preoperative care for gyecologic patient
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preoperative care for gyecologic patient preoperative care for gyecologic patient Presentation Transcript

  • SEMINAR TITLE: PRE OPERATIVE CARE FOR GYNECOLOGIC PATIENT Prepared by :mekonnen mengistu and mengistu kassa Moderator: Dr samartha
  • OUTLINE • INTRODUCTION • PREOPERATIVE EVALUATION HISTORY PHYSICAL EXAMINATION ANESTHESIOLOGIC EXAMINATION INVESTIGATION • PREOPERATIVE PREPARATION
  • INTRODUCTION • Preoperative care is the preparation and management of a patient prior to surgery. • It includes both physical and psychological preparation. • Surgical treatment of the patients with gynecologic diseases is warranted only when all the conservative treatment approaches have been exhausted.
  • • Many postoperative problems can be anticipated preoperatively, and eliminated or minimized. • There are two groups of indications for gynecological surgery: Absolute - when surgery must be undertaken, when its cancellation is life threatening. Relative - when surgery can be postponed till the most appropriate occasion for its performing.
  • • The surgeon is obliged to introduce to the patient all the reasons of the surgical treatment. INFORMED CONCENT: • The patient must submit an informed written consent to confirm that she takes the risk of the planned surgical treatment. • discussion regarding consent should be held with a qualified interpreter present.
  • • The presence of an interpreter should be included in the documentation. • The informed consent discussion should include the following: – Rationale – Complications – Unexpected findings at surgery – Personnel who will be involved in the surgery. – Documentation
  • PREOPERATIVE EVALUATION • Used to addresses issues that will potentially affect the woman during her surgical procedure and recovery. • The surgeon should use this time to review: – the patient's history – physical examination – identify physical limitations
  • – gather information required to plan surgery – optimize medical status, and – educate about what to expect from the procedure and during the recovery period. Patient history • A comprehensive history is the first step helping surgeons to determine the scope of general physical examination, laboratory, and radiologic tests.
  • • The patients undergoing minor surgery can be examined by their surgeon and anesthesiologist on the operation day during preoperative preparation but • those with more serious conditions should be examined at least a week before surgery, allowing the time for risk assessment, specialist consultations, and preparation.
  •  General medical history: includes • Personal and family diseases • History of drug use • Allergies to drugs, foods, and other environmental allergens • Hospitalizations • Earlier diseases (including previous operations and tolerance of anesthetics). • Important family data refer to malignancies, cardiovascular diseases, diabetes mellitus, cerebrovascular diseases, and osteoporosis.
  • Gynecologic and obstetric history • should contain the data about major complaints of the current disease (beginning, duration, symptoms). • past pregnancies (description of each, duration, complications, type of delivery)
  • • menstrual cycle data (intervals, duration, copiousness, dysmenorrhea, premenstrual syndrome, intermenstrual bleeding) • menarche; data on the last menstruation • if the patient is age at menopause, recent vaginal bleeding, vasomotor symptoms, hormone replacement therapy.
  • • birth control (if sexually active - active contraception, methods in the past; if sterilized - time and mode of sterilization). • sexual history • birth control (conception difficulties, infertility treatment) • infections (vaginal discharge, previous vaginal infections, sexually transmitted diseases).
  • Clinical (physical) examination • The aim of the physical examination is to establish the physical, health status, in view of history and medical condition. • Full physical examination is needed. • detailed exam of the abdomen and pelvis, as the main component of the procedure.
  •  Anesthesiologic preoperative examination • An anesthesiologist has to examine the patient before her operation.why? – b/c it helps him to get an insight into the general health condition, and – to assess whether the patient is able to tolerate the risks and duration of anesthesia for the planned surgery. • A special stress is put on the state of consciousness and vital functions of the heart, blood vessels, liver, and kidneys.
  •  Anesthesiologic surgical risk is assessed based on the assessment of physical status created by the American Society of Anesthesiology – ASA: • Group I- original disease, if it is without a systemic im-pact • Group II - moderate systemic disease without functional impediments • Group III - severe systemic disease with serious functional impediments • Group IV- severe systemic life-threatening disease
  • • Group V- moribund patient, with 24 hours; and • Group VI- confirmed brain death  INVESTIGATION • Preoperative indications for laboratory tests – Patient age – diagnosis of the disease and – risk of the procedure with careful and detailed history and physical examination.
  • • blood group determination • complete blood count with the leukocyte formula, sedimentation, bleeding and coagulation time, thrombocytes, fibrinogen. • Renal function test • liver function test • Blood glucose level • General analysis of the urine and urine culture
  • • Pregnancy test  Pregnancy testing should be performed shortly before surgery on all fertile women who could be pregnant. • Imaging studies  are often performed to select patients who will not benefit from surgery (eg, metastatic disease) or  to help biopsy tissue for diagnosis of suspicious masses
  • • Imaging study includes     An intravenous pyelogram (IVP) Computed tomography (CT) magnetic resonance imaging (MRI), and Ultrasound NB:Preoperative chest x-rays should not be routinely performed. • Investigation specific to patients problem.
  • PREOPERATIVE PREPARATION • It is important to allow adequate time for preparation prior to surgery. This includes: 1-Correction of anemia: Strategies to correct anemia preoperatively are: Iron supplementation  Medical treatment of abnormal uterine bleeding  Erythropoiesis-stimulating agents  Blood transfusion
  • 2-Smoking cessation:  Patients undergoing elective surgery should be advised to stop smoking at least eight weeks before surgery.  Preoperative smoking cessation may decrease wound complications, particularly wound infection.
  • 3-Medical consultation and stabilization  The consultant should be asked specific questions, such as is thyroid replacement adequate  hypertension well controlled CHD optimally managed, and diabetes under control
  • 4-Bowel preparation:  The gynecologic surgery literature does not address the safety and efficacy of mechanical bowel preparation.  In general, you can expect to:  Modify the diet Take a laxative or bowel preparation medication  Increase fluid intake
  • 5-preoperative antibiotics:  Provision of optimal local immunity to infection is primarily a surgical task.  A single dose of antibiotic immediately before the operation is sufficient for most surgical procedures.  If the operation is going to take more than 3 hours, administration of antibiotics should be repeated.
  • • In time consuming interventions intramuscular administration of antibiotics is preferred. • Prophylactic use of antibiotics have been demonstrated to be more successful for vaginal compared to abdominal operations. • Adequate use of antibiotics is able to reduce the rate of infections, as well as morbidity and associated costs .
  • Recommendation for choosing antibiotcs in postoperative infection prophylaxis: • Cephalosporins first generation: up to 2,0 grammes • Metronidazole 0,5 - 1,0 grammes + gentamicin 1,5 mg/kg iv. • Clindamycin 600 - 900 mg iv + Gentamicin 1,5 mg/kg • Ciprofloxacin 400 mg iv
  • Thromboprophylaxis:  reduces the incidence of symptomatic DVT or pulmonary embolism.  Types of thromboprophylaxis — pharmacologic or  mechanical
  •  Pharmacologic prophylaxis includes Low-dose unfractionated heparin (LDUH) — 5000 units subcutaneously (SC) every 8 to 12 hours. Low molecular weight heparin (LMWH) — Dalteparin 2500 units or enoxaparin 40 mg SC daily. NB: The use of aspirin for prophylaxis is NOT recommended, as other measures are more efficacious.
  • • Mechanical methods of thromboprophylaxis are placed on the patient just prior to the start of surgery and used continuously until hospital discharge. • Most commonly used methods in gynecologic surgery are: Intermittent pneumatic compression boots (IPC) Graduated compression stockings (GCS)
  • Which patients need thromboprophylaxis?  The ACCP recommendations for women undergoing gynecologic surgery are:  Low risk (ie, minor surgery in mobile patients) AND/OR entirely laparoscopic procedures with NO additional VTE risk factors — Do not require specific prophylaxis, but early and frequent ambulation is advised.  Entirely laparoscopic procedures WITH additional VTE risk factors — Mechanical, pharmacologic thromboprophylaxis, or both.
  • Major gynecologic surgery for benign disease with NO additional risk factors — IPC or pharmacologic thromboprophylaxis. Major gynecologic surgery for malignancy AND/OR in patients WITH additional risk factors — Pharmacologic therapy (LDUH should be given every eight hours). Patients who have undergone major surgery for malignancy AND/OR have a previous history of VTE should continue LMWH for up to 28 days.
  • CONCLUSION • Preoperative patient preparation for gynecologic surgery is to avoid or minimize both intra and postoperative complications, and enabling a successful outcome of surgery.
  • Reference • Up to date 19.3; Preoperative evaluation and preparation of women for gynecologic surgery. Author:William J Mann, Jr, MD. • Danforth's Obstetrics & Gynecology, 9th Edition • Clinic of Gynecology and Obstetrics • Bailey & Love’s short practice of surgery 25th ed