Pre-operative Assessment and Preparation By Dr.Rashad Al-Kashgari Associate Professor of Surgery...
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Pre-operative Assessment and Preparation
By
Dr.Rashad Al-Kashgari
Associate Professor of Surgery
2001
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Pre-operative Assessment and Preparation
Why ? How ? When ? What ?
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Pre-operative Assessment and Preparation WHY ?
Elective operation should be performed under optimal condition with full physical and psychological preparation of a fully informed patient.
Emergency operation may have to be done in less than ideal circumstances .
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Pre-operative Assessment and Preparation
HOW ?
History Physical exam Investigation
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Pre-operative Assessment and Preparation
WHEN ?
Out patient visit Pre-operative ward round ER
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Pre-operative Assessment and Preparation
WHAT TO DO ?
Six tasks To explain to the patient / relative the nature of the illness ,
implications of surgery and prognosis Identification of potential operative mortality and
postoperative morbidity To assess the fitness for operation Identification of the risks of potential postoperative
complications and prophylactic measures . Planning of operation and consent .
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Task one
Nature of surgery Implication of surgery Alleviate fear/anxiety of the patient Prognosis
To explain to the patient / relative
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Task two
Look for the risk factors?
Identification of potential operative mortality and morbidity
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Risk factors of mortality and morbidity
Myocardial infarction
Pregnancy
Thrombogenic drugs Smoking Previous anesthetics Allergies
Avoid op.whenever possible for at least 6 months
Elective op. is avoided.Risk of miscarriage & teratogenicity
Steroids & pills
Suxamthonium/halothane Penicillin/Iodine-containing drugs
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Task three
Assessment of general condition Assessment of metabolic state Assessment of cardiovascular system Assessment of respiratory system Assessment of renal system
To assess the fitness for operation
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Assessment of general condition
Careful clinical exam. Pulse rate B.P.
Full blood count Serum urea & electrolytes Blood group & save serum X-match blood if needed
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Assessment of metabolic state
Height Weight
Problems associated with obesity :
Venepuncture Anatomical landmarks Respiratory problems Thromboembolism Wound infection Wound dehiscence
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Assessment of cardiovascular system
Clinical exam of heart and vessels
ECG Echocardiogram
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Cardiovascular conditions
Hypertension Myocardial ischaemia
Cardiac arrhythmias Valve disease/septal
defect Hypovolemia
Increase risk of CVA/MI Avoid techniques /drugs which
increase heart rate/diastolic B.P/perfusion gradient
Discuss with cardiologist pre-op Cover with antibiotics
Restore blood volume pre-op
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Assessment of respiratory system
Clinical exam of chest CXR Sputum for bacteriological
exam Blood gases Pulmonary function tests:
FEV1 FVC
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Respiratory conditions
Chronic bronchitis
Asthma
Brochiectasis
Common cold
Suffer HYPOXEMIA.DO blood gases High risk patients-consider only for urgent op
. At risk of post-op respiratory failure.Give
bronchodilator. Best index: FEV1/FVC X100
Physiotherapy + Antibiotics (use local blocks instead of general anaesthesia)
Cancel op. in acute phase
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Assessment of renal system
Clinical examination Urinanalysis & microscopy Urine for microbiological
examination Serum urea Serum creatinine
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Renal disorders
Chronic retention
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Identification of risks of potential post operative complications and prophylaxis
Pulmonary collapse and infection
Cardiac complications
Acute renal failure characterized by: (oliguria, dilute urine , & urea conc.<300 mmol/l)
Pre-op breathing exercises
Avoid excessive fluid post-op in all patients with cardiac ischemia or valvular disease
Major causes are hypovolemia, sepsis, jaundice and mismatched blood
Task four
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Identification of risks of potential postoperative complications and prophylaxis (continue)
Venous Thrombosis
Wound infection
Avoid compression of legs during and after op.
If necessary,use graded compression stocking / low dose heparin 5000 I.u Q.12 hrs OR a single dose of LMW heparin
Prophylactic antibiotics (Bactericidal best guess for offending organism,high doses,three doses..when?
Task four (continue)
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Planning of the operation
The operation should be properly named after full explanation to the patient and the side of operation is marked in case of bilateral parts.
He/she should consent for it. The duration of hospital stay,convalescense
and time off work should be indicated.
Task five
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CONSENT
Explain to the patient in simple non medical language what is going to be done.
Alleviate his/her fears. Do not deceive the patient. Reassure the patient
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Pre-operative orders Keep NPO (Nil per Oral) from ??:00 hrs Medications
Essential Prophylaxis
Prepare area for surgery Cleaning Shave Enema Etc
Task six