This document outlines principles of preoperative care. It discusses evaluating patients' medical history and comorbidities, explaining the planned procedure to obtain informed consent, optimizing high-risk medical conditions before surgery, assessing surgical risk, and preparing patients with bowel cleansing or stopping certain medications. The goal is to minimize risks and optimize outcomes through thorough preoperative evaluation, planning, and preparation.

1. Principles of Preoperative
Care
- Dr. Nipun Bansal
Senior Resident
Department of General Surgery
Government Medical College & New Civil Hospital,
Surat, Gujarat, India

2.  Surgeon should explain the context of the illness, possible
nonsurgical alternatives and the benefit of different
surgical interventions, further investigations
 A recommendation regarding the need for operative
intervention can then be made by the surgeon and
discussed with the patient's family members.
 A professional and unhurried approach is mandatory, with
time taken to listen to concerns and answer questions
posed by the patient and family members.
 It fosters a bond of trust and opens a line of
communication among all participants.
Pre-Operative Preparation of
the Patient

3. Decision Making
Decision made to proceed with operative management
 the timing and site of surgery
 understand the patient's risk
 the type of anesthesia
 the preoperative preparation
Optimizes the outcome

4. Risk assessment
It takes into account both
 the perioperative (intraoperative period through 48
hours postoperatively)
 the later postoperative (up to 30 days) periods.
 Seeks to identify factors that may contribute to
patient morbidity

5. RISK CLASSIFICATION SYSTEM:
ASA classification :
I—Normal healthy patient
II—Patient with mild systemic disease; with no functional
limitation
III—Patient with severe systemic disease that limits activity
but is not incapacitating
IV—Patient who has incapacitating disease that is a
constant threat to life
V—Moribund patients not expected to survive 24 hours with
or without an operation
VI- Patients who are brain dead; for organ donation

6. Preoperative Evaluation
 Goal: to identify and quantify any
comorbidity, to uncover problem areas that
may require further investigation that may
have an impact on the operative outcome.
 If preoperative evaluation uncovers
significant comorbidity or evidence of poor
control of an underlying disease process --
 consultation

7. Preoperative Plan for the
best patient outcome
 Gather and document all relevant information
 Risk Assessment
 Choose surgery that offers minimum risk and
maximum benefits
 Anticipate and plan for adverse events
 Inform everyone concerned.

8. SYSTEMIC APPROACH TO
PREOPERATIVE
EVALUATION

9.  Consultants need to weigh the Benefits of surgery
against the Risk and determine whether any perioperative
intervention will reduce the probability of a cardiac event
e.g. coronary revascularization via coronary artery bypass
or percutaneous transluminal coronary angioplasty
 In case of Hypertension, BP Should be controlled prior to
surgery.
 If a new antihypertensive is introduced, stabilisation period
of atleast 2 weeks should be allowed.
Cardiovascular:

10.  Patients who have undergone a percutaneous
coronary intervention with stenting need to have
elective non-cardiac procedures delayed for 4 to 6
weeks, although the delay may be shortened
depending on the type of stent used (drug eluting
versus non–drug eluting
 Improvements have centered on decreasing the
adrenergic surge associated with surgery and
halting platelet activation and microvascular
thrombosis .

11. Echocardiography
 Pressure gradients across chambers
 Dimensions of chambers
 Contractility
 Ejection fraction
 Ventricular function

12.  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.
 In major noncardiac surgery, an inability to climb
two flights of stairs is an independent predictor of
perioperative morbidity, (but not mortality).
TWO FLIGHTS OF STAIRS

13. PULMONARY
consider assessment of pulmonary function for
 lung resection cases
 thoracic procedures requiring single-lung
ventilation,
 for major abdominal
 thoracic cases in patients who are older than 60
years, have significant underlying medical disease
• Thoracic and upper abdominal procedures can
decrease pulmonary function and predispose to
pulmonary complications.
 Chronic smokers, or have overt pulmonary
symptomatology
 Chronic Obstructive Pulmonary Disease

14. Necessary tests include:
 forced expiratory volume in 1 second (FEV1)
 forced vital capacity
 the diffusing capacity of carbon monoxide.
 Adults with an FEV1 of less than 0.8 L/sec, or 30%
of predicted, have a high risk for complications and
postoperative pulmonary insufficiency
 General factors that increase risk for pulmonary
complications include increasing age, lower albumin
level, weight loss, and possibly obesity (~OSA)

15.  Preoperative interventions:
• smoking cessation (>2 months before the planned procedure)
• bronchodilator therapy,
• antibiotic therapy for pre-existing infection
• pretreatment of asthmatic patients with steroids.
 Perioperative strategies include the use of epidural anesthesia and
continued bronchodilator therapy.

16. Renal
 A preoperative creatinine level of 2.0 mg/dL or
higher is an independent risk factor.
 Important Biochem testing include: Serum Urea and
Serum Creatinine levels.
 Metabolic derangements in a patient with advanced
renal failure may be mild and asymptomatic and are
revealed by electrolyte or ABGA.
 Hyponatremia is treated by volume restriction

17.  Anemia, may be present leading to fatigue, low
exercise tolerance, and exertional angina.
 Platelet dysfunction associated with uremia is often
a qualitative, platelet counts are usually normal.
 Pharmacologic manipulation of hyperkalemia,
replacement of calcium for symptomatic
hypocalcemia, and the use of phosphate-binding
antacids for hyperphosphatemia are often required.

18.  Patients with chronic end-stage renal disease undergo dialysis
before surgery to optimize their volume status and control the
potassium level.
 Intraoperative hyperkalemia can result from surgical
manipulation of tissue or transfusion of blood. Such patients are
often dialyzed on the day after surgery as well

19.  Prevention of secondary renal insults in the perioperative period :
• avoidance of nephrotoxic agents
• Maintenance of adequate intravascular volume throughout this period.
 Notably, nonsteroidal agents e.g. Diclofenac and Aminoglycosides
(e.g. Gentamicin) are avoided in patients with renal insufficiency.

20. Hepatobiliary…
Liver – Most vital Metabolic organ
 Any exposure to blood and blood products
 exposure to hepatotoxic agents.
 whether hepatitis has been diagnosed
*obtain in case an operative team member is injured
during the planned surgical procedure.
*Ensure New Medical Personnel must be given vaccine
against HEP B.

21. Symptoms/Signs
o Pruritus
o excessive bleeding
o abdominal distention / Ascites
o Hepatomegaly
o Spider nevi
o caput medusae
o palmar erythema
o clubbing of the fingertips
o Loss of hair
o Jaundice and scleral icterus may be evident with
serum bilirubin levels higher than 3 mg/dL.
o Hepatic fetor
o Asterixis

22.  Elevations in hepatocellular enzymes may suggest a diagnosis of
acute or chronic hepatitis
 serologic testing for hepatitis A, B, and C.
 Urgent or emergency procedures in acute patients are
associated with increased morbidity and mortality.
 A patient with evidence of chronic hepatitis may often safely
undergo surgery
 Elevations in hepatocellular enzymes may suggest a diagnosis of
acute or chronic hepatitis
 serologic testing for hepatitis A, B, and C.

23. Child-Pugh classification
 A patient with cirrhosis may be assessed with the Child-
Pugh classification, which stratifies operative risk
according to a score based on
Criteria 1 point 2 points 3 points
Encephalopathy None Mild to moderate Severe (Gr 3 or 4)
Bilirubin (mg/dL) <2 2-3 >3
Ascites None Diuretic Responsive Diuretic Refractory
Albumin (g/dL) >3.5 2.8- 3.5 <2.8
PT prolonged 1-4 s 5-6 s >6 s
Class A= 5-6 points
Class B = 7-9 points
Class C= 10-15 points
Ek
B
A
A
P

24.  Two common problems requiring surgical evaluation
in a cirrhotic patient are hernia (umbilical and
groin) and cholecystitis.
 An umbilical hernia in the presence of ascites is a
difficult problem
• Elective repair is best after the ascites has been
reduced to a minimum preoperatively
 Malnutrition- common ;
 hepatic glycogen stores
 hepatic protein synthesis.

25. Diabetic Profile
Preoperative testing may include:
 the adequacy of glycemic control ( HbA1c)
 fasting and postprandial glucose
 identifies the presence of diabetic complications, which may
have an impact on the patient's perioperative course.
 Nephropathy – Urinalysis may reveal Proteinuria
 Neuropathy
 Cardiac disorders – Get done ECG
 Retinopathy - Fundus reference
 wound healing and the risk for surgical site infection

26. Glycemic control
perioperatively
 Non–insulin-dependent diabetics need to discontinue long-acting
sulfonylureas such as chlorpropamide and glyburide because of
the risk for intraoperative hypoglycemia;
 a shorter-acting agent or sliding-scale insulin coverage may be
substituted in this period.
 Withhold long-acting insulin preparations; lower dosages of
intermediate-acting insulin are substituted on the morning of
surgery

27.  These patients are scheduled for early morning
surgery, when feasible.
 In patients with poor diabetic control, During
surgery, a standard 5% or 10% dextrose infusion is
used with short-acting insulin or an insulin drip to
maintain glycemic control
 Postoperative orders include frequent (every 6
hours) finger stick glucose checks and the use of
short-acting insulin.
 Patients who are on Rapid-acting (Lispro) and short-
acting (Regular) insulin preparations, these are
usually withheld when the patient stops oral intake
(NBM/NPO)

28.  Patients who take oral hypoglycemic agents typically withhold
their normal dose the day of surgery.
 Patients can resume their oral agent once diet is resumed.
 Coverage for hyperglycemia is with a short-acting insulin
preparation based on blood glucose monitoring.
 The use of metformin is stopped preoperatively because of its
association with lactic-acidosis in the setting of renal
insufficiency.
• If the patient has altered renal function, this agent needs to be
discontinued until renal function either normalizes or stabilizes.

29. Thyroid
 A patient with hyperthyroidism who takes antithyroid
medication such as propylthiouracil or methimazole is
instructed to continue this regimen on the day of
surgery
 The patient's usual doses of β-blockers or digoxin are
also continued.
 urgent surgery in a thyrotoxic patient at risk for
thyroid storm, a combination of
Adrenergic blockers and glucocorticoids may be
required and are administered in consultation with an
endocrinologist

30. Hematologic
 Anemia – Most common laboratory abnormality
encountered in preoperative patients.
 inherited or acquired coagulopathy,
 Hypercoagulable state e.g. Protein C&S Deficiency
For anemia, get done :
• Coombs Test
• Sickle cell Test
• G-6-PD Deficieny
• serum iron, total iron-binding capacity, ferritin

31.  All patients undergoing surgery are questioned to assess
their bleeding risk.
 family history
 Physical examination may reveal bruising, petechiae, or signs
of liver dysfunction.
 Qualitative defects may respond to medical management of
the underlying disease process
 Quantitative defects may require platelet transfusion when
counts are less than 50,000 in a patient at risk for bleeding

32.  Patients receiving anticoagulation therapy usually require
preoperative reversal of the anticoagulant effect.
 In patients taking warfarin, the drug is withheld for four
scheduled doses preoperatively to allow INR to fall to
the range of 1.5 or less (assuming that the patient is
maintained at an INR of 2.0-3.0).
 Patients with a recent history of venous
thromboembolism or acute arterial embolism frequently
require perioperative IV heparinization.
 The need for perioperative prophylaxis for venous
thromboembolism must be carefully reviewed in every
surgical patient - unfractionated heparin, low-molecular-
weight heparin, intermittent compression devices, and
early ambulation.

33. Obesity
 The perioperative mortality rate is significantly
increased in patients with Morbid obesity (BMI >35
kg/m2 with significant comorbid conditions).
 Severe obesity is associated with a higher
frequency of essential hypertension, pulmonary
hypertension, left ventricular hypertrophy,
congestive heart failure, and ischemic heart
disease, obstructive sleep apnoea.
 Obesity is an independent risk factor for DVT and
PE
 risk factor for postoperative wound infection.

34. Specific Medications
 In general, patients taking cardiac drugs, including
β-blockers and antiarrhythmics, pulmonary drugs
such as inhaled or nebulized medications, or
anticonvulsants, antihypertensives, or psychiatric
drugs are advised to take their medications with a
sip of water on the morning of surgery day when
the patient is Nil By Mouth.

35.  Some drugs are associated with an increased risk for
perioperative bleeding and are withheld before surgery. Drugs
that affect platelet function are withheld for variable periods:
aspirin and clopidogrel are withheld for 7 to 10 days,
 In High risk cases, Clopidogrel is stopped and Aspirin is
continued.
 The use of estrogen and tamoxifen has been associated with an
increased risk for thromboembolism, they probably need to be
withheld for a period of 4 weeks preoperatively
 Surgery is postponed for 6 weeks if HRT is being given
 Lithium should be stopped 24 hours prior to surgery

36. Bowel Preparation
 The colon should be cleansed of faecal material.
 Patients with a history of chronic constipation may
require more prolonged preparation.
 Purgatives are almost always required. In adults, either
used by oral (antegrade) or anal route (retrograde).
 Anal route: using “per rectal irrigations” - reserved for
patients who present with fecal impaction and for
patients with known or suspected colonic obstruction.
 If a patient cannot ingest a large quantity of liquid,
nasogastric infusion is a safe, effective alternative
method of administration.

37. Bowel Preparation
 Rigorous chemical purges or cleansing enemas may
be dangerous in those with partially obstructing
colonic lesions, massive lower GI bleed
 Clear liquids diet for 24 to 48 hours followed by
enema - given until returns are clear.
 Balanced by adequate oral intravenous fluid intake.

38. Informed Consent
 After discussion with the patient and
family members, they have understanding
regarding the disease, indication for the
anticipated surgical procedure, as well as
its risks and proposed benefits.
 Details should be best explained in simple
and patient’s vernacular language.
 Surgery can’t be made Risk-free, but Risks
must be known so that patient can make an
informed decision.

39. Consent
 Be sure the client has VOLUNTARILY signed the
operative consent before taking the patient in OR.
 In event client can not sign, a next of kin must then be
called for permission to operate. If not available or
located. The surgery needs to be postponed or
rescheduled.
 In emergency / unconscious, procedure might be
carried out in the “ Best Interests of the patient” by
informing Higher Hospital Authorities

40. Theatre List
 Header- date, time, surgeons and anaesthetist
 Prioritize the Patients
 Equipment
 Date, place, and time of operations- fix with availability
of Personnel
 May include specialised equipment/ use of specific
operating table
 The Operating Lists should be Distributed to All the
staff members

41.  Preoperative orders are written and reviewed.
 Written instructions regarding the time of surgery
and management of special perioperative issues
such as fasting, bowel preparation, and medication
use.

42. Preoperative Fasting
 The standard order of “NBM” for preoperative
patients is based on the theory of reduction of
volume and acidity of the stomach contents during
surgery.
 The ASA recommends that adults stop intake of
solids for at least 6 hours and clear fluids for 2
hours.
 There is high risk of Acid Aspiration syndrome in
pregnant, elderly, obese

43. Antibiotic Prophylaxis
 Prophylactic antibiotics are not generally required
for clean (class I) cases, except in the setting of
indwelling prosthesis placement
 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 both
aerobic and anaerobic activity.

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