assessment a risks and fitness for surgery and investigation done for patient preoperatively to assess

1. Presented by
Dr. Ayman Abdelaziz Arafa MD. MSc. FRCS(Glasgow)
Ass. Prof. general and laparoscopic surgery
AinShams university
Consultant general surgery king Abdulaziz specialist hospital

2. overview
 Preoperative preparation of the patient is extremely
important. This is the time when the patient can be
properly prepared physically and emotionally for a
planned procedure.
 Proper preparation of the patient scheduled to
undergo a surgical procedure can optimize patient
care, comfort, and satisfaction.
 During this time, any factors that may affect the risk of
anaesthesia or the proposed procedure can be
identified, minimizing surgical delays, preventable
cancellations, morbidity, and mortality.

3. Goals
 Proper planning, assessment, and evaluation of a
patient preparing to undergo surgery are very important to
assure the best outcome.
 During this process, the patient's medical condition and
overall health can be evaluated and risk factors identified.
 Involve other specialities for consultation, including the
anaesthesia team. Laboratory and other diagnostic testing
may be needed in advance of the procedure to assist with
the evaluation process.
 This will also provide an opportunity to present patient
education, address patient concerns, and establish a
trusting relationship between the patient and primary
care provider.

4. Preoperative evaluation should
include:
 History.
 Physical examination.
 Appropriate laboratory tests .
 Diagnostic procedures.
 An assessment of surgical and anaesthetic risks. Consultations may be
required, depending upon coexisting conditions and/or diseases.
Without appropriate preoperative planning, patients may arrive on the day of
surgery without
 receiving or understanding preoperative preparation instructions.
 Appropriate testing may not have been done.
 Patients may go through the preadmission period without appropriate
intervention until they are assessed by an anaesthesia provider the day of the
 procedure, leading to a delay or cancellation of surgery. This can cause undue
stress to the patient and their family, as well as increase costs for both the
patient and the hospital.

5. A complete history and physical
examination:
TIMING:
 Healthy patients :can be seen up to the day of surgery.
 for patients who have significant medical conditions:
should be obtained at least 1 week before the scheduled
surgery.
AIM: This will allow time for the patient to be optimally
prepared for the procedure both physically and
emotionally. Information gathered at this time will
determine if further diagnostic testing and specialty
consultation are needed.

6.  Past medical and surgical records can also be invaluable to
those involved in the patient's care.
 patient or family history of anesthesia problems such as
malignant hyperthermia.
 When obtaining a medical history, a checklist may be filled
out by the patient. It may be necessary to go over each item
 with the patient. Sometimes the patient may not
understand what is being asked, and information may be
omitted. Fore xample, some patients view having had a
caesarean section as "childbirth" and not surgery.

7. Medication History
 A detailed medication and drug history is also very
important. Many patients are taking numerous over
the counter drugs and herbal or nutritional products
that can affect the surgery and response to anesthesia.
 Many people believe that herbal and nutritional
remedies are harmless because they are "natural" and
usually do not mention them unless specifically asked.

8. Herbal Supplements and Potential
Clinical Effects
 Garlic : Inhibited platelet aggregation, enhanced
fibrinolytic activity
 Ginger : Inhibits thromboxane synthetase; bleeding.
 Gingko :Vasodilation of cerebral and peripheral
arteries (increase in cerebral blood flow, resulting in
an increase in intracranial pressure)Platelet activating
factor is inhibited; increase in bleeding time.
 Ginseng : Hypertension, CNS stimulation, possible ↑
in anesthetic requirement.
 Chamomile :Anticoagulation

9. Patient is on medication that may
need to be modified due to surgery
•
 Intake of chronic medications: for diabetes and
hypertension
 Oral anticoagulant
 Hormonal replacement therapy
 Thyroxine
 Estrogen
 Oral contraceptives
 Corticosteroids
 Aspirin
 NSAIDS

10. Medication:
 a) If patient takes prescribed medication every morning, do so on the morning
of the procedure with just a sip of water.
 b) If patients are a diabetic on insulin, take ½ of your morning dose on the
morning of the procedure.
 c) For an ache or pain you may use Tylenol as it contains no aspirin.
 d) IMPORTANT: patient is not allowed to take any non-steroidal anti
 inflammatory medications starting 7 days prior to the procedure. This
 includes but is not limited to: Celebrex, Ibuprofen
 IMPORTANT: Please check if the patient takes any blood thinners including
 but not limited to:i) Coumadin (Warfarin), Pradaxa, or Effient, Plavix.
Persantine (Dipyridamole) , Bufferin, Anacin, Excedrin, Alka-Seltzer
 F)Discontinue Redux or any kind of diet pills.

11. The extent of a preoperative
evaluation will depend upon :
 the patient's medical condition.
 the proposed surgical procedure .(Grading of surgery)
 and the type of anesthesia:
 LOCAL
 REGIONAL
 GENERAL

13.  Guidelines for Perioperative Steroid Replacement
 Therapy
 5.1. Introduction
 Patients on steroids presenting for surgery may have impaired stress
 response due to prolonged suppression of hypothalamic-pituitaryadrenal
 axis, irrespective of route of administration. Underlying
 disease process in combination with this suppression may lead to
 significant morbidity or mortality in the peri-operative period,
 especially in patients who are on high dose steroids (>10mg of
 prednisolone or equivalent). Therefore continuation of the same
 dose or additional supplementation is indicated depending on the
 duration of steroid therapy and degree of surgical trauma. According
 to recent research large doses of steroids are not necessary for
 replacement in most of the cases.
 5.2 Replacement of steroids in the peri-operative period
 5.2.1 Patients not on steroids at present
 􀂾 Discontinued within three months
 If steroid therapy has been discontinued within three months prior
 to surgery treat as if on steroids.
 􀂾 Discontinued more than three months ago
 No replacement necessary in the peri-operative period.
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14. Patients currently on regular
steroid therapy
 Prednisolone 5 mg is equivalent to :
 Hydrocortisone 20mg, Methylprednisolone 4 mg, Betamethasone 750 mcg , Dexamethasone 750 mcg
 Cortisone 25 mg,Prednisone 5 mg
 Triamcinolone 4 mg
 <10mg prednisolone per day
 Normal hypothalamic-pituitary axis
 No additional steroid cover required
 >10mg prednisolone per day
 Minor surgery (i.e. herniotomy )
 Routine preoperative steroid dose or hydrocortisone 25mg iv at induction
 Intermediate surgery (i.e. Abdominal hysterectomy)
 Routine preoperative steroid dose plus hydrocortisone 25mg iv at induction Postoperative
hydrocortisone 25 mg 6 hourly for 24 hours
 Major surgery (cardiac )
 Routine preoperative steroid dose plus hydrocortisone 25mg iv at induction
 Postoperative hydrocortisone 25 mg 6 hourly for 48-72 hrs
 High dose Steroid immunosuppression:
 Continue usual immunosuppressive dose until able to revert to normal oral intake
 E.g. Prednisolone 60mg/24h=hydrocortisone240mg/24h

15. Grading of Surgery
 Grade 1(minor): Excision of skin lesions, Incision & drainage of
skin abscesses
 Grade 2(intermediate) :Repair of inguinal hernia; stripping of
varicose veins; adeno- tonsillectomy; arthroscopies
 Grade 3(major) :Thyroidectomy; Total abdominal
hysterectomy; lumbar discectomy; endoscopic resection of
prostate
 Grade 4(major +) :Total joint replacement; lung surgery;
colonic resection; radical neck resection

16. Conditions for Which Preoperative Evaluations
Strongly Recommended Prior to the Day of Surgery.
 Medical conditions :
 Inhibiting ability to engage in normal daily activity.
 Necessitating continual assistance or monitoring at home
within the past 6 months.
 Necessitating Admission within the past 2 months for acute or
exacerbation of chronic condition.

17. Physical Classification of the American Society of
Anesthesiologists (ASA)Status Disease State
 ASA Class 1:
(normal)
No organic, physiologic, biochemical, or psychiatric disturbance.
 ASA Class 2 :
Mild to moderate systemic disturbance that may or may not be related
to the reason for surgery Examples: Heart disease that only slightly
limits physical activity, essential hypertension, diabetes mellitus,
anemia, extremes of age, morbid obesity, chronic bronchitis.
 ASA Class 3 :
Severe systemic disturbance that may or may not be related to the
reason for surgery, (does limit activity)Examples: Heart disease that
limits activity, poorly controlled essential hypertension, diabetes
mellitus with vascular complications, chronic pulmonary disease that
limits activity, angina pectoris, history of prior myocardial infarction.

18. ASA Class 4
Severe systemic disturbance that is life-threatening with or
without surgery Examples: Congestive heart failure, persistent
angina pectoris, advanced pulmonary, renal, or hepatic
dysfunction.
ASA Class 5:
Moribund patient who has little chance of survival but is
submitted to surgery as a last resort (resuscitative
effort)Examples: Uncontrolled hemorrhage as from a ruptured
abdominal aneurysm, cerebral trauma, pulmonary embolus.
Emergency Operation (E)Any patient in whom an emergency
operation is required Example: An otherwise healthy 30-year-
old woman who requires a dilation and curettage for moderate
but persistent hemorrhage (ASA Class 1 E).

19. Cardiovascular system:
 •History of angina, coronary artery disease, myocardial
infarction
 •Symptomatic arrhythmias
 • Poorly controlled hypertension (diastolic >110,
systolic >160)
 •History of congestive heart failure.

20. Respiratory system:
 •Asthma/COPD requiring chronic medication or with
acute exacerbation and progression within past 6
months
 •History of major and/or lower airway tumor or
obstruction
 •History of chronic respiratory distress requiring home
ventilator assistance or monitoring.

21. Endocrine :
 • Non-diet controlled diabetes (insulin or oral
hypoglycemic agents)
 •Adrenal disorders
 •Active thyroid disease.

22. Neuromuscular:
 • History of seizure disorder or other significant CNS
disease (e.g., multiple sclerosis)
 •History of myopathy or other muscle disorders.

23. Hepatic:
 •Any active hepatobiliary disease or compromise.

24. Musculoskeletal:
 •Kyphosis and/or scoliosis causing functional
compromise
 •Temporomandibular joint disorder
 •Cervical or thoracic spine injury.

25. Gastrointestinal:
 • Morbid obesity(super obese) (>140% ideal body
weight)
 •Hiatal hernia
 • Symptomatic gastroesophageal reflux.

26. Oncology
•
 Patients receiving chemotherapy or radiotherapy .
 Other oncology process with significant physiologic
residual or compromise.

27. Haematological disease:
 Group and save.
 Crossmatch .
 Indications of blood transfusion:
 Trigger Hb 7gm/dl
 Hb 8gm/dl sufficient in elderly and cardiac disease
unless symptomatic.
 If Hb >=10 gm/dl No transfusion.

28. Anaemia:
 Blood loss : acute or chronic eg excessive menses
 Decrease production:1- deficiency (iron ,vitb12,folate)
• 2-chronic disease
• 3-endocrine: hypothyroidism.
• 4-bone marrow infiltration(leuckemia,myelofibrosis),aplastic anaemia.
• 5-decreased erythropoietin production: renal failure
 Haemolysis(breakdown):
 Inherited :-Sickle cell disease.
• Spherocytosis
• Thalassemia.
• G6PD defficiency.

29. Acquired haemolysis:
Non immune :sepsis
valve prothesis
liver disease
renal disease
Microangiopathic anaemia.
Autoimmune:
Isoimmune:Rh and ABO incompatbility

30. coagulation disorders:
 prolonged PT ,PTT.
 THROMBOCYTOPENIA
