Short notes on preoperative preparations

1. Preoperative

3. Learning objectives
• To be able to organize preoperative care and the
operating list
• To understand surgical, medical, and anaesthetic
aspects of assessment
• How to optimize the patient’s condition
• How to take consent
• How to organize an operating list

4. 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

5. 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

6. PATIENT ASSESSMENT
o History taking
o Examination
o Investigations
o Preoperative treatment
o Documentation
o Communication

7. 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)

8. • 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,
phaeochromocyt
oma
Locomotor system
• Osteoarthritis,
inflammatory
arthropathy
Infectious
• Tuberculosis,
hepatitis, HIV
Past medical history

9. 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

10. General Physical Ex:
Aim: to check fitness for anesthesia & surgery.
• GPE
• Systemic:
- CVS
- CNS
- GIT
- Respiratory system

11. 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:

12. 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:

13. 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

14. 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

15. 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

16. PREOPERATIVE
PROBLEMS

17. Hypertension
Preoperative 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

18. Ischemic heart disease / MI
- Recent MI is strong contraindication to elective anaesthesia
- Postpone surgery 3-6 months after proven MI

19. 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

20. Anemia & blood
transfusion
• Preoperative transfusion
considered if Hb < 8g dl

21. 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

22. 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
• Secondary
complications:
Impaired clotting,
risk of renal failure
• Prophylactic
antibiotics needed

23. • 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

24. 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

25. 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

26. Adrenocortical
suppression
• Occur in patient receiving
oral adrenocortical
steroids regularly
• Require extra dose of
steroids around the time
of the surgery – avoid
Addisonian crisis

27. 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

28. 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

29. 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

30. 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

31. • 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

33. Taking a comprehensive consent
Lead 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)

34. 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

35. REFERENCES
• Bailey and Love’s Short Practice of Surgery, 26th
Edition

36. THANK YOU