This session will discus the importance of assessment & preparation of patient prior to surgery to identify
risk factor for adverse events
initiate appropriate prophylactic treatment
Approaches to preoperative evaluation differ significantly, depending on the
1.Nature of the complaint
2. The proposed surgical intervention
3. Patient age & health
4. Assessment of risk factors
5.The results of directed investigation
6. Interventions to optimize the patient's
7. Readiness for surgery
Determining the Need for Surgery
confirmation of relevant physical findings and
review of the clinical history and laboratory
and investigative tests that support the
Preoperative Decision Making
Once the decision has been made to proceed
with operative management, a number of
considerations must be addressed regarding the
1. Timing and site of surgery
2. The type of anesthesia
3. The preoperative preparation necessary
to understand the patient's risk and optimize
The aim is to identify and quantify any comorbidity that may have an impact on the operative outcome.
To uncover problem areas that may require further investigation to perform the preoperative optimization .
The preoperative evaluation is determined in light of the
1.planned procedure (low, medium, or high risk),
2. planned anesthetic technique,
3. the postoperative disposition of the patient
(outpatient or inpatient, ward bed, or intensive care).
4. to identify patient risk factors for postoperative morbidity and mortality
consultation with an internist or medical
subspecialist may be required to facilitate
the workup and direct management.
In this process, communication between the
surgeon and consultants is essential to define
realistic goals for this optimization
process and to expedite
I - Preoperative evaluation
To assess the fitness of the individual for anesthesia and surgery.
A well‐conducted history and physical examination answer several important questions:
Is this a healthy patient?
What is the indication for surgery?
Is the surgical procedure low risk, intermediate
risk, or high risk?
What is the functional status of the patient?
What is the effect of the present condition on
What improvement is expected after surgery?
Answers to these questions should then direct preoperative testing and management
1.The tests selected should therefore evaluate existing illness, screen for conditions that could affect outcomes in the
preoperative period, and help to determine preoperative
Existing illnesses that need evaluation and possible treatment
include hypertension, diabetes mellitus, cardiac, vascular,
pulmonary, renal, and hepatic diseases.
The pregnant patient, the geriatric patient, the patient with
oncologic disease, malnutrition ,or coagulation disorders also
needs directed evaluations
The initial preoperative evaluation of a patient
should be supplemented by a complete
assessment of the patient’s general health.
This involves a thorough
Surgical risk assessment
The history should include information regarding any known medical problems and ongoing treatment, previous surgical procedures, and problems if any during previous anesthesia.
These can include difficult intubation, bleeding tendencies, and anesthetic jaundice.
• Family history.
• Medications such as digitalis, insulin, and
corticosteroids should be maintained and their doses carefully regulated in the preoperative period.
• If the patient is on corticosteroids or if it has been
discontinued within a month of surgery, he or she
may have a hypofunctioning adrenal cortex resulting in impaired physiologic response to surgical stress
A comprehensive physical examination to identify co-morbid conditions should be performed
Preoperative Considerations by Organ Systems:
cardiovascular ,pulmonary ,gastrointestinal, nervous system, renal and endocrine troubles .
Poor nutrition causes poor wound healing, leading to
Loss of functional independence
Assess fluid status along with the nutritional status
Estimate serum albumin level (> 6mg/dl normal)
Consider parenteral nutritional supplementation.( very young & very old)
TPN is useful in gastric outlet obstruction, malnutrition
1.Complete blood counts
2.Blood urea and electrolytes
3.An electrocardiogram (ECG) is indicated over 40 years, .
4.Posteroanterior and lateral chest x‐rays
5.Surgical risk assessment
Surgical risk assessment includes the anaesthetic risk also
Cardiovascular and pulmonary complications are common causes of peri-operative morbidity and mortality in elders (25 to 30%)
Preoperative evaluation and optimization of patients are important components of anesthesia practice. At a minimum, the guidelines of the ASA indicate that a preanesthesia visit should include the following :
• An interview with the patient or guardian to review medical, anesthesia and medication history
• An appropriate physical examination
• Review of diagnostic data (laboratory, electrocardiogram, radiographs, consultations)
At a minimum, the preanesthetic examination includes the airway, heart and lungs, vital signs, oxygen saturation, height, and weight. Examination of the airway is always necessary. Auscultation of the heart and inspection of the pulses, peripheral veins and extremities for edema are important diagnostically and in development of care plans .
The pulmonary examination includes auscultation for wheezing and decreased or abnormal sounds. Cyanosis, clubbing and the effort of breathing are noted.
Assignment of an ASA physical status score (ASA-PS).
A formulation and discussion of anesthesia plans with the patient or a responsible adult
One of the first anesthesia risk categorization systems was the ASA classification. It has five stratifications:
ASA I— Normal healthy patient
ASAII— Patient with mild systemic disease
ASA III—Patient with severe systemic disease that limits activity but is not incapacitating
ASA IV—Patient who has incapacitating disease that is a constant threat to life
ASA V—Moribund patient not expected to survive 24hours with or without an operation
1-Consent for surgery
An informed consent in writing from the patient and/or his relatives is essential before any procedure is undertaken
Patients must receive sufficient accurate information about their illness, the proposed treatment and its prognosis.
Describe the procedure itself, including information about its practical implications and its prognosis
Outline other surgical or medical alternatives to the
proposed treatment, including non‐treatment, along
with their general advantages and disadvantages
The surgeon should gain the confidence of the patient by his kind approach and frank discussion about the problem, and possible benefits and risks especially in cases involving amputation or possible disability or disfigurement
Preoperative counseling by the doctors, trained staffs, social workers and patients who had undergone major surgery, will prevent or reduce depressive effect .
2.Prevention of CVS & respiratory complications
Efforts to maintain the circulation and ventilation have greater priority in preparing the patient for an operation.
Prophylaxis of Postoperative Deep Vein Thrombosis.
SC heparin 5000 IU 2 hours preoperatively and 8 hours postoperatively.
Respiratory complications can be prevented and also improved through
Cessation of smoking
3. Aspiration prevention
Prevention of aspiration is the most important aspect of perioperative care.
Starving the patient for 6-8 hours prior to surgery
Ryles tube aspiration during surgery
Fasting times for children are age dependent
Babies under 1 year
No breast milk for 2‐3 h before anaesthesia
No formula feed for 6 h before anaesthesia
Clear fluids may be given up to 3 h before anaesthesia
Children over 1 year
No food/milk for 6 h before anaesthesia
Clear fluids up to 3 h before anaesthesia
4.Preparation of bowel
GIT surgery needs complete evacuation and cleansing of alimentary tract
Sterilization of the bowel by oral anti microbial agents
Routine nasogastric tube aspiration and strong purgatives, enemas
Blood grouping and Rh typing: reserve necessary units of blood for possible requirement.
Sleep: Good sleep should be ensured on the night before surgery (mild sedation)
Skin preparation: haircut, shaving , taking care not to injure the skin. Patient should be given a good bath before surgery .
Bladder catheterization: Insertion of urinary catheter to prevent post operative distension of the bladder and to measure the urine output during surgery are important
Pre-medication : Routine pre-medication for anaesthesia is best avoided in the ward and is given in the operation theater under the direct supervision of the anaesthetist .
The surgeon should consider the following prior to surgery
The diagnosis, nature of the disease, its natural course, the prognosis, presence of comorbid conditions and the general condition of the patient should be taken into account.
The benefit of surgery should be weighed against the possible risk and complications
Alternative to high-risk surgery and the possibility of a conservative management should also be discussed with the patient and family members
Any requests or preferences made by the patient should also be considered
A fully equipped operation theatre, post operative ward with monitoring and resuscitative facilities, and good surgical team are preferable
The optimal timing of surgery to be fixed for better outcome