PRE-op Prep of patients for surgery

1. Preoperative prepration in
General surgery patients
• Presented by Dr Mubashir Basheer
• Moderator: Dr Ajay Thakral

2. Definition
The preoperative period runs from the time the patient is
admitted to the hospital or surgicenter to the time surgery begins.

3. Learning Objectives
1. To be able to organise preoperative care .
2. To understand surgical , medical and anaesthetic aspects of
assessment.
3. How to optimise patients condition.
4. How to take consent.
5. How to organise operating list.

4. Pre-operative plan for best patient outcomes
• 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.

5. Types of patients
• Out-Patient Department
Usually seen 1-2 weeks before surgery at preadmission clinic
• Emergency department
Need initial assessment & immediate resuscitation

6. Principles 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)

7. Examination
• General: Positive 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.

8. Medical examinatiom
• To check fitness for anesthesia & surgery.
• General physical examination
• Systemic:
- CVS
- CNS
- GIT
- Respiratory system

9. Investigations:
• Minor and intermediate surgeries generally requires no routine
investigations unless patient has comorbidities.
• Full blood count :
needed for major operations , in elderly & patients with
anaemia or having pathology with ongoing blood loss.
• Urea & Electrolytes:
major operations , patients over 60 years of age with cvs ,
renal & endocrine diseases .

10. Investigations:
• ECG:
over 60 years of age, cvs renal and cerebrovascular involvement
, in diabetics and those with severe respiratory problems.
• Clotting screen :
h/o bleeding diathesis, liver disease, eclampsia, or on
antithrombotic or anti coagulant agents.
• Chest radiography:
cardiac history , cardiac failure, COPD, pulmonary TB.

11. Investigations –
Urinalysis:
in all patients to detect urinary infection, biliuria, & glycosuria.
B-HCG:
to rule out pregnancy in women of child bearing age.
Blood glucose & HbA1c:
Patient with DM & endocrine problems.

12. Investigations –
•Liver function tests:
In patients with jaundice, hepatitis, cirrhosis malignancy or
with poor nutritional reserves.
•Viral markers : HIV I & II, HCV , HBsAg.
•Other investigations :
Further relevant investigations should be done to assess
capacity of specific organ system.

13. •Special medical problems encountered during preoperative
assessment should be corrected to best possible level.
•Many patients with severe disease will need to be referred to
specialists, referral letter should include history, examinations &
investigations results
Specific preoperative problems, referrals & management

14. Some Specific preoperative problems.
a) Hypertension & ischaemic heart disease:
Prior to elective surgery BP should be controlled to
160/90mmhg.
Elective surgery should be postponed for 3-6 months after
a proven myocardial infarct to reduce peri-operative re-
infarction .
b) Dysrhythmias:
Patients with atrial fibrillation , beta blockers, digoxin or
calcium channel blockers should be started preoperatively.

15. c) Anaemia & blood transfusion:
Anaemic patients should be treated with iron & vitamin supplementations
preoperatively.
For major procedure preoperative transfusion may b considered if Hb is
less than 8g/dl.
if excessive bleeding is expected , appropriate units of blood units should
be arranged.
d) Asthma & COPD:
Bronchodilator & steroid use should be continued preoperatively.

16. e) Infection :
Treated with antibiotics & surgery should be postponed for 4-6 weeks.
f) Smoking:
stopped at least 4 weeks prior to surgery
g)Regurgitation risk:
antacid, H2 blockers or Ppi’s goive prior to surgery.
h) Diabeties mellitus :
controlled to near normal levels prior to surgery

17. i) Renal diseases:
DM, HTN & IHD leading to chronic renal failure shopuld be stabilised
before elective surgery.
Simultaneous medical & surgical & critical care needed in peri operative
period as acute renal failure can present with acute surgical problems.
j) Coagulation disorders:
patients with low risk of thromboembolism need thromboembolism –
deterrant stockings.
high risk patients need warfarin which should be stopped before surgery
and replaced with LMWH & factor Xa inhibitors.

18. Preoperative assessment in emergency surgery
• Principles of preoperative assessment are same as in elective surgery but
due to time constraints opportunity to optimise condition is limited.
• Medical assessment & treatment should be started according to ATLS.
• Some risk may be reduced but some may persist and if possible these
need to be explained to patient & his attendants.

19. Preoperative assessment in emergency surgery
• Start – similar practices to that of elective surgery.
• Constraints- time , facilities available .
• Consent –May not be possible in life saving emergencies.
• Organisational effort – local/national algorithms for treatment of
multi-trauma patients

20. Preoperative fasting

21. Preoperative medications- TO Give or NOT to Give
• Give:
• Cardiac or blood pressure drugs except ACE inhibitors &
ARB’s .
• Epilepsy or parkinsonism drugs.
• Asthma drugs or inhalers
• Drugs to reduce gastric acid secretion.
• Thyroid medication.
• Tranquilisers, antidepressants & nicotine patches.
• Immunosuppressants & cancer drugs.
• All analgesics except NSAIDS

22. Preoperative medications- TO Give or NOT to Give?
• NOT to Give
• ACE inhibitors & ARB
• Diuretics .
• Diabetic medication .
• Asprin , clopidogral, warfarin & dipyridamole.
• Lithium.
• NSAIDS.

23. Risk assessment.
Risks – related to the comorbities, anaesthesia & surgery.
Explain –advantages , side effects , prognosis.
Language – simple to explain risks

24. Consent
Valid consent implies that it is given voluntarily by a competent &
informed person who not under any duress.
In emergency situations or in an unconscious patient, consent may not be
obtained & the procedure carried out in the best interest of patient.

25. Taking Consent - Stages
“ LED TO REASON ”
• 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 treatment proposed is in accordance with protocols.
• Options
Discuss all the options.

26. • Results
Explain likely outcome.
• Eventualities
For example, possibility of needing to remove the testicle in a hernia
surgery.
• Adverse events
Myocardial infarction, stroke and embolus & bleeding
• Sound mind
Ask if they have understood
• Open question
Check if further clarification needed
• Notes
Document everything discussed and agreed

27. Arranging the theatre list
• Date ,time & place of operation should be matched with availability of
personnel.
• Appropriate equipment & instruments should be made available.
• Distribute the OT list as early as possible to all involved.
• Prioritise patients e.g., children & diabetic patients should be kept first
• .
• Life & limb threatening surgery should get priority.

28. Thank you