Preoperative Management

1. R.S.ASOK KUMAR
1 STYEAR PG

2. INTRODUCTION
 The preoperative period runs from the time the patient is
admitted to the hospital to the time that the surgery
begins.
 It includes both physical and pschycological preparation.

3. Pre-operative plan
 Gather and record all relevant information
 Optimize patient condition
 Choose surgery that offers minimal risk and maximum benefit
 Anticipate and plan for adverse events
 Inform everyone concerned

4. Steps
 History
 Examinations
 Investigations
 Preoperative Preparation
 Documentation
 Communications – Valid consent

5. Principles of History taking
 Listen: What is the problem?
 Clarify: What does the patient expect?
 Narrow: Differential diagnosis
 Fitness: Comorbidities

6. history
 Illness
 Diabetes
 Asthma And Tuberculosis
 Hypertension And Myocardial Infraction
 Intake Of Insulin, Steriods, Antiepileptics ( At Present Or Taken
For A Long Period Of Time)
 Allergy To Any Drug.

7.  Ischaemic heart disease: angina,
 Myocardial infarction
 Hypertension
 Heart failure
 Dysrhythmia
 Peripheral vascular disease
 Deep vein thrombosis and
pulmonary embolism
Cardiovascular

8. Respiratory
 Chronic obstructive pulmonary disease
 Asthma
 Respiratory infections

9. Neurological
 Epilepsy
 Cerebrovascular accidents
 Transient Ischaemic attacks
 Psychiatric disorders
 Cognitive function

10.  Liver disease
 Urinary tract infection
 Renal dysfunction
 Rheumatoid arthritis
 Thyroid dysfunction
 Phaeochromocytoma
 Tuberculosis
 Malignancy

11.  Allergy
 Porphyria
 Human immunodeficiency virus
 Hepatitis
 Previous surgery Problems encountered
 Family history of problems with anaesthesia

12. examination
 General: + findings even if not related to the proposed procedure
should be explored
 Surgery related: Site of surgery, complications which have occurred
due to underlying pathology
 Systemic: Comorbidities and their severity

13. Examination

14. GENERAL EXAMINATON
 Nutritional status and built
 Hydration
 Anemia
 Jaundice
 Oral hygiene
 Pulmonary function

15.  Sources of infection (teeth, feet, leg ulcers)
 Cardiovascular : Pulse, blood pressure,
heart sounds, bruits, peripheral oedema
 Respiratory: Respiratory rate, chest
expansion and percussion note, breath
sounds, oxygen saturation

16.  Gastrointestinal: Abdominal
masses, ascites, bowel sounds,
hernia.
 Neurological :Consciousness level,
cognitive function, sensation,
muscle power, tone and reflexes
 Airway assessment

17.  Specific Surgical Examination:
 AIM: to confirm previous findings & diagnosis, to determine
severity & extent.
 Specific Medical Examination:
 AIM: to evaluates the presence & severity of other problems.
 E.g. Diabetic patient undergoing surgery need careful
examination for sepsis , neuropathy or microvascular disease

18. investigations

19. Investigatons
Routine:
 Hemoglobin
 TC and DC
 ESR
 Urine routine and microscopic
 Blood urea
 Blood sugar fasting and post prandial
 Xray chest
 ECG

20. investigations
 Hematology : to assess the amount of blood
may be needed during or after operation.
 Urea, Creatinine & Electrolytes: state of
dehydration & renal insufficiency.
 Liver Function Tests: Alb & Protein guide
to nutritional status & shows any clotting
problems

21. Investigations
HBsAg
HIV testing.
HbA1
Blood gas analysis

22. Preoperative preparation
Diet
 Soft diet : Edentulous patient
 Fat free diet: Biliary tract disease
 Liquid diet : Obstructing esophageal lesion
 Salt free diet: Hypertensive patient
 Vit B ,C : Indicated for debilitated patient
 Vit K : Jaundiced patient and newborn
 Frequent changing in posture of patient to avoid pressure sores

23.  Medications
 IV fluids if indicated
 The use of Antibiotics and patient’s current medication must be
carefully considered
 No medication should be given for the relief of pain until a
diagnosis has been established

25. Intramuscular injection
CONSIDERATIONS:
 Position the needle at 90˚ angle.
 Do not forget to aspirate the plunger once
injected to check for blood. (To determine if a
blood vessel was hit)
 Inject medication slowly (To minimize pain)
 Apply pressure to site and massage after (To
prevent hematoma on the injection site and
prevent oozing of blood and for proper
absorption of the medicine)

28. INTRAVENOUS INJECTION
Intravenous therapy may be used to
 Correct electrolyte imbalances,
 Deliver medications,
 For blood transfusion

29. Veins of the Hand
 1. Digital Dorsal veins
 2. Dorsal Metacarpal veins
 3. Dorsal venous network
 4. Cephalic vein
 5. Basilic vein

30. Veins of the Forearm
 1. Cephalic vein
 2. Median Cubital vein
 3. Accessory Cephalic Vein
 4. Basilic vein
 5. Cephalic vein
 6. Median ante brachial vein

31. SIGNS OF A GOOD VEIN
Soft
Visible
Bouncy
Straight
Easily palpable
Well supported
 Has a large lumen

33. Preoperative orders
 Emergency admission for emergency operation:
 Diet:Nothing by mouth
 Fluid therapy: To correct fluid and electrolyte imbalance.
 Blood: Sent for grouping and cross matching along with regular investigations.
 Antibiotics
 Nasogastric tube insertion and aspiration
 Shaving and preparation of parts
 Catheterization if necessary

34. Elective operation
 Preoperative orders written one day prior to surgery
 Documentation
 History – presented logical manner
 Investigations & Management plan – listed for action
 Drug chart – routine / prophylactic
 Fluids charts - listed

35. Written consent
 Lead in - Introduce yourself and identify the
patient
 Explore - How much does the patient know
 Diagnosis -Why the operation is being proposed
 Treatment - Explain whether the treatment
proposed is in accordance with protocols
 Options - Discuss all the options

36.  Results -- Explain likely outcome in terms of pain,
mobility, work, diet and return to normal activities
 Eventualities
 Adverse events -- Myocardial infarction, stroke and embolus,
bleeding and specific damage
 Open question -- Check if further clarification is needed
 Notes -- Document everything discussed and agreed

37. Risk assessment and consent
 Risks: Related to the comorbidities, anaesthesia and surgery
 Explain: Advantages, side effects, prognosis
 Language: Simple, use daily life comparisons to explain risks
 Consents: Valid consent is necessary except in life-saving
circumstances

38. Shaving and preparation of local parts:
 Complete scrub bath with savlon or antiseptic soap taken at
night before surgery with a particular care for skin creases and
fold
 Preparation of Skin over the site of surgery
 Again bath is given with antiseptic soap
 Application of sterile dressing

39. Nothing by mouth
 Atleast 6-8 hours allowed from
emptying of stomach to minimize
risk of vomitting and aspiration.
 Infants -- fed clear fluids 4 hours
prior to anesthesia to minimize
dehydration.

40. BLOOD:
 Sent for cross matching
 Make sure that required blood is
available and reservered prior to
surgery.

42. PREANaeSTHETIC MEDICATION
 To obtain a smoother induction,
 Maintenance,and emergence from anesthesia.
 Ensures comfort to the patient & to minimize adverse
effects of anaesthesia

43. objectives
 Relief of anxiety and apprehension
 Amnesia for pre- & intra-operative events
 Potentiate action of anaesthetics, so less dose is needed
 Antiemetic effect extending to postoperative period
 Decrease secretions
 Decrease acidity & volume of gastric juice to prevent reflux
& aspiration pneumonia
 Decrease vagal stimulation caused by anaesthetics

44. Drugs used as a premedication:
 Sedative hypnotics: Benzodiazepines ( Diazepam,
lorazepam, midazolam)
 Antihistamines: Promethazine.
 Anticholinergic drugs : Glycopyrrolate, atropine
,scoplamine.
 Opioids: Morphine , Pethidine

45. Drugs used as a premedication:
 Drugs that reduce gastric acidity:
1. H2 Blocker: Ranitidine
2. Alternative: Proton pump inhibitor- Omepazole,
pantaprazole.
 Antiemetics: Metaclopromide

47. Sedative hypnotics

48. Anticholinergics

49. Histamine blockers

51. Opioids

52. Proton pump inhibitors

53. References
 Bailey & Love’s - Short Practice of Surgery 26th edition
 Ward procedures – Mansukh B Patel & Yogesh P
Upadhyay 2E
 Miller’s Anaesthesia 8E
 Wylie & Churchill-Davidson Practice of Anaesthesia7E