PREOPERATIVE ASSESSMENT PREPARATION.pptx

PREOPERATIVE ASSESSMENT &
PREPARATION
Prepared by:
Roll:20, DLMC09

PREPARATION
• Definition
• Preoperative assessment: a process that provides information on risk, defines and
reduces the extent of known risks, and discovers unknown risks in a patient prior to
surgery
• Aims:
 Reduce morbidity & mortality associated with surgery.
 Assess pre existing medical condition.
 Plan pre-operative & past operative management of these conditions.
 Permanent unnecessary cancellation.
2

PREPARATION
Continuation of Aims:
Ensure the patient is fully prepared for surgery.
Reduce length of hospital stay.
Inform the patient of the postponed procedure and gain consent.
3

PREPARATION
Four key questions:
1) What conditions can & treat prior to surgery that will reduce the overall risk to the
patient?
2) What conditions exist that increase the patient’s risks and may alter my anesthetic
management or the help and have available?
3) How urgent is the surgery and therefore how much time is available to prepare the
patient?
4) What would be the consequences of delaying surgery?
4

PREPARATION
Key points to be discussed:
Preparation of the patient:
 History.
 Physical examination.
Pre-operative process:
 Method of assessment.
 Systematic assessment.
 Surgical Inspection:
5

PREPARATION
Informed Consent.
Preoperative instruction.
 Patient paperwork
 Patient preparation.
 Prophylaxis
6

PREPARATION
In theater preparation.
 WHO checklist
Preparation of surgery team.
Preparation surgeon.
7

PREPARATION
1.PREPARATION OF THE PATIENT
History taking.
o History of present compliant?
 Determine surgical urgency.
 Influence anesthetic technique.
 Determine the acceptable starvation period.
 Surgical condition which have systematic effect
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PREPARATION
o Medical History-
For cardiovascular disease ask:
 Exercise tolerance.
 Palpitations
 Collapse/syncope
 Ankle swelling
 History of MI/Hypertension/raised cholesterol/diabetes.
 Know vascular or congenital heart disease.
9

PREPARATION
o Medical History-
For respiratory disease ask:
 Exercise tolerance
 Cough/sputum/haemoptysis
 Smoking history
 Wheeze
 Exposure to industrial dusts
 Weight loss
 Night sweats
 Fever
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PREPARATION
oMedical History-
 Other conditions.
• Malnourished
 Dehydration
 Elderly(>75 years)
 Diabetes mellitus
 Endocrine dysfunction
 Chronic renal failure
 Nephrotic syndrome
 Obstructive jaundice
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PREPARATION
oMedical History-
Anesthetic history.
 Note details of previous anaesthetics and any problems encountered.
 Examine previous anaesthetics charts if available
 Note last exposure to halothane anaesthesia
Family history.
 Malignant hyperthermia
12

PREPARATION
 Suxamethonium apnoea
 Porphyria
 Haemoglobinopathies
Drug history
Allergies and addiction
Pregnancy
Reflex
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PREPARATION
Physical examination.
o Look at your patient as a whole to decide how sick he/she
o Assess the degree of hydration
o Check peripheral perfusion(is he cold to touch?)
o Check for cyanosis(central and peripheral)
o Check for jaundice
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PREPARATION
o Cardiovascular system and respiratory examination
 Look
 Listen(Auscultate)
 Feel
 Look other system
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PREPARATION
• Airways assessment
 Difficult mask ventilation(with or without adjuncts/aids)
 Difficult placement of LMA, difficult intubation
 Difficult surgical access to trachea(rarely required)
16

PREPARATION
Poor management of the difficult airway can result in:
 Dental trauma
 Airway trauma
 Pulmonary aspiration
 Hypoxia
 Death
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PREPARATION
Successful intubation requires:
o Good mouth opening
o Extension of the upper cervical spine
o The ability to move soft tissue within the mandible out of the way
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PREPARATION
Quick airway assessment
o Mallampati test(OPV)
o Mouth opening
o Jaw slide
o Neck movement
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PREPARATION
2.PREOPERATIVE
PROCESS
 Methods of assessment
 Assessment based on patient pathway
• Preoperative
• Perianaesthetic
• Postoperative
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PREPARATION
Systemic assessment
I. Cardiac
II. Respiratory
III. Endocrine
IV. Haemostasis
V. Gastrointestinal
VI. Nutrition
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PREPARATION
Cardiac
• Ischaemic heart disease
• Risk can be calculated clinically using Goldman cardiac index or Detsky cardiac score
Elective surgery should be delayed until 6 months after myocardial infarction
• Arrhythmia
• Patients may be on anticoagulants because of an arrhythmia
• Left ventricular failure
• Avoid negative inotropes and monitor fluid balance
22

PREPARATION
 Respiratory
• COPD
• Patient must stop smoking
• Physiotherapy should be started preoperatively
• Adequate analgesia should be given: patients in pain will not cough
• Adequate hydration should be maintained: prevents viscid secretions
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PREPARATION
Endocrine
• Steroids
• Patients on long-term steroids may need i.v. hydrocortisone postoperatively
• Diabetes mellitus
• Control blood glucose levels perioperatively
• Diet controlled
• Monitor blood sugar, unlikely to require insulin
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PREPARATION
• Oral hypoglycaemic agents
• Stop oral therapy on the day of surgery, monitor blood sugar
• For major surgery may need i.v. dextrose/insulin sliding scale
• Insulin-dependent diabetes
• Omit morning dose of insulin, monitor blood sugar
• Commence sliding scale insulin infusion
• Use sliding scale to adjust insulin dose
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PREPARATION
Haemostasis
• Thrombophilias
• Medium risk: low-dose chemoprophylaxis (heparin), mechanical prophylaxis (compression
stockings)
• High risk: mechanical prophylaxis, high-dose chemoprophylaxis, low-dose anticoagulation
• Bleeding disorders
• Inherited disorders
• Warfarin/NSAIDs
• Liver disease
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PREPARATION
Gastrointestinal disorders
• Liver disease
• Bleeding disorders
• Hypoalbuminaemia
• Reduced cellular and humoral immunity
• Poor metabolism of endogenous waste products
• Reduced metabolism of anaesthetic agents, analgesics and other drugs
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PREPARATION
• Intestinal obstruction
• Causes major fluid, sodium and potassium loss, and acid–base disorders (usually metabolic acidosis)
• Losses are generally 50% greater than recorded losses because of fluid sequestration in the bowel
lumen
Nutrition
• Obesity
• Increased risk of respiratory and cardiovascular disease, DVT, diabetes, infection
• Malnutrition
• Often not recognized. Results in poor healing and delayed recovery
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PREPARATION
Assessment
• Body weight: not a good index of nutritional status
• Body mass index (weight/height²): useful assessment of obesity
• Triceps skinfold thickness: reliable measure of subcutaneous fat
• Grip strength: indirect assessment of muscle mass, detects mild malnutrition
• Serum albumin: useful in assessing malnutrition but may be affected by disease
Management
• Attention should be given to prophylaxis
• Nutritional support essential before and after surgery: alimentary route is preferable
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PREPARATION
• Prophylactic antibiotics:
(a) Should be bacteriocidal
(b) Should have high tissue levels at time of contamination
(c) One preoperative dose given 1 h prior to surgery should suffice
(d) Should be given to patients with implanted prosthetic materials, e.g. heart valves, vascular grafts, joint
prostheses
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PREPARATION
Surgical infection
• Definitions
Infection: the process whereby organisms (e.g. bacteria, viruses, fungi) capable of causing disease gain
access and cause injury or damage to the body or its tissues
• Management of surgical infection
• Preventive measures
• Short operations
• Skin cleansing with antibacterial chemicals and detergents (patient’s, surgeons’s and nurse’s skin)
• Filtering of air in operating theatre
• Occlusive surgical masks and gowns
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PREPARATION
• Management of established infection
• Diagnosis
• Made by culture of appropriate specimens (pus, urine, sputum, blood, CSF, stool)
• Antibiotics
• Prescribe on basis of culture results and ‘most likely organism while waiting for results
• Certain antibiotics are reserved for serious infections
• Therapeutic monitoring of drug levels may be required, e.g. with aminoglycosides
• Synergistic combinations may be required in some infections, e.g. aminoglycoside,
cephalosporin and metronidazole for faecal peritonitis
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PREPARATION
• In serious infections seek advice from clinical bacteriologist
• Barrier nursing and isolation of patients with methicillin resistant Staphylococcus
aureus or vancomycin-resistant enterococcus
• Drainage
• Surgical or radiological drainage is the most important chronic inflammatory response
treatment modality for an abscess
33

PREPARATION
 Fig: Element of the immune system that counter bacterial infection.
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Physical barriers
Skin
Mucus membranes
Cilia
Gastric HCL
Tears
Urine
Sweat
Biochemical/Humoral
Acute phase proteins
Complement
Antibodies
Interferon
Cellular
Neutrophils
Macrophages
B-Lymphocytes
T-Lymphocytes
Host defense system

PREPARATION
3.Informed consent:
There are five aspects that the patient must understand to give informed consent:
1. The reason for carrying out the procedure. The patient needs to understand the nature of their
illness and its prognosis.
2. What the procedure involves. Where and how long is the scar; what is being removed; what
prosthesis will be implanted; will there be drains?
3. The risks of the procedure. Specific to the procedure (e.g. stoma, limb dysfunction) and in
general (e.g. anaesthesia, bed rest, deep vein thrombosis (DVT))
4. The benefit of the procedure. Improvement in symptoms or prognosis or purely diagnostic.
5. Alternatives. Including conservative treatment, with their advantages and disadvantages.
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PREPARATION
 Modes of consent:
• Implied consent. The patient is presumed to consent to minor procedures, e.g. X-rays,
phlebotomy, by cooperating with ward procedures.
• Express written consent. Whenever possible, this should be obtained for all patients
undergoing procedures involving an anaesthetic, complex treatments with significant
risks and side effects, or as part of research. Written consent is not legal proof that
adequate consent was obtained at the time the document was signed.
• Express verbal consent. Should be obtained when it is not possible to get written
consent, witnessed by an independent health care professional, and documented in the
notes accordingly, or for simple procedures with minimal risk of harm.
36

PREPARATION
4.PREOPERATIVE INSTRUCTION:
Patient paperwork:
• Make sure the medical notes are available and contain the most up-to date history and
examination for this admission.
• Check the blood results are up to date and specific blood results, e.g. clotting function in
anticoagulated patients, K+ in patients with renal failure, Ca2+ in parathyroidectomy
patients, have been collected.
• If they are not available in digital format, ensure imaging results that might be needed in
theatre are available with the notes (e.g. arteriograms, staging CT scans, barium enema films).
37

PREPARATION
• Check that the consent form has been completed and is on the medical notes even
though you may not be responsible for seeing the form signed.
• The drug chart should be completed and include any specific prescriptions for drugs to
be administered in theatre or the anaesthetic room. It is the job of the surgical team to
prescribe prophylactic antibiotics, etc.
38

PREPARATION
Patient preparation:
• Check that the side is marked on the patient for any operation that might involve an organ or
tissue that is bilateral. This must be done with the patient awake and verified by the nursing staff.
• If necessary, check that the patient has been assessed and marked by any relevant specialists
(stoma care if a stoma is possible; prosthetist for amputees).
• Ensure that if the patient requires any blood or blood products, these are available or requested
from the transfusion department. Most
• hospitals have protocols to ensure that the correct number of units of blood is requested for
major surgery.
• Find out well in advance if any specific preparation is required.
39

PREPARATION
Prophylaxis
Definition: the process whereby disease or complications are prevented by protective measures.
Principles of surgical prophylaxis.
• Risk of complications varies from procedure to procedure
• Prophylactic measures must be started before the operation or procedure and be continued until
the risk period has passed
• Prophylactic measure/device/drug must be effective and carry very little risk of itself
• Specific prophylaxis is used to prevent common complications or rare complications that are
catastrophic if they occur
40

PREPARATION
Surgical infection:
 Measures that reduce infection rates.
• Laparoscopy
• Skin cleansing/disinfection
• Filtering of the operating theatre air
• Surgical masks and impervious surgical microfibre gowns
• Prophylactic antibiotics
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PREPARATION
Surgical site infections:
• Superficial SSI
• Deep incisional SSI
• Organ/space SSI
In general the risk of an SSI is determined by the nature of the operation
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PREPARATION
Hospital-acquired infection (MRSA):
• Strict adherence to hospital antibiotic practice
• Always wash hands after examining patients
• Strict aseptic care of intravenous lines
• Isolation of infected cases
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PREPARATION
Trauma
• Risk of anaerobic infection, especially with contaminated wounds or after human bite
• Clostridial infection: gas gangrene (Clostridium welchii) or tetanus (Clostridium tetani)
• If no active immunization within 5 years, give booster tetanus toxoid injection
• If never immunized or gross contamination present, give human antitetanus globulin
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PREPARATION
 Deep vein thrombosis:
 1% of patients admitted to general hospitals die from PE •
 Most fatal emboli result from postoperative DVT •
 Risk factors for DVT: age > 40 years, previous DVT, surgery, trauma, sepsis,
immobility, obesity, malignancy, oestrogen
• General measures
• Adequate hydration
• Mobilization preoperatively and postoperatively
• Avoidance of oestrogen therapy
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PREPARATION
• Specific measures
• Mechanical prophylaxis
• Elevation of foot of bed by 10–15°
• Compression stockings
• Pneumatic-graded sequential compression devices
• Electrical stimulation of calf muscle
• early post operative ambulation
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PREPARATION
• Pharmacological prophylaxis:
• Warfarin sodium: effective in preventing DVT. Acts by inhibiting synthesis of vitamin K-
dependent coagulation factors (II, VII, IX, X). Cumbersome to use
• Dextran 70: administered i.v. in 500 mL of 5% dextrose at time of operation and for 2 days
postoperatively. Interferes with platelet function and fibrin polymerization
• Subcutaneous heparin: low-dose or minidose heparin is the most widely used agent for
DVT prophylaxis. Acts by accelerating antithrombin III inhibition of activated factor X.
Give 5000 units 2 h preoperatively plus 5000 units every 8–12 h postoperatively. Low-
molecular-weight heparins are a popular alternative
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PREPARATION
Respiratory problems:
• Postoperative lung function impaired by
• Pain
• Reduction of chest wall movement
• Reduction of diaphragmatic movement
• Bronchorrhoea, decreased ciliary motion
• Diminished efficacy of coughing
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PREPARATION
• Effects:
• De-aeration of the alveoli
• Patchy collapse
• Bronchopneumonia
• Patients at risk
• Cigarette smokers
• Patients with COPD
• Obese patients
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PREPARATION
• Perioperative care:
• Aerosol bronchodilators for patients with COPD
• Deep breathing exercises and incentive spirometry preoperatively
• Effective pain relief without depression of the respiratory centre, e.g. epidural block
• Vigorous postoperative chest physiotherapy and incentive spirometry
50

PREPARATION
 Acute renal failure:
• Patients at risk
• Jaundiced patients
• Patients with liver disease
• Patients undergoing cardiopulmonary bypass and aortic surgery
• Patients with blood volume deficits
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PREPARATION
• Prophylactic measures:
• Prompt correction of volume deficits
• pre operative hydration in jaundice
• Induction of natriuresis by mannitol or loop diuretic at start of operation in jaundiced
patients
• Hourly urine output (bladder catheter)
• Avoid nephrotoxic drugs/antibiotics
• Renal-dose dopamine if urine output < 30 mL/h despite volume replacement
52

PREPARATION
 Stress ulceration
• Patients at risk:
• Severe trauma (especially burns)
• Major surgery (including neurosurgery)
• Type of ulcer
1. Erosive gastritis (common)
2. Single duodenal ulcer (Curling’s ulcer)
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PREPARATION
• Management
• Suppression of gastric acid secretion
• Proton pump inhibitors (e.g. omeprazole)
• Mucosal protective agents (e.g. sucralfate)
If gastrointestinal bleeding
 Conservative treatment initially •
 Rarely, surgery required
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PREPARATION
Pressure sores
• Immobile patients at risk
• Pressure of patient’s own weight leads to ischaemic necrosis of tissues
• Considerable morbidity from infection and protein-losing catabolic state
• Common sites
• Buttocks and sacral region
• Skin over greater trochanters
• Heels
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PREPARATION
• Prevention
• Careful skin care and hygiene
• Frequent turning of patients
• Nurse at-risk patients on pneumatic mattresses
• Treatment
• Débridement (removal of slough) and drainage of pus
• Daily dressings with zinc lotion to encourage granulation tissue
• Plastic surgical treatment by flap advancement in some patients
56

PREPARATION
AIDS and hepatitis
• Generally to protect staff from injury with contaminated material
• Strict protocol to avoid ‘sharps’ injuries
• Correct disposal of all used items and clinical waste
• Vaccination of health workers against hepatitis
57

PREPARATION
5. In-theatre preparation:
Theatre is a potentially dangerous place for patients; many of these dangers
arise directly as a result of poor preparation and checking of basic facts.
WHO checklist
The WHO checklist is a basic template that sets out a series of steps, which can
be modified or adapted in different organizations, but has four areas of focus.
59

PREPARATION
Before commencement of the list
• Confirm surgical, anaesthetic, and nursing team present and identified.
• Confirm patients on the list and the order of the procedures to be performed.
• Check anaesthetic requirements are correct and functioning (machine, medication,
monitoring).
• Confirm vital imaging/equipment required for the list.
60

PREPARATION
 Before induction of anaesthesia
• Check patient identity & consent valid
• Check site & side marked, if appropriate.
• Check anaesthetic requirement are correct & functioning (machine, medication, monitoring)
• Check allergies, anticipated blood loss.
 Before skin incision
• Check all team members present and known.
• Check the procedure to be performed.
• Confirm any surgical/anaesthetic/nursing concerns.
• Confirm vital imaging/equipment available.
61

PREPARATION
Before the patient leaves the theatre
• Check the correct name for the procedure actually performed is known and
recorded.
• Check the swab and instrument count correct.
• Confirm any surgical specimens collected, ‘potted’, and labelled correctly.
• Confirm any specific instructions, either surgical or anaesthetic, which apply
to the patient in recovery or on transfer to the ward.
62

PREPARATION
6.Preparation of surgical team
• Ideal preoperative briefing
o establishes Team leader
o Facilitate communication
o Outline teamwork
o Specifies protocol
o Responsibilities, expectations & contingency plans
63

PREPARATION
7.Preparation of surgeon
Professional development of a surgeon is a privilege enduring persuit involving
o Emotional & intellectual growth
o Discipline
o Creativity
o Dedication
o Equanimity
o Technical talent
o Formal education
64

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