Pre operative care - Dr. Somaya Banaei

Under Observation:
Specialist Dr. Ghulam Reza Riaz
Submitted By:
Dr. Somaya Banaei
General surgery resident
Afghanistan-Herat Regional Hospital
Juan. 2021

Perioperative Care
Preoperative phase – begins when the decision to have surgery is made and
ends when the client is transferred to the OR table.
Intraoperative phase – begins when the client is transferred to the OR table and
ends when the client is admitted to the PACU.
Postoperative phase - begins with the admission of the client to the
PACU and ends when the healing is complete.
By: Dr. Somaya Banaei

Perioperative Care
DIAGNOSIS- PREOPERATIVE EVALUATION - PREPARATION

Perioperative Care
ANESTHESIA - OPERATION

Perioperative Care
POST ANESTHESIA CARE – ICU – INTERMEDIATE CARE- CONVALESCENCE PERIOD

DEFINITION
 The preoperative period runs from the time the patient is admitted
to the hospital or surgicenter to the time that the surgery begins.
 Preoperative begins with the decision to perform surgery and
continues until the client has reached the operating area.

INTRODUCTION
The preoperative management of any patient is part of a continuum
of care that extends from:
THE SURGEON’S INITIAL CONSULTATION
through
THE PATIENT’S FULL RECOVERY.
It depends on:
Cause
&
severity of recent
problem

The surgeon is responsible for
Balancing The Hazards of the natural history
of the condition if left untreated versus the risks of an operation.
 Not to screen broadly for undiagnosed disease
 Identify and quantify any comorbidity that may affect the operative outcome
The aim of preoperative evaluation

Steps to preoperative Evaluation
 History and physical examination.
 Surgical Risk Factors
 Preoperative Testing
 Perioperative Management of medications

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)

SOCRATES
Site
Onset
Character
Radiation
Association
Time course
Exacerbating/relieving factors
Severity

OPQRST
Onset
Precipitant
Quality
Radiation
Stop
Temporal

Cardiovascular
IHD, HTN, heartfailure, dysrhythmias,PVD,
DVT,anemia
Respiratory
COPD, asthma,fibrotic lung, conditions,
respiratory infection, malignancy
Gastrointestinal
PUD, bowel habits, malignancy, liver
disease
GenitoUrinary tract
UTI, renal dysfunction
Past medical History

Neurological
Epilepsy, CVA, psychiatric disorder, cognitive
function
Endocrine / metabolic
Diabetes, thyroid dysfunction,
phaeochromocytoma
Locomotor system
Osteoarthritis, inflammatory arthropathy
Infectious
Tuberculosis, hepatitis, HIV
Past medical History

Physical examination
 Nervous system
 Peripheral pulses
 Ischemic history(claudication, diabetes)
 Rectal and Pelvic exam
 Pop smear (>30 years)

Laboratory Exams
 Check CBC
 Serum electrolytes
 Chest x-ray
 ECG
 Antibiogram in open wounds
( >40 years old)
( >50 years old)

Preoperative evaluation and general condition
 Peripheral perfusion
 Neck vein in rest
 Orthostatic changes in BP & PR
 Hemoglobin for satisfied
perfusion
 Function of Liver / kidney
 Mental status
 History of bleeding
 Drug history
 Allergy or drugs reaction

Blood transfusion
preparation
Autologous transfusion
Blood store
Hemodilution
Phlebotomy

Operative mortality
 Is expressed in terms of deaths occurring during surgery
 And up to 28 – 30 days after surgery
 70% of all elective procedure have a mortality risk <1%
 The high risk group has a mortality risk in EXCESS OF 5%
 When the risk exceeds 20% patients are said to be extremely high risk
 High risk patients - 12.5% of all surgical procedures
 > 80% of deaths

0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Overal Standard High Risk
Population size (milione) Postoperative mortality (%)
Size and mortality rates for different population of
surgical patients

Causes
After surgery
 Tissue destruction
 Blood loss
 Fluid shifts
 Change in temperature
 Pain and anxiety
Myocardial Ischemia
Multi Organ Failure
Demands for O2 delivery to the tissue
Cardiac output & tissue O2 extraction

Factors affecting
the risk of surgery
 Decrease of 20% of weight
 Disorders in visceral protein levels:
 Serum Albumin > 3 g/dl
 Serum transferrin > 150 mg/dl
Weakening or altering in patient system
Mortality of rate in CA
or intestinal diseases
SSI x3
I. Nutritional status assessment

Factors affecting
the risk of surgery
Malnutrition!!!
Tests:
 Complete lymphocytes count
 Cell mediated immune assessment
 Neutrophil chemotaxis
 Specific lymphocyte populations count
Weakening or altering in patient system
II. Assess the adequacy of the immune system

Factors affecting
the risk of surgery Weakening or altering in patient system
Old age
Malnutritio
n
CancerBurn
Severe trauma
High risk patients
II. Assess the adequacy of the immune system

Factors affecting
the risk of surgery Weakening or altering in patient system
III. Other Risk factors for SSI

After operation:
 Hypoxia
 Atelectasis
 Pneumonia
Most important factors in history:
 Cough
 Exacerbation
 wheezing
Pulmonary dysfunction
Factors affecting
the risk of surgery

Pulmonary dysfunction
Factors affecting
the risk of surgery
O2 overuses Acidosis

Delay in wound healing
Factors affecting
the risk of surgery
Smoking
Protein
deficiency
Vit C
deficiency
DehydrationSever Edema
Sever anemia
Diabetes
mellitus

Factors affecting
the risk of surgery
Hypovolemia Vasoconstriction
Increase of
blood viscosity
Intra luminal
platelets
congestion
Red blood cells
stasis
Insufficiency of
tissue oxygen
pressure
Delay in wound
healing

Factors affecting
the risk of surgery
Long period of diuretics intake
Underlying myocardial disease
High dose corticosteroids
Chemotherapy
Radiation

Drugs effects  Penicillin & other antibiotics
 Opioids/ Barbiturates
 Procaine or other ansth. Drugs
 Aspirin or other analgesics
 Sulfonamides
 Tetanus Anti toxin or other serums
 Each other drugs / food (egg , milk,
chocolate)
 Iodine / Adhesive plaster

Aspirin
(Acetyl salicylic acid)
I. Primary prevention
II. Secondary prevention
in patients with CVD, the lifelong use of aspirin
for secondary prevention is recommended.
Discontinuation of antiplatelet therapy may
trigger a
prothrombotic rebound phenomenon .

Aspirin
(Acetyl salicylic acid)
Stop aspirin therapy for secondary CVD prevention
=
increase the risk of MI > 60%
If antiplatelet therapy is discontinued soon after PCI
The risk of stent thrombosis and MI is markedly
increased

If the perioperative risk of hemorrhage clearly exceeds the potential cardiovascular benefits,
aspirin therapy should be stopped.
In patients with previous PCI and stent implantation, long-term aspirin therapy should be
continued preoperatively, if possible.
However, a high risk of hemorrhage in a closed space (intracranial, intramedullary or posterior
chamber of the eye) is regarded as an important exception.
In patients treated with dual antiplatelet therapy after recent PCI, elective surgical procedures
should be postponed.
It has been recommended in guidelines to stop aspirin therapy, if indicated, 7 to 10 days before
surgery.
However, studies involving preoperative platelet function tests reported faster recovery of
platelet function
It is an expert opinion of some authors to stop aspirin, if indicated, 5 days before surgery
The European And US Guidelines

Risks for Thrombo
emboli
 Cancer
 Obesity
 Pulmonary dysfunction
 Age > 45
 History of thrombosis

Old age patients
 Physiological age
 Atherosclerosis
 myocardia dysfunction > 60 y
 Silent cancer
 Low dose narcotics & anesthetics drugs

The typical high risk patient is the elderly patient with
coexisting conditions such as:
 IHD
 COPD
 Undergoing major surgery
Classification of
Risk
The risk would increase if the surgery is performed as an
EMERGENCY

Classification of
Risk

spinal anesthesia IS NOT safer than general anesthesia for high-risk
patients.
No difference in cardiopulmonary complications or mortality.
Identification of the high risk patient

I. ASA American Society of Anesthesia
II. MET Metabolic Equivalent of Task
III. RCRI Revised Cardiac Risk Index
IV. CPET Cardio Pulmonary Exercise Testing
V. POSSUM Physiologic and Operative severity Score for the enUmeration of
Morality and Morbidity
Risk scoring systems

American Society of Anesthesiologists (ASA)
classification system.

Revised Cardiac Risk Index for Pre-Operative Risk
(Dr. Lee Goldman)
• High-risk surgery +1
• History of ischemic heart disease + 1
• History of congestive heart failure +1
History of cerebrovascular disease +1
• Pre-operative treatment with insulin +1
• Pre-operative creatinine >2 mg/dL / 176.8 µmol/L +1
Points Class Risk
0 I 0.4 %
1 II 0.9 %
2 III 6.6 %
3 or more IV 11 %

1 MET
3.5 ml
O2/kg per
minute
Eating and
dressing
4 MET
Climbing
two fight
od stairs
6 MET
Short run
>10
MET
Able to
participate
in strenuous
sport
Metabolic Equivalent of Task
Patients who can exercise at 4METs or above have lower risk of
preoperative mortality

Optimizing medical management of coexisting
disease and intraoperative considerations
 Stop smoking
 Reduce alcohol intake
 Losing weight
 Improving nutrition level
 Improving Hg level
In some cases there will be a need for more complex investigations

Ischemic heart disease
Preoperative MI is associated with a
High mortality (15 – 25 %)
 Supply of O2 us exceeded by its demand
 Hypotension
 Tachycardia
 Procoagulant states (SIRS)

Minimizing myocardial ischemia
 Anesthesia should avoid tachycardia, systolic hypertension / diastolic hypotension
 Pain control is important
 Invasive Atrial BP monitoring
 Monitoring of blood loss and Hg level
 Oxygen supplementation is advised for 3-4 days post operatively
 Perioperative beta blocker should be considered
 Elective post operative critical care admission should be considered

Cardiac Failure
 IHD
 Hypertension
 Cardiomyopathies
 Valves dysfunction
Left ventricular failure
Multi Organ Failure

Cardiac Failure
 IHD
 Hypertension
 Cardiomyopathies
 Valves dysfunction
EF < 35 %
Undiagnostic failure
Its Severity underestimated
HIGHEST RISK

Minimizing risks in Cardiac Failure
 The patient’s functional capacity needs to be assessed
 Surgery May Have to be delayed for investigation
 ECHO / Medication (Beta blockers / ACE inhibitors)
 Anesthesia with minimum myocardial depression
 Control Arrhythmia rapidly
 Correct electrolyte imbalance
 Invasive BP monitoring with large fluid replacement

Type of Procedure
Cardiac risk for non cardiac surgery
(American College of Cardiology and the American Heart Association(
 Emergent major operations, particularly in elderly
 Aortic and major Vascular procedures
 Peripheral Vascular procedures
 Prolonged procedures with large fluid shifts +/- blood loss
High 5%<

Type of Procedure
 Intraperitoneal /Intrathoracic surgery
 Carotid endarterectomy
 Head and neck surgery
 Orthopedic surgery
 Prostate surgery
Intermediate 5%>

Type of Procedure
 Endoscopic procedures
 Superficial procedures
 Cataract surgery
 Breast surgery
Low 1%>

Hypertension
Preoperative blood pressure
should not exceed 160/90 mmHg
Newly diagnose HTN may need further evaluation
Acute admission require urgent surgery, BP should be controlled
MORE RAPIDLY

Respiratory system
 Reduce the functional residual capacity of lungs
 Respiratory depressant effects of residual anesthetic agent
 The patient’s limited mobility
 The pain from surgery causes atelectasis
 Post operative Resp. infections
 Bronchospasm
 Pneumothorax
 ARDS By: Dr. Somaya Banaei

Optimizing preoperative respiratory function
 Needs testing to assess pul. Functional status
 Consider bronchodilator +/- steroid therapy
 Arrange pre/post operative chest physiotherapy / postural drainage
 Deep breathing exercises / cough technique
 Consider regional anesthesia
 Give good quality pain relief
 Use non invasive ventilation strategies
 Avoid extubation until analgesia, hydration, acid base status have been corrected

Diabetes
 Longer lengths of hospital stay,
 Increased rates of postoperative death and complications,
 Relatively greater utilization of health care resources
elevated postoperative blood glucose levels in diabetic patients
translate to progressively greater chances of SSIs
Current recommendations for desirable glucose ranges in critically
ill patients are commonly about 120-180 mg/dL

Instructions for preoperative management of oral anti hyperglycemic medications.
Medication Prior to Procedure After Procedure
Short-acting sulfonylureas:
Glipizide (Glucotrol), glyburide
(DiaBeta, Glynase, Micronase)
Do not take the morning
of procedure
Resume when eating
Long-acting sulfonylureas:
ƒ Glimepiride (Amaryl), glipizide
XL (Glucotrol XL)
Do not take the
evening prior to or the morning of
procedure
Resume when eating
Biguanides: ƒ Metformin (Glucophage),
metformin ER(Glucophage XL)
of procedure; do not take the day
prior to procedure if receiving
contrast
dye
Resume when eating.
After contrast
dye wait 48 h and
repeat creatinine
prior to restarting
Thiazolidinediones:
ƒ Pioglitazone (Actos), rosiglitazone
(Avandia)
of procedure
Resume when eating
DPP-4 Inhibitors: ƒ Sitagliptin (Januvia
of procedure
Resume when eating
Meglitinides: ƒ Nateglinide
(Starlix), repaglinide(Prandin)
of procedure
Resume when eating
Alpha-glucosidase
inhibitors:Acarbose (Precose), miglitol
(Glyset)
of procedure
Resume when eating

Instructions for preoperative management of insulin.
Medication Prior to Procedure After Procedure
Glargine (Lantus)
Take usual dose the night
before or the
morning of procedure
Resume usual schedule
after procedure
Detemir (Levemir)
Take usual dose the night
before or the
morning of procedure
after procedure
NPH (Humulin N,Novolin N)
Take ½ of usual dose the
morning of
procedure
when eating, ½ dose while NPO
Humalog mix 70/30, 75/25, Humulin
70/30, 50/50
Novolin 70/30 (all mixed insulins)
Do not take the morning of
procedure
when eating
Regular insulin (Humulin R, Novolin R)
of procedure
Resume when eating
Lispro (Humalog), Aspart (Novolog),
Glulisine (Apidra)
Do not take the morning of
procedure
Resume when eating
Subcutaneous insulin infusion pumps
Requires tailored recommendations. In general,
most patients may continue their usual basal
rate and correction doses, and resume mealtime
boluses when eating again

SSIs
It can reduce by multiple complex interventions that are institution-specific.
It could be result of:
 Wound contamination
 Blood loss
 Duration of the operation
 Local tissue trauma and ischemia
 Excessive electrocoagulation

EXAMPLES OF PROPHYLACTIC ANTIBIOTIC SELECTIONS FOR VARIOUS OPERATIONS
Operation Standard Selection Penicillin Allergy
Distal pancreatectomy Cefazolin Vancomycin
Hernia Cefazolin Vancomycin
Thoracotomy or laparotomy Cefazolin Vancomycin
Splenectomy Cefazolin Vancomycin
Biliary (elective) Cefazolin Clindamycin gentamicin
Biliary (emergency) Ceftriaxone Clindamycin
Colorectal surgery (elective) Cefazolin/metronidazole Clindamycin gentamicin
Gastroduodenal resection Cefazolin Clindamycin gentamicin
Whipple resection Cefazolin/metronidazole Clindamycin gentamicin
Gastrointestinal (emergency) Ceftriaxone/metronidazole
Clindamycin gentamicin

Other comorbidities
 Acute Renal Failure
 Chronic renal disease
 Peripheral vascular disease
 Liver dysfunction (Child-Pugh score )
Creatinine > 2mg/dl
=

Child-Pugh score for Liver cirrhosis and mortality

Consultation
If it is in the best interest of the patient
If requested by the patient or the patient's family
When it is of forensic importance
If there is no consensus on how to treat the patient
If the risk of surgery is very high
If there are high-risk complications
If the patient or patient’s family is too concerned about how to treat
If there is history of specific internal or surgical diseases.

ASA fasting guideline
Ingested material Minimal fasting period
Clear liquid 2h
Breast milk 4h
Infant formula 6h
Non human milk 6h
Light meal 6h
Fried foods / fatty foods or meat Additional fasting time (8 or more hours)

Risk assessment and consent
All life- or limb-threatening complications
All complications with an incidence of >= 1%
 Risks: related to comorbidities, anesthesia, and surgery
 Explain: advantages, side effects, prognosis
 Language: simple, use daily life comparisons to explain risks

Preoperative note
o PRE-OP DIAGNOSIS:
o PROCEDURE: planned surgery + type of Incision
o LABS: CBC, chemistries, PT/PTT, urinalysis, etc.
o CHEST X-RAY: note findings.
o ECG: note findings.
o BLOOD: not needed, type/screen or type/cross 2 units packed RBCs, etc.
o ORDERS: NPO, preoperative antibiotics, skin or colon preps, NGT, Folly
o CONSENT: signed.

References:
 Current
Diagnosis And Treatment Surgery
 Baily & Love’s
Short Practice Of Surgery

Pre operative care - Dr. Somaya Banaei

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