Pre-operative Assessment and Preparation

By

Dr.Rashad Al-Kashgari

Associate Professor of Surgery

2001

Pre-operative Assessment and Preparation

Why ? How ? When ? What ?

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 .

Pre-operative Assessment and Preparation

HOW ?

History Physical exam Investigation

Pre-operative Assessment and Preparation

WHEN ?

Out patient visit Pre-operative ward round ER

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 .

Task one

Nature of surgery Implication of surgery Alleviate fear/anxiety of the patient Prognosis

To explain to the patient / relative

Task two

Look for the risk factors?

Identification of potential operative mortality and morbidity

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

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

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

Assessment of metabolic state

Height Weight

Problems associated with obesity :

Venepuncture Anatomical landmarks Respiratory problems Thromboembolism Wound infection Wound dehiscence

Assessment of cardiovascular system

Clinical exam of heart and vessels

ECG Echocardiogram

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

Assessment of respiratory system

Clinical exam of chest CXR Sputum for bacteriological

exam Blood gases Pulmonary function tests:

FEV1 FVC

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

Assessment of renal system

Clinical examination Urinanalysis & microscopy Urine for microbiological

examination Serum urea Serum creatinine

Renal disorders

Chronic retention

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

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)

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

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

Pre-operative orders Keep NPO (Nil per Oral) from ??:00 hrs Medications

Essential Prophylaxis

Prepare area for surgery Cleaning Shave Enema Etc

Task six