Preoperative Preparation for Surgery

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بسم الله الرحمن الرحيم لخلق السموات والأرض أكبر من خلق الناس ولكن أكثر الناس لا يعلمون غافر غافر

Preoperative Preparation of patients for Surgery:

Preoperative Preparation of patients for Surgery Prepared by Dr. Umer Mustansir Bhatty

Preoperative preparation for surgery:

Preoperative preparation for surgery Contents Introduction Pre-operative care Pre-operative investigations Assessment of risk for surgery Preparation for surgery of specific patient groups Consent

Preoperative Preparation for Surgery:

Preoperative Preparation for Surgery Introduction To obtain satisfactory results in general surgery requires a careful approach to the preoperative preparation of patients . Specific patient groups have specific needs. High risk patients should be identified early and appropriate measures taken to reduce complications.


Overview The preoperative consultation and evaluation is an important interaction between the patient and the physician. It allows the surgeon to: carefully assess the medical condition; evaluate the patient's overall health status; determine risk factors against the procedure; educate the patient & discuss the procedure in detail.

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It helps the patient to: gain a realistic understanding of the proposed surgery; consider alternative treatment options & realize the possible complications during the preoperative period. The additional time invested in a preoperative evaluation yields an improved patient physician relationship and reduces surgical complications.

Preoperative Preparation for Surgery:

Preoperative Preparation for Surgery Prior to consideration of surgical intervention, it is necessary to prepare the patient as fully as possible so as to optimize him according to his co-morbities if any The extent of pre-operative preparation will depend on the:

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Pre-operative preparation situation Nature of surgery ( minor or major ) Location of surgery Facilities available

Preoperative Preparation for Surgery:

Preoperative Preparation for Surgery Situation Emergency :life-threatening condition requiring immediate action,(e.g. ruptured aneurysm, penetrating trauma) Urgent : surgery required within a few hours (e.g. appendicitis , wound debridement) Elective (e.g. hernia ,varicose vein)

Preoperative Preparation for Surgery:

Preoperative Preparation for Surgery The rational for pre-operative preparation is to: Anticipate difficulties Make advanced preparations and organize facilities, equipment and expertise Enhance patient safety and minimize chances of errors Relieve any relevant fear/anxiety perceived by patient

Routine Preoperative Preparation for Surgery:

Routine Preoperative Preparation for Surgery History Physical examination Special investigation Informed consent Marking the site/side of operation Thromboembolic prophylaxis Antibiotic prophylaxis

Surgical History :

Surgical History History taking is detective work. Preconceived ideas, snap judgment and hasty conclusions have no place in this process. Do not be in any doubt that a good history is not vital. If you embark on surgical treatment concentrating on a localized lesion you will be unprepared if complications developed. If you take the wrong diagnostic path all the rest of your activities get misdirected .

Surgical history:

Surgical history Presenting complaint dictates urgency, it can influence anesthetic management & any associated systemic effects of presenting pathology. Systemic assessment carefully assess each body system about its function to rule out if any other system is involved.

Surgical history:

Surgical history Past medical & surgical Hx Many diseases have direct effect on the general and anesthetic treatment and outcome ( cardiovascular and respiratory system) Any previous operation or bleeding tendency Any previous reaction to anesthetic agent Drugs &allergic Hx Interaction with anesthesia (MAOI) Related with sudden withdrawal (steroids) Drugs for HTN ,IHD to be continued over preoperative period Anticoagulant drugs (aspirin, warfarin) HRT

Surgical history:

Surgical history Family Hx Malignant hyperthermia Pseudochlinesterase deficiency. SCA Bleeding disorders Social Hx Smoking Short-term nicotin inc. myocardial o2 demand &co dec o2 delivery Long-term dec immune function , dec clearance of secretion

The physical examination:

The physical examination This includes a full physical Ex. Don’t rely on the examination of others One should acquire the habit of performing a complete Examination in exactly in the same sequence; No step is omitted and added advantage of familiarizing what is normal so that abnormalities can be more recognized Surgical signs may change and others may miss important pathology. What mind doesn't know eyes don’t see.

The physical examination:

The physical examination General Ex. Including vitals (BP, Pulse, RR, Temp) Cardiac Ex.(JVP, HS) Respiratory Ex.(trachea, accessory ms, percussion ,auscultation) Abdominal Ex. CNS Musculoskeletal Ex Peripheral vasculature Local Ex Body orifices If u don’t put your finger u will put your foot

The emergency physical examination :

The emergency physical examination The routine examination must be altered to fit the circumstances A,B,C,D,E,F Secondary survey(head-to-toe) When a number of emergencies present at the same time you must apply triage Loss of life is more important than loss of a limb .

Pre-operative investigations :

Pre-operative investigations It is worthwhile when its requested in order to answer a specific question or confirm an important clinical impression prior to intervention Investigations are performed for a number of reasons ,but all should share the feature of directing management

Pre-operative investigations:

Pre-operative investigations Exclusion of alternative dx Confirmation of dx Risk to others Assessment of fitness for surgery Medicolegal consideration To know the extent of disease

Pre-operative investigations: Blood tests :

Pre-operative investigations: Blood tests Full blood count (when to perform ?) All emergency Pre-operative cases All elective Pre-operative cases over 60 years All elective Pre-operative cases in adult females If surgery likely to result in significant blood loss Suspicion of blood loss, anemia,sepsis,CRD,coagulation problems

Pre-operative investigations Blood tests:

Pre-operative investigations Blood tests Urea &electrolytes(when to perform?) All Pre-operative cases over 65 All patient with cardiopulmonary disease. Or taking diuretics, steroids All patients with H/O renal/liver disease or abnormal nutritional state All patients with H/O diarrhea/vomiting or other metabolic/endocrine dis. All patients with IVF for more than 24hr’s Incidence of unexpected abnormality in apparently fit pt under 40 yr’s is <1%

Pre-operative investigations Blood tests:

Pre-operative investigations Blood tests Amylase Perform in all adult emergency admissions with abdominal pain, prior to consideration of surgery. RBG Acute abdomen Elective cases with DM, malnutrition, obesity Elective cases over 60

Pre-operative investigations Blood tests:

Pre-operative investigations Blood tests Clotting ; PT inc. with warfarin , liver diseases; , DIC APTT inc Heparin Hemophilia A and B BT inc .platelet low or dysfunction Liver function tests All patients with upper abdominal pain ,jaundice, hepatic disease Alcoholic Screening for Hepatitis B and Hepatitis C

Pre-operative investigations Blood tests:

Pre-operative investigations Blood tests Group and save /cross match Emergency pre-operative case Suspicion of blood loss, anemia, coagulation defects Procedure on pregnant ladies

Pre-operative investigations Imaging :

Pre-operative investigations Imaging Chest x-ray (when to perform ) All elective pre-operative cases over 60 yr’s All cases of cervical,thoracic or abdominal trauma. Acute respiratory symptoms or signs Previous CRD and no recent CXR Thoracic surgery Malignant dis. Viscus perforation Recent H/O TB Thyroid enlargement

Other Investigations::

Other Investigations: (Performed according to requirement) ECG Ultrasound CT Scan MRI Duplex Scan… Etc..

Assessment of risk for surgery:

Assessment of risk for surgery There are few patients who have no risk factor for surgery It is important to quantify the risks involved so they can be discussed with the patient; Two main prognostic scoring systems which are in current use are: APACHE SYSTEM ASA SYSTEM

Prognostic scoring system:

Prognostic scoring system It helps to predict the outcome of patients admitted to ICU and it has subsequently been applied to patients under going surgery APACHE II system Recently APACHE III has been introduced include 5 more physiological variables ( blood urea nitrogen, urine op , albumin , bilirubin and glucose ) and modified version GCS ; 12 acute physiological variables Patient’s age Chronic health points

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APACHE II classification Score is A+B+C A acute physiology score (APS) 1 recent temp. 2 MBP 3 HR 4 RR 5 Fio2 (alveolar arterial o2 gradient 6 Ph 7 serum Na 8 serum k 9 serum creatinine 10 WBC 11HCT % 12GCS B age points graded from <44 to >75 years C chronic health points 2 points for elective post-op admission 5points for Emergency op Non-operative admission Immunocompromised pt Chronicliver,CVD,respiratry or renal disease.

Prognostic scoring system:

Prognostic scoring system ASA system; It is very simple and has been widely adopted 50% of patients presenting for elective surgery are ASA grade I Operative mortality rate for these patients is less than 1 in 10,000

American Society of anesthesiologists ASA grade and predicted mortality :

American Society of anesthesiologists ASA grade and predicted mortality Mortality % Definition ASA GRADE 0.06 Normal healthy individual I 0.4 Mild systemic disease that does not limit activity II 4.5 Sever systemic disease that limits activity III 23 Sever systemic disease that constant threat to life IV 51 Moribund ,not expected to survive 24hrs with or without surgery V

prognostic scoring system GOLDMAN cardiac risk in non -cardiac surgery:

prognostic scoring system GOLDMAN cardiac risk in non -cardiac surgery Age>70 5 MI within 6 month 10 Hx S3 or JVP 11 Aortic stenosis 3 Physical Ex Rhythm other than sinus 7 >5PVCs/min 7 ECG PO2<60 or PCO2>50 K<3.0 or HCO3 <20meq/l 3 Uerea >50 creatinine >3mg/dl Abn . SGOT CLD Poor G/C Intraperitoneal, intrathoracic, aortic surgery 3 Emergency surgery 4 Operation

Preparation for surgery of specific patient groups:

Preparation for surgery of specific patient groups Thormboembolic prophylaxis

Thormboembolic prophylaxis :

Thormboembolic prophylaxis DVT is common in surgical patients. Can cause PE which carries a high mortality should be prevented. 10% of in-patient deaths. Recent surgery, immobilization and trauma were responsible for 50% of DVT(1994) Risk factors

Risk factors for DVT:

Risk factors for DVT Age Obesity Immobility Malignancy Trauma ,post-surgical Dehydration Thrombophilia patients (deficiency of protein C, S), lupus anticoagulant +ve Past history of thromboembolism Oral contraceptives HRT Pregnancy, puerperium


prophylaxis Graded elastic compression stocking Intermittent pneumatic calf compression Electrical calf muscle stimulation Post-operative leg elevation and early ambulation Heparin prophylaxis Other agents affecting blood coagulation (aspirin)

Pre-operative management Consent :

Pre-operative management Consent Details of the diagnosis and prognosis, and prognosis if condition is left untreated Options for management, include the option not to treat A detailed explanation of the proposed procedure, including common and serious side effects (>1%) For each option explanation of risks and benefits The name of the Doctor who will have responsibility for treatment An opportunity for patients and relatives to ask questions A reminder that patients may change their minds and/or seek further opinions

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