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1. PREOPERATIVE
PREPARATION
Dr Nisar Ahmed Arain
Assistant Professor
Anesthesia/Critical Care/ER

4. -Learning Objectives
-To be able to organize preoperative care and
the operating list
-To understand surgical, medical, and anesthetic
aspects of assesment
-How to optimize the patients condition
-How to take consent
-How to organize an operation list

5. -DEFINATION
-The pre-operative period runs from the time
the patient is admitted to the hospital or in
the surgicenter to the time that the surgery
begins

6. -Pre operative plan
-Gathering and recording concisely all relevant
information
-Planning to minimize risk and maximize benefit
for the patient
-Prepared for adverse events and how to deal
with them
-Communicate with patient and all members of
the team

7. -Patient assesment
-1-History taking
-2-Examination
-3-Investigations
-4-Pre-operative treatment
-5-Documentation
-6-Communication

8. -Principals of History taking
-Listen:- what is the problem ?
(open questions)
-Clarify:-what does the patient
expect ? (Closed questions)
-Narrow:-Differential diagnosis
(Focused questions)
-Fitness:-Comorbidities
(Fixed questions)

9. -Past Medical History
-Cardiovascular
-IHD, HTN, heart
Failure, Dysrhythmias
PVD, DVT, anemia
-Respiratory
-COPD, Asthma,
fibroptic lung
conditions,
respiratory infection,
malignancy
-Gastrointestinal
-Peptic ulcer disease
GERD, bowel habits
Malignancy, Liver
disease
-Genito urinary tract
-UTI, Renal dysfunction
-Neurological
-Epilepsy, CVA, Psychiatric
disorders, cognitive
function
-Endocrine /
Metabolic
-Diabetes, Thyroid
dysfunction, Pheo
chromocytoma
-Locomotor system
-Osteoarthritis
Inflammatory
arthropathy
-Infectious
-Tuberculosis, HIV
Hepatitis

10. -Examination
-General:- + findings even if not related to the proposed
procedure should be explored
-Surgery Related:-Type and site of surgery, complications
which have occurred due to underlying pathology
-Systemic:-Comorbidities and their severity
-Specific:-For example, suitability for positioning during
surgery

11. -General Physical Examination
-AIM:-To check fitness for Anesthesia and surgery
-1-GPE
-2-Systemic
-3-CVS
-4-CNS
-4-GIT
-5-Respiratorysystem

12. -Specific Surgical Examination
-AIM:-To confirm previous findings and diagnosis, to determine
severity and to gauge extent
-E.g. In inguinal hernia please confirm its inguinal not femoral
, It is reduceable or not reduceable and whether there
are any signs of bowel obstruction.

13. -Specific Medical Examination
-Aim:- is to evaluate the presence and severity
of other problems
-Diabetic patients undergoing surgery needs careful
examination for Sepsis, Neuropathy, or microvascular disease

14. -Investigations - - Routine
-Every unit and ward has its own protocol
-The tests which are normally performed
on most patients coming for surgery
-Full Blood count
-Basic Biochemistry
-Chest Radiograph

15. -Investigations ---Targeted tests
-Hematology:-To exclude Anemia, for platelets
count
and to asses the amount of blood may be needed
during or after operation
-Urea, Creatinine, and Electrolytes:-State
of
dehydration and renal insufficiency
-Liver Function Tests:-Albumin and Protein
guide to nutritional status and shows any clotting
problems.

16. -Investigations – Others(Non specific)
-ECG:-Its recommended in all patients >65 years, patients
with blood loss and cardiovascular / Pulmonary problems
-Urinalysis:-Used for determination of renal function,
inflammation, infection, and metabolic disorders
-Pregnancy Test:- (B- HCG )
-HBsAg and HIV testing
-RBS and HbA1c :- Diabetes
-Blood Gas analysis :-Occ required

18. -Hypertension
-Preoperative Blood Pressure
should not exceed 160/90
mmHg
-Newly diagnosed HTN may need
further evaluation
-Acute admission require urgent
surgery, BP should be
controlled more rapidly

20. -Dysrhythmias
-Fast Atrial Fibrillation must be
controlled before surgery
-Warfarin should be stopped 3 to 4 days
before surgery
-Regular measurement of serum
potassium is essential
-Some conduction disorders may require
pacing
preoperatively, 2nd and 3rd degree heart
block

21. -Anemia and
Blood transfusion
a-Pre-operative transfusion should
be considered if Hb < 8g/dl

22. -Respiratory system
-Infection:-To be treated before surgery
-Asthma:-
a-Establish the severity and the course
of illness
b-Patients inhalers usually should be
continued
-COPD:-
a-Pre-operative X Ray chest required
b-Significant COPD who need major
surgery, should be referred to
Respiratory Physician
c-ABG analysis is required

23. -Gastro-Intestinal disease
-Regurgitation Risk
a-H2 receptor blockade / PPI, NG tube to
empty distended stomach
b- Nil by mouth before surgery
a-Solids (6 hours)
b-Fluids (2 hours)
-Jaundice:-
a-Secondary complications, Impaired
clotting risk of renal failure
b-Prophylactic antibiotics should be
given

24. -Clinically obese patient (BMI >30)
a-Increased risk of post-operative complications
-Some cases might better delay the elective surgery
until they loose some weight.
-Determine nutritional status of patient, nutritional
assesment
-Malnourished patient:-Nutritional support minimum
of two weeks

25. -Genito-Urinary disease
-Renal Impairment:-
-Categorize pre renal, renal, postrenal
a-appropriate measure for acidosis,
Hypocalcemia, Hyperkalemia
b-Continue peritoneal or Hemodialysis until few
hours before surgery
- Urinary tract Infection
-Treat such infection before high risk
elective surgery
-Urgent Procedure
Antibiotics should be started and
ensure that patient is having good urinary
output

26. -Metabolic disorders
-Diabetes
-Check HbA1c level
-Pre-operative risk reduction strategies(Lipid-
lowering agent, diabetic control)
-Minor surgery in non insulin dependent
diabetic-omitting morning dose, listening
early surgery, restarting treatment
-Sgnificant surgery in insulin dependent-
intravenous insulin infusion require

27. -Adreno-cortical suppression
-Occur in patient receiving oral
adrenocortical steroid regularly
-Require extra dose of steroid
around the time of the surgery—
Avoid Addisonian crisis

28. -Coagulation disorder
-Thrombophilia
-Identify the risk factor for thrombosis
a-Age
b-Obesity
c-Trauma or surgery(abdomen, pelvis, lower limb
d-Reduced mobility > 3 days
e-Pregnancy
f-Drugs:- estrogen, HRT
g-Fmily history of thrombosis
-Prophylaxis in perioperative period
(Mechenical / Phamacological)
-HRT should be stoped 6 weeks prior to
surgery

29. -Other disorders
-Neurological:-
-H/O stroke, with neurological Deficit
-Withdraw antiplatelet agents
a-Aspirin (7 days before)
b-Clopidogrel (10 days before)
-Neuropathies / Myopathies
need prolonged ventilation
-Psychiatric:-
-Need GA
-Certain medication
Mono-amine-oxidase
-inhibitor. Unwanted
interaction and anesthetic
medication
-Locomotor:-
-Inflammatory arthropathies
to be identified

30. -Management Plan---KEY POINTS
-Provide all information necessary for the
patient to make an informed decision
-Discuss the options, rather then telling the
patient what will be done
-Give the patient time to think, things over
-Encourage to discuss the things– as a
trusted person

31. -Risk assesment and consent
-All life:- or limb—threatening complications rather all the
complications with an incidence of 1% or more should
be thoroughly discussed with the patient
-Risks:-Related to comorbidities, anesthesia 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

32. -Patients mouth is open and tongue protruding
-Look for loose teeth, scars, infections, thickness of neck
which indicates difficulty in visualizing airway
-Neck movement, thyromental distance, and Mallampati score

33. -Thyromental distance
-Tip of thyroid cartilage to the tip
of the chin (mentum)

35. -Arranging the theatre list
-Date, Time and Place of operation should be matched
with availability of the personnel.
-Appropriate equipment and instruments should be made
available
-Operation list should be distributed as early as possible
to all staff who are involved.
-Prioritize all the patients
a-First:-Children and diabetic patients
b-Life and Limb threatening surgery
c-Cancer patients