5%
 Emergent major
operations,
particularly in
elderly
 - Aortic and major
vascular
procedures
 - Peripheral
vascular
procedures
 - Prolonged
procedures with
large fluid shifts
+/- blood loss
Intermediate
>5%
Intraperitoneal /
Intrathoracic surgery
Carotid endarterectomy
Head and neck surgery
Orthopedic surgery
Prostate surgery
Low
>1%
Endoscopic
procedures
Superficial
procedures
Cataract surgery
Breast surgery

15.  Many physicians have mistakenly assumed that spinalMany physicians have mistakenly assumed that spinal
anesthesia is safer than general anesthesia for high-riskanesthesia is safer than general anesthesia for high-risk
patients.patients.
 randomized studies comparing the 2 modalities haverandomized studies comparing the 2 modalities have
shownshown no differenceno difference in cardiopulmonary complicationsin cardiopulmonary complications
or mortality.or mortality.
 The final decisionThe final decision about the type of anesthesia isabout the type of anesthesia is
ultimately the responsibility of the anesthesiologist.ultimately the responsibility of the anesthesiologist.

16. Patients Risk
Factors

17.  The ACS NSQIP surgical risk calculator
is a decision-support tool based on reliable
multi-institutional clinical data, which can
be used to estimate the risks of most
operations.
 The ACS NSQIP surgical risk calculator will allow
clinicians and patients to make decisions using
empirically derived, patient-specific
postoperative risks.
SABISTON TEXTBOOK of SURGERY 20th
edition-2017
ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program

18. ACS NSQIP, American College of Surgeons National Surgical Quality Improvement Program

19. Patients Risk Factors

20. ACC-AHA - American College of Cardiology and the American Heart Association

21. American College of Cardiology (ACC)/American Heart Association (AHA

23. Preoperative laboratory testingPreoperative laboratory testing
OrderingOrdering fewer selective as indicatedfewer selective as indicated by:by:
the medical historythe medical history
physical examination .physical examination .
medicationsmedications

25.  Complete blood cell (CBC) count:
 Hemoglobin level for major surgery with significant
expected blood loss or in patients 65 years or
older.
 S.Electrolytes
 not routinely recommended.
 serum creatinine
 for all patients older than 50 years, especially if
hypotension or the use of nephrotoxic medications
is anticipated.
Routine preoperative testing
for elective surgery in healthy individuals.

26.  Blood sugar (blood glucose)
 routine measurement of glucose is not
recommended in all cases. Only in certain
operations, such as:
 vascular surgery and
 coronary artery bypass grafting (CABG),
 diabetes was associated with higher
perioperative risks.
 Liver enzymes:
 Because most patients with severe aminotransferase
enzyme elevation are likely to be symptomatic, and
jaundice may be detected by physical examination,
routine preoperative testing (preoperative screening) is
not recommended for healthy individuals.
Routine preoperative testing
for elective surgery in healthy individuals.

27.  Hemostasis:
 in healthy elective surgery patients :
-PT, aPTT, and bleeding time are not recommended
for routine preoperative testing (preoperative
screening).
 Pregnancy testing
 in all reproductive-age group women.
 History alone may not be completely reliable to
exclude pregnancy.
 Urinalysis (UA)
 urine analysis should not be routinely done for
asymptomatic patients .

28. Imaging studies
 ECG :
 in patients undergoing high-risk surgery (eg,
vascular surgery) or intermediate-risk
surgery and with at least one risk factor
 The AHA recommends ECG in all severely
obese patients (body mass index ≥40kg/m2
)
with at least one other risk factor
 CXR in patients older than 60 years
unless underlying heart or lung disease
is a possibility.

29. Recommendations for specific surgery grades
© NICE (2016) Routine preoperative tests for elective surgery
Recommendations for specific surgery grades
(minor, intermediate, and major or complex) and
ASA grades

31. ASA grades

37. Preoperative investigations:
 No laboratory test must be repeated
if results were normal within 4
months of the surgery and no change
in the patient's clinical status
occurred.

39. General The preoperative preparation
 Rules, interventions
 Psychological support (to release fear
and anxiety) .
 Analgesia.
 Removal of cosmetics, contact lenses,
dentures, etc.
 Menstruation is not a contraindication;
the operation need not be postponed.
 Fasting ??

40. ASA fasting guidelines
ASA (American Society of Anesthesiologists)
SABISTON TEXTBOOK of SURGERY 20th
ed.

41. General The preoperative preparation
 securing intravenous routes for fluid
therapy, drug administration or transfusion
(if necessary).
 Emptying the intestines (enemas and
laxatives).
 Nasogastric catheter (if necessary).
 urinary catheters (if necessary).
 Toilette (bathing and shaving ???).
 Thrombosis prophylaxis.
 Antibiotic prophylaxis (if necessary, e.g.
before a septic operation).

42. Shaving hair
 Hair should not be removed from the operative site
unless it physically interferes with accurate anatomic
approximation of the wound edges.
 If hair must be removed, it should be clipped in the
operating room.
 Shaving hair from the operative site, particularly on
the evening before surgery or immediately before the
wound incision, increases the risk for wound infection.
 Povidoneiodine and chlorhexidine/alcohol should be
allowed to dry.
RUSH UNIVERSITY MEDICAL CENTER Review of Surgery Fifth Edition

43. Special
preoperative preparation

44. Special preoperative preparation
 Depending on the type of the operation
 Operation for obstructive jaundice : Vitamins K and C, fresh frozen
plasma and placing stents to secure bile drainage.
 Removal of stomach tumor: Gastric lavage, ..
 Colon surgery: as in ERAS

45. o Specific Considerations in Preoperative Management
(depending on the (organ) system)

46. Cerebrovascular disease
 Known or suspected cerebrovascular disease requires special
consideration:
1. The asymptomatic carotid bruit :
 Fewer than 50% of bruits reflect hemodynamically significant
disease .No increase in risk of stroke has been demonstrated
during noncardiac surgery in the presence of an asymptomatic
bruit.
1. Patients with recent transient ischemic attacks (TIAs):
 Patients with symptomatic carotid artery stenosis should have an
endarterectomy or carotid stenting before elective surgery.
1. Elective surgery for patients with a recent CVA :
 should be delayed for a minimum of 2 weeks, ideally for 6 weeks.

47. Cardiovascular disease
 Cardiovascular disease is one of the leading causes of death after
noncardiac surgery.
 The following risk factors have been associated with perioperative
cardiac morbidity:
 The patient's age (>70 years)
 Unstable angina
 Elective operation in patients with unstable angina is
contraindicated and should be postponed pending further
evaluation.
 Recent MI
 General recommendations are to wait 4 to 6 weeks
after MI to perform elective surgery.

48. Respiratory system
 Pulmonary Complications of Noncardiac Surgery
 More recently, the definition of a "pulmonary
complication" has been restricted to those that are
clinically significant, including:
 pneumonia,
 respiratory failure with prolonged mechanical ventilation,
 bronchospasm,
 atelectasis,
 exacerbation of underlying chronic lung disease.

49. Respiratory system
 All patientsAll patients undergoing noncardiac surgery should be assessed for riskundergoing noncardiac surgery should be assessed for risk
of pulmonary complicationsof pulmonary complications ..

Patients undergoingPatients undergoing
 emergencyemergency
 prolonged (>3 h) surgeryprolonged (>3 h) surgery
 aortic aneurysm repairaortic aneurysm repair
 vascular surgeryvascular surgery
 major abdominal surgerymajor abdominal surgery
 thoracic surgerythoracic surgery
 neuro, head, and neck surgery; and general anesthesia.neuro, head, and neck surgery; and general anesthesia.
should be considered to be atshould be considered to be at higher riskhigher risk
for postoperative pulmonaryfor postoperative pulmonary
complications.complications.

50. Pulmonary riskPulmonary risk reductionreduction preoperativelypreoperatively
 Decrease or cease smoking.
 Cessation for 2 weeks will improve carbon monoxide levels, but secretions still can be a problem.
 Increase/optimize bronchodilator therapy. treat airflow obstruction in
patients with COPD or asthma
 Administer antibiotics and delay surgery if respiratory infection is present.
 Incentive spirometry. begin patient education regarding post-operative lung-
expansion maneuvers.
)benefit if at least 8
weeks preoperatively(

51. Diabetes MellitusDiabetes Mellitus
 the stress response to surgery and many of the drugs usedthe stress response to surgery and many of the drugs used
during surgery and anaesthesia increase insulin resistance,during surgery and anaesthesia increase insulin resistance,
worseningworsening diabetic controldiabetic control..
 Tighter controlTighter control of the glucose level may improve outcomes inof the glucose level may improve outcomes in
critically ill patients.critically ill patients.
 Tight glucose control isTight glucose control is not associatednot associated with a significantwith a significant
reduction inreduction in hospital mortality.hospital mortality.
 The American College of EndocrinologyThe American College of Endocrinology recommends a targetrecommends a target
glucose ofglucose of <110 mg/dL<110 mg/dL in patients requiringin patients requiring ICU careICU care andand <180<180
mg/dLmg/dL in all other inpatients.in all other inpatients.
 There isThere is no evidenceno evidence that high levels ofthat high levels of HbA1cHbA1c are associatedare associated
with a higher risk forwith a higher risk for complications.complications.

52. DM contDM cont.
 Perioperative management of all diabetic patients requiresPerioperative management of all diabetic patients requires
frequent blood glucose monitoringfrequent blood glucose monitoring to prevent hypoglycemia andto prevent hypoglycemia and
to ensure prompt treatment of hyperglycemia .to ensure prompt treatment of hyperglycemia .
 Patients whose diabetes is controlled byPatients whose diabetes is controlled by diet alonediet alone do notdo not
require any special preoperative measures other thanrequire any special preoperative measures other than
monitoring serum glucose.monitoring serum glucose.
 PatientsPatients taking insulintaking insulin are most often givenare most often given half to two thirdshalf to two thirds ofof
their usual intermediate-acting insulin on the morning oftheir usual intermediate-acting insulin on the morning of
surgery and are then givensurgery and are then given short-acting insulin on a slidingshort-acting insulin on a sliding
scalescale based on finger stick monitoring.based on finger stick monitoring.

53. DM contDM cont..
MetforminMetformin should be discontinued in patientsshould be discontinued in patients 4848
hourshours before surgery to minimize the likelihood ofbefore surgery to minimize the likelihood of
developing lactic acidosis.developing lactic acidosis.
 AnyAny long-acting orallong-acting oral agents should beagents should be
discontinueddiscontinued 48 to 72 hours48 to 72 hours before surgery.before surgery.
because of the risk forbecause of the risk for intraintraoperativeoperative
hypoglycemia.hypoglycemia.

54. Essential Surgical Practice Fifth Edition 2015
Withholding insulin from patients with type 1 diabetes leads
to acidosis and may prove fatal.

55. HyperthyroidismHyperthyroidism
 Surgery need not be delayed in patients withSurgery need not be delayed in patients with mildmild
hyperthyroidism.hyperthyroidism.
 Elective surgery:Elective surgery:
 should beshould be postponedpostponed in patients who are symptomatic or have restingin patients who are symptomatic or have resting
tachycardia until they aretachycardia until they are euthyroid .euthyroid .
 Treatment ofTreatment of a thyrotoxica thyrotoxic patient undergoingpatient undergoing urgent orurgent or
emergency surgeryemergency surgery includes a combination of :includes a combination of :
to control the resting heart rate toto control the resting heart rate to < 90< 90
beats per minutebeats per minute..
β-blockers,β-blockers,
antithyroid agents,antithyroid agents,
and iodineand iodine
as well as prophylactic corticosteroid supplementation, as used foras well as prophylactic corticosteroid supplementation, as used for
thyroid stormthyroid storm

56. HypothyroidismHypothyroidism
 Patients withPatients with mild to moderatemild to moderate hypothyroidism tolerate surgeryhypothyroidism tolerate surgery
reasonably well .reasonably well .
 Elective surgery:Elective surgery:
should be delayed in patients with severe hypothyroidism untilshould be delayed in patients with severe hypothyroidism until
adequate thyroid hormone replacement can be achieved.adequate thyroid hormone replacement can be achieved.
 For emergency surgeryFor emergency surgery::
 Intravenous l-thyronineIntravenous l-thyronine (T(T33) or T) or T4.4.

57. Adrenal gland suppression or adrenal insufficiency
 In general, patients who have taken any dose of
corticosteroid for less than 3 weeks or who are being
managed chronically with alternative therapy should
take the same dose perioperatively.
 perioperative stress therapy with hydrocortisone,.
 Tapering to preoperative maintenance doses can be
accomplished in 2 to 3 days.
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58. pheochromocytoma
 control of hypertension
 Morphine and phenothiazines may precipitate a
hypertensive crisis and should be avoided
preoperatively.
 arterial line inserted, and a central venous pressure.
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59. Renal Perioperative MedicineRenal Perioperative Medicine
 In patients undergoing noncardiac surgery, renalIn patients undergoing noncardiac surgery, renal
insufficiency is an independent predictor ofinsufficiency is an independent predictor of
postoperative cardiac and pulmonary complications.postoperative cardiac and pulmonary complications.
(serum creatinine >2.0 mg/dL) & (blood urea nitrogen(serum creatinine >2.0 mg/dL) & (blood urea nitrogen
>22 mg/dL)>22 mg/dL)
 Elective surgery should be delayed in patients who areElective surgery should be delayed in patients who are
volume depletedvolume depleted until volume repletion occurs.until volume repletion occurs.
 Patients on hemodialysisPatients on hemodialysis should be dialyzedshould be dialyzed the daythe day
before surgerybefore surgery to minimize acute shifts in fluid-to minimize acute shifts in fluid-
electrolyte and acid-base balance and should be followedelectrolyte and acid-base balance and should be followed
by a nephrologist perioperatively.by a nephrologist perioperatively.

60. Hepatic Perioperative MedicineHepatic Perioperative Medicine
 Patients withPatients with acute viral or alcoholic hepatitisacute viral or alcoholic hepatitis tolerate surgerytolerate surgery
poorly, andpoorly, and delaying surgerydelaying surgery until recovery is recommended ifuntil recovery is recommended if
possible.possible.
 Patients withPatients with chronic hepatitischronic hepatitis without evidence of hepaticwithout evidence of hepatic
decompensation generally tolerate surgery well.decompensation generally tolerate surgery well.
 Preoperative treatmentPreoperative treatment to improve encephalopathy, ascites,to improve encephalopathy, ascites,
and coagulopathy appears to reduce risk in these patients.and coagulopathy appears to reduce risk in these patients.

61.  A conservative approach would be toA conservative approach would be to avoid elective surgeryavoid elective surgery inin
patients withpatients with class Cclass C cirrhosis and those withcirrhosis and those with class A or Bclass A or B
cirrhosis and concomitant active hepatitiscirrhosis and concomitant active hepatitis..

62. Hematologic Risk
 Anemia is the most common laboratory
abnormality encountered in preoperative patients.
 Mild anemia does not predict poor operative outcome and
while it is traditional to recommend that patients be
transfused for hematocrit < 30 % , this may be unnecessary
for patients with chronic anemia.
 Hematocrit < 24 % was associated with increased morbidity.
 Similarly, severe thrombocytopenia (< 50,000) is associated
with increased bleeding complications.

63.  Patients on antiplatelet medications (such as aspirin) or
who are chronically anticoagulated fall into two
categories.
1) Those needing "tight control" - i.e. those with
mechanical heart valves ,PCI can be placed on heparin
preoperatively.
2) Those in whom "loose control" is acceptable -
patients on aspirin for CAD or warfarin for CVA
prophylaxis - can discontinue anticoagulation a week prior
to surgery and resume the medications on postoperative
day one.
 NSAIDS should also be discontinued five to seven days
before surgery.

64.  In polycythemia vera,In polycythemia vera,
phlebotomyphlebotomy should be performedshould be performed
to decrease the hematocrit toto decrease the hematocrit to
< 47%< 47% before elective operations.before elective operations.

65. Perioperative Management of MedicationsPerioperative Management of Medications
 Herbal medicinesHerbal medicines be discontinued 1 week prior tobe discontinued 1 week prior to
surgery;surgery;
 GingerGinger , Ginseng, Garlic, Ginseng, Garlic  can causecan cause bleeding.bleeding.
 GinsengGinseng  associated withassociated with hypoglycemiahypoglycemia..
 GarlicGarlic associated withassociated with hypoglycemia andhypoglycemia and
hypotension.hypotension.

67. Summary
 Good communication is an essential feature of
preoperative evaluation.
 The goal of preoperative risk assessment is to determine if a
patient is at average or increased risk for a specific procedure,
or to recommend diagnostic testing if this determination
cannot yet be made.
 Utilize a stepwise approach to preoperative risk assessment.
 Clinical data from a careful history and physical
examination are the critcal initial steps.
 Use noninvasive testing judiciously.

68. Summary Cont.
 Findings and recommendations should always be discussedFindings and recommendations should always be discussed
withwith medical consultant. ..
 Notes medical consultant should be brief, focused and
specific.
 Follow the patient postoperatively.

69. THANK YOU
.