Preoperative preparation in surgical patients

1. Principles of Preoperative
Preparation

2. Preoperative Preparation
• Preoperative preparation is necessary in all forms of surgeries, emergent, urgent and elective surgery.
• The degrees of preparation in the emergent may be less extensive due to risk of delay in surgical
intervention
• There are general guiding principles or procedures in preoperative, but the specific implementation varies
depending on the circumstance, the surgery, premorbid and morbid status of the patient
• The goal is to stratify and assess risk in order to reduced risk of operative complication or improve operative
outcomes.
• The preoperative preparation significantly affects the operative outcome even more than the operative and
postoperative events.
• Routine and unguided testing is not cost effective and does may not be predictive of perioperative morbidity
and mortality

3. • To optimize- means to improve the patients preoperative medical/physiologic status to as best as possible
before the operation.
• Resuscitation; is to retrieve the patient from jaws of death , or retrieve the patient from life threatening
condition.
• In general, the goal of preoperative preparation is to do 3 things
1. Identify factors that may compromise or increase the risk of anesthesia
2. Identify factors that my increase the risk of morbidity and mortality of operation being planned
3. Institute prophylactic measures based on the above 2 factors

4. To achieve the first 2 goals
1) Detailed Clinical Evaluation ( history and examination) to achieve the following
 identify the primary disease condition and diagnosis ,
 determine the extent or secondary systemic effect,
 to identify co-morbidity
 identify the best operative intervention, and direct investigations
2) Investigation- based on the clinical evaluation and the planned operation

5. Risk stratification
• General risk stratification methods
• Specific risk stratification methods ( based on different systemic diseases
for the liver, heart, lungs , risk of venous thromboembolism etc )

6. General Risk Stratification
American Society of Anesthesiologists (ASA)
• The most common preoperative risk stratification method
• Accurate

8. General issues to consider in the
perioperative period
• Psychological preparation and consenting
• Nutritional Status
• Handling Medications
• Investigations and responding to investigation findings

9. Psychological issues and consenting
• Consider the psychological and medicolegal issues
• The disease and likely cause in the context of the patient
• Options of treatment available and reason for offering surgery
• The benefits of surgery and risk of nonsurgical intervention
• The goals of surgery and follow up plan
• The risk of surgery and how to mitigate
• Establish patient expectation and ensure you are on same page
• Establish a patient proxy to take decision in case of incapacity in perioperative period

10. Nutrition
• History- symptoms, history of unintentional weightloss >10% in
6months
• Clinical evaluation – (anthropometric measures)
• Laboratory tests- hemogram, serum albumin <30mg%

11. More general Preparation
• Feeding
• Medications
• Anesthetist Review

12. Specific Organ-system Evaluation and
Preoperative interventions
• Cardiovascular
• Cardiac Arrythmias increase the risk of Myocardial
infarction, stroke or Cerebrovascular accident,
Embolism
• Patients with coronary artery disease, Hypertension,
Obesity, Hyperlipedemia, DM and Smoking have
increased risk of MI
• Patients with recent history of myocardial infarction (
heart attack) they have increased risk of recurrence.
• History in the last 3-6 month has risk increase of 10%,
• in the last 3 months has 30% increase and
• in the last 6 weeks has risk of 50% recurrence
• Operation duration of 3 hours or more increases
risk of MI
Investigations and Intervention
Hypertension- ECG, CXR, E/U/Cr,
continue medications till morning of
surgery
Control diastolic BP to less than
110mmgh even for emergent surgery
Delay surgery to control BP
For recent MI delay surgery for at least 6
month
Close monitoring as MI is usually within
72 hours postop
Prophylactic antithrombotic

13. Cardiovascular risk factors Still
• Cardiac failure- Remove factors exacerbating it such as anemia, hypertension control
• Give diuretics , ionotropes and vasodilators , may need to delay surgery to control if possible
• Will need ICU care and artificial ventilation for pulmonary edema with reduced lung compliance
• Arrythmias- defer surgery, stabilize arythmias with cardioversion or pacemaker insertion . the
pacemaker may be set o fixed rate mode temporarily
• Pacemaker- avoid diathermy and use bipolar instead of monopolar that passes current through the
patient, the active electrode use should be more than 15cm from the location of the pacemaker,
change the pacemaker to fixed- rate mode, avoid use of suxamethonium

14. Smoking
Intervention
• Stop smoking 12-24 hours before emergency will
reduce the systemic effects of carbon monoxide but not
eliminate them
• Stopping for 6weeks will improve the mucociliary
escalator system, decreases the airway reactivity and
decrease mucus secretion
• Recommend pre and postoperative physiotherapy to
improve the lung functions
• Increases the risk of pulmonary complications by 6
times
• the Co in smoke reducing systemic oxygenation
• CO cause cardiac depression
• CO increased airway reactivity and mucus secretion
with risk of spasm and obstructive plugging
• CO Depresses the clearance of airway be impairing the
tracheobronchial escalator system
• CO Immunodepression on the pulmonary
macrophages, Natural killer cells and Immunoglobulins
• Nicotine increase the work of heart and oxygen demand
by increase the heart rate and systemic vasospasm (
hypertension)
• Impairs wound healing due to reduced oxygenation

15. Asthma
• Obstructive hypoxia,
• airway spasm for reactivity usually during recovery,
• Spontaneous pneumothorax ,
• viscid sputum and impaired airway clearance system
impaired with risk of infection
Intervention
• Get steroid, and other drugs ready, preferably
• electively take over the airway , avoid stressors,
• if in active phase delay surgery if possible until remission
• Recommend chest physiotherapy and
• Rule out spontaneous pneumothorax with CXR
• Ensure adequate level of anesthesia, pain control
• Have steroid aminophylline and bronchodilators handy
• Increase the dose of bronchodilators in the perioperative
period
• Delay surgery if possible

16. Upper Respiratory tract infection
Risk of transferring to lower tract
infection and sepsis,
Increased airway reactivity and
spasm,
Impaired clearance of drugs
Intervention
• Delay Surgery if possible
• Treat infection
• Have bronchodilators ready
• Delay for 6 weeks from onset of
symptoms or 2 weeks from
resolution of symptoms

17. Anemia/ Hemoglobinopathy
• Risk of systemic hypoxia, cerebral hypoxia, heart failure, impaired wound healing
• Loss of sympathetic compensatory response leads to features of heart failure
Intervention
• FBC, CXR, ECG
• Emergency need blood transfusion, make transfusion 48 hours before surgery
• Delay surgery: use blood formers; hematinics, erythropoietin
• Exchange transfusion of hemoglobinopathy
• Use minimally invasive technique
• Use hemostatic methods
• For HBSs ensure adequate hydration, analgesia, oxygenation, warmth

18. Obesity
• Hypoventilation due to weight – causes atelectasis, impair
airway clearance and infection, Pickwickian
Syndrome(decreased respiratory excursion with CO2 retention)
• Challenges of vitals signs monitoring due to inappropriate
cuff and breath sounds , heart sounds and abdominal evaluation
• Problem of venous access and intubation due to common
short neck
• Risk of hypertension, diabetes, hyperlipedemia, DVT, CVA
• Problem of operative access of body cavity eg abdomen and
chest
• Prolonged gastric emptying time with risk of acid aspiration
and Mendelson syndrome
• Poor excretion of anesthetic agents due to poor respiration
and Retention of anesthetic agents by fat lead to slow recovery
or reversal to anesthetic state shortly after recovery
Interventions
• Delay admission
• Physiotherapy /compression stocking
• Ask to shed weight
• Appropriate investigation
• Appropriate risk stratification and counseling
• Exercise increases fibrinolysis and reduces stasis
• Institute Dvt prophylaxis,
• Adequate preoxygenation and
• careful monitoring in the immediate recovery period

19. Hepatic or jaundiced patients
• Risks
• Coagulopathy, or thrombosis
• hypo or hyperglycemia, Coagulopathy or thrombosis,
• Fluid problems, ascites, edema peripheral and pulmonary,
• hepatorenal syndrome,
• hepatopulmonary syndrome,
• Anemia encephalopathy
• Challenges with drug metabolism and infection
• Interventions
• Adequate hydration, ensure adequate urine output , control ascites and prophylactic antibiotics
• Prevent hypoglycemcia and correct coagulopathy
• Use isoflurane which is least hepatoxic

20. Diabetes
• Fluid and electrolyte imbalance
• Autonomic neuropathy with silent MI
• Impaired sympathetic response to blood loss and stress
• Delayed gastric emptying
• Microangiopathy and effect on peripheral vessels, coronary vessels, cerebral and renal vessels
Intervention
Control blood sugar/ Thomas-Alberti (GKI) Regimen
Appropriate investigations for cardiac- ECG, CXR, Echocardiogram, renal functions- E/U/Cr, Urinalysis
Delay surgery if not urgent

21. Endocrinopathies
• Diabetic emergencies
• Thyroid crisis- identify and make euthyroid before surgery
• Addisonian crisis- will need hormone replacement
• Hypothyroidism or myxedema coma- identify and make euthyroid before surgery
• Pheochromocytoma- labile BP, hypertension, cardiac arrythmias : continuous intraarterial bp monitoring,
control bp with both alpha and beta blockers, use short acting hypotensive agents eg sodium- nitropruside and
have antiarrhythmics handy.
• Do not block completely to avoid recalcitrant hypotension after surgery . use phenoxybenzamine

22. Renal Failure
• Fluid and electrolyte imbalance , fluid challenges and pulmonary
edema, hypertension
• Anemia
• Uremia with hemostatic challenges
• Encephalopathy
• Anesthetic risk from poor excretion of anesthetic agents
• Challenges of drug excretion and toxicity
Intervention
• FBC, E/U/C, urinalysis, CXR, ECG, clotting
profile
• Correct electrolyte derangement
• Dialysis ( before and after surgery, if limited delay dialysis till after
surgery and blood transfusion)
• Diuretics
• Correct anemia and coagulopathy
• Maintaining hemodynamic stability, and preserving intravascular
volume ensures renal perfusion and reduces risk of further kidney
damage
• Avoid nephrotoxic agents – such as colloids, radiocontrast agents

23. Social Drugs and Medications
• Steroids may cause Addisonian crises if completely removed, hence use intravenous replacements
with hydrocortisone
• Drugs of addiction may cause withdrawal syndromes if removed, use replacement or allow to
continue to use in controlled manner.
• Alcohol- causes enzyme induction with unexpected drug action or inaction; hypoglycemia, high risk
of liver and cardiac disease, hypokalemia with difficult reversal of neuromuscular blockers effect
• OCP- DVT risk . DC 4-6 weeks before surgery
• Warfarin – DC 1 week before surgery and monitor clotting system and change to heparin
• Dc heparin- 12 hours before and recommence 12 hours after surgery
• Aspirin-antiplatelet DC 5 to7 days before surgery
• Drugs to continue: hypertensive, antiepileptic, steroids, and antithyroid drugs
•

24. More of social drugs and medications
• Remember steroid may be in creams and
other cosmetic items , you should get this in
social history
• Remember green medications and food
additives or supplements medications may
content drugs with potent effect for example
• Use of herbs may cause hepatic and renal
dysfunction
• When you get history of herbs use, you need
to find out the active ingredients to prepare the
patient appropriately.
Garlic Potential to increase risk for bleeding, especially when
combined
• with other medications that inhibit platelet aggregation
• Inhibition of platelet aggregation
• (may be irreversible); increased
• fibrinolysis; equivocal
• hypertensive activity
• Discontinue at least 7 days
• before surgery
• Ginkgo Potential to increase risk for bleeding, especially when
combined
• with other medications that inhibit platelet aggregation
• Inhibition of platelet-activating
• factor
• Discontinue at least 36 hr
• before surgery
• Ginseng Hypoglycemia; potential to increase risk for bleeding;
potential to
• decrease anticoagulative effect of warfarin
• Lowers blood glucose; inhibition of
• platelet aggregation (may be
• irreversible); increased PT/PTT in
• animals
• Discontinue at least 7 days
• before surgery

25. Conclusion
• Preoperative preparation is guided by the findings on
clinical evaluation and risk stratification

26. Questions