The document discusses preoperative preparation and optimization of patients for surgery. It covers preoperative care, investigations, assessing surgical risk, and preparing specific patient groups. The goals of preoperative preparation are to anticipate difficulties, enhance patient safety, minimize complications, and optimize high-risk patients. Key aspects include obtaining medical history, conducting physical exams and tests, discussing risks and obtaining consent, and providing prophylaxis for issues like thrombosis. Careful preoperative preparation helps improve surgical outcomes.
Caring for perioperative clients
Contents Outline
Objectives.
Introduction.
Phases of perioperative care.
Types of surgery.
Categories of surgery based on urgency.
Preoperative assessment.
Surgical risk factors.
Preoperative preparation.
Nursing diagnosis and intervention in preoperative phase.
Postoperative care.
Nursing diagnosis and intervention in postoperative period.
Postoperative complications.
Caring for perioperative clients
Contents Outline
Objectives.
Introduction.
Phases of perioperative care.
Types of surgery.
Categories of surgery based on urgency.
Preoperative assessment.
Surgical risk factors.
Preoperative preparation.
Nursing diagnosis and intervention in preoperative phase.
Postoperative care.
Nursing diagnosis and intervention in postoperative period.
Postoperative complications.
COLONOSCOPY- A PICTORIAL OVERVIEW
• Dear viewers,
• Greetings from “Surgical Educator”
• This week I have uploaded a video on Colonoscopy- the Lower GI Endoscopy.
• In this episode, I showed only the colonoscopic features of common pathologies in colon and rectum.
• I restricted my talk to the essential minimum that an undergraduate medical student must know about the Colonoscopy.
• I discussed about the diagnostic and therapeutic procedures you can do with the Colonoscopy.
• I hope it would be interesting and very useful to all my viewers.
• You can access this video in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Principles of surgery. Day case surgery is a rapidly evolving surgical sub speciality that seeks to eliminate the need for prolonged admission in surgical patients and the attendant complications of prolonged immobilization. It is based on the documented evidence that most post op patients does not require specialised post op care and hence can be allowed to recover at home. This form of surgery appeals to patients and their families due to the fact that it allows only minimal interruption of patient's social life
ENDOTRACHEAL TUBE INTUBATION II Parts II Details II Clinical DiscussionSwatilekha Das
What is endotracheal intubation?
Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often done under deep sedation. In emergency situations, the patient is often unconscious at the time of this procedure.
For detailed information plz watch the slides till end.......
And plz like, share and comment and follow......
COLONOSCOPY- A PICTORIAL OVERVIEW
• Dear viewers,
• Greetings from “Surgical Educator”
• This week I have uploaded a video on Colonoscopy- the Lower GI Endoscopy.
• In this episode, I showed only the colonoscopic features of common pathologies in colon and rectum.
• I restricted my talk to the essential minimum that an undergraduate medical student must know about the Colonoscopy.
• I discussed about the diagnostic and therapeutic procedures you can do with the Colonoscopy.
• I hope it would be interesting and very useful to all my viewers.
• You can access this video in the following links:
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Principles of surgery. Day case surgery is a rapidly evolving surgical sub speciality that seeks to eliminate the need for prolonged admission in surgical patients and the attendant complications of prolonged immobilization. It is based on the documented evidence that most post op patients does not require specialised post op care and hence can be allowed to recover at home. This form of surgery appeals to patients and their families due to the fact that it allows only minimal interruption of patient's social life
ENDOTRACHEAL TUBE INTUBATION II Parts II Details II Clinical DiscussionSwatilekha Das
What is endotracheal intubation?
Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often done under deep sedation. In emergency situations, the patient is often unconscious at the time of this procedure.
For detailed information plz watch the slides till end.......
And plz like, share and comment and follow......
Patient & Family Education: A Multi-modal approach to improve the experienceWellbe
This session will describe educational concepts to enhance the orthopaedic patient experience. The elective nature of orthopedic surgery creates an opportunity to intervene with patients and family early and often throughout the episode of care. Multimodal teaching strategies (individual, group learning, written materials and web based tools) delivered prior to surgery and reinforced multiple times across care transitions can reduce anxiety, increase satisfaction, improve ability to manage pain and help patients feel more prepared for surgery.
Improving the patient experience is increasingly important as quality and satisfaction metrics are becoming linked to reimbursement. Transitional care interventions, such as discharge planning, follow up calls with emphasis on participation in self care have shown to improve continuity of care, reduce readmissions and prevent poor health outcomes.
About the Speaker:
Jack Davis MSN, RN, ONC is the Manager of Patient Education Programs at Hospital for Special Surgery in NYC. Jack has over 30 years experience in orthopaedic nursing. He has been an active member of the National Association of Orthopaedic Nurses (NAON) since 1991. Jack currently serves as Director of the Orthopaedic Nurses Certification Board (ONCB). He is passionate about preparing patients and family for surgery and seeks to improve nursing practice through research, promoting specialty certification and nursing continuing education.
Perioperative Management of Hypothyroid Patients Undergoing Nonthyroidal SurgeryTerry Shaneyfelt
In these annotated PowerPoint slides I describe the perioperative evaluation and management of patients with hypothyroidism needing nonthyroid surgery. Remember to download these slides to view the annotations for each slide.
perioperative preparations in obstetrics and Gynecology.pptxEkramNasher
This PowerPoint describe all preparations that doctors follow during preparation obstetrical and Gynecological cases for operations and the important instructions which should be taken
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. Preoperative preparation for surgery
• Introduction
• Pre-operative care
• Pre-operative investigation
• Assessment of risk for surgery
• Preparation of surgery of specific patient groups( system
wise approach)
• Consent
3. Introduction
• To obtain satisfactory results in general surgery requires a
careful approach to preoperative preparation of patients
• Specific patient groups have specific needs
• High risk patients should be identified early and appropriate
measures taken to reduce complications
4. Overview
• The preoperative consultation and evaluation is an important
interaction between the patient and physician.
• It allows the surgeon to :
• Carefully access the medical condition;
• Evaluate the patient’s overall health status;
• Determine risk factors against procedures;
• Educate the patient
• Discuss the procedure in detail.
5. • It helps the patient to :
• Gain a realistic understanding of the proposed surgery;
• Consider alternative treatment options
• Realise the possible complications during perioperative period.
• The additional time invested in preoperative evaluation yields
an improved patient physician relationship and reduces
surgical complications
6. Preoperative preparation for sugery
• Prior to consideration of surgical intervention, it is necessary to
prepare the patient as fully as possible so as to optimise him
according to his co-morbidities
• The extent of pre-operative preparation will depend on:
10. • The rational for pre-operative preparation is to:
Anticipate difficulties
Make advanced preparation and organize facilities, equipment
and expertise
Enhance patient safety and minimize chances of errors
Relieve any relevant fear/anxiety perceived by patient
11. Routine preparation for surgery
• History
• Physical examination
• Special investigation
• Informed consent
• Marking the site/side of operation
• Thromboembolic prophylaxis
• Antibiotic prophylaxis
12. Surgical history
Presenting complaint
dictates urgency, it can influence
anesthetic management and any
associated systemic effects of
presenting pathology
Systemic assessment
Carefully assess each body system
about its function to rule out if any
other system is involved
13. Past medical & surgical
Hx
Many diseases have direct
effect on general and anesthetic
treatment and outcome
Any previous operation or
bleeding tendency
Any previous reaction to
anaesthetic agent
Drugs and Allergic Hx
interaction with anesthesia
(MAOI)
Related with sudden withdrawal(
steroids)
Drugs for HTN, IHD to be
continued over perioperative
period
Anticoagulant drugs (aspirin,
warfarin)
HRT
14. Famliy History
Malignant Hyperthermia
Pseudo cholinesterase deficiency
Bleeding disorders
Social History
Smoking:
Short term :
Increadesd myocardial oxygen
demand and decreased oxygen
delivery
Long term:
decreased immune function and
decreased clearance
15. Physical Examnaton
• Includes a full physical examination
• Don’t rely on the ex. of others. Surgical signs may change
and others may miss imp pathology
“What mind doesn’t know, eyes cant see”
• No step is omitted and added advantage of familiarizing
what is normal so that abnormalities can be more recognised
16. • General Ex. Including vitals.
• Cardiac ex. ( JVP, HS)
• Respiratory Ex. ( trachea, accessory ms, percussion,
auscultation)
• Abdominal Ex.
• CNS
• Musculoskeletal system
• Peripheral vasculature
• Local Ex
• Body orifices
If you don’t put your finger, you will put your foot
17. Emergency Physical Examination
• The routine examination must be altered to fit the
circumstances.
• A,B,C,D,E
• Secondary survey( head to toe)
• When a number of emergencies present at same time-
Triage
19. Blood tests:
• Full blood count ( when to perform?)
• All emergency preoperative cases
• All elective preoperative cases over 60 years
• All elective preoperative cases in adult females
• If surgery is likely to result in significant blood loss
• Suspicion of blood loss, anemia, sepsis, CKD, coagulation
problems
20. Blood tests
• Urea and electrolytes (when to perform?)
• All preoperative cases over 65 years
• All patients with cardiopulmonary disease or taking diuretics
or steroids
• All patients with h/o renal/liver disease or abnormal
nutritional state
• All patients with h/o diarrhea, vomiting other
metabolic/endocrine disease
• All patients with IVF for more than 24 hrs.
Incident of unexpected abnormality in apparently fit patient under 40 yrs
is < 1%
21. Blood Tests:
• Amylase:
• Perform in all adult emergency admissions with abdominal
pain, prior to consideration of surgery
• Random Blood Glucose:
• Acute abdomen
• Elective cases with DM, malnutrition, obesity
• Elective cases over 60
22. • Coagulogram studies:
• h/o of bleeding disorder, liver disease or excessive alcohol use
• Patients receiving anticoagulants( PT/INR done on the
morning of surgery for patients instructed to discontinue
warfarin)
• Cardiothoracic surgery
• Vascular surgery
• Angiographic procedures
• Craniotomy procedures
23. • Liver function tests
• All patients with upper abdominal pain, jaundice, hepatic
disease
• Alcoholic
• Screening for Hepatitis B and Hepatitis C
• Blood group/ cross match
• Emergency preoperative case
• Suspicion of blood loss, anemia, coagulation defects
• Procedure on pregnant ladies
24. • Chest X-ray:
• All elective preoperative cases over 60 years
• All cases of cervical, thoracic or abdominal trauma
• Acute respiratory symptoms or signs
• Previous CRD or no recent CXR
• Thoracic surgery
• Malignant disease
• Viscous perforation
• Recent h/o TB
• Thyroid enlargement
25. • Electrocardiogram
• within 12 weeks of surgery ( or less if condition warrants) for
patients with known cardiac disease
• Within 6 months prior to surgery for all patients >50 years
• Other investigations
• Performed according to requirement
• Ultrasound
• CT scan
• MRI
26. Assessment of risk of surgery
• There are few patients who have no risk for surgery
• It is important to quantify the risks involved so they be
discussed with the patients
• Two main prognostic scoring systems which are in current
use are
APACHE SYSTEM
ASA SYSTEM
27. APACHE SYSTEM
• “Acute Physiology And Chronic Health Evaluation”
• Helps to predict the outcome of patients admitted to ICU and has
subsequently been applied to patients undergoing surgery
• APACHE II
• 12 acute physiological variables
• Patient’s age
• Chronic health points
• APACHE III introduced in 1991 includes 5 more physiological
variables (blood urea nitrogen, urine output, albumin , bilirubin
and glucose) and modified version of GCS
28. APACHE II Classification
• Score is A+B+C
• A ( Acute physiology score) C( Chronic Health Problems)
2 points for elective post-op admission
5 points for emergency op, nonoperative
admission, immunocompromised pts, CLD,
CVD, respiratory or renal disease
1. Recent temp.
2. MBP
3. HR
4. RR
5. FiO2(alveolar arterial O2 gradient)
6. pH
7. Serum Na
8. Serum K
9. Serum creatinine
10. WBC
11. Hct %
12. GCS
• B(Age points) graded from <44 to >75 yrs
29. ASA System
• “ American Society of Anaesthesiologist”
• It is very simple and widely accepted
• 50% patients presenting for elective surgery are in ASA Gr
I
• Operative mortality rate for these patients is less than 1 in
10,000
30. ASA Grading and Predictive Mortality
ASA Grade Definition Mortality %
I Normal healthy individual 0.06
II Mild systemic disease that doesn’t limit
activity
0.4
III Severe systemic disease that limits activity 4.5
IV Severe systemic disease that is constant
threat to life
23
V Moribund, not expected to survive 24hrs
with or without surgery
51
31. Clinical Predictors of increased risk
Major predictors
Acute or recent MI
Unstable or Severe Angina
Strongly positive stress test
Decompensated heart failure
Severe Valvular disease
Significant Arrythmias
Intermediate predictors
Mild angina
Previous MI by history or by Q waves
Compensated heart failure
Diabetes
Renal insufficiency ( Cr >2.0)
Minor predictors
Advanced Age
Abnormal ECG( LVH,LBBB,ST changes)
Low functional capacity
h/o of stroke
Uncontrolled systemic hypertension
33. Thromboembolic prophylaxis
• DVT is common in surgical patients
• Can cause PE which carries a high mortality
• Surgery, trauma and immobilization are responsible for
50% of DVT
34. • RISK FACTORS FOR DVT:
Age
Obesity
Immobility
Malignancy
Trauma
Surgery
Dehydration
Past h/o thromboembolism
Oral contraceptives
HRT
Pregnancy, peurperium
36. Level of risk Definition of risk level Prevention strategy
Low Minor surgery in patients <40 yr with no
additional risk factor
Aggressive, early
mobilization
Moderate Minor surgery with risk factors
Minor surgery with age 40-60 years with
no risk factor
Major surgery in <40yrs with no risk
factors
Graded compression
stockings, IPC
LDUH 5000 U BD
LMWH- enoxparin 40mg/d
daltaperin 5000iu/d
fondaparinaux 25mg/d
High Major surgery > 60 yrs, major surgery
40-60yrs with risk factors
IPC with
LDUH 5000 u TID,
enoxaparin 40mg/d,
dalatperin 5000 iu/d,
fondaparinaux 2.5 mg/d
Very High Major surgery > 60 year with risk factor Same as above
For mod-high risk patients prophylaxis given 12-24 hr after procedure
For very high risk prophylaxis started 2-12 hrs before surgery and restarted 12-24
hrs after procedure
37. Antibiotic Prophylaxis
• Appropriate antibiotic prophylaxis depends upon
• the most likely pathogen encountered
• Class of the operative procedure( clean, clean contaminated,
contaminated , dirty)
• Class I cases don’t require antibiotic prophylaxis, except in
cases of indwelling prosthesis placement or bone incision
• Class II cases only single preoperative prophylactic dose
• Class III & IV cases- mechanical preparation plus
parenteral antibiotics with aerobic and anaerobic cover
38. Nature of operation Common pathogens Antibiotics
Cardiac Staph. Aureus and epidermidis Cefazolin ,Vancomycin
Esophageal , gastroduadenal Enteric gram negative bacilli, gram
positive cocci
High risk only: Cefazolin
Biliary tract Enteric gram negative bacilli,
enterococci,clostridia
High risk only : Cefazolin
Colorectal Enteric gram negative bacilli
Anaerobes, enterococci
Oral: neomycin+erythromycin or
metronidazole
Parenteral : cefazolin +
metronidazole or Ampicillin-
salbactum
Genitourinary Enteric gram negative baciili, enterococci High risk only: ciprofloxacin
Neurosurgery S.aureus, S.epidermidis Cefazolin or Vancomycin
Thoracic ( non cardiac) S. aureus, S.epidermidis, streptococci,
enteric gram negative bacilli
Cefazolin or cefuroxime or
Vancomycin
Prophylactic antibiotics should be given 60 minutes or less before the incision
For patients allergic to penicillin and cephalosporins, clindamycin with
gentamicin,ciprofloxacin,levofloxacin or aztreonam
40. CARDIOVASCULAR SYSTEM
• The contribution of cardiovascular disease to
perioperative mortality in noncardiac surgery is
significant
• In US, about 30% of patients undergoing surgery have
significant coronary artery disease or other cardiac co
morbid condition
• Much of the preoperative risk assessment and patient
preparation centers on cardiovascular disease
41. Cardiac Risk Indices
• Various assessment tools for stratification of the
cardiovascular portion of anesthetic risk have been devised:
Goldman Cardiac Risk Index, 1977
Detsky Modified Multifactorial Index. 1986
Eagle’s Criteria for Cardiac Assess,ent,1989
Revised Cardiac Risk Index
42. Goldman Cardiac Risk Index
• /l
•Third heart sound or jugular venous distension 11
•Recent myocardial infarction 10
•Nonsinus rhythm or premature atrial contraction on ECG 7
•>5 premature ventricular contractions 7
•Age >70 yrs 5
•Emergency operations 4
•Poor general medical condition 3
•Intrathoracic, intraperitioneal or aortic surgery 3
•Important valvular aortic stenosis 3
Cardiac complication rate
0-5 points = 1%
6-12 points = 7%
13-25 points = 14%
>26 points = 78%
43. Revised Cardiac Risk Index
•Ischemic heart disease 1
•Congestive heart failure 1
•Cerebral vascular disease 1
•High risk surgery 1
•Preoperative insulin treatment of diabetes 1
•Preoperative creatinine level >2 mg/dl 1
Each increment in points increases risk for postoperative
myocardial morbidity
44. • A joint committee of ACC and AHA have developed a
stepwise approach to preoperative cardiac assessment for
non cardiac surgery
• This methodology takes into account:
• Previous coronary revascularization
• Clinical risk assessment: major, intermediate, minor
• Functional capacity
45. Need for emergency
noncardiac
surgery
Operating room
Evaluate and treat
per ACC/AHA
Guidelines
Vigilant perioperative
and postoperative
management
Consider
Operating Room
Low Risk
Surgery
Active
cardiac
conditions
No
Yes
Yes
No
Proceed with
planned surgery
Asymptomatic and
good functional
capacity ≥ 4 MET
Yes
Proceed with
planned surgery
No
Yes
Manage based on
clinical risk factors
No
46. Manage based on
clinical risk factors
3 or more clinical
risk factors*
1 or 2 clinical
risk factors*
No clinical
risk factors*
Vascular
Surgery
Intermediate
risk surgery
Vascular
Surgery
Intermediate
risk surgery
Proceed with
planned surgery
Proceed with planned surgery with HR control
or consider non-invasive testing
Consider Testing
*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal
insufficiency, cerebrovascular disease
47. • Surgeon and the consultants
• weigh the benefits vs. risk of the procedure
• whether the perioperative intervention is beneficial
• Perioperative intervention includes:
• Coronary revascularization ( bypass or percutaneous transluminal angioplasty)
• Modification of choice of anesthetic
• Invasive intraoperative monitoring
• Patients having PCI with stenting should defer the elective procedure for 4 – 6 weeks (
or less depending on the type of stent)
• In case of MI, elective surgery should be postponed for 4-6 weeks
• Medical therapy with beta blockers have been recommended as per ACC/AHA
guidelines:
48. AHA/ACC GUDELINES FOR PERIOPERATIVE β BLOCKERS
CLASS RECOMMENDATION
CLASS I β blockers should be continued in patients undergoing surgery who are receiving β blockers for
treatment of condition with ACC class I indication for the drugs
CLASS IIa 1. β blockers titrated to HR and BP are recommended for patients undergoing vascular surgery
who are at high cardiac risk because of CAD or the finding of cardiac ischemia on
preoperative testing
2. β blockers titrated to HR and BP are reasonable for patients in whom preoperative
assessment for vascular surgery identifies high cardiac risk, as defined by presence of more
than one clinical risk factor
3. β blockers titrated to HR and BP are reasonable for patients in whom preoperative
assessment identifies CAD or high cardiac risk, as defined by the presence of more than one
clinical risk factor, who are undergoing intermediate risk surgery
CLASS IIb 1. The usefulness of β blockers is uncertain for the patients who are undergoing intermediate
risk surgery or vascular surgery in whom preop assessment identifies a single clinical risk
factor in the absence of CAD
2. The usefulness of β blockers in uncertain in patients undergoing vascular surgery with no
clinical risk factor who are not currently taking β blockers
CLASS III 1. β blockers should not be given to patients undergoing surgery who have absolute
contraindication to β blockade
2. Routing administration of high dose β blockers in the absence of dose titration is not useful
and may be harmful to patients not currently taking β blockers who are undergoing noncadiac
surgery
49. PULMONARY SYSTEM
• Assessment of pulmonary function should be done in:
• All lung resection cases
• Thoracic procedures requiring single lung ventilation
• Major abdominal and thoracic cases in patients older than 60 years,
having underlying medical disease, smoke or have overt pulmonary
symptomatology
50. • Tests which need to be done include:
• Forced vital capacity in 1 sec.
• Forced vital capacity
• Diffusing capacity of carbon monoxide
• Adults with FEV1 less than 0.8 liter/sec or 30% of
predicted, have high risk for complications and
postoperative pulmonary insufficiency; nonsurgical
solutions sought.
51. RISK GROUP FOR PPC
• General :
• Age > 70years
• Cigarette smoking
• Renal failure
• Poor nutrition
• Asthma related
• Recent asthma attack
• Past h/o endotracheal intubation for asthma management
• Surgery and anaethesia related
• Emergent surgery
• Thoracic, vascular and upper abdominal surgery
• Blood loss > 4 pints of PRBCs (2000ml)
• Anesthesia time >180 minutes
• General anesthesia with endotracheal intubation
52. • Preoperative interventions
1. Smoking cessation ( within 2 months before planned
surgery)
2. Incentive spirometry
3. Encouraging exercise preoperatively. Patient should be
encouraged to walk 3 miles in less than an hour several
times weekly
4. Bronchodilator therapy
5. Antibiotic therapy for pre existing infection
6. Pretreatment of asthmatic patients with steroids
53. RENAL SYSTEM
• About 5% of population has some degree of renal
dysfunction which may affect multiple organ system and
increase perioperative morbidity
• Preoperative creatnine levels of >2mg/dl is an independent
risk factor for cardiac complications
• Goals of preoperative evaluation:
• Identification of coexisting cardiovascular dysfunction
• Identification of circulatory dysfunction
• Identification hematologic dysfunction
• Identification metabolic derangements
54. Assessment of Renal Function
• History:
Congenital abnormality, Obstructive uropathy, PCKD, Recurrent UTI
Presence of underlying systemic disease
Known renal sufficiency
• Physical examination:
Intravascular volume overload ( pulmonary oedema, jugular venous
distension, peripheral odema)
Evidence of coagulopsthy( petechie or ecchymosis)
Lethargy or altered mental status
Pericardial and pleural rub
56. Complication assciated with renal disease
• Fluid and electrolyte homeostasis is altered
Hypertension
Peripheral edema
Salt retention
Electrolyte imbalance( hyponatremia, hyperkalemia, metabolic
acidosis)
• Hematological dysfunction
Anemia
Coagulation defects
Altered platelet adhesion and aggregation
Altered calcium and parathyroid hormone metabolism
57. • Nutritional status:
Proteinuria as high as 25 g/day
Decreased body stores of nitrogen
Decreased dietary intake
• Immune function:
Increased UTIs
Impaired mucosal barriers
Increased pulmonary infections
Impaired phagocytosis
Impaired elimination of certain viruses
58. PREOPERATIVE OPTIMISATION
• Anemia is treated with erythropoietin or darbepoietin
• Manipulation of hyperkalemia
• Replacement of calcium for symptomatic hypocalcaemia
• Use of phosphate binding antacids for hyperphosphatemia
• Correction of metabolic acidosis ( sod bicarbonate is given
i/v if levels fall below 15meq/l
• Hyponatremia is treated by fluid restriction
• Avoid nephrotoxic drugs
59. • Dialysis
• Improves many of the uremic symptoms and abnormality
and electrolyte abnormalities
• Preoperative dialysis should be done 24 hrs before elective
surgery to minimize the effect of iv heparin and allow the
patient to stabilize.
• Correction of coagulopathy by:
• Preoperative adequate dialysis
• Pre and postop FFPs
60. HEPATOBILIARY SYSTEM
• ASSESSMENT OF HEPATIC FUNCTION:
• HISTORY:
Prior h/o jaudice, hepatitis, hemolytic anemia, parasitic
infection, biliary stone disease, pancreattits, enzyme deficiency,
prior malignanacy
h/o drug or alcohol abuse and possible exposure to infectious
agents( tattoos, blood transfusion), environmenmtal or other
hepatotoxins
h/o prior hepatotoxicity after imhaled anaesthesia
63. CHILD-PUGH SCORING SYSTEM
• Stratification of operative risk in patient with cirrhosis
• Class A :- 5-6 points Mortality : 10%
• Class B :- 7-9 points Mortality : 31%
• Class C :- 10-15points Mortality : 76%
Parameter 1 2 3
Encephalopathy None Stage I or II Stage III or IV
Ascitis Absent Slight
( controlled
with diuretics)
Moderate
despite diuretic
treatment
Bilirubin (mg/dl) <2 2-3 >3
Albumin(g/l) >3.5 2.8-3.5 <2.8
INR <1.7 1.7-2.3 >2.3
64. Approach to patient with liver disease
Acute hepatitis
Patient with liver
disease facing
surgery
Obstructive
jaundice
Postpone elective
surgery
Chronic
hepatitis
Surgery safe
1. Perioperative fluid Mx to
prevent renal dysfunction
2. No dopamine or
mannitol
3. Lactulose may be helpful
4. Antibiotic prophylaxis
5. No routine preoperative
biliary drainage
6. Check for abnormal
coagulation parameter
65. Cirrhosis
Child’s A and B: Treat ascitis, coagulopathy
and proceed to surgery
Child’s C: Postpone until the patient’s Child’s
class could be improved or cancel surgery for
conservative Mx
Coagulopathy
Target PT- no more than 2 sec above
normal
1. Vit K- 10 mg SQ
2. FFP if no improvement Vit K
3. Cryoprecipitate as needed
Encephalopathy
1. Treat with lactulose
2. Prevent by treating
ppt. condition like GI
bleed, uremia,
alkalosis
Ascites
1. Fluid restriction
2. Diuretics- furosemide or
spironolactone
3. Paracentesis –
diagnostic/therapeutic with
administration of albumin
66. Endocrine System
• Diabetes mellitus:
• History and examination:
• To assess adequacy of glycemic control
• To access evidence of diabetic complication
• Investigation :
• Fasting and postprandial blood glucose
• HbA1c
• Serum electolytes
• BUN to identify metabolic disturbances and renal involvement
• Serum creatnine
• Urine analysis
• ECG
67. • `Preoperative optimization:
Morning dose of OHA should be omitted
Patient should be started on variable rate intravenous insulin
infusion(VRIII)
VRIII should be adjusted to maintain blood sugars b/w 140-
180 mg/dl
If possible patient should be posted first in the list
If the blood sugars are not controlled the elective surgery
should be deferred till glycemic control is achieved
68. • Hyperthyroidism:
Elective surgery deferred until euthyroid state achieved
Preop ECG and serum electrolytes done
Anithyroid drugs and beta blockers/digoxin continued on the
day of surgery
In case of emergency surgery in thyrotoxic patient at risk of
thyroid storm, a combination of beta blocker and
glucocorticoids used
• Hypothyroidism:
Severe hypothyroidism can cause MI, coagulation defects
and electrolyte imbalance
Elective surgery to be deferred until euthyroid state achieved
69. • Patients with h/o steroid use/ Suppression of HPAA:
Patients who have taken > 5mg of prednisolone or
equivalent for > 3 weeks are at risk when undertgoing major
surgery
Minor procedures: no additional steroid required
Moderate operation: 50-75 mg/day of hydrocotisone (or eq)
for 1 -2 days
Major operation: 100-150 mg/day hydrocortisone (or eq)
for 2-3 days
70. • Pheochromocytoma :
Require preoperative pharmacologic Mx to prevent
intraoperative hypertensive crisis or vascular collapse
A combination of alpha and beta adrenergic blockade started
1-2 weeks before surgery
Liberalisation of sodium in diet
71. Hematologic System
• Hematologic assessment leads to identification of disorders such
as anemia, neutropenia , coagulopathy or hypercoagulable state
• ANAEMIA:
Often asymptomatic but history an examination may reveal
complaints of energy loss, dyspnea , palpitations, or pallor.
Evaluated for lymphadenectmoy, hepatomegaly, splenomegaly, pelvic
and rectal examinations done
CBC, reticulocyte count, serum iron, TIBC, ferritin, Vit B12 and
folate levels obtained for investigation of cause
72. • Healthy individuals with minimal anticipated blood loss
during surgery- 6-7 g/dl
• Cardiac or pulmonary disease- 10g/dl
• In case of elective surgery:
• Correctable cause of anemia- delay surgery
• Uncorrectable cause – blood trasfusion
• Blood transfusion are also required during emergency
surgeries
73. Patients on anticoagulants
•
Require preoperative reversal of anticoagulant effect
• Warfarin should be witheld for 5 scheduled doses
preoperatively to reduce the INR to 1.5 or less
• Patients at risk of thromboembolic event are recommended to
have full bridging while off anticoagulation
• For those on LMWH last dose should be given 20 -24 hours
prior to surgery and restarted approx. 12-24 hours
postoperatively.
74. Indication for
Chronic
Anticoagulation
Patient Characteristics Perioperative
Management
Prosthetic heart
valves
High risk
Recent (<1 mo) stroke or TIA
Any mitral valve
Caged ball or tilting disc aortic valve
Moderate risk- Bileaflet aortic valve with two or more risk
factors for stroke
Low risk- bileaflet aortic valve with fewer than two risk
factors for stoke
Strongly recommend
bridging
Consider bridging
Bridging optional
Chronic atrial
fibrillation
High risk
Recent stroke or TIA
Rheumatic mitral valve disease
Moderate risk- chronic atrial fibrillation with 2 or more risk
factors for stroke
Low risk- chronic atrial fibrillation with < 2 risk factors
Strongly recommend
bridging
Consider bridging
Bridging optional
Venous
thromboembolism
High risk
Recent(< 3 wk) VTE
Active (< 6 mo or palliative) cancer
Antiphospholipid antibody
Major comorbid disease( cardiac/pulmonary)
Moderate risk
VTE in last 6 mo
VTE with interruption of anticoagulant
Low risk- none of above
Strongly recommend
bridging
Consider bridging
Bridging optional
75. Coagulopathy
• Coagulopathy may arise from
• inherited or acquired platelet or factor disorder
• organ dysfunction
• Medications
• Personal and family history of bleeding asked
• H/o easy bruising or petechie
• Risk factors for post-op bleeding- liver disease, mal
absorption, malnutrition, chronic a/b use
76. • Investigation :
• Complete haemogram
• Coagulogram
• Finrinogen leves
• D-dimer
• In Vit K deficiency or mild liver disease- PT is prolonged while
aPPT may be normal
• Severe liver disease- both PT, aPPT tend to prolong
• Haemophilia – aPPT is prolonged but PT is normal
• In DIC all test are abnormal and fibrin split products and d-dimer
are increased
77. • Management:
• In case of severe factor deficiency, 4-6 units of FFP and
cryoprecipitate should be given rapidly
• Conditions associated with low platelet count or abnormal
platelets:--- platelet transfusion
• One unit of platelet concentrate increases platelet count by
5000-10000
78. • In patients on heparin:
• Elective procedure- discontinue heparin 6 hrs before surgery
• Emergency operation- 10 mg of protamine sulphate in 50 ml
of NS iv over 10 min f/b 20 mg in 50 ml NS over 30 min
79. Nutritional assesment
• Malnutrition increases increases risk of
• morbidity, wound infection, sepsis, pneumonia, delayed wound
healing, anasmotic complication.
• Assesment include careful history and examination.
• Usual weight, recent wt loss, loss of muscle bulk, change in
bowel habit.
• IBS,DM,bulmia and anorexia nervosa.
• Nutritional risk assesement (15.19x sr albumin g/dl+41.7x
present wt/usaual weight.
• NRI < 83% indicates increased mortality.