Preoperative preparations by Dr.Syed Alam Zeb


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Preoperative preparations by Dr.Syed Alam Zeb

  1. 1. Preoperative preparation!! <ul><li>Dr.Syed Alam Zeb </li></ul>
  2. 2. Role of Surgeon during preoperative preparations: <ul><li>Gathering & recording information; </li></ul><ul><li>Minimizing risk, maximizing success; </li></ul><ul><li>Contingency plans for adverse events; </li></ul><ul><li>Communications </li></ul>
  3. 3. Steps of P.O.P ’ s: <ul><li>History </li></ul><ul><li>Examinations </li></ul><ul><li>Investigations </li></ul><ul><li>Preoperative treatments </li></ul><ul><li>Communications </li></ul><ul><li>Informed consent </li></ul><ul><li>Operating lists </li></ul><ul><li>On arrival to OT table </li></ul>
  4. 4. Types of patients: <ul><li>Out-Patient Department </li></ul><ul><li>Usually seen 1-2 weeks before surgery at preadmission clinic </li></ul><ul><li>Emergency department </li></ul><ul><li>Need initial assessment & immediate resuscitation </li></ul>
  5. 5. History : <ul><li>A- listen to ur patient complains </li></ul><ul><li>B- clarify his problem by questions </li></ul><ul><li>C- try to reach to a diagnosis by confirming & excluding. </li></ul><ul><li>D- determine the fitness of ur patient for a surgery physically & psychologically. </li></ul>
  6. 6. Examinations: <ul><li>General medical examinations </li></ul><ul><li>Specific surgical examinations </li></ul><ul><li>Specific medical examinations </li></ul>
  7. 7. General Medical Ex: <ul><li>To check fitness for anesthesia & surgery. </li></ul><ul><li>GPE </li></ul><ul><li>Systemic: </li></ul><ul><li>CVS </li></ul><ul><li>CNS </li></ul><ul><li>GIT </li></ul><ul><li>Respiratory system </li></ul>
  8. 8. Specific Surgical Ex: <ul><li>Its aim: to confirm previous findings & diagnosis, to determine severity & to gauge extent. </li></ul><ul><li>e.g. in inguinal hernia confirm it ’ s inguinal not femoral , reducible or not & whether there are any signs of bowel obstruction. </li></ul>
  9. 9. Specific Medical Ex: <ul><li>Its aim: to evaluates the presence & severity of other problems. </li></ul><ul><li>e.g. Diabetic patient undergoing surgery need careful examination for sepsis , neuropathy or microvascular disease </li></ul>
  11. 12. Investigations: <ul><li>I. Routine Investigation </li></ul><ul><li>Every unit and ward has its own protocol. </li></ul><ul><li>The tests which normally performed on most patient coming to surgery: </li></ul><ul><li>* F ull B lood C ount </li></ul><ul><li>* Basic B iochemistry </li></ul><ul><li>* C hest R adiography </li></ul>
  12. 13. Investigations: <ul><li>II. Targeted Surgical Tests: </li></ul><ul><li>Hematology : to exclude anemia, for platelets count & to assess the amount of blood may be needed during or after operation. </li></ul><ul><li>Creatinine & Electrolytes : state of dehydration & renal insufficiency. </li></ul><ul><li>Liver Function Tests : Alb & Protein guide to nutritional status & shows any clotting problems. </li></ul>
  13. 14. Investigations: <ul><li>ECG : It ’ s recommended in all patient >65years, pt. with blood loss & cardiovascular/pulmonary problems. </li></ul><ul><li>Urinalysis : used for determination of renal function, inflammation, infection & metabolic disorders. </li></ul><ul><li>Pregnancy Test : ( B- human chorionic gonadotrophin ) </li></ul><ul><li>HBsAg , HCV Antibodies & HIV testing. </li></ul>
  14. 15. Communication: <ul><li>Information for the patient : </li></ul><ul><li>He should be aware of his surgeon, procedure, stuff & what is going on. </li></ul><ul><li>Information for stuff : </li></ul><ul><li>Team work is the main key for success. </li></ul><ul><li>Recording : </li></ul><ul><li>All important information should be recorded clearly in patient notes because it is the reference database. </li></ul>
  15. 16. Preoperative Treatments: <ul><li>Antibiotics : should be at peak level when surgery starts. </li></ul><ul><li>Transfusion : sort anemia well in advance. </li></ul><ul><li>Nutrition : improve situation whatever possible. </li></ul><ul><li>Thromboprophylaxis : needs for high risk patient only. </li></ul>
  16. 17. Prophylactic Antibiotics: <ul><li>The commonest infective organism is Staphylococcus aureus . </li></ul><ul><li>Some surgeon use flucloxacillin , but most used b road s pectrum a ntibiotics which cover S. aureus, streptococci & anaerobes . </li></ul><ul><li>In GIT surgery combination of cephalosporin & metronidazole . </li></ul><ul><li>Prophylactic antibiotic best administered just prior to induction. </li></ul>
  17. 18. Anemia & Blood Transfusion: <ul><li>Preoperative transfusion should be considered if major blood loss is anticipated during surgery or if Hb% < 8 g/dl. </li></ul>
  18. 19. Malnutrition: <ul><li>Malnourished patient is at high risk of morbidity & mortality following surgery. </li></ul><ul><li>Nutritional support is required for a minimum of 2 weeks prior to surgery. </li></ul><ul><li>Malabsorption overcome by vitamins & enzymes while obstructive conditions N/G feed, I/V fluids, surgical bypass & formal enterostomy. </li></ul>
  19. 20. Thromboprophylaxis: <ul><li>Methods of anticoagulation : </li></ul><ul><li>I. Pharmaceutical : </li></ul><ul><li>Aspirin is the best choice. </li></ul><ul><li>II. Mechanical : </li></ul><ul><li>Foot & calf pumps believed to prevent stasis. </li></ul><ul><li>III. Physical : </li></ul><ul><li>Early mobilization & minimizing length of stay in hospital reduce stasis & DVT. </li></ul>
  20. 21. Preoperative Tx for special cases : <ul><li>Diabetes: </li></ul><ul><li>If controlled orally: omit morning dose of oral hypoglycemic </li></ul><ul><li>Insulin-dependent: managed on I/V infusion of dextrose & insulin </li></ul><ul><li>Extra K needed </li></ul>
  21. 22. Preoperative Tx for Special cases: <ul><li>Respiratory disease: </li></ul><ul><li>Blood gases & pulmonary function tests needed to assess severity. </li></ul><ul><li>Stop smoking & continue inhalers </li></ul><ul><li>Involve physiotherapists & anesthetists. </li></ul><ul><li>Avoid respiratory suppressants (narcotics) </li></ul><ul><li>Mobilize early </li></ul><ul><li>Give O2 </li></ul>
  22. 23. Preoperative Tx for special cases: <ul><li>Hypertension : </li></ul><ul><li>BP > 160 systolic or > 95 diastolic their surgery postpone till controlling of BP. </li></ul><ul><li>Plasma Potassium (K) checking is necessary in Pt. with diuretics. </li></ul><ul><li>Routine Medication: </li></ul><ul><li>Most can be given as usual </li></ul><ul><li>Stop aspirin if bleeding is suspected </li></ul><ul><li>Discuss ACE inhibitors or unusual drugs with anesthetists. </li></ul>
  23. 24. Informed Consent: <ul><li>STAGES OF INFORMED CONSENT: </li></ul><ul><li>I. Preparation </li></ul><ul><li>II. Explanation </li></ul><ul><li>III. Competence </li></ul><ul><li>IV. Closure </li></ul>
  24. 25. I. Preparation: <ul><li>A. Introduction : </li></ul><ul><li>Ur name </li></ul><ul><li>Pt name </li></ul><ul><li>Explain what are u doing & by which authority </li></ul><ul><li>B. Background : </li></ul><ul><li>Check what pt knows </li></ul><ul><li>Explore how much he/she actually want to know. </li></ul>
  25. 26. II. Explanation: <ul><li>A. What is wrong: Explain the diagnosis is simple language. </li></ul><ul><li>B. Action : what is the proposed action? Is it differ from national or other guidelines ? justify </li></ul><ul><li>C. Outcome : describe the likely short & long outcome </li></ul><ul><li>D. Choices: describe all viable choices, including doing nothing </li></ul>
  26. 27. II. Explanation: <ul><li>E. Complications: </li></ul><ul><li>Explain in clear language all serious complications & those with a risk > 1% </li></ul><ul><li>Describe actions that will be taken to prevent each </li></ul><ul><li>Explain how they will managed them if they do occur </li></ul><ul><li>F. Right of Refusal: </li></ul><ul><li>Make it clear that the final decision is the patient ’ s alone </li></ul><ul><li>Give the patient time to think about the decision </li></ul>
  27. 28. III. Competence: <ul><li>Check the ability of patient to take in, retain & consider the information provided & articulate the decision. </li></ul><ul><li>Can be achieved by recording the patient ’ s answer to the questions “ Tell me what you have understood ” . </li></ul>
  28. 29. IV. Closure: <ul><li>A. Open question : </li></ul><ul><li>e.g. “ Is there anything else you would like to discuss? ” . </li></ul><ul><li>B. Record: </li></ul><ul><li>Record & write every thing was discussed & what was agreed. </li></ul>
  29. 31. Operating List: <ul><li>Diabetic patients first. </li></ul><ul><li>Day cases early </li></ul><ul><li>Major cases before minor </li></ul><ul><li>“ Dirty ” cases last </li></ul><ul><li>Operating lists final check: </li></ul><ul><li>Patients: name, number & location correct </li></ul><ul><li>Side written & marked </li></ul><ul><li>Radiographs & results available </li></ul><ul><li>Blood cross-matched & ready </li></ul><ul><li>Consent is taken </li></ul><ul><li>Nurses informed of timing </li></ul><ul><li>Theatres informed of special needs </li></ul>
  30. 32. On Arrival to Surgery
  31. 33. On Arrival for Surgery: <ul><li>The patient: </li></ul><ul><li>- Confirm identity, notes, problem, tests result & blood if ordered. </li></ul><ul><li>The operating theatre & team: </li></ul><ul><li>Good communication with stuff </li></ul><ul><li>All required instruments is ready </li></ul><ul><li>Surgeon not usually the leader </li></ul>
  32. 34. References: <ul><li>Bailey & Love’s Short Practice of Surgery 24 th edition. </li></ul><ul><li>Internet websites. </li></ul>