pre op care seminar.pptx

Pre op preparation of oatients

1. Preoperative care Presenter: Dr. Moti ( OSR-1) Moderator :- Dr. Endale (Anesthesiologist) April 2022 1

2. Outline Objectives Introduction Patient assessment Specific preop problems and management Preop assessment in emergency surgery Risk assessment and consent Arranging the theatre list References 2

3. Objectives Be able to organize preoperative care and the operating list To understand Surgical, medical and anesthetic aspects of assessment To understand How to optimize the patient’s condition To understand How to take consent 3

4. Introduction Definition: Peri -operative Pre-operative Intra-operative Post-operative 4

5. Introduction Preoperative care is a comprehensive approach which begins with the decision to perform surgery and continues until the patient enters the OR.

6. Components of preoperative care Preoperative assessment Reviewing client’s health status( Hx&Px ) Investigating Optimization of pt condition

7. Patient assessment T o look actively for risks and manage them so as to enable surgery to go ahead safely. D one by the surgical, nursing team and/or anesthetic team Includes history, physical examination and investigations The aim of preoperative evaluation is not to screen broadly for undiagnosed disease, but to identify and quantify any co morbidity that may affect the operative outcome. 7

8. Patient Assessment Goals: Assess the Risk of surgical vs non-surgical Rx. Assess the extent of known disease present. Identify unknown or hidden diseases(risks ). Develop an individualized anesthetic plan. 8

9. Risk Assessment Two major questions Is the patient in optimal medical condition for surgery? Benefits of surgery vs associated risk balance. Is it worthy? 9

10. I. Review the client’s health status History Hx of present illness and reason for surgery Past medical Hx Prior Hx of problem with anesthesia Allergies and current medications Substance use Review of system

11. Physical examination General Cardiovascular Respiratory Gastrointestinal Musculoskeletal Neurological Airway assessment

12. Airway evaluation Purpose is to predict and possibility of intubation look for- neck mobility short neck protruding teeth large tongue Mallapati test

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14. INVESTIGATIONS Rationale for preoperative testing To detect unsuspected abnormalities To establish a baseline value for a test For medico-legal reasons Routine preoperative testing Not cost-effective Less predictive of perioperative morbidity Should be individualized 15

15. Preoperative Ixs Should be individualized CBC, BG and X- match S/electrolytes R FT U/A CXR ECG Other tests – coagulation studies, radiographic, TFT, RBS, HbA1C PFT, LFT as necessary

16. III. SPECIFIC PREOP PROBLEMS AND OPTIMISATION

17. CVS is the leading cause of death in the industrialized world, and its contribution to perioperative mortality during noncardiac surgery is significant   All patients scheduled to undergo noncardiac surgery should have an assessment of the risk of a cardiovascular problems 18

18. Cardiovascular disease Contributes to perioperative mortality. The degree of risk can be assessed using the: Goldman Index Lee’s criteria(RCRI) MET NYHA 19

19. Goldman Index Risk factor Score Age > 70 years 5 MI within 6 months 10 Third heart sound /gallop rhythm 11 Aortic stenosis 3 Rhythm other than sinus 7 > 5 Ventricular ectopics per min 7 Emergency surgery 5 Abdominal or thoracic operation 3 Poor general condition 3 Cardiac Complication Rate: Class I ( 0-5 )……0.9% Class ii (6-12 )……. 7.1% Class iii (13-25 )….. 16% Class iv ( > 26 ) …….. 63.6 % above 26 has a mortality of 50% and only life- saving operations should be considered 20

20. Metabolic equivalent of task (MET). 1 MET= 3.5 mL O2/kg per minute (oxygen consumption by 40 year , 70 kg man at rest) 1 MET = eating and dressing 4 MET = climbing two flights of stairs 6 MET = short run >10 MET = able to participate in strenuous sport NB Patients who can exercise at 4 METS or above have lower risk of perioperative mortality 22

21. NYHA Functional Class Class I No limitation of physical activity; ordinary activity does not cause fatigue, palpitations or syncope Class II Slight limitation of physical activity; ordinary activity results in fatigue, palpitations or syncope Class III Marked limitation of physical activity; less than ordinary activity results in fatigue, palpitations or syncope; comfortable at rest Class IV Inability to do any physical activity without discomfort; symptoms at rest 23

22. Very high-risk patients need optimization Recent MI Unstable angina Decompensated heart failure High-grade arrhythmias Hemodynamically important VHD   Uncontrolled Hypertension

23. Hypertension Most common medical reason for postponing surgery Leads to many complications P oorly controlled hypertension DBP > 110 or SBP > 160 25

24. Cardiovascular disease… Elective surgery DBP >110mmHg should not undergo elective surgery CBC, RFT, ECG and CXR Bp should be controlled to near 160/90 mmHg If a new antihypertensive is introduced stabilisation for at least 2 weeks 26

25. Cardiovascular disease… W ell-controlled hypertension continue medication up to, and including, the day of surgery Premedication benzodiazepines two hours prior to surgery Emergency Surgery B p may need to be controlled more rapidly but don’t drop B p precipitously

26. Ischemic Heart Disease Dangerous risk factor Recent MI is strong contraindication for elective surgery At least 3-6 months should be lapsed after an attack Significant mortality from anesthesia within 3 mon. Elective surgery- should be delayed for 6 months. If urgent surgery needed - aggressive therapy. − meticulous optimization of O2 and fluid balance throughout the perioperative period must be obtained 28

27. CVS …cont’d Valvular heart disease: Cardiologist and anesthesiologist evaluation Warfarin should be stopped 5days before surgery with INR of 1.5 UFH infusion if INR is/falls below 1.5 until 2hrs before surgery with aPTT goal of 1.5 times norma Continue postoperatively.. 29

28. CVS …cont’d Dysrhythemia AF should be controlled before surgery. If Digoxin used- measure K reguraly 2 nd & 3 rd degree heart block – pacemaker. Anemia & Transfusion Preop HgB less than 6-7mg/dl Symptomatic Active bleeding 30

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30. Respiratory disease Perioperative pulmonary physiology: Vital capacity (VC) is reduced by 50 to 60 percent and may remain decreased for up to one week. Functional residual capacity (FRC) is reduced by about 30 percent. 32

31. Respiratory disease … cont’d  Risk factors for pulmonary complications can be grouped into patient-related and procedure-related risk 1. Procedure-related risk factors  Surgical site   Duration of surgery (>3-4hrs) Type of anesthesia Type of neuromuscular blockade 2. Patient-related risk factors 33

32. Pulmonary Disease… D ecrease postoperative pulmonary complications smoking cessation (>2 mos before the planned procedure ) bronchodilator therapy antibiotic therapy for preexisting infection pretreatment of asthmatic patients with steroids use of epidural anesthesia vigorous pulmonary toilet and rehabilitation

33. Pulmonary Disease… COPD & ASTHMA Management P reoperative bronchodilator R egional anesthesia is better I ntra op stress dose steroid administration Infection elective surgery should be postponed treat with antibiotics and physiotherapy operation rescheduled after 4–6 weeks

34. Respiratory disease … cont’d Pulmonology referral : Severe disease deteriorating from usual Major surgery for resp. comorbidities Right side heart failure Young pt with COPD 36

35. Gastrointestinal disease NPO and regular medications: Clear liquids- 2hrs Breast milk- 4hrs Cow milk, formula milk, light meal- 6hrs Fried or fatty food or meat – 8hrs Medications with sips of water 37

36. Gastrointestinal disease…cont’d Regurgitation risk: hiatus hernia, obesity, pregnancy and diabetes are at risk of regurgitation even after NPO Rx with clear antiacids , H2 blocker/PPIs Liver disease: any evidence of clotting problems, renal involvement, alcoholic hepatitis and encephalopathy, surgery should be postponed at least 12wks/patient r ecover . In chronic hepatitis surgery can be safely done 38

37. Genitourinary disease Renal disease CKD : rx cxs like acidosis, hypocalcemia, and hyperkalemia >6mmol/l If pt is on dialysis continue until few hours before surgery and determine RFT, CBC and serum electrolytes Anemia is usually well tolerated AKI with emergency surgery needs simultaneous surgical and medical rx with critical care support as needed UTI Should be treated 1 st for elective surgery, but in case of emergency rx started and surgery after good urine output 39

38. Endocrine and metabolic disorders Malnutrition : Nutritional assessment : ABC Anthropometry and body weight BMI<18.5 nutritional impairment BMI<15 is associated with major hospital mortality Skin fold thickness MUAC Biochemical (laboratory studies) Serum albumin<30g/l indicator of poor prognosis Lymphocyte count and skin test for delayed hypersensitivity Clinical MUST- five step screening tool 40

39. 41 Nutritional support for a minimum of 2 weeks before surgery is required to have any impact on subsequent morbidity

40. Endocrine and metabolic disorders… cont’d Obesity : morbid obesity BMI>35 is associated with increased risk of postop cxs Perioperative sleep apnea DVT Aspiration Rx : prolong surgery if possible CPAP and cholesterol reducing agents Prophylaxis for aspiration and DVT 42

41. Endocrine and metabolic disorders… cont’d Diabetes mellitus Strict glycemic control is needed b/c surgery and GA causes neuroendocrine stress response Assess for Type of DM Long term cxs Baseline glycemic control if >200mg/dl associated with deep wound infection Hypoglycemia hx Hx of therapy Type of anesthesia and surgery Ixs : ECG,RFT, RBS, and HgbA1c 43

42. Endocrine and metabolic disorders… cont’d Goals of glycemic control General goal Avoid hypoglycemia Prevent DKA/Hyperosmolar state Maintenance of fluid and electrolyte Avoid marked hyperglycemia Glycemic targets 110-180mg/dl in noncritical hospitalized pt 80- 180mg/dl in perioperative pt 44

43. Endocrine and metabolic disorders… cont’d Perioperative phase: Pts should have surgery as early as possible in morning T2DM with diet rx alone Do not require rx perioperatively Correction insulin if RBS is above target Monitor RBS every 2hr for long surgery(>2hs)or surgeries with expected high glucose level T2DM on oral hypoglycemic agent Continue routine medication until morning dose(hold) If HgbA1c <7.0% will not need insulin Determine RBS every 2hrs and put on sliding scale every 6hrs if hyperglycemic 45

44. Endocrine and metabolic disorders… cont’d T1DM or T2DM on insulin Pt undergoing morning procedure where breakfast and lunch likely to be missed: Omit short acting insulin Reduce to 1/3 - 1/2 of dose on intermediate and long acting Pt on continuous infusion can continue Start on D5W at rate of 75-125 ml/ hr to avoid metabolic change of starvation RBS every hour or less if RBS is <100mg/dl Put on sliding scale if hyperglycemia develops Postoperative phase: perioperative rx regimen maybe reinstated once pt is eating well 46

45. 7. Thromboprophylaxis

46. Thromboprophylaxis… Mechanical Prophylaxis Compression Stocking Inferior Vena Cava Filter Pharmacologic Prophylaxis warfarin LMWH p entasaccharide (Fondaparinux) aspirin (acetylsalicylic acid)

47. THROMBOSIS RISK Patients with increased risk of VTE balance with risk of bleeding AAOS risk factors for major bleeding bleeding disorders history of a recent gastrointestinal bleed history of a recent hemorrhagic stroke AAOS risk factors for pulmonary embolus hypercoagulable state previous documented pulmonary embolism

48. Neurological and psychiatric disorders Hx of stroke , pre-existing neurologic deficit on antiplatelet and anticoagulant If risk of cardiovascular thrombotic is low stop aspirin 7days and clopidogrel 10 days before surgery If risk is high continue aspirin only Anticonvulsant and anti parkinson medication is continued perioperatively Lithium should be stopped 24 hours prior to surgery Inform anesthetist about TCA , MAOIs as they interact with anisthesia 50

49. Musculoskeletal and other disorders RA of cervical spine can lead to unstable cervical spine with the possibility of spinal cord injury during intubation In ankylosing spondylitis spinal/epidural anesthesia are often challenging SLE may be associated with hypercoagulable state along with airway difficulties NSAID- hold 3 days prior to surgery Methotrexate- continue up to including day of surgery, in patient with renal insufficiency hold 2 weeks prior to surgery 51

50. Pre op Medication OCP/HRT—4-6 weeks Asprin—1 week?? Warfarin -5-7 days NSAIDS –5-7 days ACEI Lasix Metformin Heparin 52 Discontinue Early Discontinued on Day of Surgery

51. DMARDs Anti epileptics Steroids?? Beta blockers H2 blockers PPI Anxiolytics PCM 53 Don’t Stop(continue) Add

52. Prophylactic antibiotics to prevent surgical site infection 30min to 2 hour before surgical incision I ndications clean surgery involving insertion of a prosthesis or implant clean-contaminated surgery c ontaminated surgery should be discontinued within 24 hours of surgery

53. Antimicrobial prophylaxis Orthopedic surgery    Antimicrobial prophylaxis is warranted for spinal procedures, repair of hip and other closed fractures, implantation of internal fixation device (screws, nails, plates, and pins), and total joint replacement. Antimicrobial prophylaxis is not warranted for clean orthopedic procedures; these include arthroscopy and other procedures involving the hand, knee, or foot with no implantation of foreign materials. 55

54. Peri -operative Skin Preparation 56 Whole body cleansing with chlorhexdine . The night before & morning. Clipping of hair is preferable . Hair should be removed as close as to the surgery.

55. Preoperative assessment in emergency surgery Start: Similar principles to that for elective surgery Constraints : Time, facilities available Consent: May not be possible in life-saving emergencies Organizational efforts: For example, local/national algorithms for treatment of multi-trauma patient 57

56. Risk assessment Risk after surgery is a complex interaction of multiple factors : 1. Patient factors History of severe cardiac disease:- IHD, MI, CHF Severe respiratory disease :- COPD, respiratory failure Aged >70 years with limited physiological reserve in one or more vital organs Metabolic disease :- renal failure, poorly controlled diabetes Morbid obesity Late stage vascular disease Poor nutrition 58

57. Risk assessment… cont’d 2. Surgical factors Prolonged duration of surgery (>1.5 hours) Extensive surgery (e.g. oesophagectomy , gastrectomy) Type of surgery (thoracic, abdominal, vascular) Emergency surgery (e.g. perforated viscus, gangrenous bowel , gastrointestinal bleeding) Acute massive blood loss (>2.5 litres ) Septicaemia (positive blood cultures or septic focus) Severe multiple trauma e.g. >3 organs or >2 systems or ≥ 2 body cavities open 59

58. Risk assessment… cont’d Number of scoring systems have been developed over the years with the aim of identifying high-risk patients Risk scoring systems ASA is simple, but subject to user interpretation MET measures exercise tolerance related to daily living RCRI used to predict cardiac risk for non-cardiac surgery POSSUM can only be used postoperatively and better for some types of surgery, e.g. colorectal, vascular CPET is non-invasive, objective and becoming increasingly popular 60

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61. Consent Valid consent implies that it is given voluntarily by a competent and informed person who is not under duress In emergency situations or in an unconscious patient, consent may not be obtained and the procedure carried out ‘ in the best interests of the patient’ 63

62. consent… Steps in consent taking patient’s demographic details should be checked make sure that the patient understands who you are what your role is the planned operation should be outlined and confirmed with the patient a brief explanation of the planned operation the risks and benefits involved alternatives the risks and benefits of doing nothing

63. consent… Discuss the type of anesthetic proposed Give the patient time and space to make the final decision Check that the patient understands and has no more questions Record clearly and comprehensively what has been agreed

64. Preoperative Preparation Immediately Before Surgery… 4/29/2022 Consent if they want the consent process to be repeated any questions happy to proceed with surgery should be recorded in the notes Check that a ll relevant results and imaging are available The side or area to be operated on should be marked.

65. Preoperative P reparation I mmediately Before Surgery 4/29/2022 The patient’s identity should be confirmed A check should be made no change in the patient’s condition for any sepsis (skin, teeth, urine and chest )

66. Arranging the theatre list Date , place and time of operation Appropriate equipment and instrument Operating list should be distributed to all staff Priorities for: Children Diabetic Limb and life threatening Cancer pts 68

67. References Bailey & Love’s short practice of surgery, 27 th edition Sabiston Textbook of Surgery 20 th edition Uptodate 2022 ASA classification system Apley and Solomon’s System of Orthopaedics and Trauma Orthobullet 69

68. Thank you ! 70 Questions ?