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pre op care seminar.pptx
- 1. Preoperative care Presenter: Dr.Moti( OSR-1) Moderator :- Dr. Endale(Anesthesiologist) April 2022 1
- 2. Outline • Objectives • Introduction •Patient assessment • Specific preop problems and management • Preop assessment in emergency surgery • Risk assessment and consent • Arranging the theatre list • References 2
- 3. Objectives • Be ableto organize preoperative care and the operating list • To understand Surgical, medical and anesthetic aspects of assessment • To understand How to optimize the patient’s condition • To understand How to take consent 3
- 4.
- 5. Introduction • Preoperative careis a comprehensive approach which begins with the decision to perform surgery and continues until the patient enters the OR.
- 6. Components of preoperativecare • Preoperative assessment Reviewing client’s health status(Hx&Px) Investigating • Optimization of pt condition
- 7. Patient assessment • Tolook actively for risks and manage them so as to enable surgery to go ahead safely. • Done by the surgical, nursing team and/or anesthetic team • Includes history, physical examination and investigations • The aim of preoperative evaluation is not to screen broadly for undiagnosed disease, but to identify and quantify any co morbidity that may affect the operative outcome. 7
- 8. Patient Assessment • Goals: Assess the Risk of surgical vs non-surgical Rx. Assess the extent of known disease present. Identify unknown or hidden diseases(risks ). Develop an individualized anesthetic plan. 8
- 9. Risk Assessment • Twomajor questions 1. Is the patient in optimal medical condition for surgery? 2. Benefits of surgery vs associated risk balance. Is it worthy? 9
- 10. I. Review theclient’s health status History Hx of present illness and reason for surgery Past medical Hx Prior Hx of problem with anesthesia Allergies and current medications Substance use Review of system
- 11. Physical examination • General •Cardiovascular • Respiratory • Gastrointestinal • Musculoskeletal • Neurological • Airway assessment
- 12. Airway evaluation • Purposeis to predict and possibility of intubation • look for- neck mobility short neck protruding teeth large tongue Mallapati test
- 13.
- 15. INVESTIGATIONS • Rationale forpreoperative testing – To detect unsuspected abnormalities – To establish a baseline value for a test – For medico-legal reasons • Routine preoperative testing – Not cost-effective – Less predictive of perioperative morbidity – Should be individualized 15
- 16. Preoperative Ixs Should beindividualized • CBC, BG and X- match • S/electrolytes • RFT • U/A • CXR • ECG • Other tests – coagulation studies, radiographic, TFT, RBS, HbA1C PFT, LFT as necessary
- 17. III. SPECIFIC PREOPPROBLEMS AND OPTIMISATION
- 18. CVS • is theleading cause of death in the industrialized world, and • its contribution to perioperative mortality during noncardiac surgery is significant • All patients scheduled to undergo noncardiac surgery should have an assessment of the risk of a cardiovascular problems 18
- 19. Cardiovascular disease • Contributesto perioperative mortality. • The degree of risk can be assessed using the: – Goldman Index – Lee’s criteria(RCRI) –MET –NYHA 19
- 20. Goldman Index Risk factorScore Age > 70 years 5 MI within 6 months 10 Third heart sound /gallop rhythm 11 Aortic stenosis 3 Rhythm other than sinus 7 >5 Ventricular ectopics per min 7 Emergency surgery 5 Abdominal or thoracic operation 3 Poor general condition 3 Cardiac Complication Rate: Class I ( 0-5)……0.9% Class ii (6-12)……. 7.1% Class iii (13-25)….. 16% Class iv ( > 26) …….. 63.6 % • above 26 has a mortality of 50% and only life- saving operations should be considered 20
- 22. Metabolic equivalent oftask (MET). – 1 MET= 3.5 mL O2/kg per minute (oxygen consumption by 40 year, 70 kg man at rest) – 1 MET = eating and dressing – 4 MET = climbing two flights of stairs – 6 MET = short run – >10 MET = able to participate in strenuous sport NB Patients who can exercise at 4 METS or above have lower risk of perioperative mortality 22
- 23. NYHA Functional Class Class I Nolimitation of physical activity; ordinary activity does not cause fatigue, palpitations or syncope Class II Slight limitation of physical activity; ordinary activity results in fatigue, palpitations or syncope Class III Marked limitation of physical activity; less than ordinary activity results in fatigue, palpitations or syncope; comfortable at rest Class IV Inability to do any physical activity without discomfort; symptoms at rest 23
- 24. Very high-riskpatients need optimization • Recent MI • Unstable angina • Decompensated heart failure • High-grade arrhythmias • Hemodynamically important VHD • Uncontrolled Hypertension
- 25. Hypertension • Most commonmedical reason for postponing surgery • Leads to many complications • Poorly controlled hypertension – DBP > 110 or SBP > 160 25
- 26. Cardiovascular disease… • Electivesurgery – DBP >110mmHg should not undergo elective surgery – CBC, RFT, ECG and CXR – Bp should be controlled to near 160/90 mmHg – If a new antihypertensive is introduced • stabilisation for at least 2 weeks 26
- 27. Cardiovascular disease… • Well-controlledhypertension – continue medication up to, and including, the day of surgery • Premedication – benzodiazepines – two hours prior to surgery • Emergency Surgery – Bp may need to be controlled more rapidly – but don’t drop Bp precipitously
- 28. Ischemic Heart Disease •Dangerous risk factor • Recent MI is strong contraindication for elective surgery • At least 3-6 months should be lapsed after an attack • Significant mortality from anesthesia within 3 mon. • Elective surgery- should be delayed for 6 months. • If urgent surgery needed - aggressive therapy. − meticulous optimization of O2 and fluid balance throughout the perioperative period must be obtained 28
- 29. CVS …cont’d Valvular heartdisease: – Cardiologist and anesthesiologist evaluation – Warfarin should be stopped 5days before surgery with INR of 1.5 – UFH infusion if INR is/falls below 1.5 until 2hrs before surgery with aPTT goal of 1.5 times norma – Continue postoperatively.. 29
- 30. CVS …cont’d • Dysrhythemia oAF should be controlled before surgery. o If Digoxin used- measure K reguraly o 2nd & 3rd degree heart block – pacemaker. • Anemia & Transfusion o Preop HgB less than 6-7mg/dl o Symptomatic o Active bleeding 30
- 31.
- 32. Respiratory disease • Perioperativepulmonary physiology: – Vital capacity (VC) is reduced by 50 to 60 percent and may remain decreased for up to one week. – Functional residual capacity (FRC) is reduced by about 30 percent. 32
- 33. Respiratory disease …cont’d Risk factors for pulmonary complications can be grouped into patient-related and procedure- related risk 1. Procedure-related risk factors – Surgical site – Duration of surgery (>3-4hrs) – Type of anesthesia – Type of neuromuscular blockade 2. Patient-related risk factors 33
- 34. Pulmonary Disease… • Decreasepostoperative pulmonary complications – smoking cessation (>2 mos before the planned procedure) – bronchodilator therapy – antibiotic therapy for preexisting infection – pretreatment of asthmatic patients with steroids – use of epidural anesthesia – vigorous pulmonary toilet and rehabilitation
- 35. Pulmonary Disease… COPD &ASTHMA Management – Preoperative bronchodilator – Regional anesthesia is better – Intra op stress dose steroid administration Infection • elective surgery should be postponed • treat with antibiotics and physiotherapy • operation rescheduled after 4–6 weeks
- 36. Respiratory disease …cont’d Pulmonology referral : – Severe disease deteriorating from usual – Major surgery for resp. comorbidities – Right side heart failure – Young pt with COPD 36
- 37. Gastrointestinal disease NPO andregular medications: – Clear liquids- 2hrs – Breast milk- 4hrs – Cow milk, formula milk, light meal- 6hrs – Fried or fatty food or meat – 8hrs – Medications with sips of water 37
- 38. Gastrointestinal disease…cont’d Regurgitation risk:hiatus hernia, obesity, pregnancy and diabetes are at risk of regurgitation even after NPO – Rx with clear antiacids , H2 blocker/PPIs Liver disease: any evidence of clotting problems, renal involvement, alcoholic hepatitis and encephalopathy, surgery should be postponed at least 12wks/patient recover . In chronic hepatitis surgery can be safely done 38
- 39. Genitourinary disease Renaldisease – CKD: rx cxs like acidosis, hypocalcemia, and hyperkalemia >6mmol/l If pt is on dialysis continue until few hours before surgery and determine RFT, CBC and serum electrolytes – Anemia is usually well tolerated – AKI with emergency surgery needs simultaneous surgical and medical rx with critical care support as needed UTI – Should be treated 1st for elective surgery, but in case of emergency rx started and surgery after good urine output 39
- 40. Endocrine and metabolicdisorders Malnutrition: • Nutritional assessment : ABC – Anthropometry and body weight • BMI<18.5 nutritional impairment • BMI<15 is associated with major hospital mortality • Skin fold thickness • MUAC – Biochemical (laboratory studies) • Serum albumin<30g/l indicator of poor prognosis • Lymphocyte count and skin test for delayed hypersensitivity – Clinical • MUST- five step screening tool 40
- 41. 41 Nutritional support fora minimum of 2 weeks before surgery is required to have any impact on subsequent morbidity
- 42. Endocrine and metabolicdisorders… cont’d Obesity : morbid obesity BMI>35 is associated with increased risk of postop cxs – Perioperative sleep apnea – DVT – Aspiration • Rx : prolong surgery if possible – CPAP and cholesterol reducing agents – Prophylaxis for aspiration and DVT 42
- 43. Endocrine and metabolicdisorders… cont’d Diabetes mellitus Strict glycemic control is needed b/c surgery and GA causes neuroendocrine stress response Assess for • Type of DM • Long term cxs • Baseline glycemic control if >200mg/dl associated with deep wound infection • Hypoglycemia hx • Hx of therapy • Type of anesthesia and surgery Ixs : ECG,RFT, RBS, and HgbA1c 43
- 44. Endocrine and metabolicdisorders… cont’d Goals of glycemic control General goal Avoid hypoglycemia Prevent DKA/Hyperosmolar state Maintenance of fluid and electrolyte Avoid marked hyperglycemia Glycemic targets 110-180mg/dl in noncritical hospitalized pt 80- 180mg/dl in perioperative pt 44
- 45. Endocrine and metabolicdisorders… cont’d • Perioperative phase: – Pts should have surgery as early as possible in morning – T2DM with diet rx alone • Do not require rx perioperatively • Correction insulin if RBS is above target • Monitor RBS every 2hr for long surgery(>2hs)or surgeries with expected high glucose level – T2DM on oral hypoglycemic agent • Continue routine medication until morning dose(hold) • If HgbA1c <7.0% will not need insulin • Determine RBS every 2hrs and put on sliding scale every 6hrs if hyperglycemic 45
- 46. Endocrine and metabolicdisorders… cont’d • T1DM or T2DM on insulin – Pt undergoing morning procedure where breakfast and lunch likely to be missed: • Omit short acting insulin • Reduce to 1/3 - 1/2 of dose on intermediate and long acting • Pt on continuous infusion can continue • Start on D5W at rate of 75-125 ml/hr to avoid metabolic change of starvation • RBS every hour or less if RBS is <100mg/dl • Put on sliding scale if hyperglycemia develops • Postoperative phase: perioperative rx regimen maybe reinstated once pt is eating well 46
- 47.
- 48. Thromboprophylaxis… • Mechanical Prophylaxis –Compression Stocking – Inferior Vena Cava Filter • Pharmacologic Prophylaxis – warfarin – LMWH – pentasaccharide (Fondaparinux) – aspirin (acetylsalicylic acid)
- 49. THROMBOSIS RISK • Patientswith increased risk of VTE balance with risk of bleeding • AAOS risk factors for major bleeding – bleeding disorders – history of a recent gastrointestinal bleed – history of a recent hemorrhagic stroke • AAOS risk factors for pulmonary embolus – hypercoagulable state – previous documented pulmonary embolism
- 50. Neurological and psychiatric disorders •Hx of stroke , pre-existing neurologic deficit on antiplatelet and anticoagulant – If risk of cardiovascular thrombotic is low stop aspirin 7days and clopidogrel 10 days before surgery – If risk is high continue aspirin only • Anticonvulsant and anti parkinson medication is continued perioperatively • Lithium should be stopped 24 hours prior to surgery • Inform anesthetist about TCA , MAOIs as they interact with anisthesia 50
- 51. Musculoskeletal and otherdisorders • RA of cervical spine can lead to unstable cervical spine with the possibility of spinal cord injury during intubation • In ankylosing spondylitis spinal/epidural anesthesia are often challenging • SLE may be associated with hypercoagulable state along with airway difficulties • NSAID- hold 3 days prior to surgery • Methotrexate- continue up to including day of surgery, in patient with renal insufficiency hold 2 weeks prior to surgery 51
- 52. Pre op Medication •OCP/HRT—4-6 weeks • Asprin—1 week?? • Warfarin -5-7 days • NSAIDS –5-7 days • ACEI • Lasix • Metformin • Heparin 52 Discontinue Early Discontinued on Day of Surgery
- 53. • DMARDs • Antiepileptics • Steroids?? • Beta blockers • H2 blockers • PPI • Anxiolytics • PCM 53 Don’t Stop(continue) Add
- 54. Prophylactic antibiotics • toprevent surgical site infection • 30min to 2 hour before surgical incision Indications – clean surgery involving insertion of a prosthesis or implant – clean-contaminated surgery – contaminated surgery • should be discontinued within 24 hours of surgery
- 55. Antimicrobial prophylaxis Orthopedic surgery •Antimicrobial prophylaxis is warranted for spinal procedures, repair of hip and other closed fractures, implantation of internal fixation device (screws, nails, plates, and pins), and total joint replacement. • Antimicrobial prophylaxis is not warranted for clean orthopedic procedures; these include arthroscopy and other procedures involving the hand, knee, or foot with no implantation of foreign materials. 55
- 56. Peri-operative Skin Preparation 56 •Whole body cleansing with chlorhexdine. • The night before & morning. • Clipping of hair is preferable . • Hair should be removed as close as to the surgery.
- 57. Preoperative assessment in emergencysurgery • Start: Similar principles to that for elective surgery • Constraints: Time, facilities available • Consent: May not be possible in life-saving emergencies • Organizational efforts: For example, local/national algorithms for treatment of multi-trauma patient 57
- 58. Risk assessment • Riskafter surgery is a complex interaction of multiple factors : 1. Patient factors History of severe cardiac disease:- IHD, MI, CHF Severe respiratory disease :- COPD, respiratory failure Aged >70 years with limited physiological reserve in one or more vital organs Metabolic disease :- renal failure, poorly controlled diabetes Morbid obesity Late stage vascular disease Poor nutrition 58
- 59. Risk assessment… cont’d 2.Surgical factors – Prolonged duration of surgery (>1.5 hours) – Extensive surgery (e.g. oesophagectomy, gastrectomy) – Type of surgery (thoracic, abdominal, vascular) – Emergency surgery (e.g. perforated viscus, gangrenous bowel, gastrointestinal bleeding) – Acute massive blood loss (>2.5 litres) – Septicaemia (positive blood cultures or septic focus) – Severe multiple trauma e.g. >3 organs or >2 systems or ≥2 body cavities open 59
- 60. Risk assessment… cont’d •Number of scoring systems have been developed over the years with the aim of identifying high- risk patients • Risk scoring systems – ASA is simple, but subject to user interpretation – MET measures exercise tolerance related to daily living – RCRI used to predict cardiac risk for non-cardiac surgery – POSSUM can only be used postoperatively and better for some types of surgery, e.g. colorectal, vascular – CPET is non-invasive, objective and becoming increasingly popular 60
- 61.
- 62.
- 63. Consent • Valid consentimplies that it is given voluntarily by a competent and informed person who is not under duress • In emergency situations or in an unconscious patient, consent may not be obtained and the procedure carried out ‘in the best interests of the patient’ 63
- 64. consent… Steps in consenttaking • patient’s demographic details should be checked • make sure that the patient understands – who you are – what your role is • the planned operation should be outlined and confirmed with the patient • a brief explanation of the planned operation – the risks and benefits involved – alternatives – the risks and benefits of doing nothing
- 65. consent… • Discuss thetype of anesthetic proposed • Give the patient time and space to make the final decision • Check that the patient understands and has no more questions • Record clearly and comprehensively what has been agreed
- 66. Preoperative Preparation ImmediatelyBefore Surgery… 7/19/2023 • Consent – if they want the consent process to be repeated – any questions – happy to proceed with surgery – should be recorded in the notes • Check that all relevant results and imaging are available • The side or area to be operated on should be marked.
- 67. Preoperative Preparation ImmediatelyBefore Surgery 7/19/2023 • The patient’s identity should be confirmed • A check should be made – no change in the patient’s condition – for any sepsis (skin, teeth, urine and chest)
- 68. Arranging the theatrelist • Date, place and time of operation • Appropriate equipment and instrument • Operating list should be distributed to all staff • Priorities for: – Children – Diabetic – Limb and life threatening – Cancer pts 68
- 69. References Bailey &Love’s short practice of surgery, 27th edition Sabiston Textbook of Surgery 20th edition Uptodate 2022 ASA classification system • Apley and Solomon’s System of Orthopaedics and Trauma • Orthobullet 69
- 70.
Editor's Notes
- #5 The perioperative period is a term used to describe the three distinct phases of any surgical procedure, which includes the preoperative phase, the intraoperative phase, and the postoperative phase. the preoperative phase, begins with the decision to have surgery and ends when the patient is wheeled into surgery. This phase can be extremely brief, such as in the cases of acute trauma, or require a long period of preparation during which time a person may be required to fast, lose weight, undergo preoperative tests, or await the receipt of an organ for transplant. The second phase, known as the intraoperative phase, involves the surgery itself. It starts when the patient is wheeled into the surgical suite and ends when the patient is wheeled to the post-anesthesia care unit (PACU). The final phase, known as the postoperative phase, is the period immediately following surgery. As with the preoperative phase, the period can be brief, lasting a few hours, or require months of rehabilitation and recuperation.
- #7 Emotional state Mind Competency Coping strategies Support system
- #9 Toassesstheris kofsurgeryvs.non-surgicia ltreatments i nordertoallowachoiceoftreatment stobeofferedand informe dconsentaboutagivenoperationtobeobtained *Toassessth eextentofknowndiseasepresen ti nthe patien ti nordert oallowappropriatetreatmen tt obe employedpreoperativelyandpostoperatively Toidentif yunknownorhiddendiseases(risks )i norder t oallowprophylacti ctreatmen tthatmightreduc eth e ris kandallo wplannin gfo rmanagementofpotential Patientselectionistheoverallprocessofassessmentand riskcomparisonthatallowsthesurgeontomakeadecisionregardingthesuitabilityofapatientforagivenoperation.Previously,therewasverylittleselectioninvolved inthedecisiontooperate,particularlyinlife-threatening Conditions.
- #10 Risk assessment Morbidity and mortality — The American Society of Anesthesiologists (ASA) physical status classification system is a relatively simple system that has proven effective in stratifying overall perioperative risk of morbidity and mortality for patient-specific risk factors (table 2) [2]. Patients are classified according to the degree to which underlying medical problems produce functional limitations. A higher ASA physical status is associated with increased risk of complications, unexpected hospital admission after ambulatory surgery, postoperative admission to the intensive care unit (ICU), longer hospital length of stay, higher costs, and mortality due to patient-specific and surgery-specific factors Assessment should be completed by classifying the patients according to ASA physical status and grading of surgery so that high risk patients with poor reserves will require consultation with specialists to help optimize the physical status for surgery and anaesthesia
- #11 Personal or family history of anesthetic complications — Malignant hyperthermia is a rare complication of anesthetic administration that is inherited in an autosomal dominant fashion. Due to the morbidity and potential mortality associated with this condition, the preoperative history should include questioning about either a personal or family history of complications from anesthesia.
- #16 For the first rationale, three actions are possible regarding an abnormal test result. First, clinicians may take action to correct the abnormality before surgery with the hope that correction will decrease the risk of perioperative complications. Second, a serious abnormality might result in the clinician recommending that the surgery be canceled or the nature of the surgery be modified to a less intensive procedure. Third, the abnormality simply may be ignored.
- #19 Of the 27 million patients undergoing surgery in the United States every year, 8 million, or nearly 30%, have significant coronary artery disease or other cardiac comorbid conditions.
- #21 The risk of life-threatening cardiac complications is only 1% with total score up to 5. The risk becomes 5% if the points total up to 12, increases to 11% with counts up to 25, and reaches 22% when the points >25.
- #23 1-4 METS-standard home activity, walk around house, walk 1-2 blocks on level ground at 3-5 km/h 5-9 METS- climb a flight of stairs, walk up a hill, walk on level ground at >6km/h, run short distance, moderate activities (dancing) 10 or above- strenuous activities like swimming, bicycle An easy, inexpensive method to determine cardiopulmonary functional status for noncardiac surgery is the patient's ability or inability to climb two flights of stairs. Two flights of stairs is needed because it demands greater than 4 metabolic equivalents (METs). In a review of all studies of stair climbing as preoperative assessment, prospective studies have shown it to be a good predictor of mortality associated with thoracic surgery.[7] In major noncardiac surgery, an inability to climb two flights of stairs is an independent predictor of perioperative morbidity, but not mortality.
- #26 Severe untreated hypertension in the perioperative period AMI, left ventricular failure Cerebral hemorrhage, hypertensive encephalopathy Renal failure Marked swings in blood pressure Bleed more during surgery These results suggest that elective surgery in patients with hypertension does not need to be delayed as long as the diastolic blood pressure is less than 110 mmHg and intraoperative and postoperative blood pressures are carefully monitored to prevent hypertensive or hypotensive episodes. On the other hand, when hypertension has caused end-organ disease such as congestive heart failure and renal insufficiency, the probability of adverse cardiac outcome in the perioperative period increases significantly [12]. (See "Evaluation of cardiac risk prior to noncardiac surgery".) The impact of systolic hypertension on operative risk is less clear. One study of patients undergoing carotid endarterectomy found that a systolic pressure greater than 200 mmHg was associated with an increased risk of postoperative hypertension and neurologic deficits [13]. Patients with isolated systolic hypertension are at increased risk for cardiovascular morbidity after coronary artery bypass surgery
- #27 Prior to elective surgery blood pressure should be controlled to near 160/100 mmHg. If a new antihypertensive agent is introduced, a stabilisation period of at least 2 weeks should be allowed BLOOD PRESSURE RESPONSE DURING ANESTHESIA — Sympathetic activation during the induction of anesthesia can cause the blood pressure to rise by 20 to 30 mmHg and the heart rate to increase by 15 to 20 beats per minute in normotensive individuals [5]. These responses may be more pronounced in patients with untreated hypertension in whom the systolic blood pressure can increase by 90 mmHg and the heart rate by 40 beats per minute. The mean arterial pressure tends to fall as the period of anesthesia progresses due to a variety of factors, including direct effects of the anesthetic, inhibition of the sympathetic nervous system, and loss of the baroreceptor reflex control of arterial pressure. These changes can result in episodes of intraoperative hypotension. Patients with preexisting hypertension are more likely to experience intraoperative blood pressure lability (either hypotension or hypertension) [6], which may lead to myocardial ischemia
- #28 Patients with well-controlled hypertension responded similarly to normotensive subjects. Other studies have found that a diastolic pressure over 110 mmHg immediately before surgery is associated with a number of complications including dysrhythmias, myocardial ischemia and infarction, neurologic complications, and renal failure Severe hypertension — An early study found that patients with untreated severe hypertension (mean systolic and diastolic pressures of 211 and 105 mmHg, respectively) had exaggerated hypotensive responses to the induction of anesthesia and marked hypertensive responses to noxious stimuli
- #29 Significant or worsening angina needs investigation by a cardiologist before elective surgery (Fig. 13.2). If urgent surgery is required, aggressive medical therapy is indicated and meticulous optimisation of oxygenation and fluid balance throughout the perioperative period must be obtained Postoperative MI is associated with hospital mortality rates of 15% to 25%; these patients also are at greater risk for cardiovascular death and nonfatal MI during the 6 months after surgery. The optimal timing of a surgical procedure after MI depends on the duration of time since the event and assessment of the patient’s risk for ischemia by clinical symptoms or noninvasive study. Any patient can be evaluated as a surgical candidate after an acute MI (within 7 days of evaluation) or a recent MI (within 7 to 30 days of evaluation). The infarction event is considered a major clinical predictor in the context of ongoing risk for ischemia. General recommendations are to wait 4 to 6 weeks after MI to perform elective surgery
- #30 In patients with mechanical heart valves, warfarin needs to be stopped for 5 days before surgery, and an infusion of unfrac-tionated heparin started when the INRfalls below 1.5. The acti-vated partial thromboplastin time (APTT) should be monitored to keep it at 1.5 times normal and the infusion is then stopped 2 hours before surgery. Heparin and warfarin should be started in the postoperative period and heparin is stopped when the full effect of warfarin is realised
- #31 Cardiac output can increase by 15% if sinus rhythm is restored in patients with atrial fibrillation, β-blockers, digoxin or calcium channel blockers should be started preoperatively (or continued if the patient is already on such medication) in order to control rate and possibly rhythm. ardiac output can increase by 15% if sinus rhythm is restored. Warfarin in patients with atrial fibrillation (AF) should be stopped 5 days preoperatively to achieve an international normalised ratio (INR) of 1.5 or less, which is safe for most surgery The newer anticoagulants such as dabigatran (direct thrombin inhibitor) or rivaroxaban, apixaban and edoxaban (direct factor Xa inhibitors) do not have antagonists and must be stopped preoperatively, generally for 2–3 days in patients with normal renal function and longer when renal function is impaired. Alternative anticoagulation is not required in the perioperative period unless the risk of stroke is high (high CHA2DS2- VACs score) Prosthetic or leaking cardiac valves Prophylactic antibiotic cover is usually necessary in these patients, especially if turbulent flow is likely to occur or the surgery may produce a bacteraemia.
- #33 postoperative pulmonary complications are the most costly of major postoperative medical complications (including cardiac, thromboembolic, and infectious)
- #34 Type of neuromuscular blockade — Residual neuromuscular blockade can cause diaphragmatic dysfunction, impaired mucociliary clearance, and ultimately contribute to postoperative pulmonary complications. Pancuronium, a long-acting neuromuscular blocker, leads to a higher incidence of postoperative residual neuromuscular blockade compared with shorter acting agents [41]. Residual neuromuscular blockade is also an important risk factor for critical respiratory events in the immediate postoperative period
- #35 As there is no evidence of harm related to a short duration of cigarette abstinence, we advise all patients anticipating elective surgery to quit smoking as soon as possible, regardless of the anticipated date of surgery. When time allows, a longer duration (at least eight weeks) of cessation is optimal stopped smoking < 2mon : stopped for > 2 mon ; 4:1(57% : 14.5%) quit smoking > 6 months : never smoked ; 1:1 (11.9% : 11%) Operative risk reduction has only been documented after 8 weeks of smoking cessation; however, there are physiologic benefits to stopping as little as 48 hours before surgery.
- #36 Despite the increased risk of postoperative pulmonary complications in patients with obstructive lung disease, there appears to be no prohibitive level of pulmonary function below which surgery is absolutely contraindicated For patients who present with symptoms or signs suggestive of an exacerbation of COPD, elective surgery should be delayed pending treatment and a return to baseline pulmonary functionPatients who have received >20 mg of prednisone per day or its equivalent (eg, 16 mg/day of methylprednisolone, 2 mg/day of dexamethasone, or 80 mg/day of hydrocortisone) for more than three weeks during the previous six months are assumed to have suppression of hypothalamic-pituitary-adrenal function. We recommend empiric use of stress-dose glucocorticoids in these patients immediately before induction of anesthesia to avoid potential adrenal insufficiency
- #38 NB If the surgery is delayed, oral (until 2 hours of surgery) or intravenous fluids should be started especially in the vulnerable groups of patients, e.g. children, elderly and diabetics.
- #41 30 % of surgical patients with gastrointestinal disease and 60 % prolonged hospital stay because of postoperative complications
- #42 *If height, weight or weight loss cannot be established, use documented or recalled values (if considered reliable). When measured or recalled height cannot be obtained, use knee height as surrogate measure. If neither can be calculated, obtain an overall impression of malnutrition risk (low, medium, high) using the following: (i) Clinical impression (very thin, thin, average, overweight); (iia) Clothes and/or jewellery have become loose fitting; (iib) History of decreased food intake, loss of appetite or dysphagia up to 3–6 months; (iic) Disease (underlying cause) and psychosocial/physical disabilities likely to cause weight loss. † Involves treatment of underlying condition, and help with food choice and eating when necessary (also applies to other categories).
- #53 ACE inhibitors and angiotensin receptor blockersContinuation can result in hypotension.Discontinue night before surgery unless using for HF and baseline blood pressure is adequate.Discontinue on night before surgery unless using for HF and baseline blood pressure is not low. Use parenteral enalaprilat as needed in postoperative period.
- #54 Allay anxiety and fear. Reduce secretions. Enhance the hypotonic effect of anaesthetic agents. Reduce postoperative nausea & vomiting. Produce amnesia. Reduce the volume & increase pH of gastric contents. Reduce vagal reflexes. Limitation of sympathoadrenal response
- #57 Alcohol is used as an antiseptic because of its rapid antimicrobial action. 11 One systematic review of five RTCs found that CHG-alcohol formulations were more effective at preventing SSI than aqueous povidoneiodine solutions, and in other studies there was no conclusive evidence that CHG-alcohol solutions were more effective than povidone-iodine products dissolved in alcohol or aqueous solutions. 20 While we cannot make a claim about the superiority of CHG over iodine-based antiseptics, it is suggested that whichever agent is chosen, it be dissolved in alcohol.
- #61 ASA, American Society of Anesthesiologists; CPET, cardiopulmonary exercise testing; MET, metabolic equivalent of task; RCRI, revised cardiac risk index; POSSUM, Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity
- #65 First, the patient’s demographic details should be checked with the patient. Second, the planned operation should be outlined and confirmed with the patient. All life- or limb-threatening complications and all minor complications with an incidence of 1% or more should be discussed. Check details (correct patient)
- #67 All relevant results, investigations and imaging must be available. Adequate preoperative planning should have been undertaken and preferably recorded in the notes. A check should be made for any sepsis (skin, teeth, urine and chest). Any neurovascular complications, the neurovascular status should also be recorded at this stage. The side to be operated on should be marked with indelible pen Informed consent remains valid for an indefinite period, allowing advance consent to be sought, providing that the patient's condition has not changed, and/or new information concerning the proposed intervention or alternative treatments have not come to light in the intervening period.3 It is good practice, if consent was obtained in advance, to confirm consent at the time of surgery
- #68 PREOPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY Patient preparation Both the operating surgeon and the anaesthetist should see the patient prior to surgery. The patient’s identity and the proposed surgery should be confirmed. After explaining the risks and benefits to the patient, valid consent for surgery should be obtained. There should be an opportunity for questions, and the patient should have adequate time to make their decision (see LED TO REASON Table 16.6). Any changes in the patient’s condition since listing for surgery should be noted, and a check made for any contraindications to elective surgery, e.g. intercurrent illness or remote site infection. In procedures that may cause neurovascular complications, the preoperative neurovascular status should be assessed and documented. Check that all relevant results and imaging are available, and that the side or area to be operated on is marked with an arrow at or near to the incision site. The patient’s identity should be confirmed the patient should be asked to confirm what surgery is being carried out. The case notes should agree with this and with what is written on the operating schedule. A check should be made that there has been no change in the patient’s condition since they were last seen and, if the patient’s condition has changed, this needs to be recorded. Consent. The patient should be asked if they want the consent process to be repeated and, even if not, they should be asked whether they have any questions and whether they are happy to proceed with surgery. This should be recorded in the notes