The document discusses preoperative preparation and assessment of patients. It outlines the key steps which include gathering relevant medical history, conducting a physical exam, ordering appropriate tests and labs, identifying and managing any medical conditions, developing a treatment plan, discussing risks and obtaining consent. The goals are to optimize the patient's condition, minimize risks and communicate effectively with the surgical team. Key aspects of the physical exam and specific considerations for various medical conditions are also described. Finally, the document discusses arranging the operating room schedule to ensure proper resources and prioritization of patients.

1. PREOPERATIVE
PREPARATION
Dr Nisar Ahmed Arain
Assistant Professor
Anesthesia/Critical Care/ER

4. -Learning Objectives
-To be able to organize preoperative care and
the operating list
-To understand surgical, medical, and anesthetic
aspects of assesment
-How to optimize the patients condition
-How to take consent
-How to organize an operation list

5. -DEFINATION
-The pre-operative period runs from the time
the patient is admitted to the hospital or in
the surgicenter to the time that the surgery
begins

6. -Pre operative plan
-Gathering and recording concisely all relevant
information
-Planning to minimize risk and maximize benefit
for the patient
-Prepared for adverse events and how to deal
with them
-Communicate with patient and all members of
the team

7. -Patient assesment
-1-History taking
-2-Examination
-3-Investigations
-4-Pre-operative treatment
-5-Documentation
-6-Communication

8. -Principals 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)

9. -Past Medical History
-Cardiovascular
-IHD, HTN, heart
Failure, Dysrhythmias
PVD, DVT, anemia
-Respiratory
-COPD, Asthma,
fibroptic lung
conditions,
respiratory infection,
malignancy
-Gastrointestinal
-Peptic ulcer disease
GERD, bowel habits
Malignancy, Liver
disease
-Genito urinary tract
-UTI, Renal dysfunction
-Neurological
-Epilepsy, CVA, Psychiatric
disorders, cognitive
function
-Endocrine /
Metabolic
-Diabetes, Thyroid
dysfunction, Pheo
chromocytoma
-Locomotor system
-Osteoarthritis
Inflammatory
arthropathy
-Infectious
-Tuberculosis, HIV
Hepatitis

10. -Examination
-General:- + findings even if not related to the proposed
procedure should be explored
-Surgery Related:-Type and site of surgery, complications
which have occurred due to underlying pathology
-Systemic:-Comorbidities and their severity
-Specific:-For example, suitability for positioning during
surgery

11. -General Physical Examination
-AIM:-To check fitness for Anesthesia and surgery
-1-GPE
-2-Systemic
-3-CVS
-4-CNS
-4-GIT
-5-Respiratorysystem

12. -Specific Surgical Examination
-AIM:-To confirm previous findings and diagnosis, to determine
severity and to gauge extent
-E.g. In inguinal hernia please confirm its inguinal not femoral
, It is reduceable or not reduceable and whether there
are any signs of bowel obstruction.

13. -Specific Medical Examination
-Aim:- is to evaluate the presence and severity
of other problems
-Diabetic patients undergoing surgery needs careful
examination for Sepsis, Neuropathy, or microvascular disease

14. -Investigations - - Routine
-Every unit and ward has its own protocol
-The tests which are normally performed
on most patients coming for surgery
-Full Blood count
-Basic Biochemistry
-Chest Radiograph

15. -Investigations ---Targeted tests
-Hematology:-To exclude Anemia, for platelets
count
and to asses the amount of blood may be needed
during or after operation
-Urea, Creatinine, and Electrolytes:-State
of
dehydration and renal insufficiency
-Liver Function Tests:-Albumin and Protein
guide to nutritional status and shows any clotting
problems.

16. -Investigations – Others(Non specific)
-ECG:-Its recommended in all patients >65 years, patients
with blood loss and cardiovascular / Pulmonary problems
-Urinalysis:-Used for determination of renal function,
inflammation, infection, and metabolic disorders
-Pregnancy Test:- (B- HCG )
-HBsAg and HIV testing
-RBS and HbA1c :- Diabetes
-Blood Gas analysis :-Occ required

18. -Hypertension
-Preoperative Blood Pressure
should not exceed 160/90
mmHg
-Newly diagnosed HTN may need
further evaluation
-Acute admission require urgent
surgery, BP should be
controlled more rapidly

20. -Dysrhythmias
-Fast Atrial Fibrillation must be
controlled before surgery
-Warfarin should be stopped 3 to 4 days
before surgery
-Regular measurement of serum
potassium is essential
-Some conduction disorders may require
pacing
preoperatively, 2nd and 3rd degree heart
block

21. -Anemia and
Blood transfusion
a-Pre-operative transfusion should
be considered if Hb < 8g/dl

22. -Respiratory system
-Infection:-To be treated before surgery
-Asthma:-
a-Establish the severity and the course
of illness
b-Patients inhalers usually should be
continued
-COPD:-
a-Pre-operative X Ray chest required
b-Significant COPD who need major
surgery, should be referred to
Respiratory Physician
c-ABG analysis is required

23. -Gastro-Intestinal disease
-Regurgitation Risk
a-H2 receptor blockade / PPI, NG tube to
empty distended stomach
b- Nil by mouth before surgery
a-Solids (6 hours)
b-Fluids (2 hours)
-Jaundice:-
a-Secondary complications, Impaired
clotting risk of renal failure
b-Prophylactic antibiotics should be
given

24. -Clinically obese patient (BMI >30)
a-Increased risk of post-operative complications
-Some cases might better delay the elective surgery
until they loose some weight.
-Determine nutritional status of patient, nutritional
assesment
-Malnourished patient:-Nutritional support minimum
of two weeks

25. -Genito-Urinary disease
-Renal Impairment:-
-Categorize pre renal, renal, postrenal
a-appropriate measure for acidosis,
Hypocalcemia, Hyperkalemia
b-Continue peritoneal or Hemodialysis until few
hours before surgery
- Urinary tract Infection
-Treat such infection before high risk
elective surgery
-Urgent Procedure
Antibiotics should be started and
ensure that patient is having good urinary
output

26. -Metabolic disorders
-Diabetes
-Check HbA1c level
-Pre-operative risk reduction strategies(Lipid-
lowering agent, diabetic control)
-Minor surgery in non insulin dependent
diabetic-omitting morning dose, listening
early surgery, restarting treatment
-Sgnificant surgery in insulin dependent-
intravenous insulin infusion require

27. -Adreno-cortical suppression
-Occur in patient receiving oral
adrenocortical steroid regularly
-Require extra dose of steroid
around the time of the surgery—
Avoid Addisonian crisis

28. -Coagulation disorder
-Thrombophilia
-Identify the risk factor for thrombosis
a-Age
b-Obesity
c-Trauma or surgery(abdomen, pelvis, lower limb
d-Reduced mobility > 3 days
e-Pregnancy
f-Drugs:- estrogen, HRT
g-Fmily history of thrombosis
-Prophylaxis in perioperative period
(Mechenical / Phamacological)
-HRT should be stoped 6 weeks prior to
surgery

29. -Other disorders
-Neurological:-
-H/O stroke, with neurological Deficit
-Withdraw antiplatelet agents
a-Aspirin (7 days before)
b-Clopidogrel (10 days before)
-Neuropathies / Myopathies
need prolonged ventilation
-Psychiatric:-
-Need GA
-Certain medication
Mono-amine-oxidase
-inhibitor. Unwanted
interaction and anesthetic
medication
-Locomotor:-
-Inflammatory arthropathies
to be identified

30. -Management Plan---KEY POINTS
-Provide all information necessary for the
patient to make an informed decision
-Discuss the options, rather then telling the
patient what will be done
-Give the patient time to think, things over
-Encourage to discuss the things– as a
trusted person

31. -Risk assesment and consent
-All life:- or limb—threatening complications rather all the
complications with an incidence of 1% or more should
be thoroughly discussed with the patient
-Risks:-Related to comorbidities, anesthesia and surgery
-Explain:-Advantages, side effects, prognosis
-Language:-Simple, use daily life comparisons to
explain risks
-Consents:-Valid consent is necessary except in
life—saving circumstances

32. -Patients mouth is open and tongue protruding
-Look for loose teeth, scars, infections, thickness of neck
which indicates difficulty in visualizing airway
-Neck movement, thyromental distance, and Mallampati score

33. -Thyromental distance
-Tip of thyroid cartilage to the tip
of the chin (mentum)

35. -Arranging the theatre list
-Date, Time and Place of operation should be matched
with availability of the personnel.
-Appropriate equipment and instruments should be made
available
-Operation list should be distributed as early as possible
to all staff who are involved.
-Prioritize all the patients
a-First:-Children and diabetic patients
b-Life and Limb threatening surgery
c-Cancer patients