The document discusses preoperative preparation and planning. It emphasizes minimizing physiological stress from surgery through careful history taking, examination, optimization of medical conditions, and anticipating adverse events. High-risk patients require detailed assessment, medical optimization, and potentially postoperative critical care. Obtaining fully informed consent is also emphasized.

1. Preoperative Preparation
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2. • The stress of major surgery can lead to increased oxygen demand by about
40%.
• Changes such as cytokine release-related inflammatory changes, endocrine
responses, hypercoagulability and redistribution of fluid between
compartments may last several postoperative days.
• The purpose of careful preoperative planning is to minimize the unwanted
effects of these physiological changes.
• Systematic history taking, examination and ordering of investigations at the
preoperative clinic should include baseline information.

3. • A plan for the operating list should be drawn-up and all those involved in
making the list run smoothly should be informed.
• The World Health Organization (WHO) checklist, which is started since 2012 in
Myanmar

5. Perioperative plan for the best patient outcomes
• Gather and record all relevant information
• Optimize patient condition
• Choose surgery that offer minimal risk and maximum benefit
• Anticipate and plan for adverse events
• Adequate hydration, nutrition and exercise are advised

6. Patient assessment
• Principles of history taking
• Listen. What is the problem? (open questions)
• Clarify. What does the patient expect? (closed questions)
• Narrow. Differential diagnosis (focused questions)
• Fitness. Comorbidities (fixed questions)

7. Key topics in past medical history
Cardiovascular
• Ischaemic heart disease – angina, myocardial infarction
• Hypertension
• Heart failure
• Dysrhythmia
• Peripheral vascular disease
• Deep vein thrombosis and pulmonary embolism

8. Respiratory
• Chronic obstructive pulmonary disease
• Asthma
• Respiratory infections
Gastrointestinal Tract
• Peptic ulcer disease and gastroesophageal reflux
• Liver disease
Genitourinary Tract
• Urinary tract infection
• Renal dysfunction

9. Neurological
• Epilepsy
• Cerebrovascular accidents and transient ischaemic attacks
• Psychiatric disorders
• Cognitive function
Endocrine
• Diabetes
• Thyroid dysfunction
• Phaeochromocytoma
• Porphyria
Locomotor system
• Osteoarthritis
• Inflammatory arthropathy such as rheumatoid arthritis

10. Other
• Human immunodeficiency virus
• Hepatitis
• Tuberculosis
• Malignancy
• Allergy
Previous Surgery
• Problems encountered
• Family history of problem with anaesthesia

11. Summary of Examination
General - Positive findings even if not related to the proposed
procedure should be explored further
Surgery related - Type and site of surgery, complications
occurred due to underlying pathology
Systemic - Comorbidities and extent of limitation of each organ
function
Specific - For example, suitability for positioning during surgery

14. Investigations
Investigations needed
• Type of surgery - Major surgery can lead to organ system
dysfunction needing most investigations
• Patient - For example, sickle cell test for patients of AfroCaribbean
origin with family history of sickle cell disease
• Comorbidities - For example, peak flow rates for severe asthmatics

15. Full Blood Count
• Needed for major operations
• Elderly, those with anaemia or pathology with ongoing blood loss and
chronic disease
• Sickle cells test for history of sickle cell crisis and afro Caribbean and Indian
subcontinent origin
Urea & electrolytes
• Needed before all major operations
• Most patients over 65 years of age and
• Especially with cardiovascular, renal and endocrine disease
• If the significant blood loss is anticipated
• Medications that affect electrolyte levels e.g. steroids, diuretics, digoxin,
NSAIDS, IV fluid or nutrition therapy and endocrine problems

16. Electrocardiography
• Patients over 65 years of age and symptomatic patients with history of
• Rheumatic fever, diabetes, cardiovascular, renal and cerebrovascular
disease with and without severe respiratory problems. It also depends on
surgery is minor or major
Chest Radiograph
• Patients with cardiac failure
• COPD acute respiratory symptoms,
• Pulmonary cancer,
• Metastasis or effusion or those who are deemed to be at risk of active
pulmonary tuberculosis

17. Clotting screen
• History of clotting diathesis, liver disease, eclampsia, cholestasis
• Family history of bleeding disorder, or is on antithrombotic or
anticoagulant agents
• The effects of antiplatelet agents, low molecular weight heparins and
newer agents affecting factor Xa cannot be measured by routine laboratory
tests
Urinalysis
• Dipstick testing to detect urinary infection, biliuria, glycosuria and
inappropriate osmolality

18. B-Human chorionic gonadotrophin
• Women of childbearing age , after obtaining concent from the patient
Blood glucose and HbA1c
• Poor diabetes control leads to perioperative infection and slow recovery
• HbA1C indicates how well diabetes has been controlled over long duration
Arterial blood gases
• In acute or chronic severe respiratory conditions, acid base disturbances
and conditions where there is changing milieu, e.g. immediately before
kidney transplant

19. Liver Function Tests
• Patients with jaundice, known or suspected hepatitis, cirrhosis, malignancy
or in patients with poor nutritional status
Other investigations
• Specialist radiological views and other recent imaging

20. Specific preoperative problems and management
Specific medical problems encountered during preoperative should be
corrected to the best possible level.
Cardiovascular disease
• It is important to identify the patients who have a high perioperative risk of
major adverse cardiovascular events (MACE)
• Patients who can climb a flight of stairs without getting short of breath or
chest pain or needing to stop are likely to tolerate a wide range of surgeries
with an acceptable risk of perioperative cardiovascular morbidity and
mortality.

21. Patients at high risk are
• ischaemic heart disease (IHD),
• congestive cardiac failure (CCF),
• arrhythmias,
• severe peripheral vascular disease,
• cerebrovascular disease
• significant renal impairment,
• especially if they are undergoing major intra-abdominal or intra-thoracic
surgery
• In patients with ischaemic heart disease the cardiac and coronary reserve
can be evaluated using a stress test (stress ECG, stress echocardiogram,
myocardial scintigraphy).

22. • In patients with any suggestion of valvular heart disease or poor left
ventricular function, an echocardiogram should be obtained. an ejection
fraction of less than 30% is associated with poor patient outcomes.
The patient should be referred to a cardiologist if:
• A murmur is heard and the patient is symptomatic.
• The patient is known to have poor left ventricular function or
cardiomegaly.
• Ischaemic changes can be seen on ECG even if the patient is not
symptomatic (silent ischaemia, silent MIs are frequent).
• There is an abnormal rhythm on the ECG, for example tachy-/bradycardia
or heart block.

23. Hypertension, ischaemic heart disease (IHD) and
coronary stents
• Prior to elective surgery blood pressure should be controlled to near
160/100 mmHg.
• If a new antihypertensive agent is introduced, a stabilisation period of at
least 2 weeks should be allowed.
• The indications for coronary revascularisation in these patients before
major surgery are the same as the medical indications.
• Pharmacological protection is indicated.
• Patients on β-blockers and on statins should be maintained on their
medication.

24. • Angiotensin-converting enzyme (ACE) inhibitors and receptor blockers
are often omitted 24 hours prior to surgery and reintroduced gradually in
the postoperative period
• After a proven myocardial infarction, elective surgery should be
postponed for 3–6 months to reduce the risk of perioperative
reinfarction.
• primary percutaneous intervention is the treatment of choice for acute
coronary syndromes, many patients receive stents and are on dual
antiplatelet therapy for 12 months
• If surgery is absolutely necessary within the period of dual antiplatelet
therapy, the management strategy should be decided jointly by surgeon,
cardiologist, anaesthetist and patient.

25. Dysrhythmias
• In patients with atrial fibrillation,β-blockers, digoxin or calcium channel
blockers should be started preoperatively (or continued if the patient is
already on such medication)
• Warfarin in patients with atrial fibrillation (AF) - should be stopped 5
days preoperatively to achieve an international normalised ratio (INR) of
1.5 or less, The newer anticoagulants such as dabigatran (direct thrombin
inhibitor) or rivaroxaban, apixaban and edoxaban (direct factor Xa
inhibitors) do not have antagonists and must be stopped preoperatively,
generally for 2–3 days in patients with normal

26. • Bridging therapy with unfractionated heparin or low molecular weight
heparin (LMWH) is recommended for patients with AF and a mechanical
heart valve undergoing procedures that require interruption of warfarin.
Decisions on bridging therapy should balance the risks of stroke and
bleeding

27. • Checks and appropriate reprogramming should be done preoperatively
by specialists.
• Monopolar diathermy activity during surgery may be sensed by the
pacemaker as ventricular fibrillation. Therefore, cardioversion and
overpace modes must be turned off or converted to ‘ventricle paced, not
sensed with no response to sensing’ (VOO) mode.
• Bipolar diathermy should be made available at surgery.
Implanted pacemakers and cardiac defibrillators

28. Valvular heart disease

31. • Patients on oral steroid treatment, oxygen therapy or who have a forced
expiratory volume in the first second (FEV1) less than 30% of predicted
value (or PaCO2 level of greater than 6kPa, have severe disease and are
at risk of pneumonia and respiratory failure in the postoperative period.
• Patients should continue to use their regular inhalers until the start of
anaesthesia.
• Brittle asthmatics may also need extra steroid cover.
• Encourage the patients to be compliant with the medications, take a
balanced diet and stop smoking
• Stopping smoking reduces carbon monoxide levels and offers the
patient a better ability to clear sputum.
• preoperative inspiratory muscle training significantly improves
respiratory (muscle) function in the early postoperative period, reducing
the risk of pulmonary complications.

32. The patient should be referred to a respiratory physician if:
-There is a severe disease or significant deterioration.
-Major surgery is planned in a patient with significant respiratory
comorbidities.
-Right heart failure is present – dyspnoea, fatigue, tricuspid regurgitation,
hepatomegaly and oedematous feet.
-The patient is young and has severe respiratory problems (indicates a rare
condition)

33. Gastrointestinal disease
-Nil by mouth and regular medications.
-Patients are advised not to take solids within 6 hours and clear fluids
(isotonic drinks and water) within 2 hours before anaesthesia to avoid the
risk of acid aspiration syndrome.
-If the surgery is delayed, oral intake of clear fluids should be allowed
until 2 hours before surgery or intravenous fluids should be started.
Regurgitation risk -
-Patients with hiatus hernia, obesity, pregnancy and diabetes are at high
risk of pulmonary aspiration, even if they have been NBM before elective
surgery.
Clear antacids, H2-receptor blockers, e.g. ranitidine, or proton pump
inhibitors, e.g. omeprazole, may be given at an appropriate time in the
preoperative period.

34. Liver disease
• In patients with liver disease, the cause of the disease needs to be known,
as well as any evidence of clotting problems, renal involvement and
encephalopathy.
• Elective surgery should be postponed until any acute episode has settled
• The blood tests that need to be performed include liver function tests,
coagulation, blood glucose and U&Es.
• The presence of ascites, oesophageal varices, hypoalbuminaemia and
sodium and water retention should be noted, as all can influence the choice
and outcome of anaesthesia and surgery

35. Genitourinary disease
Underlying conditions leading to chronic renal failure such as
diabetes mellitus, hypertension and ischaemic heart disease, should
be stabilised before elective surgery
Appropriate measures should be taken to treat acidosis,
hypocalcaemia and hyperkalaemia of greater than 6 mmol/L.
Arrangements should be made to continue peritoneal or
haemodialysis until a few hours before surgery.
After the final dialysis before surgery, a blood sample should be sent
for FBC and U& E

36. • Chronic renal failure patients often suffer chronic microcytic anaemia
• Acute kidney injury can present with an acute surgical problem, for
example bowel obstruction needing emergency surgery.
• In these patients, medical treatment should be started at the earliest
opportunity and carried on through surgery and through into the critical
care unit

37. Urinary tract Infection

38. Endocrine and metabolic disorders,Malnutrition
• Body mass index (BMI) is weight in kilograms divided by height in
metres squared.
• A BMI of less than 18.5 indicates nutritional impairment and
• a BMI below 15 is associated with significant hospital mortality.
• Nutritional support for a minimum of 2 weeks before surgery is
required to have any impact on subsequent morbidity.

39. Obesity
Morbid obesity can be defined as BMI of more than 35 -
associated with increased risk of postoperative complications
Associated sleep apnoea can be predicted by using a clinical
scoring system, the perioperative sleep apnoea prediction (P-
SAP) score
Patient outcomes improve with more than 6 weeks of use of a
continuous positive airway pressure (CPAP) device
preoperatively, and cholesterol reducing agents in the
perioperative phase

40. Diabetes Mellitus
• An intravenous insulin sliding scale should be started for insulin-
dependent diabetes mellitus patients undergoing major surgery, or if
blood sugar is difficult to control for other reasons
• Diabetes and associated cardiovascular and renal complications
should be controlled to as near normal level as possible before
embarking on elective surgery.
• Any history of hyper- and hypoglycaemic episodes, and hospital
admissions, should be noted.
• HbA1c levels should be checked. For elective surgery, HBA1c of
<69mmol/mol is recommended
• Patients with diabetes should be first on the operating list and, if the
operation is in the morning, advised to omit the morning dose of
medication and breakfast

41. Adrenocortical suppression
• Patients receiving oral adrenocortical steroids should be asked about
the dose and duration of the medication
• supplementation with extra doses of steroids perioperatively, to avoid
an Addisonian crisis

42. Coagulation disorders-Thrombophilia

43. • Patients with a low risk of thromboembolism can be given
thromboembolism-deterrent stockings to wear during the perioperative
period.
• High-risk patients with
- a history of recurrent DVT,
- pulmonary embolism and arterial thrombosis
- will be on warfarin.
- This should be stopped before surgery and replaced by low molecular
weight heparin or factor Xa inhibitors.
• The progesterone-only contraceptive pill should be continued;
• Consider stopping oestrogen-containing oral contraceptives or hormone
replacement therapy 4 weeks before surgery

44. Neurological and psychiatric disorder

45. Musculoskeletal disorders
Rheumatoid arthritis can lead to an unstable cervical spine with
the possibility of spinal cord injury during intubation.
In ankylosing spondylitis patients, in addition to the problems
discussed above, techniques of spinal or epidural anaesthesia are
often challenging.
Patients with systemic lupus erythematosus may exhibit a
hypercoagulable state along with airway difficulties.

46. Identification of the high-risk patient

47. Airway assessment

49. Management of risks
A practical approach to the care for the high-risk patient
• Identify the high-risk patient
• Assess the level of risk
• Detailed preoperative assessment
• Adequate resusciatation
• Optimise medical management
• Investigation to define the underlying surgical problem
• Immediate and definitive treatment of underlying problems
• Consider admission to a critical care facility postoperatively

50. Optimization of the high-risk patient

51. Consent
The guidance outlines the key principles of consent and how the
discussion should:
• give the patient the information required to make a decision;
• be tailored to the individual patient;
• explain all reasonable treatment options;
• discuss all material risks.
• should be written and recorded on a form;
• the key points of the discussion should be recorded in the case notes

53. ARRANGING THEATRE LIST

54. Perioperative teams