PRE OPERATION PREPARATION

PRE OPERATION PREPARATION

1. PRE OPERATION PREPARATION Facilitator- Dr Mahipendra Tiwari Prepared By- Dr Lalit K Shah Resident General Surgery

2. INTRODUCTION Pre operative preparation is the preparation of a patient requiring surgery to optimise postopeartive outcomes The preparation begins from the time of contact of the patient with the surgeon and ends on the day of surgery in the preoperative room

3. PREOPEARTIVE PLAN 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

4. PATIENT ASSESSMENT History Taking Examination Investigations Preoperative management of systemic diseases Preoperative assessment in emergency surgery Risk assessment and consent

5. 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)

6. History Taking A standard history should be taken firstly open questions then on specific questions aimed at clarifying the diagnosis and severity of symptoms(closed question) A set of fixed questions are needed to determine fitness for surgery Surgery specific symptoms (including features not present), onset, duration and exacerbating and relieving factors should also be documented

7. Cardiovascular history: chest pains, palpitations, syncope, dyspnoea and poor exercise tolerance Respiratory history: History of smoking, productive cough, wheeze, dyspnoea, hoarseness of voice or stridor. Increasing severity of symptoms generally indicates worsening of symptoms

8. Neurological History: Epilepsy, cerebrovascular accidents and TIA, psychiatric disorder Past History: Past medical history(e.g MI, HTN, Heart failure, COPD, DM, Thyroid disoredr, UTI, etc) Previous surgery and problem encountered can reveal problems that may present during current hospitalisation Problem with anasthesia

9. Drug and Allergy History: The use of recreational drugs and alcohol consumption should be noted as they are known to be associated with adverse outcomes Patient under drug for any medical condition, any known drug allergies

10. Family History: History of similiar illness in family History of any significant medical history in family Socio-economic history:

11. EXAMINATION General: Positive findings even if not related to the proposed procedure should be explored further Surgery related: Type and site of surgery, complications occurred due to underlying pathology Systemic: Comorbidities and extent of limitation of each organ function

12. EXAMINATION General: Anaemia, jaundice, cyanosis, nutritional status, sources of infection (teeth, feet, leg ulcers) Cardiovascular Pulse, blood pressure, heart sounds, bruits, peripheral oedema Respiratory Respiratory rate and effort, chest expansion and percussion note, breath sounds, oxygen saturation

13. EXAMINATION Gastrointestinal Abdominal masses, ascites, bowel sounds, hernia, genitalia Neurological Consciousness level, cognitive function, sensation, muscle power, tone and reflexes Airway assessment

14. EXAMINATION Examination specific to surgery: The clinical findings, site, side, specific imaging or investigation findings related to the pathology for which the surgery is proposed should be noted Sources of potential bacteraemia can compromise surgical results especially if artificial material is implanted

15. Check and treat infections in the preoperative period Surgery puts the patient’s life ‘at risk’ and so the benefit of the procedure should outweigh the risk of surgery Type of surgery along with patient comorbidities determine perioperative risks(for e.g perioperative mortality in major surgery such that of aortic aneurysm repair is 4-5% in UK)

16. INVESTIGATIONS Full blood count RFT ECG Chest radiography Clotting screen Urinalysis

17. Blood Glucose/HbA1c Others LFT B-HCG Relevant investigations to assess capacity of specific organ system and risk associated

18. Preoperative management of patient with systemic disease Capacity: Baseline organ function capacity should be assessed Optimisation: Medication, lifestyle changes, specialist referral will improve organ capacity Alternative: Minimally impacting procedure, appropriate postoperative care will improve outcomes Theatre preparations: Timing, teamwork, special instruments and equipment

19. Cardiovascular Disease At preoperative assessment it is important to identify the patients who have a high perioperative risk of major adverse cardiovascular events (MACE) including myocardial infarction (MI), and make appropriate arrangements to reduce this risk.

20. Patients at high risk are those with ischaemic heart disease (IHD), congestive cardiac failure (CCF), arrhythmias, severe peripheral vascular disease, cerebrovascular disease or significant renal impairment, especially if they are undergoing major intra-abdominal or intra-thoracic

21. The patient should be referred to a cardiologist if: A murmur is heard and the patient is symptomatic The patient is known to have poor left ventricular function or cardiomegaly. Ischaemic changes can be seen on ECG even if the patient is not symptomatic (silent ischaemia, silent MIs are frequent). There is an abnormal rhythm on the ECG, for example tachy-/bradycardia or heart block

22. Respiratory Disease Postoperative respiratory complications, such as pneumonia, are a major cause of morbidity and mortality especially after major abdominal and thoracic surgery A patient’s current respiratory status should be compared with their ‘normal state’ A preoperative chest radiograph or scan is useful

23. Make a note of the severity of the asthma and COPD, such as past hospital admissions for treatment of the condition, records of pulmonary function tests, use of oral steroids,home oxygen, non-invasive ventilation support and evidence of right heart failure

24. The patient should be referred to a respiratory physician if: There is a severe disease or significant deterioration. Major surgery is planned in a patient with significant respiratory comorbidities. Right heart failure is present – dyspnoea, fatigue, tricuspid regurgitation, hepatomegaly and oedematous feet. The patient is young and has severe respiratory problems (indicates a rare condition)

25. Gastrointestinal Disease Patients are advised not to take solids within 6 hours and clear fluids within 2 hours before anaesthesia to avoid the risk of acid aspiration syndrome In patients with liver disease, the cause of the disease needs to be known, as well as any evidence of clotting problems, renal involvement and encephalopathy. Elective surgery should be postponed until any acute episode has settled (e.g. cholangitis)

26. Patients with hiatus hernia, obesity, pregnancy and diabetes are at high risk of pulmonary aspiration, even if they have been NBM before elective surgery. Clear antacids, H2-receptor blockers, e.g. ranitidine, or proton pump inhibitors, e.g. omeprazole, may be given at an appropriate time in the preoperative period.

27. Genitourinary Disease Underlying conditions leading to chronic renal failure, such as DM, HTN and ischaemic heart disease, should be stabilised before elective surgery UTI should be treated before embarking on elective surgery For emegency procedures, antibiotics should be started and care taken to ensure that pt maintains good urine output before, during and after surgery

28. Endocrine Disorders Diabetes and associated cardiovascular and renal complications should be controlled to as near normal level as possible before elective surgery HbA1c should be checked Patients with DM should be first on the operating list and if they are operated on in the morning advised to omit the morning dose of medication and breakfast

29. Coagulation Disorders Patients with a strong family history or previous history of thrombosis should be identified Pateints with a low risk of thromboembolism can be given thromboembolism-deterrent stockings High risk patients with a history of recurrent DVT, pulmonary embolism and arterial thrombosis will be on warfarin

30. Warfarin should be stopped before surgery and replaced by low molecular weight heparin or factor Xa inhibitors

31. Pre anesthetic evaluation Airway evaluation 1. Appearance(beard,size of neck,fat on face) 2. Atlanto-occipital joint movement 3. Neck joint movement 4. Mouth opening 5. Mentohyoid/mentothyroid distance 6. Mallahampati Grading

32. Pre anesthetic order 1. written informed consent 2. Pre-op medication 3. NPO 4. orders regarding previous medication

33. Orders regarding previous medication 1. oral anti-hypertensive drugs- continue till the day of surgery 2. oral hypoglycemic drugs -minor/intermediate surgery: stop 24 hours prior -major surgery: stop 24 hours prior and put patient on insulin

34. 3. Anti-psychotic/depressant/epileptic -cotinue till day of surgery except TCA stop 21 days prior and lithium stop 24-28 days prior 4. Throid medication cotinue till day of surgery

35. 5. Anti coagulants -Aspirin: continue till day of surgery -clopidegrol: stop 7 days prior -ticlopidine: stop 14 days prior -warfarin: stop 3-4 days prior -LMWH: stop 12-24 hour prior -unfractioned heparin: stop 6 hour prior

36. Preoperative assessment in emergency surgery Assessment should be the same as in elective surgery, except that the opportunity to optimise the condition is limited by time constraints. Medical assessment and treatments should be started (e.g. as per Advanced Trauma Life Support guidelines) even if there is no time to complete them before the start of the surgical procedure. Some risks may be reduced but some may persist and, whenever possible, these need to be explained to the patient.

37. Start: Similar principles to that for elective surgery Constraints: Time, facilities available Consent: May not be possible in life-saving emergencies Organisational efforts: For example, local/national algorithms for treatment of the patient with multiple injuries

38. Risk assessment and consent Risks: related to comorbidities, anesthesia 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

39. A practical approach to the care for the high-risk patient Identify the high-risk patient Assess the level of risk Detailed preoperative assessment Adequate resusciatation

40. Optimise medical management Investigation to define the underlying surgical problem Immediate and definitive treatment of underlying problems Consider admission to a critical care facility postoperatively

41. Arranging Theatre List The date, place and time of operation should be matched with availability of personnel Appropriate equipment and instruments should be made available The operating list should be distributed as early as possible to all staff who are involved in making the list run smoothly

42. American society of Anaesthesiologists system

43. Consent Consent should be both voluntary and informed The guidance outlines the key principles of consent and how the discussion should: give the patient the information required to make a decision; be tailored to the individual patient; explain all reasonable treatment options; discuss all material risks.

44. Furthermore, the guide explains that consent: should be written and recorded on a form; the key points of the discussion should be recorded in the case notes

45. Consent should be voluntary and informed Supported decision-making is considered good practice Explain all treatment options and material risks Capacity is needed for a patient to give their consent

46. Skin preparation Preopeartive skin preparation reduces the number of transient and commensal microorganisms Common solutions include povidone-iodine scrub (betadine), chlorhexidine alcohol scrub, isoprpyl alcohol A multi-institutional randomized comparison of chlorhexidine alcohol versus povidone-iodine scrub and paint for clean-contam_x0002_inated surgeries found a lower rate of SSI in the chlorhexidine-alcohol group (9.5% versus 16.1%).

47. Hair removal prior to incision can improve exposure and allow skin marking Hair should not be removed at the operative site unless the presence of hair will interfere with the operation. Do not use razors. If hair removal is necessary, remove hair outside the operating room using clippers

48. Elimination Ezivac enema Peglec (before major G.I suregry) Urinary voiding before surgery

49. Preparing the person on the day of surgery Tell the patient to remove jewelry, makeup, hairpins, nailpolish perform mouth care ask the patient void put on surgicl gown and cap

50. Antibiotic prophylaxis Timing: Historic data from early 1990, lowest rate of surgical wound infection was associated with antibiotic administration within 2 hours prior to incision, compared to earlier or postoperative administration.

51. Recent trial shows the lowest infection risk when antibiotic were administered within 30 minutes of incision or between 31 and 60 minutes before incision

52. References Sabiston Textbook Of Surgery 21st edition Bailey & Love 26th edition Pubmed

53. THANK YOU