describes all the parameters of the preoperative optimization of the patients in the surgeons point of view

1. PREOPERATIVE
PREPARATION
BY
DR NIKHIL AMEERCHETTY
MS general surgery RESIDENT
E- MAIL : nikhilameerchetty@gmail.com

2. AIMS AND OBJECTIVES
Gather and record all the information
Optimise the patient condition
Choice of surgery
Prepare for the adverse effects
Inform the concerned

3. History taking
Open
questions
Closed
questions
Focussed
questions
Fixed
questions

5. EXAMINATION
General
Surgery related
Systemic
Specific

7. INVESTIGATIONS
Minor and intermediate
procedures require no
investigations unless the
patient is having
comorbidities
• MAJOR OPERATIONS
• Full blood count
• Urea and electrolytes
• Electrocardiography
• Clotting screen
• Chest radiography
• Urinalysis
• Beta-Human chorionic gonadotrophin
• Blood glucose and HbA1c
• ABG,LFT OTHERS

8. SPECIFIC PREOPERATIVE PROBLEMS,
REFERRALS AND MANAGEMENT
CAPACITY
Base line organ
function
OPTIMISATION
Medication
,lifestyle ,refferal
ALTERNATIVE
Minimally impacting
procedures
THEATRE
PREPARATIONS
Timing and
teamwork.

10. CARDIOVASCULAR DISEASE
• Flight Of Stairs
• Myocardial Infarction (MI),IHD,VHD : Postpone Surgery For 4-6weeks.
• Stents : Patients On Asprin And Clopidogrel , Surgery After 6weeks Of Stoppage
• For Cases Of Low Risk Bleeding And Surgery Cannot Be Postponed Can Go Ahead
With Surgery .
• For High Risk and surgery cannot be postponed Stop Clopidogrel And Continue Asprin .
• Percutaneous Coronary Intervention With Stenting postpone surgery For 4 To 6
Weeks.
• B blocker

11. • Warfarin for atrial fibrillation stopped 5 days preoperatively
(INR <1.5)
• warfarin for a case of mechanical heart valves stop 5 days
prior when INR <1.5 start unfractionated heparin .
• Blood pressure to be kept below160/90mmhg .

15. WHEN TO REFER
1. A Murmur Is Heard And The Patient Is Symptomatic.
2. Poor Left Ventricular Function Or Cardiomegaly.
3. Ischaemic Changes Can Be Seen On Ecg Even If Patient Is Not
Symptomatic (Silent Mi).
4. Abnormal Rhythm On The Ecg, Tachy/Bradycardia Or A Heart Block
That May Lead To Cardiovascular Compromise
5. Decreasing The Adrenergic
6. Surge Associated With Surgery And Halting Platelet Activation And
7. Microvascular Thrombosis.

16. RESPIRATORY DISEASE
• Current Respiratory Status Should Be Compared With Their ‘Normal State’
• Steroid Use : If > 10 Mg Of Prednisolone And Undergoing High-risk
Surgery Will Need Perioperative Steroid Supplements.
• COPD : Fev1 <80%
• Infections : Postpone 4-6 Weeks

17. OPTIMIZATION
• Smoking Cessation (Within 2months Before The Planned Procedure)
• Antibiotic Therapy For Preexisting Infection
• Pretreatment Of Asthmatic Patients With Steroids and bronchodilators can be used till
the induction time .
• Exercise (3 Miles In Less Than 1 Hour Several Times Weekly).

18. REFFERAL
• There is a severe disease or significant deterioration from
usual condition.
• Major surgery is planned in a patient with significant
respiratory comorbidities.
• Right heart failure is present: dyspnoea, fatigue, tricuspid
regurgitation, hepatomegaly and oedema of the feet.
• The patient is young with COPD (indicates a rare and
lifethreatening condition).

19. GASTROINTESTINAL DISEASE
• NPO For Solid Food 6hrs , Water 2 Hrs
• In Infants Clear Drink 2hrs , Breast Feed Upto 3 Hrs ,Formula Feeds 6hrs
• Intravenous Fluids In Cases Children, Elderly And Diabetics If Surgery Is
Delayed .
• The Presence Of Ascitis, Oesophageal Varices, Hypoalbuminaemia,

20. •HEPATOBILIARY SYSTEM

21. PREPARATION OF JAUNDICE PATIENT
• Admit at least 72 hours before surgery for preparation
• Use of lactulose and bowel preparation reduce risk of hepatic encepalopahty
• Prophylactic antibiotics necessary because stagnant bile is a good culture
medium
• Adequate hydration ( four liters daily to prevent hepatorenal syndrome and
reduce risk of hepatic encephalopathy from dehydration )
• Intravenous fluid should be normal saline alterating with 5 or 10% dextrose
, avoid ringers lactate.

22. •High calorie because risk of hypoglycemia by taking
glucose drinks
•High protein diet
•Correct anemia by transfusion with packed cells
•Correct coagulopathy with intravenous vitamin K, fresh
frozen plasma , fresh whole blood )
•Other Vitamin supplements : vitamin B Co, vitamin C

24. CHILD-PUGH SCORING SYSTEM

25. GENITOURINARY DISEASE
• GOAL
• Identification of coexisting cardiovascular, circulatory, hematologic, and metabolic
derangements
• creatinine level of 2.0 mg/dL or higher is an independent risk factor for cardiac
complications.
• Anemia, treated with erythropoietin or darbepoietin

26. • DIABETES MELLITUS,
• HYPERTENSION
• ISCHAEMIC HEART DISEASE,
• ACIDOSIS
• HYPOCALCAEMIA
• HYPERKALAEMIA
• UTI

27. ESRD
• Replacement Of Calcium For Symptomatic Hypocalcaemia,
• Phosphate-binding Antacids For Hyperphosphatemia
• Sodium Bicarbonate Below 15 Meq/Liter. It Can Be Administered In
Intravenous (IV) fluid As One To Two Ampules In One Liter Of 5%
Dextrose Solution.
• Hyponatremia Is Treated By Volume Restriction

28. ENDOCRINE AND METABOLIC DISORDERS
DIABETES MELLITUS
• AIM:
• Optimize Blood sugar control prior to surgery
• MONITORING:
• Check Blood Glucose every 4 hours prior to surgery
• Perioperative Blood Sugar Monitoring frequency per anesthesia
protocol
• Prefer perioperative mild Hyperglycemia to Hypoglycemia

30. • Insulin
• Long acting Insulin (Lantus, Levemir)
• Take full Lantus dose the night before the procedure
• Take 80% of the usual morning dose on the day of the procedure
• Intermediate Insulin (NPH Insulin)
• Take full NPH dose the night before the procedure
• Take 66% of the usual morning dose on the day of the procedure
• Mixed-Insulin (e.g. Insulin 70/30)
• Do not take mixed Insulin on the morning of surgery
• Give NPH at 66% of the usual morning dose (NPH component only of the mixed Insulin) on the day of the procedure
• Insulin Pump
• Insulin Pumps should only deliver basal rate (not bolus)
• Consider Running at 50% of the rate
• Short-Acting, Rapid-acting or bolus Insulin (e.g. Lispro, Regular, Aspart, Glulisine)
• Do not take bolus Insulin (short-acting Insulin) on the morning of the procedure

31. ORAL HYPOGLYCEMIC DRUGS
1.Hold long-acting Sulfonylureas 2-3 days before
surgery
2.Hold short-acting Sulfonylureas on the night
before surgery
3.Hold Metformin on day before surgery (risk
of Lactic Acidosis)
4.Thiazolidinediones may be continued

32. • For a case of hyperthyroidism postpone the surgery till
euthyroid state is achieved
• Patient of hyperthyroidism under medication can continue till
the day of surgery
• Hypothyroidism usually does not require correction but
severe case need to be optimised
• Hypothyroidism increase the sensitivity of the other
medications
• Pheochromocytoma is controlled by alpha and beta
blockade

33. COAGULATION DISORDERS
• The Progesterone-only Pill Can Be Continued.
• Combined Pill ( Risk Of Significant Thrombosis)
• Hormone Replacement Therapy (HRT) Should
Be Stopped 6 Weeks Prior To Surgery.

34. • Warfarin
• Hold for 5 doses and maintain INR <1.5
• For high risk cases replace with LMWH and hold upto 24hrs
before surgery
• For intravenous heparin hold before 6hrs of start of operation
• Postponed for 4 weeks after an episode of venous or arterial
thromboembolism.

36. GUIDELINES FOR BLOOD TRANSFUSION

37. NEUROLOGICAL AND PSYCHIATRIC
DISORDERS
• Anticonvulsant and antiparkinson medication is
continued perioperatively to help early
mobilisation of the patient.
• Lithium should be stopped 24 hours prior to
surgery .

38. RISK FACTORS

40. RISK ASSESSMENT AND CONSENT

41. Guidelines for patients undergoing
surgery as part of an Enhanced
Recovery Programme (ERP)
PRINCIPLES
Clear communication: a full range
of information and explanation
Fully structured and well organised
sequence of clinical care.

42. Six key steps
■ Referral from primary care: involvement of the GP.
■ Pre-operative care by the hospital team.
■ Admission to hospital.
■ Care during the operation by the surgeon and the anaesthetist.
■ Post-operative care in the hospital.
■ Follow-up – rehabilitation and going home.

43. NEW ELEMENTS OF CARE IN ERP
1. Nutrition: A key part of enhanced recovery is keeping you well fed. carbohydrate nutritious
drinks to be drunk before you arrive at the hospital.
2. Drinks : safe to drink water until just two hours before your operation.
3. Preparation of the bowel if undergoing colo-rectal surgery: traditional
methods of flushing out the bowel before operations on the bowel are not always necessary.
4. Discharge planning

44. THANK YOU
….