Preop & consent

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Helpful tips for houseman for preparation of patient who are going up for surgery

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Preop & consent

  1. 1. NUR HAZIERAH MUHAMMAD SYAZWAN SUPERVISOR: MR. KUMAR DR CHE AHMAD MUTTAQIN
  2. 2. OUR AIMS (1) identify the patient's medical problems (2) determine if further information is needed to characterize the patient's medical status (3) establish if the patient is medically optimized (4) confirm the appropriateness of the planned procedure
  3. 3. Correct abnormalities Informed consent Details of Preparations Lab Investigations Cross-match blood Physiotherapy Breathing Exercise DVT Prophylaxis Anaesthetic Premedications Principles of Preoperative Preparation
  4. 4. The Assessments Full History Examination Lab Test Radiographs ECG Appropriate Procedure
  5. 5. Risk factors associated with increased perioperative mortality and morbidity  Age > 60 years  Arterial and pulmonary hypertension  Body mass index of <20 kg/m2 or >35 kg/m2  Congestive cardiac failure  Peripheral vascular disease  Diabetes mellitus  Renal insufficiency  Acute coronary syndromes  Chronic pulmonary disease  Neurological disease  Previous cardiac surgery
  6. 6. General Problems in Surgical Patients • Extreme age • Limits: cardiac, repiratory, renal reserve • Smaller doses of narcotics, sedatives & analgesics Age • Affects wound healing • High incidence of respiratory problems • DVT & Pulmonary embolism are common • Bedsores Obesity • Reduced response to trauma & infection • Causes: Immunosuppressive drugs, uremia. Malnutrition or liver disease Compromised Host
  7. 7. General Problems (cont.) • Sensitivity to sedatives, anaesthetic, antibiotic drugs or dressing • Unexpected reaction might occur • Severe cases -> Anaphylactic shock Allergies • Diabetics might need to change to sliding scale • Patient on steroids may need additional cover during major surgery • Adjustment anticoagulant therapy • Warfarin -> Heparin (perioperatively) • Clopidogrel contraindicated in regional anaesthesia (causing epidural hematoma) • Acetylcholine & ATH Inhibitor (Antithrombin + Heparin inhibitor) should stop 24hours before surgery to prevent severe & refractory hypotension Drugs
  8. 8. COMORBIDDISEASE CARDIOVASCULAR DISEASE RESPIRATORY DISEASE & SMOKING MALNUTRITION, ADHESION AND JAUNDICE RENAL DISEASE HEMATOLOGICAL DISEASE OBESITY DIABETES MELLITUS
  9. 9. ASA Physical Status Classification System 1 • A normal healthy patient 2 • A patient with mild/moderate systemic disease 3 • A patient with severe systemic disease which limits activities 4 • A patient with severe systemic disease that is a constant threat to life 5 • A moribund patient who is not expected to survive without the operation 6 • A declared brain-dead patient whose organs are being removed for donor purposes
  10. 10. Routine testsBiochemistry • Electrolytes (Na+, K+), urea, creatinine • Glucose (RBS/CBS) • Liver function tests Haematology • FBC • Coag. studies (PT, APTT, INR) Imaging/Others • CXR • Resting ECG • Pulmonary function tests (spirometry)
  11. 11. PRE-OPERATIVE INVESTIGATIONS Patient status ECG CXR BUSE FBC RBS LFT COAG <50years, ASA 1 No investigations needed >50 years, ASA 1 X >60 years, ASA 1 X X X X Diabetes X X X X HPT, IHD X X X Anemia X Renal disease X X X Liver disease X X X X Haematological disease X X Respiratory disease X Alcohol abuse X On Chemotherapy X On Anticoagulants X Procedures with blood loss >15% X X
  12. 12. PROPHYLACTIC MEASURES AGAINST COMMON POST OPERATIVE COMPLICATONS • Antibiotics before op such as IV Rocephine and Flagyl Surgical infections • Chemical – Heparin • Mechanical –compression stokings DVT • Adequate renal perfusion • Adequate oxygenation Renal failure
  13. 13. REASONS FOR ANESTHETIC REFERRAL Allergy or intolerance to certain substances, drugs or classes of drugs  Documented allergy to anesthetic drugs, analgesics, local anesthetics or muscle relaxants Instability or immobility of the cervical spine  Rheumatoid arthritis, Down’s syndrome, Ankylosing spondylitis  Previous instrumentation of the cervical spine Known or potential difficult airway  Limited jaw opening (temperomandibular joint arthritis, trismus related to oral or submental sepsis, previously wired teeth, facial radiotherapy or burns, previous reconstructive surgery to mandible, tongue or mouth).  Small mandible  Large tongue (acromegaly, morbid obesity)
  14. 14. Difficult venous access  Previous chemotherapy  Abusers of intravenous drugs  Burns to upper limb  Severe and widespread skin disorders (psoriasis, epidermolysis bullosa, pemphigus, pemphigoid)  Morbid obesity Clotting disorders  Treatment with anticoagulant or anti-platelet drugs  Haemophilia and variants  Platelet disorders
  15. 15. ASSESSMENT OF THE LIKELY IMMEDIATE POST-OP COURSE & THUS THE NEED FOR HDU/ICU SUPPORT Circumstance in which patients requiring ICU care postoperatively:-  When an operation causes major physiological disturbances requiring close monitoring and /or organ support (e.g. major surgery)  When an unexpected major medical or surgical complication occurs during surgery, threatening organ dysfunction (e.g. intraoperative haemorrhage and myocardial infarction)  When previous intercurrent disease compromises physiological reserve (e.g. patient with severe COPD undergoes major abdominal surgery)
  16. 16. PART II: SURGICAL CONSENT
  17. 17.  Informed consent serves to identify and respect a patient’s best interest by giving each patient the opportunity to decide autonomously what his/her best interest are in light of the planned procedure. SURGICAL CONSENT
  18. 18. CONSENT  Important because: i) Rights of the patient ii) Patient education iii) Prevent misunderstanding iv) Prevent medico-legal cases
  19. 19. INFORMED CONSENT
  20. 20. INFORMING THE PATIENT
  21. 21. IN GENERAL  Should presented clearly as possible  Include discussion of the diagnosis  Should include explanation of the procedure  Explanation of risks  Benefits  Potential consequences of the procedure  Treatment options  Alternatives to treatment (including nonsurgical management or non intervention)
  22. 22.  The consent process can technically be done without satisfying any of the essential elements of the “informed” component  Permissible for actual signature to be obtained by resident, physician assistants after surgeon properly informed the patients.  the actual informed consent documents need to fullfill a number of criteria (table 2) OBTAINING CONSENT FROM THE PATIENTS
  23. 23. Essential Components of Documenting Consent
  24. 24. What is Legally Effective Informed Consent Under ordinary circumstances, legally effective informed consent is obtained by reviewing the approved informed consent with the subject, answering any questions, and getting the subject’s signature.
  25. 25. Subject Unable to Consent • What if the subject • Lacks capacity • Has diminished decisional capacity • Is a minor • Is unconscious
  26. 26. Who is a Legally Authorized Representative • Legal Guardians • Healthcare Surrogates • Proxies • Attorneys-in-fact
  27. 27. Other Considerations: • Patient may refuse an operation because he/she unable to make decision • Surgeon should explore with the patients the reason for refusing  this gives some insight into patient’s thought process. PATIENT REFUSAL • Cognitive dysfunction, psychiatric illness • Should consult with psychiatrists, lawyers, or other physicians  goal is to improve the patient’s decision-making capacity. Not to simply obtain that the patient needs a proxy decision-maker. DIMINISHED CAPACITY • Korean americans, japanese americans, mexican americans • Believe that terminal diagnosis relevant to treatment should be withheld from patient, and instead communicated only with the patient’s family. CULTURAL AND FAMILIAL ISSUES

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