The document discusses the importance of preoperative assessment and preparation of patients prior to surgery. Key aspects of assessment include taking a thorough medical history, conducting a physical examination, evaluating nutritional status, ordering relevant investigations, and determining surgical risk. Important elements of preparation are obtaining informed consent, preventing cardiovascular and respiratory complications, reducing risk of aspiration, preparing the bowels if needed, and ensuring adequate sleep, skin preparation, catheterization and pre-medication when applicable. The goals are to identify risk factors, optimize the patient's health status, and reduce postoperative complications.

1. Dr. Mahmoud E Khalifa Assistant prof Oral &Maxillofacial Surgery

2. Introduction To achieve an acceptably high standard of clinical practice, it is essential that all surgeons including dentists and oral surgeons - have a background knowledge of surgery in general.

3. Such a knowledge of 'surgery in general' is essential for dental/oral surgeons to ensure that they will be able to: • recognise disease by detecting key abnormalities in the patient assessment • recognise important disorders that might impinge on their practice • assess and balance the needs for treatment against the risks of avoiding therapy in the patient with coincidental illness • identify illness that needs to be treated • refer patients with specific problems to appropriate specialists • avoid operating on patients who have specific or relative contraindications to surgery • understand the need to have the patient in optimal condition before surgery and how to achieve this

4. treat and manage basic problems that might arise in the course of patient care afford a good level of patient care pre- and postoperatively understand the basic principles of surgical techniques be aware of potential problems, especially life threatening complications, which may arise in the course of surgery and how to manage these understand the role of specialist colleagues in all aspects of patient care.

5. Diagnosis Medication Physician Patient Surgical referral

6. Surgical operation Preoperative phase Assessment preparation Intraoperative phase Anaesthesia Surgery Postoperative phase Postoperative care follow up

7. This session will discus the importance of assessment & preparation of patient prior to surgery to identify risk factor for adverse events initiate appropriate prophylactic treatment

8. Approaches to preoperative evaluation differ significantly, depending on the 1.Nature of the complaint 2. The proposed surgical intervention 3. Patient age & health 4. Assessment of risk factors 5.The results of directed investigation 6. Interventions to optimize the patient's overall status 7. Readiness for surgery

9. Determining the Need for Surgery confirmation of relevant physical findings and review of the clinical history and laboratory and investigative tests that support the diagnosis .

10. Preoperative Decision Making Once the decision has been made to proceed with operative management, a number of considerations must be addressed regarding the 1. Timing and site of surgery 2. The type of anesthesia 3. The preoperative preparation necessary to understand the patient's risk and optimize the outcome

11. Preoperative Evaluation The aim is to identify and quantify any comorbidity that may have an impact on the operative outcome. To uncover problem areas that may require further investigation to perform the preoperative optimization .

12. The preoperative evaluation is determined in light of the 1.planned procedure (low, medium, or high risk), 2. planned anesthetic technique, 3. the postoperative disposition of the patient (outpatient or inpatient, ward bed, or intensive care). 4. to identify patient risk factors for postoperative morbidity and mortality

13. consultation with an internist or medical subspecialist may be required to facilitate the workup and direct management. In this process, communication between the surgeon and consultants is essential to define realistic goals for this optimization process and to expedite surgical management

14. I - Preoperative evaluation To assess the fitness of the individual for anesthesia and surgery. A well‐conducted history and physical examination answer several important questions:

15. Is this a healthy patient? What is the indication for surgery? Is the surgical procedure low risk, intermediate risk, or high risk? What is the functional status of the patient? What is the effect of the present condition on the patient? What improvement is expected after surgery?

16. Answers to these questions should then direct preoperative testing and management 1.The tests selected should therefore evaluate existing illness, screen for conditions that could affect outcomes in the preoperative period, and help to determine preoperative risks. Existing illnesses that need evaluation and possible treatment include hypertension, diabetes mellitus, cardiac, vascular, pulmonary, renal, and hepatic diseases. The pregnant patient, the geriatric patient, the patient with oncologic disease, malnutrition ,or coagulation disorders also needs directed evaluations

17. The initial preoperative evaluation of a patient should be supplemented by a complete assessment of the patient’s general health. This involves a thorough history physical examination. Nutritional assessment Investigations Surgical risk assessment

18. 1.History The history should include information regarding any known medical problems and ongoing treatment, previous surgical procedures, and problems if any during previous anesthesia. These can include difficult intubation, bleeding tendencies, and anesthetic jaundice. • Family history. Drugs allergies

19. • Medications such as digitalis, insulin, and corticosteroids should be maintained and their doses carefully regulated in the preoperative period. • If the patient is on corticosteroids or if it has been discontinued within a month of surgery, he or she may have a hypofunctioning adrenal cortex resulting in impaired physiologic response to surgical stress

20. 2.Physical examination A comprehensive physical examination to identify co-morbid conditions should be performed Preoperative Considerations by Organ Systems: cardiovascular ,pulmonary ,gastrointestinal, nervous system, renal and endocrine troubles .

21. 3.Nutritional assessment Poor nutrition causes poor wound healing, leading to Wound dehiscence Infection Weakness Loss of functional independence Assess fluid status along with the nutritional status

22. Estimate serum albumin level (> 6mg/dl normal) Consider parenteral nutritional supplementation.( very young & very old) TPN is useful in gastric outlet obstruction, malnutrition

23. 4.Investigations 1.Complete blood counts 2.Blood urea and electrolytes 3.An electrocardiogram (ECG) is indicated over 40 years, . 4.Posteroanterior and lateral chest x‐rays 5. Hb%

24. 5.Surgical risk assessment Surgical risk assessment includes the anaesthetic risk also Cardiovascular and pulmonary complications are common causes of peri-operative morbidity and mortality in elders (25 to 30%)

25. Anaesthesia Preoperative evaluation and optimization of patients are important components of anesthesia practice. At a minimum, the guidelines of the ASA indicate that a preanesthesia visit should include the following : • An interview with the patient or guardian to review medical, anesthesia and medication history • An appropriate physical examination • Review of diagnostic data (laboratory, electrocardiogram, radiographs, consultations)

26. At a minimum, the preanesthetic examination includes the airway, heart and lungs, vital signs, oxygen saturation, height, and weight. Examination of the airway is always necessary. Auscultation of the heart and inspection of the pulses, peripheral veins and extremities for edema are important diagnostically and in development of care plans .

27. The pulmonary examination includes auscultation for wheezing and decreased or abnormal sounds. Cyanosis, clubbing and the effort of breathing are noted. Assignment of an ASA physical status score (ASA-PS). A formulation and discussion of anesthesia plans with the patient or a responsible adult

28. One of the first anesthesia risk categorization systems was the ASA classification. It has five stratifications: ASA I— Normal healthy patient ASAII— Patient with mild systemic disease ASA III—Patient with severe systemic disease that limits activity but is not incapacitating ASA IV—Patient who has incapacitating disease that is a constant threat to life ASA V—Moribund patient not expected to survive 24hours with or without an operation

29. II-Preoperative preparation 1-Consent for surgery An informed consent in writing from the patient and/or his relatives is essential before any procedure is undertaken

30. Patients must receive sufficient accurate information about their illness, the proposed treatment and its prognosis. Describe the procedure itself, including information about its practical implications and its prognosis Outline other surgical or medical alternatives to the proposed treatment, including non‐treatment, along with their general advantages and disadvantages

31. Counseling The surgeon should gain the confidence of the patient by his kind approach and frank discussion about the problem, and possible benefits and risks especially in cases involving amputation or possible disability or disfigurement Preoperative counseling by the doctors, trained staffs, social workers and patients who had undergone major surgery, will prevent or reduce depressive effect .

32. 2.Prevention of CVS & respiratory complications Efforts to maintain the circulation and ventilation have greater priority in preparing the patient for an operation. Prophylaxis of Postoperative Deep Vein Thrombosis. SC heparin 5000 IU 2 hours preoperatively and 8 hours postoperatively. Respiratory complications can be prevented and also improved through Cessation of smoking Treating bronchospasm Reducing secretions Chest physiotherapy

33. 3. Aspiration prevention Prevention of aspiration is the most important aspect of perioperative care. Starving the patient for 6-8 hours prior to surgery Ryles tube aspiration during surgery Fasting times for children are age dependent

34. Babies under 1 year No breast milk for 2‐3 h before anaesthesia No formula feed for 6 h before anaesthesia Clear fluids may be given up to 3 h before anaesthesia Children over 1 year No food/milk for 6 h before anaesthesia Clear fluids up to 3 h before anaesthesia

35. 4.Preparation of bowel GIT surgery needs complete evacuation and cleansing of alimentary tract Sterilization of the bowel by oral anti microbial agents Routine nasogastric tube aspiration and strong purgatives, enemas

36. 5.Others Blood grouping and Rh typing: reserve necessary units of blood for possible requirement. Sleep: Good sleep should be ensured on the night before surgery (mild sedation) Skin preparation: haircut, shaving , taking care not to injure the skin. Patient should be given a good bath before surgery . Bladder catheterization: Insertion of urinary catheter to prevent post operative distension of the bladder and to measure the urine output during surgery are important Pre-medication : Routine pre-medication for anaesthesia is best avoided in the ward and is given in the operation theater under the direct supervision of the anaesthetist .

37. Preoperative considerations The surgeon should consider the following prior to surgery The diagnosis, nature of the disease, its natural course, the prognosis, presence of comorbid conditions and the general condition of the patient should be taken into account. The benefit of surgery should be weighed against the possible risk and complications Alternative to high-risk surgery and the possibility of a conservative management should also be discussed with the patient and family members

38. Any requests or preferences made by the patient should also be considered A fully equipped operation theatre, post operative ward with monitoring and resuscitative facilities, and good surgical team are preferable The optimal timing of surgery to be fixed for better outcome

39. Preoperative Assessment & Preparation Assessment Preparation 1.History 2.Physical examination 3.Nutritional assessment 4.Investigations 5.Surgical risk assessment 1.Consent for surgery 2.Prevention of CVS & respiratory complications 3. Aspiration prevention 4.Preparation of bowel 5.Others