Preoperative Evaluation.pptx

perioperative evaluation of surgical patients

1. Preoperative Evaluation

2. Goals 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

3. Patient assessment History Taking Ask for chief complaints with duration History of present illness History of past illness Personal history Family history Treatment history History of any Allergy

4. General examination Built/Nutritional status Pulse Blood pressure Respiratory rate Temperature

5. Pallor Clubbing Oedema Jaundice Neck veins (any visible veins, jugular venous pressure) Neck glands (local lymph node status, salivary glands) Skin (any scar marks, drug abuse injection sites, local infections)

6. Systemic examination Cardiovascular : Pulse, blood pressure, heart sounds , murmurs, bruits , peripheral oedema Respiratory : Respiratory rate and effort, chest expansion and percussion note, breath sounds, oxygen saturation Gastrointestinal : Abdominal masses, ascites, bowel sounds, hernia, genitalia Neurological : Consciousness level, cognitive function, sensation, muscle power, tone and reflexes

7. Investigations The UK National Institute of Health and Clinical Excellence (NICE) guidelines : Full blood count (CBC) Urea and electrolytes (sodium, potassium, bicarbonates) Electrocardiography Clotting screen (PT, APTT, INR) Chest radiography

8. Blood glucose levels (FBS, PPBS) and HbA1c Arterial blood gases Liver function tests (ALT, AST, ALP, bilirubin ) Urinalysis B-Human chorionic gonadotrophin (to exclude pregnancy) Other investigations (as per indications)

9. Preoperative management of patients 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

10. Checklist for optimal preoperative assessment of Geriatric surgical patients Assess Patient’s Cognitive ability Screen for depression Identify risk factors for developing post-op delirium Screen for substance abuse/dependence Cardiac evaluation

11. Pulmonary evaluation Determine baseline Frailty score Document functional status and history of falls Assess patients nutritional status Accurate and detailed medication history Determine patient’s family and social support system

12. Cognitive assessment with Mini-Cog Tell the patient 3 words and ask him to say it, remember it and repeat it later Give 3 tries to patient to repeat. If unable, proceed to next Scoring: 3 items recall (0-3 points) Ask to draw a clock in a circle on a paper and put the numbers in order and set the time to 10 past 11 If subject is unable to finish the clock in 3 minutes; discontinue and ask him to recall the 3 words Clock draw score: (0 or 2 points) Say: “what were the 3 words I asked you to remember?”

13. Functional assessment Functional capacity MET Range Examples Poor <4 Sleeping, writing, watching tv Moderate 4-7 Climbing a flight of steps, slow bicycling Good 7-10 Jogging, aerobics Excellent >10 Rope jumping Functional status is assessed from patient’s activities of daily living”(ADLs) and expressed in metabolic equivalents (METs) 1 MET = avg O2 consumption of a 40yr old male

14. Frailty score Shrinkage Unintentional weight loss>10 past year Weakness Decreased grip strength Exhaustion Self reported poor energy and endurance Low physical activity Low weekly energy expenditure Slowness Slow walking Criteria Definition

15. Systems approach to preoperative evaluation

16. Cardiovascular system Revised Cardiac Risk index : Points H/o ischemic heart disease 1 H/o congestive heart failure 1 H/o cerebrovascular disease ( stroke or TIA) 1 H/o diabetes requiring pre-op insulin use 1 Chronic kidney disease (Sr. creatinine: >2mg/dl) 1 Undergoing suprainguinal vascular, intraperitoneal or intrathoracic surgery 1

17. Risk for cardiac death, non fatal MI, and non fatal cardiac arrest 0 predictors: 0.4% 1 predictor: 0.9% 2 predictors: 6.6% >=3 predictors: >11%

18. Patients who experience MI after non cardiac surgery have hospital mortality of 15%-25% Risk factors : Age>70 yrs Unstable angina Recent MI(<6 mnths ) Untreated CHF Diabetes mellitus Valvular heart disease Arrhythmias Peripheral vascular disease

19. Patients with pacemakers should have them turned to uninhibited mode before surgery Bipolar cautery should be preferred over unipolar Patients with internal defibrillators should have device turned off during surgeries Recent studies, POISE trial suggest that beta blockers reduce peri -operative ischemia, risk of MI and death in high risk patients. Each patients dose should be titrated to achieve adequate benefit from beta blockade while avoiding risk of hypotension and bradycardia

20. Current guidelines are to delay non cardiac surgery at least 6 weeks after coronary angioplasty or stenting Because they require 6 weeks of dual antiplatelet therapy P lacement of drug eluting stents requires 12 months of dual anti platelet therapy Elective surgeries should be postponed for this period

21. Pulmonary system Current respiratory status should be compared with their normal state The following should be noted: regular treatment records of PEFR use of steroids home oxygen and continuous positive airway pressure (CPAP) ventilation evidence of right heart failure

22. Risk factors for pulmonary complications Patient related factors : Age >60yrs COPD CCF OSA Pulm . HTN Smoking Preoperative sepsis Weight loss >10% in 6 months Serum albumin <3.5mg/dl, BUN >21mg/dl, Sr. Creatinine >1.5mg/dl

23. Surgery related factors : Prolonged operation >3hr Site of surgery Emergency operations General anaesthesia Perioperative transfusion Residual neuromuscular blockade after an operation

24. Preoperative interventions that may decrease post-op pulmonary complications are: Smoking cessation (within 2 months of surgery ) --- bailey Current guidelines favor cessation regardless of any time frame Bronchodilator therapy Antibiotic therapy for pre-existing infections Pre treatment of asthmatics with steroids Pulmonary toilet Incentive spirometry

25. Physical examination should be focussed on signs of any lung disease Wheezing Prolonged inspiratory -expiratory ratio Clubbing Use of accessory muscles of respiration A chest XRAY should only be performed for acute symptoms, unless it is indicated for the specific procedure ABG can be considered in patients with H/O lung disease and acid base abnormality PFT is controversial and unnecessary in stable patients

26. Gastro-intestinal system Nil by mouth and regular medications Patients are advised not to take solids within 6 hours Clear fluids (isotonic drinks and water) within 2 hours Infants are allowed a clear drink up to 2 hours mother’s milk up to 3 hours cow or formula milk up to 6 hours ------bailey Patients can continue to take their specified routine medications with sips of water in the nil by mouth period.

27. Regurgitation risk Patients with hiatus hernia, obesity, pregnancy and diabetes are at high risk of pulmonary aspiration even if they have been NPM before elective surgery H2 blockers and PPIs should be administered in such cases.

28. Hepato-biliary system cause of the disease needs to be known any evidence of clotting problems Renal involvement, and encephalopathy Elective surgery should be postponed until any acute episode has settled Ascitis , oesophageal varices, hypoalbuminaemia , sodium and water retention should be noted all these can influence choice and outcomes of anaesthesia and surgery .

29. Genitourinary disease Renal disease Underlying conditions leading to chronic renal failure diabetes mellitus h ypertension ischaemic heart disease should be stabilised before elective surgery Measures should be taken to treat acidosis, hypocalcaemia and hyperkalaemia of greater than 6 mmol/L

30. Laboratory data: Serum electrolytes Serum bicarbonate Blood urea nitrogen Serum creatinine CBC - to evaluate anemia and thrombocytopenia Dialysis should be performed, if indicated, within 24 hrs of planned procedure

31. Risk factors for development of ARF: Elevated preoperative BUN or creatinine CHF Advanced age Intraoperative hypotension Sepsis Use of nephrotoxic and radionucleotide agents Management: Adequate hydration Use of low osmolality contrast agents Bicabonate drip Oral N- acetylcysteine

32. Urinary tract infection Uncomplicated urinary infections are common in women outflow uropathy with chronically infected urine is common in men infections should be treated before embarking on elective surgery For emergency procedures, antibiotics should be started care taken to ensure that the patient maintains a good urine output before, during and after surgery

33. Endocrine and metabolic disorders Malnutrition BMI of less than 18.5 indicates nutritional impairment BMI of less than 15 is associated with significant hospital mortality Nutritional support for a minimum of 2 weeks before surgery Obesity Morbid obesity is defined as BMI of more than 35 Associated sleep apnoea should use a CPAP device If possible, delay surgery until the patients are more active and have lost weight

34. Diabetes mellitus HbA1c levels should be checked Patients with diabetes should be first on the operating list patient’s blood sugar levels should be checked every 2 hours those on the afternoon list breakfast can be given with half their regular dose of insulin or full-dose oral anti-diabetic agents An iv insulin infusion should be started for IDDM undergoing major surgery or if blood sugar is difficult to control

35. Oral hypoglycemic agents should be discontinued the evening before scheduled surgery Long acting agents should be stopped 2-3 days prior Patients undergoing major surgery should recieve ½ of their morning insulin dose and 5% dextrose intravenously Subcutaneous insulin pumps should be inactivated the morning of surgery

36. Adrenocortical suppression Patients receiving oral adrenocortical steroids should be asked about the dose and duration of the medication And should be supplemented with extra doses of steroids perioperatively to avoid an Addisonian crisis.

37. Coagulation disorders Thrombophilia Patients with a strong family history or previous personal history of thrombosis should be identified POPs should be continued, HRT should be stopped 6 weeks prior to surgery antiplatelet agents should be withdrawn (7 days for aspirin, 10 days for clopidogrel ) If high risk of bleeding, aspirin alone should be continued

38. High-risk patients with a history of recurrent DVT, pulmonary embolism (PE) and arterial thrombosis will be on warfarin This should be stopped before surgery and replaced by LMWH (stopped 24hrs prior to surgery) or factor Xa inhibitors

39. For safer surgeries, preoperative INR should be below 1.5 Those with INR between 2.0-3.0, require witholding of medications for 5 days preoperatively UFH should be stopped 24 hrs prior to surgery In emergencies, where anticoagulation cannot be reversed before surgery, FFP must be administered Oral Vit K can also be administered but takes 8hrs for effective action

40. Neurological and psychiatric disorders Anticonvulsant and antiparkinson medication is continued perioperatively to help early mobilisation of the patient Lithium should be stopped 24 hours prior to surgery Blood levels should be measured to exclude toxicity

41. Anaesthetist should be informed well in advance if patient is on anti-psychotics and MAO-inhibitors As these medications interact with the anaesthetics administered H/o seizure disorder or other significant CNS disorder like multiple sclerosis H/o myopathy or other muscle disorders should be recorded

42. Musculoskeletal and other disorders Rheumatoid arthritis unstable cervical spine with the possibility of spinal cord injury during intubation flexion and extension lateral cervical spine x-rays should be obtained Ankylosing spondylitis techniques of spinal or epidural anesthesia are often challenging

43. Systemic lupus erythematosus may exhibit a hypercoagulable state along with airway difficulties Other disorders like: Kyphosis or scoliosis cause functional compromise Temporomandibular joint disorders Cervical or thoracic spine injuries Patients receiving chemotherapy should be recorded

44. Airway assessment Samsoon and Young modified Mallampati test Fauces , pillars, soft palate and uvula seen ----------- Grade 1 Fauces , soft palate with some part of uvula seen ----------- Grade 2 Soft palate seen ----------- Grade 3 Hard palate only seen ----------- Grade 4

45. Preoperative checklist Pre operative evaluation concludes with a review of all studies and information obtained from investigative tests. Informed consent after discussion with the patient and family members is documented Preoperative orders are written and reviewed

46. Appropriate antibiotic prophylaxis depending on the type and site of surgery Antibiotic is administered within 60mins of surgical incision 120 mins for vancomycin and fluoroquinolones Repeat dosing is done usually at 3hrs for long abdominal procedures Careful review of the patients home medication is done (including psychiatric drugs, hormones, and herbal medicines with dosages and frequency)

47. Preoperative shower with chlorhexidine the night prior Preoperative fasting – Standard order of NPO past midnight in order to minimise aspiration of stomach contents Part preparation of the local area by clipping the hairs Xylocaine sensitivity testing Mechanical bowel preparation for abdominal surgeries Anti-anxiety medications on the night before procedure if indicated

48. Thank you