This document discusses preoperative preparation and optimization of surgical patients. It outlines assessing patient history, risk factors, and medical conditions; performing examinations and tests; identifying and managing issues like cardiovascular disease, respiratory disease, diabetes, malnutrition, and coagulation disorders; discussing risks and obtaining consent; and arranging the operating room and prioritizing patients. The goal is to identify and address any factors that could increase surgical risks, and to ensure patients are medically optimized and prepared for their procedures.
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Preoperative preparation
1. LT COL SM SHAHADAT HOSSAIN
MCPS,FCPS( Surgery),FCPS(Thoracic
surgery)
Surgical Spl & Thoracic Surgeon
CMH, Bogra
PREOPERATIVE PREPARATION
2. INTRODUCTION
To obtain satisfactory results in surgery requires a
careful approach to preoperative preparation is
necessary
High risk patients should be identified early and
appropriate measures taken to reduce complications
The approach is multidisciplinary. It involves
participation of anaesthetic and surgical teams,
radiologists, pathologists, specialist nursing staff and
Operating Room staffs.
3. PREOPERATIVE PLAN
Preoperative plan for the best patient
outcomes
Gather and record all relevant information
Optimise patient condition
Choose surgery that offers minimal risk and
maximum benefit
Anticipate and plan for adverse events •
Inform everyone concerned
5. ROUTINE PREPARATION FOR SURGERY
History
Physical examination
Special investigation
Informed consent
Marking the site/side of operation
Thromboembolic prophylaxis
Antibiotic prophylaxis
6. PATIENT ASSESSMENT
HISTORY TAKING:
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: Co morbidities (Fixed questions)
7. History
Past History:
Ischaemic heart disease ,arrhythmias
Hypertension, Heart failure
Diabetes, Thyroid dysfunction
Chronic obstructive pulmonary disease, Asthma,
Tuberculosis
Renal dysfunction, Hepatitis, Malignancy, Allergy
Drug History: HTN,OHA,Thyroid,
Personal history:
11. Investigations
Full blood count, Blood grouping
Serum creatinine, Urea, Electrolytes, LFT, Urinalysis
Blood glucose and HbA1C
Electrocardiography
Chest radiography
Others ( Clotting screening, β-Human chorionic
gonadotrophin, Arterial blood gases, Liver function tests,
Relevant investigations to assess capacity of specific
organ system and risk associated)
12. SPECIFIC PREOPERATIVE
PROBLEMS AND MANAGEMENT
Cardiovascular disease
Hypertension, ischaemic heart disease (IHD) and coronary
stents
Prior to elective surgery blood pressure should be
controlled to near 120/80 mmHg.
In case new antihypertensive, a stabilisation period of at
least 2 weeks prior to surgery.
After myocardial infarction elective surgery should be
postponed for 3–6 months
13. Specific preoperative problems
Dysrhythmias
β-blockers, digoxin or calcium channel blockers should
be started preoperatively
Warfarin should be stopped 5 days preoperatively to
achieve an international normalised ratio (INR) of 1.5 or
less
Antiplatelet agents should be withdrawn (7 days for
aspirin, 10 days for clopidogrel)
14. Specific preoperative problems
Anaemia and blood transfusion
In case of elective surgery:
Correctable cause of anemia- delay surgery e.g. Iron/Vit
Deficiency
Uncorrectable cause e.g. Haemorrhoid, GI bleeding –
blood transfusion
Blood transfusion are also required during emergency
surgeries
15. Specific preoperative problems
Respiratory disease
Postoperative pneumonia increase the morbidity and
mortality
Assessment should be done in:
All lung resection cases
Major abdominal and thoracic cases in patients older
than 60 years
16. Specific preoperative problems
Tests should be done:
CT scan of chest
Forced vital capacity in 1 sec(FEV-1)
Forced vital capacity
Diffusing capacity of carbon monoxide
17. Specific preoperative problems
Risks group:
General : Age > 70years, Poor nutrition
Cigarette smoking
COPD, Asthma
Emergent surgery
Thoracic, vascular and upper abdominal surgery
Blood loss > 4 pints (2000ml)
Anesthesia time >180 minutes
General anesthesia with endotracheal intubation
18. Specific preoperative problems
Preoperative interventions:
1.Smoking cessation ( within 6-8 weeks before surgery)
2. Incentive spirometry
3. Encouraging exercise; patient should be encouraged to
walk 2 KM 3 days weekly
4. Bronchodilator therapy
5. Antibiotic
19. Specific preoperative problems
Liver disease
Elective surgery should be postponed if patients have
acute episode (e.g. cholangitis).
The blood tests:
Liver function tests
Coagulation( PT,APTT,INR)
Blood glucose and u&es
Viral markers
Serum protein
20. Specific preoperative problems
Renal disease
Diabetes mellitus, hypertension and ischaemic heart
disease should be stabilised
Treat acidosis, hypocalcaemia and hyperkalaemia of
greater than 6 mmol/L.
Arrangements for peritoneal or haemodialysis until a few
hours before surgery
21. Specific preoperative problems
Diabetes mellitus
History and examination:
To assess adequacy of glycemic control
To access evidence of diabetic complication e.g.
Infection,HTN,Retinopathy
Investigation:
Fasting and postprandial blood glucose
HbA1 <69 mmol/mol
Serum electolytes
BUN ,Serum creatnine
Urine analysis
ECG
22. Specific preoperative problems
Preoperative optimization: Should be controlled
Morning dose of OHA should be omitted
Intravenous insulin infusion
Maintain blood sugars 6-8mmol/L levels should be
checked 2 hourly
Thyroid dysfunction(Hypo/Hyperthyroidism):
FT4, FT3,TSH- preoperatively
Drug should be continued
23. Specific preoperative problems
Malnutrition
A BMI of less than 18.5
BMI below 15 is associated with significant hospital
mortality
Nutritional support for a minimum of 2 weeks before
surgery
Obesity
If BMI more than 35 is associated with increased risk of
postoperative complications
Patients should be advised on healthy eating and
regular exercise
24. Coagulation disorders
Thrombophilia
Family history or personal history of thrombosis should
be identified
Patients with a low risk: Elastic stockings should wear
during the perioperative period
High-risk patients: Warfarin should be stopped replaced
by low molecular weight heparin
25. Risk factors for thrombosis
Patient factors
Age
Obesity
Varicose veins
Immobility
Pregnancy
Puerperium
High-dose oestrogen therapy
Previous deep vein thrombosis or pulmonary embolism
Thrombophilia
26. Risk factors
Disease or surgical procedure
Trauma or surgery, especially of pelvis, hip and lower
limb
Malignancy, especially pelvic, and abdominal
metastatic
Heart failure
Recent myocardial infarction
Paralysis of lower limb(s)
Infection
Inflammatory bowel disease
Nephrotic syndrome
Polycythaemia
Paraproanticoagulant
27. Low-, medium- and high-risk patient groups
LOW
Minor surgery <30 minutes; any age; no risk factors
Major surgery >30 minutes; age <40; no other risk
factors
Minor trauma or medical illness
MODERATE
Major surgery; age 40+ or other risk factors
Major medical illness: heart/lung disease, cancer,
inflammatorybowel disease
Major trauma/burns
DVT, PE or thrombophilia
28. Low-, medium- and high-risk patient groups
HIGH
Major orthopaedic surgery or fracture of pelvis, hip,
lower limb
Major abdominal/pelvic surgery for cancer
Lower limb paralysis (e.g. stroke, paraplegia)
Major lower limb amputation
30. MEDICATIONS
Continue medication for hypertension, ischaemic heart
disease.
Convert oral steroid to intravenous hydrocortisone.
Stop oral anticoagulation 3-4 days.
Stop antiplatelet 5 days before surgery.
31.
32. RISK ASSESSMENT AND CONSENT
Risks: Related to the co-morbidities, anaesthesia and
surgery
Explain: Advantages, side effects, prognosis
Language: Simple
Consents: Valid consent is necessary except in life-saving
circumstances
35. ARRANGING THE THEATRE LIST
Date, place and time of operation
Appropriate equipment and instruments should be
available
The operating list should be distributed as early as
possible
36. PRIORITISE PATIENTS
Children and diabetic patients should be placed at the
beginning of the list
Life- and limb-threatening surgery should take priority
Cancer patients need to be treated early
37. SPECIAL CONSIDERATIONS
Nil by mouth
Patients are advised not to take solids within 6 hours
and clear fluids (isotonic drinks and water) within 2
hours before anaesthesia
Infants are allowed a clear drink up to 2 hours, mother's
milk up to 3 hours and cow or formula milk up to 6 hours
before anaesthesia