Preoperative preparations part 1

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  • Preoperative preparations part 1

    1. 1. Preoperative evaluation of surgical patients Part 1 Dr. Piyush Giri
    2. 2. Introduction • Preoperative preparation is the preparation of a patient requiring surgery to optimize postoperative outcomes • Begins from the time of contact of the patient with the surgeon and ends on the day of surgery • The approach is multidisciplinary
    3. 3. Preoperative patient preparation 1. Gathering and recording: History, examination, investigation, conclusion and treatment plan 2. Planning to minimize risk and maximize benefit for the patient 3. Being prepared for adverse events and plan to how to deal with them 4. Communicating with patient and all other members of the team
    4. 4. Patient assessment • History • Examination • Investigations
    5. 5. History • Presenting illness • History of presenting illness • Past medical history • Drug history • Social history
    6. 6. Examination • General examination • Cardiovascular system • Respiratory system • Gastrointestinal • Neurological
    7. 7. • Explaining to the patient: discussing the proposed management plan
    8. 8. Investigations • Commonly needed investigations are 1. Full blood count : clinical diagnosis, anaemia, blood loss 2. Urea and electrolyte: >65 yrs, h/o of CVS, Pulmonary or renal problems
    9. 9. 3. Liver function tests: Jaundice, Infection, cirrhosis, clotting problems, Portal Hypertension
    10. 10. • Hepatic risk: • Predictors of mortality: Bilirubin (>2mg/dl), Serum albumin (<3gm/dl), PT (>16secs), Encephalopathy • 40% mortality : if either of these present • 80-85% mortality if 3 or more are present or if bilirubin alone >4, albumin alone<2gm/dl, or ammonia concentration > 150mg/dl
    11. 11. Investigations Contd. 4. Clotting screen: Anti coagulant therapy, Abnormal LFT, bleeding disorder 5. Arterial blood gases: Acid- base abnormality suspected or respiratory conditions 6. EKG: > 65 years, Past h/o of CVS, pulmonary or anesthetic problems 7. Chest radiography: CVS and Pulmonary problems
    12. 12. • Cardiac risk: • Ejection fraction: <35% = incidence of MI 75-85% and mortality 55-90% • Goldman’s index: 11 points to raised JVP, • 7 points to Premature ventricular contraction, • 4 points to emergency surgery • 3 points each to: Aortic valve stenosis, poor medical condition, surgery within chest or abdomen
    13. 13. • Interpretation of Goldman index and cardiac complication • <5 – 1% • <12 – 5% • <25 – 11% • >25 – 22%
    14. 14. 8. Urinalysis: detects infections, glycosuria, osmolarity, Haematuria 9. Beta- Human chorionic gonadotrophin: in all female patients of childbearing age with abdominal pain or if she is unconscious
    15. 15. 10. Viral Serology: Hepatitis/ Human immunodeficiency
    16. 16. NICE guidelines • Guideline help guide appropriate routine preoperative investigations • Based on ASA grading and Surgery Grading
    17. 17. ASA Grading • ASA Grade 1: Normal healthy patient • ASA Grade 2 : A patient with mild systemic disease • ASA Grade 3 :A patient with severe systemic disease • ASA Grade 4 :A patient with severe systemic disease that is a constant threat to life
    18. 18. • Grade 1 (minor): Excision of lesion of skin • Grade 2 (Intermediate): Primary repair of inguinal hernia • Grade 3 (Major): Endoscopic resection of prostate • Grade 4 (Major +): Colonic resection;
    19. 19. SPECIFIC PREOPERATIVE PROBLEMS 1. Cardiovascular: • Hypertension: BP: >160/95 mmHg: elective surgery should be deferred • Ischaemic heart diseases: recent MI is stong contraindication, significant mortality rate from anaesthesia if within 3 months elective surgery can be delayed upto 6 months
    20. 20. • Dysrhythmias: AF to be controlled, Heart block: preoperative pacing, bipolar diathermy should be used when possible • Cardiac failure: Oxygenation and fluid balance • Anaemia and blood transfusion: transfusion if Hb < 8gm/dl
    21. 21. 2. Respiratory Problems: • Infection: LRTI should be controlled before surgery • Asthma: Inhalers to be continued • Chronic obstructive pulmonary disease: regional anesthesia
    22. 22. 3. Gastrointestinal system. BMI CLASSIFICATION • <16 Severe malnutrition • 16–16.99 Moderate malnutrition • 17–18.49 Mild malnutrition • 18.5–24.9 Normal • 25–29.9 Overweight • 30–34.9 Obese class 1 • 35–39.9 Obese class 2 • ≥40 Obese class 3
    23. 23. • Malnutrition: Nutritional support for minimum 2 weeks,
    24. 24. MUST (Malnutrition Universal Screening) Tool: BMI , Weight loss and Acute disease effect Total: 6 0: low risk of undernutrition: routine clinical care 1: Medium risk: Observe 2 or more : Treat: dietician or local policies, later food fortification
    25. 25. • Obesity: BMI > 30 Advice to lose weight for elective procedure
    26. 26. • Regurgitation risk: in Hiatus hernia, bowel obstruction, Paralytic ileus decresed by Nil per oral: solid food 6 hours and 2 hours for liquids and also by: H2 receptor blockers and Nasogastic tube insertion
    27. 27. • Jaundice: increased secondary complications: Impaired clotting: Vitamin K Renal failure: patient kept well hydration Increased infection: prophylactic antibiotics
    28. 28. 3. Metabolic Disorder: • Diabetes Mellitus: Are at high risk for Complications, • Improving Diabetic control • Lipid lowering drugs • Treating significant vascular stenosis • For minor surgery: omiting morning dose, and in insulin dependents: IV insulin given
    29. 29. • Adrenocortical Suppresion: adrenocoritcal steroid> 2 months, need extra doses at the time of surgery.
    30. 30. 4. Coagulation disorder: INR to be < 1.5: Warfarin: stopped 3-4 days earlier in Atrial Fibrillation. Is replaced with heparin where thrombosis is significant, eg. Mechanical heart valve. Asprin and Clopidogrel to be stopped before 1 week of surgery.
    31. 31. • Disseminated intravascular coagulation and haemophilia to be treated accordingly. • Prophylaxis against thrombosis: • Mechnical: Early mobilisation, stockings, calf and foot pumps. • Pharmacological: Heparin and low molecular weight heparin, Warfarin, Asprin
    32. 32. 5. Neurological and psychiatric disorder: Anticonvulsant: to be continued Psychiatrically disturbed: may require general rather than regional Tricyclic antidepressents and Monoamine oxidase inhibitor to be discontinued: may have unwanted interaction
    33. 33. 6. Locomotor disorder: Most catastrophic being unstable cervical spine. Disease modifying drugs may be continued in Rheumatoid Arthritis
    34. 34. 7. Remote site infection: from teeth or toe, to be treated preoperatively or given appropriate antibiotic prophylaxis
    35. 35. Documentation It should include: • Clinical notes • Investigations • Management plan
    36. 36. Consent to be obtained, from person fully conversent on planned surgery, alternative and complication
    37. 37. Multiprofesional team Members • For Theatre: • Ward staff • List organiser and circulator • Theatre nursing staff • Anaesthetic staff • Radiology department • Pathology department
    38. 38. • For Postoperative recovery: • Rehabilitation staff • Social care worker • ITU/ High dependency unit staff • Specialist nurse counsellor (stoma/ amputation)
    39. 39. • THANK YOU

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