The document outlines the preoperative preparation process for surgical patients, emphasizing the importance of evaluating and optimizing comorbidities to reduce risks during surgery. Key components include thorough history taking, appropriate investigations, and the establishment of effective communication between surgeons, patients, and families. As surgical populations become more complex, careful planning and risk assessment are vital to ensure safe surgical outcomes.

1. PRE OPERATIVE
PREPARATION OF A
SURGICAL PATIENT
GUIDED BY : DR TEJASVI KUMAR C
PRESENTED BY : Dr. Amrit preetam panda

2. DEFINITION
 The preoperative period extends from the
time the patient is admitted to the hospital to
the time the surgery begins
 The preoperative preparation of the surgical
patient serves to evaluate and optimize
comorbidities in order to minimize morbidity and
mortality during and immediately following the
surgical procedure.

3. INTRODUCTION
 It is important for the surgeon to explain the context of the illness
and the benefit of different surgical interventions, further investigation,
possible nonsurgical alternatives when appropriate, and
what would happen if no intervention were undertaken.
 The surgeon’s approach to the patient and family during the
initial encounter should foster a bond of trust and open a line of
communication among all participants.
 A professional and unhurried
approach is mandatory, with time taken to listen to concerns
and answer questions posed by the patient and family members.

4. PRE OPERATIVE ASEESSMENT
 History taking
 Examination
 Investigations
 Preoperative treatment
 Documentation
 Communication n consent

5. HISTORY
TAKING
(PHOTO)

6. 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)

7. PAST
MEDICAL
HISTORY

8. EXAMINATION OF THE PATIENT
 Patients should be treated with respect and dignity, receive a clear explanation
of the examination undertaken and kept as comfortable as possible.
 An female attendant should always be present while examination of any female
patients.

9. EXAMINATION SPECIFIC TO SURGERY
 This is the local examination
 Its divided to
 INSPECTION,
 PALPATION,
 PERCUSSION,
 AUSCULTATION

10. INVESTIGATIONS

11. INVESTIGATIONS
 Full blood count : to exclude anemia, platlets count and to assess how much
blood is required during or after operations
 Urea, creatinine , electrolytes: state of dehydration and any renal
insufficiency
 Urine analysis: to detect any urinary infection,inflammation,glycosuria,
metabolic disorders
 Hiv, hbsag testing
 Rbs and hb1ac: for diabetes
 Chest radiography :The ASA does not recommend routine CXRs but does
recommend consideration for obtaining CXRs in patients who are smokers,
have had recent upper respiratory tract infections, have chronic obstructive
pulmonary disease (COPD), and have heart disease.
 Ecg : its required in all patients above 60 years in patients having any
pathology in cvs, respi, or diabetes

12. INVESTIGATIONS (cont..)
 Clotting screen : If a patient has a history suggestive of bleeding diathesis,
liver disease, eclampsia, cholestasis or has a family history of bleeding
disorder, or is on antithrombotic or anticoagulant agents, then coagulation
screening will be needed.
 Upt test : it should be done in all women of child bearing age
 Lft : These are indicated in patients with jaundice, known or suspected
hepatitis, cirrhosis, malignancy or patients with poor nutritional reserves
 ABG: it allows detailed assessment of respiratory problems and acid base
disturbances
 Other investigations : Further relevant investigations should be undertaken to
assess capacity of specific organ system and risks associated.

13. TREATMENT
CHART

15. Cardiovascular system
 Patients who can climb a flight of stairs without getting short of breath or
having chest pain, or indeed stopping have a lower risk of perioperative
morbidity and mortality of cardiovascular origin than those who cannot.
 HYPERTENSION : Prior to elective surgery, blood pressure should be controlled
to near 160/90 mmHg. If a new antihypertensive is introduced, a stabilisation
period of at least 2 weeks should be allowed.
 ISCHEMIC HEART DISEASE : recent mi is a strong contraindication to surgery,
elective surgeries are postponed 3 to 6 months after proven mi
 Patients may have had coronary stents inserted for IHD and should be asked
about effectiveness of the treatment, concurrent antiplatelet medications,
e.g. clopidrogel and/or aspirin. Their INR status should be evaluated and
antiplatelet drugs should be stopped after consulting a cardiologist
 Warfarin in patients with atrial fibrillation should be stopped 5 days
preoperatively to achieve an INR (international normalized ratio) of 1.5 or
less, which is safe for most surgery;

16. Anemia and blood transfusion
 Patients found to be anaemic at preoperative assessment should be treated
with iron and vitamin supplements.
 If hb is less than 8 gm/dl blood should be transfused
 If excessive bleeding is expected, then a preoperative ‘group and save’ should
be performed and an appropriate number of units of blood crossmatched.

17. Respiratory system
 Infection : to be treated completely before surgery
 Asthma : establish the severity and the course of illness,
do pft, patients usual inhalers should be continued
 COPD : preoperative xray, abg analysis,if fev1 is below
30% of predictive value chest physician should be refered
to optimise their condition

18. Renal diseases
 Renal failure :Appropriate measures should be taken to treat acidosis,
hypocalcaemia and hyperkalaemia of greater than 6 mmol/L. arrangements
for dialysis before and after surgery should be made
 UTI : Uncomplicated urinary infections are common in women, while outflow
uropathy with chronically infected urine is common in men. These infections
should be treated before embarking on elective surgery. Antibiotics should be
started and the urine output monitored

19. Endocrine and metabolic disorders
 Nutritional status :
 A BMI of less than 18.5 indicates nutritional impairment and a BMI of less than 15 is
associated with significant hospital mortality. Nutritional support for a minimum of
2 weeks before surgery is required to have any impact on subsequent morbidity.
 Morbid obesity is defined as BMI of more than 35 and is associated with increased
risk of postoperative complications. Patients should be made aware of risks
involved and encouraged to lose their weight.
 Diabetes : Diabetes and associated cardiovascular and renal complications
should be controlled to as near normal level as possible before embarking on
elective surgery.
 Patients with diabetes should be first on the operating list and if they are operated
on in the morning advised to omit the morning dose of medication and breakfast.
 Adreno corticoid suppression : Patients receiving oral adrenocortical steroids
should be asked about the dose and duration of the medication in view of
supplementation with extra doses of steroids perioperatively to avoid an
Addisonian crisis

20. RISK FACTORS FOR THROMBOSIS
 Age >60 years
 Obesity: body mass index (BMI) >30 kg/m2
 Trauma or surgery (especially of the abdomen, pelvis and lower
 limbs), anaesthesia >90 minutes
 Reduced mobility for more than 3 days
 Pregnancy/puerperium
 Varicose veins with phlebitis
 Drugs, e.g. oestrogen contraceptive, hormone replacement therapy (HRT),
smoking
 Known active cancer or on treatment, significant medical comorbidities, critical
care admission
 Family/personal history of thrombosis, e.g. deficiencies in antithrombin III,
protein S and C

21. COAGULATION DISORDERS
 Patient having family or previous h/o thrombosis should be identified. They
will need prophylaxis in the perioperative period
 OCP, HRT should be stopped 6 weeks before surgery however progesterone
only pill can be allowed to continue
 Patients with a low risk of thromboembolism can be given thromboembolism-
deterrent stockings to wear during the perioperative period.
 Patient on warfarin treatment should be stopped before surgery and replaced
by low molecular weight heparin or factor Xa inhibitors

22. CENTRAL NERVOUS SYSTEM
 In patients with a history of stroke, pre-existing neurological deficit
should be recorded.
 If the patient is on anti platelet drugs like asprin or clopidrogel then
they should be stopped
 If the risk of thromboembolism is high then asprin can be allowed
 The anticonvulsant medicines and anti parkinsonism medicines is
continued perioperatively
 Lithium should be stopped 24 hours prior to surgery and the blood
levels should be measured
 The anaesthetist should be informed if patients are on psychiatric
medications such as tricyclic antidepressants or monoamine oxidase
inhibitors, as these may interact with anaesthetic drugs

23. AIRWAY ASSESSMENT
 The ability to intubate the trachea and oxygenate the patient are basic and
crucial skills of the anesthetist
 The ease or difficulty in performing airway manoeuvres can be predicted by
simple examination findings of full mouth opening (modified Mallampati class)

24. NPO / NBM
 The standard order of “NPO past midnight” for preoperative patients is based on
the theory of reduction of volume and acidity of the stomach contents during
surgery.
 Hence a ppi is also given in the night n morning to further decrease the acid
secretions
 The ASA recommends that the adults should stop intake of solid foods atleast 6
hours and clear fluids for 2hrs before the surgery.
 Pediatric patients should fast from human breast milk for 4 hours and from
infant formula for 6 hours prior to the start of anesthesia.
 A clear liquid includes water, coffee,or tea without dairy; clear fruit juice
without pulp; and clear carbonated beverages.
 These recommendations include fasting before administration of anesthesia
regardless of type of anesthetic—general, regional, or monitored anesthesia
care.

25. CLASS OF WOUNDS

26. ANTIBIOTIC PROPHYLAXIS
 Appropriate antibiotic prophylaxis in surgery depends on the most likely pathogens
encountered during the surgical procedure
 Prophylactic antibiotics are generally NOT required for clean (class I) cases except in the
setting of indwelling prosthesis placement or when bone is incised.
 Patients who undergo class II procedures benefit from a single dose of an appropriate
antibiotic administered before the skin incision
 Contaminated (class III) cases require mechanical preparation or parenteral antibiotics
with aerobic and anaerobic activity.
 Dirty or infected cases often require the same antibiotic spectrum, which can be
continued into the postoperative period in the setting of ongoing infection or delayed
treatment
 The appropriate antibiotic is chosen before surgery and administered within 60 minutes
before surgical incision
 Repeat dosing occurs at an appropriate interval, usually 3 hours for abdominal cases or
twice the half-life of the antibiotic

27. PRE-OPERATIVE CHECKLIST
 The preoperative evaluation concludes with a review of all pertinent studies and information obtained
from investigative tests.
 This review is documented in the chart, which represents an
 opportunity to ensure that all necessary and pertinent data have
 been obtained and appropriately interpreted.
 Informed consent after discussion with the patient and family members regarding the indication for
the anticipated surgical procedure and its risks
 and proposed benefits is documented in the chart.
 The preoperative checklist also gives the surgeon an opportunity to review the need for beta
blockade, DVT prophylaxis, and prophylactic antibiotics.

28. Pre operative assessment in emergency
surgeries
 In urgent or emergency surgery, the principles of preoperative assessment
should be the same as in elective surgery, except that the opportunity to
optimise the condition is limited by time constraints.
 Medical assessment and treatments should be started(e.g. according to the
Advanced Trauma Life Support (ATLS) guidelines) even if there is no time to
complete those before the surgical procedure is started.
 Some risks may be reduced, but some may persist and whenever possible
these need to be explained to the patient (Summary box 16.6).

29. SUMMARY
 As our medical capabilities and knowledge expand, our surgical
population grows more complex. Today our perioperative patients
have more comorbidities than ever before. Similarly, the preoperative
preparation of our patients is more important than ever. Our
common goal is to safely get these patients into and out of the operating room.
 A robust and detailed history should be taken
 Gather and record all relevant investigations
 Optimise the patient condition
 Choose a surgery that offers minimal risk and maximal benefit
 Anticipate and plan for adverse events based on the patient’s comorbidities
 Inform to everyone concerned

30. REFERENCES
 Bailey and love’s short practice of surgery ,26th edition
 Faraqsons textbook of operative surgery
 Sabiston textbook of surgery
 Current surgical therapy by james cameron

31. THANK YOU