PREOPERATIVE PROCEDURES AND CARE OF PATIENTS

1. PREOPERATIVE
PROCEDURES AND CARE

2. INTRODUCTION
• Preoperative care is the care given before surgery when physical and
psychological preparations are made for the operation, according to
the individual needs of the patient. The preoperative period runs from
the time the patient is admitted to the hospital or surgery center to the
time that the surgery begins.
• This is to optimise postoperative outcomes.

3. HISTORY TAKING
• At the start of each consultation the surgeon should introduce him/herself to
the patient, explaining who he/she is. Patient details should be confirmed.
• Do not assume that the history has already been adequately covered
previously. Important points may have been overlooked in a busy out-
patient clinic. In addition, there may have been a substantial delay between
the clinic appointment and the admission for surgery, during which time
symptoms and signs may have changed considerably.

4. PRINCIPLE OF HISTORY-TAKING
• Listen: what does the patient see as the problem? (Open questions)
• Clarify: what does the patient expect? (Closed questions)
• Narrow the differential diagnosis. (Focused questions)
• Fitness: what other comorbidities exist? (Fixed questions)

5. LAYOUT OF A STANDARD HISTORY
• Presenting Complain; This summarizes the immediate problem(s) that the patient
wants to resolve.
• History of the Presenting Complaint; This section should describe the time course
and severity of the patient’s symptoms. Some assessment of the extent to which
the problem is interfering with the patient’s life should be made.
• Past Medical History; There will frequently be many negative responses in this
section but any positive findings need to be recorded in some detail including
dates, causes, treatment and subsequent control of symptoms. These should
include history of previous surgeries, infectious diseases, systemic disorders.
• Drug History; This includes the alternative therapies such as herbal remedies
already taken by the patient and previous clinic visited. Ask about any Allergic
reactions.
• Social History; This should include a smoking and alcohol history as well as the
patient’s occupation and social circumstances.

6. PREOPERATIVE
EXAMINATION

7. • A pre-operative physical examination is generally performed
upon the request of a surgeon to ensure that a patient is
healthy enough to safely undergo anesthesia and surgery.
• This evaluation usually includes a physical examination,
cardiac evaluation, lung function assessment, and appropriate
laboratory tests.

8. In the pre-operative examination, two distinct examinations are
performed;
• The general examination (to identify any underlying undiagnosed
pathology present): Perform a full general examination, looking
closely for any obvious cardiovascular (in particular undiagnosed
murmurs or signs of heart failure), respiratory, or abdominal signs.
• The airway examination (to predict the difficulty of airway
management e.g. intubation).
If appropriate, the area relevant to the operation can also be examined.
An anaesthetic examination, including an airway
assessment (typically using the Mallampati score), will also be
performed by the anaesthetist prior to any surgery

9. General Examination
Examinations to be done include:
• Vital signs
• Mental attitude of patient
• Fluffiness of hair
• Pallor
• Jaundice
• Cyanosis
• Parotid fullness
• Pharyngitis
• Finger clubbing
• Peripheral limb oedema
• Sacral oedema
• Hydration

10. Airway Examination
• The assessment of the patient’s airway is an integral part of
the preoperative evaluation. It’s purpose is to predict
potential problems, allowing a management plan to be
developed ahead of time and avoid an unanticipated difficult
airway.
• Basically, the aim is to predict and therefore avoid potential
problems in two areas:
1. Laryngoscopy and intubation
2. Ventilation, i.e oxygenation

11. Airway Examination
• The following factors are expected to be taken into consideration
1. Dental Status
2. Mallampati score
3. Mouth opening/inter-incisor gap (IIG)
4. Thyromental distance
5. TMJ mobility
6. Neck mobility
7. Other patient features

12. Thyromental distance (TMD)
• Thyromental distance is the distance from mental prominence (most
anterior part of the bony chin) to the tip of the thyroid
cartilage (thyroid notch or 'Adam's apple') during maximum head
extension with the mouth
• Thyromental distance (TMD) is supposed to be a measure of the ease
of tongue displacement with a 'standard' laryngoscope (not
videolaryngoscope) blade during intubation. The bigger the TMD the
larger the mandibular or submandibular space into which the
tongue is pushed with the laryngoscope

13. Mouth opening/inter-incisor gap (IIG)
• The interincisior gap (IIG) is the distance in cm between the
patient's upper and lower incisiors with maximal mouth
opening.
• Similarly to the measurement of thyromental distance (TMD)
(see below), measurement of IIG is usually done by finger
breadths in clinical practice rather than a tape measure.
• IIGs of >5cm for intubation and >4cm for insertion of a
supraglottic airway have been suggested to have a fairly
high predicitve value for success.

14. • An IIG of less than 3.5cm is below a range that is considered 'normal'.
A significantly reduced IIG of less than 2.5cm will make insertion of a
LMA Unique impossible. Below 1.5cm (one finger breadth in a
majority of people) insertion of a (video)laryngoscope blade will be
impossible.
• Mouth opening/ IIG can be reduced for mechanical or
functional reasons. A functional impariment of mouth opening (e.g.
due to TMJ pain/ discomfort) may improve with general anesthesia
and muscle relaxation.

15. Mallampati Score
• This is assessed by asking the patient (in a sitting or upright position) to open his/ her mouth
and protrude the tongue maximally without phonation, with the observer being at eye level
with the patient. Visibility of faucial pillars, soft palate and uvula inside the patient's mouth will
result in a score between one and three.
• The Mallampati test gives and idea of the relationship between tongue size and mobility and
size of the oral cavity. This relationship is important because it somewhat predicts how easily the
tongue can be displaced by a laryngoscope blade during intubation.

16. Other patient features
• There are a number of anatomical features of the patients face and neck that can be visually assessed if
not easily measured and predict difficult mask ventilation and/ or laryngoscopy. Since measurements
and classifications are lacking, quantifying these features and assigning predicitve value to them is
difficult. Noticing them in a patient and expecting challenges in airway management based in their
presence comes down to clinical experience. These include:
Facial hair/ beard
• Facial hair can be problematic for two reasons:
• It can make bag-mask ventilation more challenging since it is more difficult to achieve a seal between
mask and facial hair that between mask and skin
• A large beard can obscure facial features that are predicitive of difficult mask ventilation and/ or
intubation such as a receding chin or a 'small' mouth opening
High-arched palate
• A high-arched palate can impair the laryngoscopy view. It is associated with an above normal
overbite and relatively reduced mandibular protrusion (the patient might be able to protrude the
mandible to the normal extent, but because of the overbite, might still not be able to score high for
jaw protrusion or on the upper lip bite test).

17. Preoperative Investigations
Preoperative investigations are routine test carried out before the the surgery. It is
an assessment of the general state of the patients and to rule out variables that
might affect the surgery.
The most common test carried out include:
(1)E/u/Cr: This is the Electrolyte,Urea and Creatinine test. It is to assess the
baseline renal function which help to determine fluid management and drug
decision for anesthesia and post surgery analgesic.

18. (2) Full Blood Count: This assess the total number of red blood cells,platelets and white
blood cell,packed cell volume,Hb etc. It reveals the presence of anemia,throbocytopenia,
infection and the coagulative ability.
(3) Urinalysis: This is an assessment of the component of the urine. It is used to assess
the kidney and bladder function and also the presence of drugs in the body.
(4) Fasting Blood Glucose:it is ised to determine the glucose content of the blood to
determine whether the patient is hyperglycemic or hypoglycemic.
(5) Electrocardiogram: Its is the measure of the electrical activity of the heart. ECG is
done to determine the functional state of the heart. Echocardiography can also be done.

19. • (6)Liver Function Tests (LFTs): Important in the assessing liver
metabolism and synthesising function, useful for peri-operative
management; if there is suspicion of liver impairment, LFTs may help
direct medication choice and dosing

20. PREPARATION FOR THE THEATRE
1. Consent form
There should be informed consent for anesthesia and operation and disabilities from the
procedure should be pointed out e.g sterility after prostatectomy.
2. The bowel and bladder should be empty so the patient does ni soil himself/herself during
the procedure or during recovery.
3. Stomach should be empty
In GI operations, a nasogastric tube is inserted to decompress the stomach and minimize or
prevent vomiting
During labour, solids should not be taken. Semi-solid or clear foods are indicated.

21. PREPARATION FOR THE THEATRE contd

22. NIDDM patients are managed in that way till the day of surgery
IDDM and NIDDM patients are stabilized on soluble insulin
preoperatively using a sliding scale.
Alberti regime:-
500ml of 10% glucose
10 units of soluble insulin
10 mmol of KCl
To run at a rate of 100 ml/hour
Ideal glucose should be between 4-10 and potassium 3.5-4.5mmol/L

23. Intravenous fluid are divided into two:-
Colloids:- not widely used
Crystalloids:- dextrose, normal saline, hartmann solution

24. PERI-OPERATIVE CARE
• Anaesthetic agents are potent and may produce emergencies during
anaesthesia. All inhalational and intravenous agents have some effect
on the cardiovascular and respiratory systems and most of the
complications of anaesthesia are referable to these two systems.
• Per-operative care of the patient entails the following:
l. Checking of equipment.
2. Correct positioning of the patient.
3. Monitoring.

25. PERI-OPERATIVE PROBLEMS
• Hypotension
• This is most likely to occur at induction in patients who are in
hypovolaemic states. Whilst conscious, an intact vasomotor centre
(VMC) may ensure adequate vasoconsrriction. The ability is lost with
the depression of the VMC by the anaesthetic agent. The generalized
vasodilatation which follows may so reduce the venous rerum as to
cause cardiac arrest in some patients.
• Blood loss is the commonest cause of hypotension

26. CARDIAC ARREST
• A sudden, unexpected loss of heart function, breathing and
consciousness . Causes of cardiac arrest in the peri-operative period
are:-
• i) Stimulation of the viscerocardiac reflex.
• ii) Tissue hypoxia from:-
• (a) Decreased blood volume from massive blood loss.
• (b) Decreased circulating oxygen from moderate blood loss in a previously
anaemic patient.
• (c) Respiratory causes-low oxygen tension; asphyxia

27. HYPOXIA
• Causes include
• i) Reduced oxygen in inspired air. This is preventable. There should be
regular and frequent checks of the oxygen cylinders and flow meters
in case the oxygen has been switched off accidentally or the cylinder is
empty. An oxygen analyzer in the supply line would prevent this
happening.

28. CONCLUSION
• It is no doubt that for surgeries of any kind to go on well with little
post op problems, the surgeon and his team must engage in a proper
pre-operative as well as peri-operative procedures.
• This will not only minimise the rate of post-op infection but as
improve and increase the survival rate of patients.
• Hence, pre and peri operative procedures and care is a MUST for
surgeons

29. •THANK YOU FOR
LISTENING