preoperative care and managment

1. Preoperative care
Presenter-Dr. Abdurahman(OSR1)
Moderator- Dr Yemane (Consultant Anethiologist )

2. outline
● Objective
● Overview
● Approach
● Diagnostics
● Medication management
● Informed consent
● Take home message

3. Objectives
● Approach to preop patient
● Optimize patients for operation

4. Preop Evaluation
Preoperative evalutation is performed to determine whether a
patient is in optimal health for a planned surgical procedure
Its extent depends on the urgency of the surgery

5. Approach
1. Confirming the surgical procedure and indication for the surgery
2. Evaluate surgical procedural risk based on the surgery type and
urgency
3. Evaluate patient health and indivisual risk of perioperative
complications
4. Make recommnenation for the surgical team
5. Coordinate perioperative preparation steps

6. Multidisciplinary team roles
● Medical practitioner
○ determines if the patient is medically optimized
○ initiates measures to optimize the patient’s health if necessary
○ alerts the perioperative team to special health concerns and abnormal test results
● Surgeon
○ obtains consent
○ determines if surgery can be delayed for further optimization
● Anesthesiologist
○ Chooses the appropriate anesthetic technique

7. Evaluating surgical procedural risk
Type of surgical procedure
● intraperitoneal,intrabdominal,intrathoracic,major vascular surgery
● greater blood loss,longer procedures,emergency procedures
Perioperative mortality by type of surgery
Risk Examples
Low(<1%) Knee Arthroscopy
Intermediate(1-5%) Total hip arthroplasty
High(>5%)

8. Urgency of the surgery
Urgency Timing Perioperative mortality at 30
days
Emergency surgery as soon as possible 3.7%
Urgent surgery 24-48hrs 2.3%
Time-sensitive surgery 1-6 weeks
Elective surgery 12 months 0.4%

9. evaluating patient health
Goals
1. assess whether acute or chronic illnessess are being optimally managed
2. begin treatment of untreated or undertreated medical conditions
3. identify high risk patients who may benefit from
○ advanced diagnostic testing
○ medical specialist referral
○ delay in surgery
○ higher levels of postoperative care

10. Full history and physical examination
● previous anesthetic hx
● allergies
● regular medications
● presenting complaint
● past medical history
● airway assesment
○ malampati score

11. Perioperative functional assesment
● Subjective patient reporting of exercise capacity
● Duke activity status index
● Cardiopulmonary exercise testing

12. Risk stratification tools
Validated risk stratification tools identify which patients may benefit from
● medical intervention
● perioperative daignostic testing
● consultation

13. Thirty day
mortality
<0.1%
<1%
1-2%
~10%
>50%
N/A
E Emergency surgery(appended to grades I-IV)

14. Emergency perioperative evaluation
● simaltenous rescutiation and managment
● focus on clinical evaluation on conditions associated with high morbidity
● order diagnostic test that reflects dual roles of assesment and resucitation
○ CBC,CMP
○ ABG,Lactate
○ ECG
○ coagulation
● Notify members of the perioperative team of urgent finding

15. Rationale for preoperative testing
● establish a new diagnosis
● impact decision on surgery
● influence choice of anesthetic tecnique
● alter intraoperative monitoring or managment
● change postoperative disposition

16. Diagnostic
● Low risk surgery
○ low risk patients-no routine diagnostic test is required
○ high risk patients-consider testing as routine managment for chronic conditions
● High risk or intermediate risk surgery
○ All patients
○ High risk patients-consider additional specialist consultation

17. Study Indication
cbc surgery associated with significant blood loss
age >65 and major procedure
RFT age > 50 with intermediate or high risk surgery
known renal, cardiac or dm
medications that impair renal function
nephrotoxic drug
blood
glucose,HgbA1c
DM
liver function test cld
coaugulation studies anticoagulant use
urine analysis
pregnancy test women of child bearing age
ECG BMI>40 with risk factor,High risk surgery
CXR BMI>40 with syptoms,high risk surgery

18. Cardiovascular system
perioperative cardiac risk-MI,heart failure , arrythmias, stroke , death
● existing cardiovascular disease
● poor functional status
● older age
● diabetes
○ ECG
○ Echocardiography
● Blood pressure- <160/100
● MI - delay 2 month

19. Respiratory system
procedure related risk factors
1. surgical site
2. duration of surgery
3. type of anesthesia
investigation
chest xray
-age > 50 with high risk surgery

20. Evaluation and managment of other systems
● Malnourishment
consult a dietitian
1. BMI<18.5
2. Unplanned weightloss >10% in 6 month
3. decrease in dieatry intake of 50% in the last week
4. serum albumin <3g/dl

21. Hepatic disorders
○ Acute hepatitis- delay surgery until there is documented improvement in liver function tests
○ Chronic liver disease-Child score
● Hematologic disorders
○ Venous thromboimbolism-minimum 1 month ideally 3 month
○ Anemia
Endocrine
○ DM-Hemoglobin A1C-<8

22. Neurological disorders
○ Cerebrovascular accidents- delay 9 month
Renal disorders
CKD- increased risk for akI

23. Medications managment
● Cardiac
○ Coutinue- Beta blockers,calcium channel blockers, nitrates, statins
○ Hold- ACEI,ARB for 24 hrs
○ hold morning dose-Diuretics
● Hematologic
○ Vit K antagonist -hold 7 days and bridge
○ aspirin- hold only in high risk bleeding procedures
● Endocrine
○ Insulin
■ Short acting- skip Morning dose
■ Intermediate acting- 50% in morning
■ Long acting and insulin pump- 60-80%
■ Premixed(NPH 70:Regular 30) - BG> 200 give 50% ,BG < 200 give 50% of long or
intermediate componet

24. Oral antidiabetics - Hold morning dose except SGLT-2 inhibitors hold 3-4 days
Estrogen,progestrons,androgens - continue,/one month
corticosteroids- continue
Throid hormones - continue
● CNS -
○ Parkinsons, antiepelpetics,Psycotropic - continue
○ MAOI - 2-3 weeks
● NSAIDS
○ Short acting - 24 hrs
○ Intermediate acting - 4 days
○ Long acting - 10 days

25. Preoperative preparation measures
● Lifestyle modification
○ Smoking cessation - 4-8 weeks
○ Alchol - 4 weeks ,avoid abrupt withdrawal 1-3 days
● Fasting
○ 2hrs-NPO
○ 4hrs-Breastmilk
○ 6hrs-non human milk, solid food, infant formula
○ 8hrs - meat, fried food, fatty food
● Antibiotic
○ 30-60minutes prior to skin incision

26. Informed consent
● patient is informed of all medical issues
● patient is informed of recommendations and all options of care
● patient is aware of the benefits and risks of options of care
● patients personal expectations and concerns are considered
● providers consider the patient’s viewpoints
● providers answer all the patient question’s
● patient actively participates in all decisions

27. Take home message
● Routine perioperative testing of healthy indivisuals undergoing elective
surgery is not recommended.
● Patients with high disease burden and having high risk surgery often require
extensive testing and possible postponment of surgery.
● Patients having emergency surgery still require evaluation eventhough
managment beyond rescusitation is typically limited.