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Pre-operative Preparation & managment 1.pptx
- 1. Pre-operative Preparation &management AbdifatahOsman Nur, MBBS,Mmed (General and laparoscopic Surgeon)
- 2. Pre-operative preparation • Thepreoperative period runs from the time the patient is admitted to the hospital or surgicenter to the time that the surgery begins.
- 3. Pre-operative Plan • Gathering& recording concisely all relevant information • Planning to minimise risk & maximise benefit for the patient • Prepare for adverse events & how to deal with them • Communicate with patient & all members of the team
- 4. • The extentof preoperative preparation will depend on: -Nature of surgery(minor or major) -Facilities available -Situation
- 5. Nature of surgery •Major surgery :Involves expensive reconstruction or alternation in body parts and Poses great risk. • Minor surgery :Involves minimal alternative in body parts often designed to correct deformities involves minimal risk compared with major procedure. e.g. Cataract extraction, facial plastic surgery, tooth extraction
- 6. Situation • Emergency :life-threateningcondition requiring immediate action(Rupture of aneurysm,penetrating trauma) • Urgent: surgery required within few hours(intestinal obstruction, appendicitis….) • Elective (Hernias, colorectal cancers, breast cancer)
- 7. General preparation • PsycologicalPreparation o Trauma to the patient o Possible complications o Encouragement • Physiological pre. • System review(History and physical examination)
- 8. Physiological pre. • QuitSmoking(4months) • Nutrition diet • Skin preparation –Head, abdominal wall, perianal region and axillary zone –shave the day before or operation • Blood and fluid transfusion- for massive op,must.
- 9. Pre-operative Assessment andPreparation • Why ? • How ? • When ? • What ?
- 10. Pre-operative Assessment andPreparation Why ? • Elective operation should be performed under optimal condition with full physical and psychological preparation of a fully informed patient. • Emergency operation may have to be done in less than ideal circumstances .
- 11. Pre-operative Assessment andPreparation How ? • History • Physical exam • Investigation
- 12. Pre-operative Assessment andPreparation When ? • Out patient visit • Pre-operative ward round • ER
- 13. Pre-operative Assessment AndPreparation What To Do ? Six tasks .
- 14. Task one • Natureof surgery • Implication of surgery • Alleviate fear/anxiety of the patient • Prognosis To explain to the patient / relative
- 15. Task two • Lookfor the risk factors? Identification of potential operative mortality and morbidity
- 16. Risk factors ofmortality and morbidity • Myocardial infarction • Pregnancy • Smoking • Previous anesthetics &surgery • Allergies • Avoid op.whenever possible for at least 6 months • Elective op. is avoided. • Risk of miscarriage & teratogenicity • Suxamthonium/halothane • Penicillin/Iodine-containing drugs.
- 17. Task three • Assessmentof general condition • Assessment of metabolic state • Assessment of cardiovascular system • Assessment of respiratory system • Assessment of renal system • GI system assessment • Endocrine assessment. To assess the fitness for operation
- 18. Assessment of generalcondition • Careful clinical exam. • Pulse rate • B.P. • Full blood count • Serum urea & electrolytes • Blood group & save serum • X-match blood if needed • Nutrional status
- 19. Assessment of metabolicstate • Height • Weight • Diabetics • Problems associated with obesity : • Venepuncture • Anatomical landmarks • Respiratory problems • Wound infection • Wound dehiscence
- 20. Assessment of cardiovascularsystem • Clinical exam of heart and vessels • ECG • Echocardiogram
- 21. Cardiovascular conditions • Hypertension •Myocardial ischaemia • Cardiac arrhythmias • Valve disease/septal defect • Hypovolemia • Increase risk of CVA/MI • Avoid drugs which increase heart rate • Discuss with cardiologist pre-op • Cover with antibiotics • Restore blood volume pre- op
- 22. Assessment of respiratorysystem • Clinical exam of chest • Infection - to be treated before surgery • Asthma - Establish the severity and the course of illness - Patient usual inhalers should be continued • COPD - Preoperative chest x-ray - Significant COPD who need major surgery, refer respiratory physician - ABG analysis
- 23. Assessment of renalsystem • Clinical examination • Urinanalysis & microscopy • Urine for microbiological examination • Serum urea • Serum creatinine • Chronic retention
- 24. Digestive system assessment •Hepatic Risk: The liver is required to metabolize toxins and anesthesia. • The Child-Pugh Score can be used to ascertain the functionality of the liver. • Bilirubin, Albumin, PT (or INR), Encephalopathy, and Ascites are used to determine risk. • If any one is abnormal there’s a 40% mortality risk.
- 25. Endocrine disease • Throiddisease-All patients with planed elective operation should be euthyroid. • Pheochrocytoma -
- 26. Identification of risksof potential post operative complications and prophylaxis • Pulmonary collapse and infection • Cardiac complications • Acute renal failure characterized by: (oliguria, dilute urine) • Pre-op breathing exercises • Avoid excessive fluid post-op in all patients with cardiac ischemia or valvular disease • Major causes are hypovolemia, sepsis. Task four
- 27. Identification of risksof potential postoperative complications and prophylaxis (continue) • Venous Thrombosis • Wound infection • Avoid compression of legs during and after op. • If necessary,use graded compression stocking / low dose heparin 5000 I.u Q.12 hrs OR a single dose of LMW heparin • Prophylactic antibiotics (Bactericidal best guess for offending organism? Task four (continue)
- 28. Planning of theoperation • The operation should be properly named after full explanation to the patient and the side of operation is marked in case of bilateral parts. • He/she should consent for it. • The duration of hospital stay,convalescense and time off work should be indicated. Task five
- 29. Consent form • Validand informed consent. • Explain to the patient in simple non medical language what is going to be done. • Alleviate his/her fears. • Do not deceive the patient(Risks and Benefits). • Reassure the patient • 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’.
- 30. Pre-operative orders • KeepNPO (Nil per Oral) from ??:00 hrs • Medications »Essential »Prophylaxis • Prepare area for surgery »Cleaning »Shave »Enema »Etc Task six
- 32. The Operative Team •Ward, theatre and specialist nursing staff (circulating, scrub) • Anaesthetic and surgical teams • Radiology, pathology involvement
- 33. Common Causes ForPostponing Surgery(Elective) • Acute upper respiratory tract infection. • Untreated medical diseases. • Inadequate resuscitates pt in emergency( 1/3 of fluid lost ) in dehydrated pt & in shock pt. • Recent ingestion of food. • Failure to obtain informed consent. • MI : wait 6 months (at least)
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