This document provides guidance on preoperative evaluation and management of patients undergoing elective surgery. It recommends focusing the evaluation on the patient's medical history and physical exam rather than routine screening tests. It provides criteria for when basic lab tests or specialist consultations are warranted based on a patient's health conditions and type of surgery. Guidance is given for the preoperative management of common patient populations like those with cardiac, pulmonary, renal or liver disease, diabetes, or who are pregnant/elderly.

1. By Dr.Manzuri & Dr.Roodsarabi
Attend: Dr. Khajeh

2. PREOPERATIVE EVALUATION
 Surgery and anesthesia profoundly alter the
normal physiologic and metabolic states. The task
of the preoperative evaluation is to estimate the
patient’s ability to respond to these stresses in the
postoperative period. This discussion is a review of
the elements in the patient’s history or findings on
physical examination that may suggest the need to
modify care in the perioperative period.

3. Preoperative Screening Tests and
Consultations
 the potential harm caused by the routine screening of
asymptomatic patients is greater than any benefit
derived from uncovering occult abnormalities.
 Obtaining data to establish a “baseline” is not
recommended for the asymptomatic patient.
 Normal laboratory results obtained within 4 months
of an elective operative procedure need not be
repeated, because abnormalities can be predicted on
the basis of the patient’s history.

4. screening of Hb
 Routine screening of hemoglobin concentration is
performed only in individuals undergoing procedures
that are associated with extensive blood loss (typically
>500 mL), or who may be harboring anemia
unbeknownst to the treating team.
 Patients with a history of anemia, malignant disease,
renal insufficiency, cardiac disease, diabetes mellitus,
or pregnancy should have baselin determinations of
serum hemoglobin concentration.

5. Serum Electrolytes
 Evaluation of baseline serum electrolyte concentrations,
including serum creatinine, is appropriate in individuals
whose history or physical examination suggests chronic
medical disease (e.g., diabetes, hypertension,
cardiovascular, renal, or hepatic disease).
 Patients with the potential for loss of fluids and
electrolytes, including those receiving long-term diuretic
therapy, and those with intractable vomiting, should also
have preoperative determination of serum electrolytes. The
elderly are at substantial risk for chronic dehydration, and
testing is appropriate in these patients as well.

6.  Preoperative U/A is recommended only for patients who
have:
 urinary tract symptoms
or history of chronic urinary tract disease
 or in those who are undergoing urologic procedures.
• ECG is recommended for :
men>40
women> 50
and patient with known coronary artery disease,
diabetes and hypertension.

7. Recommendation for laboratory testing before elective surgery
test indication

8. Perioperative medication managment
Preoprative management Postoprative management

10. Medical Consultation
 Specialty consultation may be required to optimize the
patient’s chance for a successful operation.
Medical consultants should not be asked to “clear”
patients for a surgical procedure
 their primary value is in helping to define the degree
of perioperative risk and making recommendations
about how best to prepare the patient to successfully
undergo the operation and postoperative course.

11. Cardiac Evaluation
 The surgical stress response involves a catecholamine surge in
response to the pain and anxiety associated with the operative
procedure or the disease process itself. The result is an
increase in the myocardial oxygen requirement. A second
alteration suppresses the fibrinolytic system, predisposing the
patient to thrombosis.
 An ECG may be indicated for select patients with higher risk
procedures and significant medical comorbidities, including
known coronary artery disease ,significant arrhythmia,
peripheral arterial disease, or other significant structural
heart disease.
 Further testing with an echocardiogram or cardiac stress test
may also be warranted in high-risk patients with poor or
unknown functional capacity

12. Pulmonary Evaluation
 there is no need for routine CXR or pulmonary function tests.
CXR is recommended for patients undergoing intrathoracic
procedures and those with signs and symptoms of active
pulmonary disease.
 Potential risk factors for postoperative pulmonary
complications include:
age, chronic lung disease, tobacco abuse, congestive
heart failure, functional dependence, and the American
Society of Anesthesiologist (ASA) classification >2.
(The ASAclassification system stratifies patients into six categories on the
basis of their overall health, from a normal, healthy patient in ASA I, to a
moribund patient in ASA V, to an organ donor in ASA VI. )

13.  Preoperative interventions that may reduce postoperative
pulmonary complications include:
 smoking cessation for at least 6 weeks
preoperatively inspiratory muscle training
bronchodilator therapy
 antibiotic therapy for preexisting infection
pretreatment of asthmatic patients with steroids.

14. RENAL DYSFUNCTION
 The risk of AKI in surgical patients has been estimated to
be approximately 1%.
 Factors associated with an increased risk of AKI include:
age, past history of kidney disease, left ventricular
ejection fraction of <35%, cardiac index <1.7 L/min/m2,
hypertension, peripheral vascular disease, diabetes
mellitus, emergency surgery, and type of surgery.
 The surgeries with the highest risk include coronary artery
surgery, cardiac valve surgery, aortic aneurysm surgery, and
liver transplant surgery.

15.  Daily weighting and accurate intake and output records are
essential.
Maintenance of euvolemia and renal perfusion is the goal in the
perioperative management of patients with CKD or AKI.
 Avoidance of hypotension and careful administration of
medications can prevent exacerbation of renal failure.
 Most drugs can be nephrotoxic, and doses must be
adjusted frequently on the basis of an estimated degree of
renal function.

16.  Analgesic requirements in the perioperative period are an
important consideration in patients with AKI or CKD, as
opioids can accumulate in patients with CKD, placing them
at a higher risk of respiratory depression.
 NSAID drugs are generally not recommended because of
their nephrotoxic side effects.
 Electrolytes, particularly potassium, calcium, magnesium,
and phosphorous, must be followed carefully.

17. HEPATIC DYSFUNCTION
 Routine testing with liver biochemical tests preoperatively
for screening purposes in asymptomatic patients without
risk factors or physical findings indicating liver disease is
not recommended.
 When liver disease is suspected ,additional investigations
should be undertaken, and should include biochemical
and serologic testing for viral hepatitis, autoimmune liver
disease, and metabolic disorders and radiologic evaluation
with abdominal ultrasonography, MRI, or CT scans.
 Although serologic and radiologic testing is often adequate
for diagnosis and perioperative risk assessment, liver
biopsy remains the gold standard for the diagnosis and
staging of liver disease.

18.  Contraindication to elective surgery in patients
with liver disease
Acute liver failure
Acute kidney injury
Acute viral hepatitis
Alcoholic hepatitis
Cardiomyopathy
Hypoxemia
Severe coagulopathy (despite treatment)

19.  In patients with Cirrhosis, the Child-Pugh classification
and Model for End-stage Liver Disease (MELD) score
should be calculated to assist in preoperative risk
assessment.
 In general, elective surgery:
 is well tolerated in patients with Child class A
cirrhosis,
 is permissible with preoperative preparation in
patients with Child class B cirrhosis (except those
undergoing extensive liver resections or cardiac
surgery),
 and is contraindicated in patients with Child class
C cirrhosis.

20. Child-Pugh Classification of Cirrhosis
Class Albumin Bili Ascites
Encephal
opathy
Nutritio
nal State
Mortality
Rate
A >3.5 <2.0 Absent Absent Good <10
B 3.0–3.5 2.0–3.0 Minimal Minimal Fair 40
C <3.0 >3.0 Severe Severe Poor >80

21.  The MELD score is based on serum bilirubin, serum
creatinine, and the INR. Scores range from 6 to 40, with 6
reflecting “early” disease and 40 “severe” disease.
 In patients undergoing laparoscopic cholecystectomy:
a MELD score of <8, the mortality is 0%,
MELD score is >8, the mortality is around 6%.
 Among patients undergoing abdominal surgery,
orthopedic surgery, and cardiovascular surgery:
MELD score <=7have a mortality rate of 5%
MELD score of 8-11 have a mortality of 10%
MELD score of 12 - 15 have a mortality of 25%.

22.  Ascites increases the risk of wound dehiscence and
abdominal wall hernias after abdominal surgery. Also,
large-volume ascites can impair ventilation and cause
respiratory compromise.
 Alcholic patients are at risk for alcohol withdrawal. These
include delusions, tremors, agitation, and tachycardia.
Benzodiazepines may prevent major withdrawal symptoms
if they are instituted prophylactically.
 Patients with alcohol-induced liver disease are often
deficient in thiamine and folate and have depleted levels of
total body potassium and magnesium. Wernicke-Korsakoff
syndrome (i.e., ataxia, ophthalmoplegia, and
confusion) may follow if thiamine is not administered
prior to the administration of glucose.

23. THE DIABETIC PATIENT
 The task of the surgeon in managing the diabetic patient is
to achieve euglycemia
 The perioperative management of patients with diabetes is
approached as follows:
Rapid-acting and short-acting insulin preparations
are usually withheld at midnight the day before surgery.
 Intermediate-acting and long-acting insulin
preparations are administered at two-thirds the normal
evening dose the night before surgery and half the
normal morning dose the morning of surgery.
 Long-acting oral agents are stopped 48 to 72 hours
before surgery, whereas short-acting agents can be
withheld the night before or the day of surgery.

24.  The patient should receive a continuous infusion of 5%
dextrose to provide 10 g glucose/hour. Fingerstick
glucose levels are monitored intraoperatively and
followed postoperatively at least every 6 hours.
The goal is to maintain a glucose level of between
120 and 180 mg/dL

25.  DKA is deceptively easy to overlook because it can
mimic postoperative ileus. It may present as nausea,
vomiting, and abdominal distension, or in association
with polyuria (which is commonly mistaken for
mobilization of intraoperative fluids).
 A glucose level that is <250 mg/dL does not mean that
the patient is not at risk for DKA; DKA develops
because of the metabolism of fuel in the absence of
glucose. Hence, the development of DKA does not
depend on a certain level of glucose, but on the
absence of insulin.

26. THE ADRENALLY INSUFFICIENT PATIENT
 A prednisone-equivalent dose of 20 mg/day for at least
3 weeks can be presumed to be associated with HPA
axis suppression.
 Physical findings of a Cushingoid appearance should
also raise the index of suspicion.
 Present recommendations are based on the degree of
surgical stress anticipated (i.e., minor, moderate, or
major) and are detailed in the Table. In all cases,
patients should receive their morning steroid dose
with a sip of water.

27. Stress Steroid Coverage
Magnitude of Procedure Steroid Replacement: Take Usual
Morning Steroid Dose, and:
Minor procedures or surgery under
local anesthesia (e.g., inguinal
hernia repair)
No extra supplementation is
necessary
Moderate surgical stress (e.g., lower
extremity revascularization,
total joint replacement)
50 mg hydrocortisone IV just before
the procedure and 25 mg of
hydrocortisone every 8 hr for 24 hr.
Resume usual dose thereafter.
Major surgical stress (e.g.,
esophagogastrectomy, total
proctocolectomy)
100 mg of hydrocortisone IV just prior
to induction of anesthesia,
and 50 mg every 8 hr for 24 hr. Taper
dose by half per day to
maintenance level.

28. THE PREGNANT PATIENT
 One in every fourteen pregnancies is complicated by injury.
Every injured woman of childbearing age should be screened for
pregnancy.
 The enlarging uterus displaces abdominal viscera and can alter
the location of pain in some common intra-abdominal
conditions such as appendicitis.
 A gravid uterus can compress the inferior vena cava and reduce
venous return when the woman assumes the supine position.
Pelvic venous compression produces or exacerbates hemorrhoids
in over one-third of pregnant women.
 Lower extremity venous insufficiency and the hypercoagulable
state of pregnancy itself increase the risk of venous
thromboembolic events, especially if the pregnant patient is
placed at bed rest.

29.  Heart rate, stroke volume, and plasma volume are
increased. This increase in blood volume can mask blood
loss or delay the classic presentation of hypovolemia,
especially after injury.
 The appearance of normal vital signs can be deceptive and
obscure fetal distress.
 The leukocytosis associated with a normal pregnancy
reduces the utility of this laboratory test.
 Placental abruption can occur even after minor injury and
is not consistently accompanied by vaginal bleeding. The
presence of a hard uterus, larger than expected for
gestational age, is suspicious for abruption.

30.  Because sensitization of Rh-negative women occurs
with miniscule amounts of fetal Rhpositive blood, all
injured Rh-negative women should be considered for
Rh-immunoglobulin therapy, unless the injury is
relatively minor and remote from the uterus.
 If surgery is necessary, it is best performed during the
second trimester
 Laparoscopy can be performed safely during the
second trimester

31. THE GERIATRIC PATIENT
 The elderly have less reserve than their younger
counterparts. They are often on medications that can
distort physiologic responses (e.g., β-blockers). They are
also often on medications that can impact the response to
surgery (e.g., warfarin or platelet aggregation–inhibiting
agents).
 It is always important that the patient and physician talk
openly about the level of aggressiveness to be exerted on
behalf of the patient and strengths and weaknesses of
different approaches are compared, until the physician and
patient arrive at a plan of action.

32. Informed Consent
 Informed consent is a process, not an event, and not a
form. It is the process wherein the patient and surgeon
together decide on a plan. Informed consent is different
from a consent form. A consent form is intended to
serve as legal documentation of these discussions
between the physician and the patient.

33. Documentation
 Daily progress notes record the patient’s clinical course
throughout his or her hospital stay. Noting the hospital day
number, the postoperative day, or the days after injury is
helpful. The format for progress notes varies among
hospitals and even among services within the hospital.
 Discharge notes should be concise and list the patient’s
reason for hospitalization (also referred to as the “principal
diagnosis”), a brief summary of the patient’s hospital
course, what medications the patient is to be discharged
on, what medications the patient will take after discharge,
where the patient is to go after discharge, what the patient’s
level of activity is, and what the plan for follow-up is.

34. Tubes and Drains
Gastrointestinal Tract Tubes
 Nasogastric tubes are usually used to evacuate the gastric
contents. They are most commonly used in patients who
have ileus or obstruction.
 Nasoenteric tubes are usually intended for feeding. These
should be soft and fine bore. A word about safety is in
order.
Nothing should be instilled into a feeding tube of
any kind (nasogastric or nasoenteric) unless the
position of the tube is known.
 Auscultation of injected air over the epigastrium can be
misleading; a tube can be intrabronchial and still transmit
the sound of injected air to the epigastrium

35. Respiratory Tract Tubes
 Chest tubes are placed into the pleural cavity to evacuate air
(pneumothorax), blood (hemothorax), or fluid (effusion). They
are connected to a special suction system that (1) permits a
constant level of suction (usually 20 cm H2O), (2) allows
drainage of air and liquid from the pleural cavity, and (3)
prevents air from entering the pleural space from the outside.
This latter function is known as a “water seal”.
 Endotracheal tubes for adults are cuffed to maintain a seal
between the tracheal wall and the tube. These tubes are used
when patients need short-term mechanical ventilation or when
they cannot maintain a patent airway.
 Tracheotomy tubes are placed directly into the trachea via the
neck. They are used for patients who require long-term
mechanical ventilation or who cannot maintain a patent airway
over the long term.

36. Urinary Tract Tubes
 Bladder catheters, commonly referred to as “Foley”
catheters, are placed to straight drain.
 Nephrostomy tubes are usually placed in the renal
pelvis to drain urine above an area of obstruction or
above a delicate ureteral anastomosis.

37. Surgical Drains
 Closed suction drains (Jackson-Pratt and Hemovac are two
common types) are placed intraoperatively to evacuate
actual or potential fluid collections.
 Passive tubes (Penrose drains) simply maintain a pathway
for fluid to follow, without suction to enhance flow. These
are soft, cylindrical latex drains. Because suction is not
applied to them, they are very much a twoway path for
bacteria.
 Tubes placed percutaneously to drain abscesses are often
known as “pigtail catheters” and are another example of a
passive tube. They are usually placed by interventional
radiologists with the help of imaging technology.

38. Wound Care
 A saline-moistened cotton gauze dressing is used to
gently fill the cavity. (The wound cavity should not be
packed tightly because this leads to tissue ischemia.)
This helps collect drainage and prevent the abscess
cavity from sealing over. A variety of substances are
used to moisten the gauze for wounds managed in this
way. Some examples include 0.25% acetic acid
solution, Dakin’s solution (sodium hypochlorite), and
povidone–iodine solutions.

39. Pain Management
 Asking the patient how their pain level is should be a
routine part of the review of systems taken on daily rounds.
For patients who are unable to speak, attention to their
facial expressions and vital signs will give clues as to their
level of discomfort.
 The nature of the patient’s disease process and
comorbidities will determine the type of pain management
strategy. For example, many patients with thoracic or
abdominal incisions are well served with epidural
analgesia. Where possible, intravenous patient-controlled
analgesia should be used for the intense pain that
accompanies the early postoperative state.

40. Deep Vein Thrombosis Prophylaxis
 Some surgical patients are at particular risk for VTE
because they have each of Virchow’s three risk factors for
venous thrombosis: stasis, hypercoagulability, and
endothelial injury.
 Patients who are at highest risk:
who are immobile,
 who have congestive heart failure or malignancy,
who undergo pelvic or joint replacement operations,
who have vertebral, pelvic, or long bone fractures

41. POSTOPERATIVE COMPLICATIONS
Atelectasis
 Under anesthesia, patients do not sigh or cough, and mucociliary
cleaning of the tracheobronchial tree is impaired. Mucous
plugging of small airways may result. Absorption atelectasis, the
uptake of gas from the alveoli in the face of proximal
obstruction, further contributes to lung unit collapse. The effect
is an increase in shunt fraction, that is, low ventilation to
perfusion ratio, resulting in hypoxia.
 The postoperative period is characterized by incisional pain,
somnolence from analgesic use, suppressed cough, lack of
mobility, and nasopharyngeal instrumentation. These factors all
contribute to perpetuate a situation in which tidal ventilation is
reduced and periodic re-expansion of collapsed alveolar units by
maximum inspiratory efforts is suppressed.

42.  Management of postoperative atelectasis should begin
preoperatively, by :
encouraging cessation of smoking for 8 weeks
preoperatively
and instituting inspiratory exercises.
 Chest physiotherapy may also begin, particularly for
patients with productive cough or chronic bronchitis.
 Re expansion techniques (incentive spirometry) are
appropriate for all patients.
 One of the advantages of minimally invasive surgery is the
significant reduction in atelectasis as well as other more
serious pulmonary problems.
The most important strategies involve adequate
postoperative pain management, frequently obtained with
epidural analgesia, and early mobilization.

43. Surgical Wound Failure
 Acute wound healing failure involves an alteration in
wound healing process as a result of mechanical
forces, infections, or aberrations of the normal
biologic response of injured tissue.
 The force exerted across the wound is greater than the
strength of suture material or of the fascia itself. This
latter failure is generally caused by ischemia of the
tissue from suture material placed too tightly or
becoming too tight as edema develops at the site of
wounding.

44.  The spontaneous discharge of serous fluid from a
wound is a sign heralding acute fascial dehiscence.
These patients should be returned expeditiously to the
operating room for examination and repair of the
closure.

45. Surgical-Site Infection
 Surgical-site infections are the second most common
nosocomial infection and will occur in 2% to 5% of all
surgical patients.
 surgical-site infections are those associated with
inflammation:
redness (rubor), swelling (tumor), localized heat and
erythema (calor), and increased pain at the incision
site (dolor).
Tachycardia may be the first sign and fever may develop
only later
 Prompt drainage minimizes these sequelae and antibiotics
play a secondary role, unless there are extenuating
circumstances

46. Fever
 a temperature elevation to 38.3°C is the trigger to initiate an
investigation.
 The first evaluation process begins with a review of the
circumstances surrounding the patient:
 patient location (intensive care unit vs. ward),
 length of hospitalization
 presence of mechanical ventilation and its duration
 instrumentation (e.g., catheters, vascular lines, tubes in the nose
or chest), duration of the instrumentation,
 medications,
 surgical sites and the reason for the surgical procedure (e.g.,
elective, emergent, trauma, gastrointestinal tract),
 current treatments, and diagnosis

47.  Second, a directed physical examination is performed
to look for clues and/or confirmation of a suspected
source.
Only after these two steps have been taken should
consideration be given to ordering diagnostic study.
References: Essentials of General Surgery edition 6th dies.

48. The End
thanks for your attention