PRE OPERATIVE PREPARATION OF A SURGICAL PATIENT.pptx

Preoperative preparation of a surgical patient

1. PRE OPERATIVE PREPARATION OF A SURGICAL PATIENT GUIDED BY : DR TEJASVI KUMAR C PRESENTED BY : Dr. Amrit preetam panda

2. DEFINITION The preoperative period extends from the time the patient is admitted to the hospital to the time the surgery begins The preoperative preparation of the surgical patient serves to evaluate and optimize comorbidities in order to minimize morbidity and mortality during and immediately following the surgical procedure.

3. INTRODUCTION It is important for the surgeon to explain the context of the illness and the benefit of different surgical interventions, further investigation, possible nonsurgical alternatives when appropriate, and what would happen if no intervention were undertaken. The surgeon’s approach to the patient and family during the initial encounter should foster a bond of trust and open a line of communication among all participants. A professional and unhurried approach is mandatory, with time taken to listen to concerns and answer questions posed by the patient and family members.

4. PRE OPERATIVE ASEESSMENT History taking Examination Investigations Preoperative treatment Documentation Communication n consent

5. HISTORY TAKING (PHOTO)

6. 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)

7. PAST MEDICAL HISTORY

8. EXAMINATION OF THE PATIENT Patients should be treated with respect and dignity, receive a clear explanation of the examination undertaken and kept as comfortable as possible. An female attendant should always be present while examination of any female patients.

9. EXAMINATION SPECIFIC TO SURGERY This is the local examination Its divided to INSPECTION, PALPATION, PERCUSSION, AUSCULTATION

10. INVESTIGATIONS

11. INVESTIGATIONS Full blood count : to exclude anemia , platlets count and to assess how much blood is required during or after operations Urea, creatinine , electrolytes: state of dehydration and any renal insufficiency Urine analysis: to detect any urinary infection,inflammation,glycosuria , metabolic disorders Hiv , hbsag testing Rbs and hb1ac: for diabetes Chest radiography : The ASA does not recommend routine CXRs but does recommend consideration for obtaining CXRs in patients who are smokers, have had recent upper respiratory tract infections, have chronic obstructive pulmonary disease (COPD), and have heart disease. Ecg : its required in all patients above 60 years in patients having any pathology in cvs , respi , or diabetes

12. INVESTIGATIONS (cont..) Clotting screen : If a patient has a history suggestive of bleeding diathesis, liver disease, eclampsia, cholestasis or has a family history of bleeding disorder, or is on antithrombotic or anticoagulant agents, then coagulation screening will be needed. Upt test : it should be done in all women of child bearing age Lft : These are indicated in patients with jaundice, known or suspected hepatitis, cirrhosis, malignancy or patients with poor nutritional reserves ABG: it allows detailed assessment of respiratory problems and acid base disturbances Other investigations : Further relevant investigations should be undertaken to assess capacity of specific organ system and risks associated.

13. TREATMENT CHART

14. Cardiovascular system Patients who can climb a flight of stairs without getting short of breath or having chest pain, or indeed stopping have a lower risk of perioperative morbidity and mortality of cardiovascular origin than those who cannot. HYPERTENSION : Prior to elective surgery, blood pressure should be controlled to near 160/90 mmHg. If a new antihypertensive is introduced, a stabilisation period of at least 2 weeks should be allowed. ISCHEMIC HEART DISEASE : recent mi is a strong contraindication to surgery, elective surgeries are postponed 3 to 6 months after proven mi Patients may have had coronary stents inserted for IHD and should be asked about effectiveness of the treatment, concurrent antiplatelet medications, e.g. clopidrogel and/or aspirin. Their INR status should be evaluated and antiplatelet drugs should be stopped after consulting a cardiologist Warfarin in patients with atrial fibrillation should be stopped 5 days preoperatively to achieve an INR (international normalized ratio) of 1.5 or less, which is safe for most surgery;

15. Anemia and blood transfusion Patients found to be anaemic at preoperative assessment should be treated with iron and vitamin supplements. If hb is less than 8 gm/dl blood should be transfused If excessive bleeding is expected, then a preoperative ‘group and save’ should be performed and an appropriate number of units of blood crossmatched .

16. Respiratory system Infection : to be treated completely before surgery Asthma : establish the severity and the course of illness, do pft , patients usual inhalers should be continued COPD : preoperative xray , abg analysis,if fev1 is below 30% of predictive value chest physician should be refered to optimise their condition

17. Renal diseases Renal failure :Appropriate measures should be taken to treat acidosis, hypocalcaemia and hyperkalaemia of greater than 6 mmol /L. arrangements for dialysis before and after surgery should be made UTI : Uncomplicated urinary infections are common in women, while outflow uropathy with chronically infected urine is common in men. These infections should be treated before embarking on elective surgery. Antibiotics should be started and the urine output monitored

18. Endocrine and metabolic disorders Nutritional status : A BMI of less than 18.5 indicates nutritional impairment and a BMI of less than 15 is associated with significant hospital mortality. Nutritional support for a minimum of 2 weeks before surgery is required to have any impact on subsequent morbidity. Morbid obesity is defined as BMI of more than 35 and is associated with increased risk of postoperative complications. Patients should be made aware of risks involved and encouraged to lose their weight. Diabetes : Diabetes and associated cardiovascular and renal complications should be controlled to as near normal level as possible before embarking on elective surgery. Patients with diabetes 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. Adreno corticoid suppression : Patients receiving oral adrenocortical steroids should be asked about the dose and duration of the medication in view of supplementation with extra doses of steroids perioperatively to avoid an Addisonian crisis

19. RISK FACTORS FOR THROMBOSIS Age >60 years Obesity: body mass index (BMI) >30 kg/m2 Trauma or surgery (especially of the abdomen, pelvis and lower limbs), anaesthesia >90 minutes Reduced mobility for more than 3 days Pregnancy/puerperium Varicose veins with phlebitis Drugs, e.g. oestrogen contraceptive, hormone replacement therapy (HRT), smoking Known active cancer or on treatment, significant medical comorbidities, critical care admission Family/personal history of thrombosis, e.g. deficiencies in antithrombin III, protein S and C

20. COAGULATION DISORDERS Patient having family or previous h/o thrombosis should be identified. They will need prophylaxis in the perioperative period OCP, HRT should be stopped 6 weeks before surgery however progesterone only pill can be allowed to continue Patients with a low risk of thromboembolism can be given thromboembolism-deterrent stockings to wear during the perioperative period. Patient on warfarin treatment should be stopped before surgery and replaced by low molecular weight heparin or factor Xa inhibitors

21. CENTRAL NERVOUS SYSTEM In patients with a history of stroke, pre-existing neurological deficit should be recorded. If the patient is on anti platelet drugs like asprin or clopidrogel then they should be stopped If the risk of thromboembolism is high then asprin can be allowed The anticonvulsant medicines and anti parkinsonism medicines is continued perioperatively Lithium should be stopped 24 hours prior to surgery and the blood levels should be measured The anaesthetist should be informed if patients are on psychiatric medications such as tricyclic antidepressants or monoamine oxidase inhibitors, as these may interact with anaesthetic drugs

22. AIRWAY ASSESSMENT The ability to intubate the trachea and oxygenate the patient are basic and crucial skills of the anesthetist The ease or difficulty in performing airway manoeuvres can be predicted by simple examination findings of full mouth opening (modified Mallampati class)

23. NPO / NBM The standard order of “NPO past midnight” for preoperative patients is based on the theory of reduction of volume and acidity of the stomach contents during surgery. Hence a ppi is also given in the night n morning to further decrease the acid secretions The ASA recommends that the adults should stop intake of solid foods atleast 6 hours and clear fluids for 2hrs before the surgery. Pediatric patients should fast from human breast milk for 4 hours and from infant formula for 6 hours prior to the start of anesthesia . A clear liquid includes water, coffee,or tea without dairy; clear fruit juice without pulp; and clear carbonated beverages. These recommendations include fasting before administration of anesthesia regardless of type of anesthetic—general, regional, or monitored anesthesia care.

24. CLASS OF WOUNDS

25. ANTIBIOTIC PROPHYLAXIS Appropriate antibiotic prophylaxis in surgery depends on the most likely pathogens encountered during the surgical procedure Prophylactic antibiotics are generally NOT required for clean (class I) cases except in the setting of indwelling prosthesis placement or when bone is incised. Patients who undergo class II procedures benefit from a single dose of an appropriate antibiotic administered before the skin incision Contaminated (class III) cases require mechanical preparation or parenteral antibiotics with aerobic and anaerobic activity. Dirty or infected cases often require the same antibiotic spectrum, which can be continued into the postoperative period in the setting of ongoing infection or delayed treatment The appropriate antibiotic is chosen before surgery and administered within 60 minutes before surgical incision Repeat dosing occurs at an appropriate interval, usually 3 hours for abdominal cases or twice the half-life of the antibiotic

26. PRE-OPERATIVE CHECKLIST The preoperative evaluation concludes with a review of all pertinent studies and information obtained from investigative tests. This review is documented in the chart, which represents an opportunity to ensure that all necessary and pertinent data have been obtained and appropriately interpreted. Informed consent after discussion with the patient and family members regarding the indication for the anticipated surgical procedure and its risks and proposed benefits is documented in the chart. The preoperative checklist also gives the surgeon an opportunity to review the need for beta blockade, DVT prophylaxis, and prophylactic antibiotics.

27. Pre operative assessment in emergency surgeries In urgent or emergency surgery, the principles of preoperative 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. according to the Advanced Trauma Life Support (ATLS) guidelines) even if there is no time to complete those before the surgical procedure is started. Some risks may be reduced, but some may persist and whenever possible these need to be explained to the patient (Summary box 16.6).

28. SUMMARY As our medical capabilities and knowledge expand, our surgical population grows more complex. Today our perioperative patients have more comorbidities than ever before. Similarly, the preoperative preparation of our patients is more important than ever. Our common goal is to safely get these patients into and out of the operating room. A robust and detailed history should be taken Gather and record all relevant investigations Optimise the patient condition Choose a surgery that offers minimal risk and maximal benefit Anticipate and plan for adverse events based on the patient’s comorbidities Inform to everyone concerned

29. REFERENCES Bailey and love’s short practice of surgery ,26 th edition Faraqsons textbook of operative surgery Sabiston textbook of surgery Current surgical therapy by james cameron

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