This document discusses preoperative patient preparation. It outlines the goals of preoperative evaluation which include determining the need for surgery, additional investigations, alternative treatment options, and timing and type of anesthesia. The document then details the components of a routine preoperative evaluation, including history, physical exam, investigations, risk assessment, informed consent, and prophylactic treatments. It also discusses the management of specific medical conditions like cardiovascular disease, respiratory disease, liver and renal disease, and endocrine disorders in the preoperative period.

1. Preoperative patient
preparation
Presenter: Dr Dawit Yadessa(GSR1)
Moderator: Dr Gersam Abera(General
Surgeon, Pediatric Surgeon)
9/20/2019 by dr dawit y 1

2. Outline
• Introduction
• Preoperative evaluation
• Pre-operative investigation
• Assessment of risk for surgery
• Specific Preoperative Problems And Mgt
• Medications
• consent
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3. Introduction
• 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.
• So the purpose of careful preoperative planning is to
minimize the unwanted effects of these physiological
changes.
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4. Preoperative evaluation
The rationale for pre-operative evaluation is
– need for operative intervention should be
discussed with the patient or guardian.
– Need additional investigations,
– alternative therapeutic options
– Timing & type of surgery
– Type of anesthesia
9/20/2019 by dr dawit y 4

5. Preoperative evaluation cont…
 The extent of pre-operative preparation will
depend on
• Nature of surgery (minor or major)
• Facilities available
• Situation
Emergency
Urgent
Elective
9/20/2019 by dr dawit y 5

6. Preoperative evaluation cont…
 Routine preparation for surgery
– Hx -- premedication
– P/E
– Investigation
– Risk assessment
– Informed consent
– Marking the site/side of operation
– Thromboembolic prophylaxis
– Antibiotic prophylaxis
9/20/2019 by dr dawit y 6

7. Hx
Major compliant
• Reach to a diagnosis
• Extent of the disease
–Co-morbidities that need optimization
–‘finess’ for surgery and anaesthesia.
–Increasing severity of symptoms
–Hx of past surgery and anaesthesia
9/20/2019 by dr dawit y 7

8. Hx cont…
• use of recreational drugs and alcohol
consumption
• Check for allergies and risk factors for deep vein
thrombosis (DVT).
• Social history
• ability to communicate and mobility ---
important in planning rehabilitation after
surgery.
9/20/2019 by dr dawit y 8

9. P/E
• General Ap.
• v/s.
• HEENT
• LGS
• Respiratory
• CVS
• Abdominal Ex.
• GUS
• MSS/INT
• CNS
• Local Ex
• Body orifices ; “ If you don’t put your finger, you will put your
foot”
•
9/20/2019 by dr dawit y 9

10. P/E cont…
• Examination with with respect and dignity
• A chaperone -- for intimate examinations
• Cardiac
– JVP, fine pulmonary crackles, gallop rhythm
• Peripheral vascular disease
– loss of peripheral pulses, ulcerations
• valvular heart disease with characteristic murmurs
– ejection systolic murmur in aortic stenosis,
– pansystolic murmur in tricuspid regurgitation and mid-diastolic
murmur in mitral stenosis
• Respiratory
– rapid respiratory rate, reduced air entry,
crepitations and rhonchi
9/20/2019 by dr dawit y 10

11. Emergency P/E
 The routine exam must be altered to fit the
circumstances.
 A,B,C,D,E of life
 Secondary survey( head to toe)
 When a number of emergencies present at
same time --- Triage
9/20/2019 by dr dawit y 11

12. Preoperative Investigations
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13.  CBC ( when to perform?)
 Hematologic disorder
 Bleeding disorder
 malignancy
 renal d/se
 significant blood loss
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14.  Urea and electrolytes
 Most preoperative cases over 65 years
 All major operations
 All patients with cardiopulmonary disease or taking diuretics
or steroids
 All patients with hx renal/liver disease or abnormal nutritional state
 All patients with hx diarrhea, vomiting other metabolic/endocrine
disease
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15.  Coagulation profile:
hx of bleeding disorder, liver disease or excessive alcohol
use
eclampsia,
cholestasis
onantithrombotic or anticoagulant agents
 Pts receiving anticoagulants
Cardiothoracic surgery
Vascular surgerY
Craniotomy procedures
9/20/2019 by dr dawit y 15

16. • ECG
– patients over 65 years of age
– symptomatic patients with a history of rheumatic
fever
– diabetes
– cardiovascular, renal and cerebrovascular disease,
with and without severe respiratory problems
– It also depend on if the surgery is
minor/intermediate or major.
9/20/2019 by dr dawit y 16

17.  Chest X-ray:
 All elective preoperative cases over 60 years
 cases of cervical, thoracic or abdominal trauma
 Acute respiratory symptoms or signs
 Thoracic surgery
 Malignant disease
 Viscous perforation
 Recent hx TB
9/20/2019 by dr dawit y 17

18. Urinalysis
• Dipstick in all patients to
detect uti, biliuria,
glycosuria and
inappropriate osmolality.
β-HCG.
 Women of child-bearing age
RBS:
• Acute abdomen(DKA)
• Elective cases with DM,
malnutrition, obesity
• Elective cases over 60 yrs
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19. LFT
• patients with jaundice
• known or suspected
hepatitis
• cirrhosis, malignancy or
in patients with poor
nutritional status.
BG/ cross match
• Emergency preoperative
case
• Suspicion of much blood
loss, anemia, coagulation
defects
 Procedure on pregnant ladies
Other investigations
• Performed according to requirement
• Ultrasound
• CT scan
• MRI, … etc
9/20/2019 by dr dawit y 19

20. Assessment Of Risk Of Surgery
• There are few patients who have no risk for surgery
• It is important to quantify the risks involved so they
must be discussed with the pts
• main prognostic scoring systems which is currently
being used is:
ASA SYSTEM
9/20/2019 by dr dawit y 20

21.  ASA System
“ American Society of Anaesthesiologist”
 It is very simple and widely accepted
50% patients presenting for elective surgery are
in ASA Gr I
Operative mortality rate for these patients is less
than 1 in 10,000
9/20/2019 by dr dawit y 21

22. Specific Preoperative Problems And Mgt
• Specific medical problems encountered during preoperative
assessment should be corrected to the best possible level.
Cardiovascular disease
• Perioperative cardiovascular complications are frequent.
• Three elements must be assessed.
– Patient specific clinical variables
• History
• P/E
• Non/ invansive tests
– Exercise capacity
– Surgery-specific risk
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24. • Surgery-specific risk
• High risk(>5%)
– Aortic and other major
vascular surgery
– Peripheral artery surgery
• Intermediate risk (1 to
5%)
– Carotid endarterectomy
– Head and neck surgery
– Intraperitoneal and
intrathoracic surgery
– Orthopedic surgery
– Prostate surgery
• Low risk(<1%)
– Ambulatory surgery
– Endoscopic procedures
– Superficial procedure
– Cataract surgery
– Breast surgery
9/20/2019 by dr dawit y 24

25. valvular heart disease
• echocardiogram should
be obtained.
• an EF of less than 30% is
associated with poor pt
outcomes.
mechanical heart valves
• Stop warfarin 5 days before
surgery
• unfractionated heparin started when
the INR falls below 1.5.
• (APTT), should be monitored to keep
it at 1.5 times normal
• the infusion is then stopped 2 hours
before surgery
• Heparin and warfarin should be
started in the postoperative period,
and heparin is stopped when the full
effect of warfarin takes effect.
MI
• Pts on β-blockers and on statins
should be maintained on their
medication.
• Most long-term cardiac medns
should be continued over the
perioperative period.
• 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.
9/20/2019 by dr dawit y 25

26. Dysrhythmias
• β-blockers, digoxin or calcium channel blockers should be started
preoperatively (or continued if on such medication) in order to control
rate and possibly rhythm.
• Cardiac output can increase by 15% if sinus rhythm is restored.
• Warfarin in patients with atrial firillation (AF) should be stopped 5 days
before surgery
• Bridging therapy with unfractionated heparin or low molecular weight
heparin (LMWH) 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
9/20/2019 by dr dawit y 26

27.  Anaemia and blood transfusion
• Anaemic pt should be investigated for
the cause of their anaemia
• Chronic anaemia is well tolerated but
major surgery need transfussion
• preoperative ‘group and save’ should
be performed
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28. Respiratory disease
• Specific pulmonary risk
factors include:
– Age,COPD,smoking,
Pneumonia ,obst.sleep
apnea.
• Concurrent comorbid
conditions :
– impaired sensorium,
previous stroke, CHF, ARF.
• Incisions closest to the
diaphragm .
• Age
– Independent predictor
• Respiratory infection
• URI
– Pediatric- increased
incidence of laryngospasm,
bronchospasm, or oxygen
desaturation.
• Lower respiratory
Infection
– should be treated before
surgery except when the
surgery is life-saving.
9/20/2019 by dr dawit y 28

29. • Asthma
– no increased risk for
patients with well
controlled asthma.
– usual inhalers should be
continued
– Brittle asthmatics or
symptomatic need
oral/parentral steroid
cover.
• Smoking
– highest risk when smoked
within the past two
months
– When stopped more than
six months risk is similar to
those who had never
smoked.
– stop smoking at least eight
weeks before surgery
– a brief period of
abstinence does not
improve perioperative
pulmonary outcomes
9/20/2019 by dr dawit y 29

30. Tests which need to be done include:
– FEV in 1 sec.
– Forced vital capacity
– Diffusing capacity of carbon monoxide
• Adults with FEV1 less than 0.8 liter/sec or 30%
of predicted, have high risk for postoperative
complications (PPC)
9/20/2019 by dr dawit y 30

31. Risk Group For PPC
 General :
 Age > 70years
 Cigarette smoking
 Renal failure
 Poor nutrition
 Asthma related
 Recent asthma attack
 Past h/o endotracheal intubation for
asthma management
 Surgery and anaethesia related
 Emergent surgery
 Thoracic and upper abdominal surgery
 Blood loss > 2000ml
 Anesthesia time >180 minutes
 General anesthesia with endotracheal
intubation
preoperative interventions
1. Smoking cessation ( within 2
months before planned
surgery)
2. Encouraging exercise
preoperatively.
3. Bronchodilator therapy
4. Antibiotic therapy for pre
existing infection
5. Pretreatment of asthmatic
patients with steroids
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32. HEPATOBILIARY SYSTEM
• In pts with liver disease, the cause of the disease needs
to be known
• Elective surgery should be postponed until any acute episode
has settled (e.g. cholangitis).
Investigations
LFT, coagulation profile, blood glucose , viral markers
urea & electrolyte .
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33. CHILD-PUGH SCORING SYSTEM
• Stratification of operative risk in patient with
cirrhosis
• Class A :- 5-6 points Mortality : 10%
• Class B :- 7-9 points Mortality : 31%
• Class C :- 10-15points Mortality : 76%
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34. • Approach to patient with liver disease
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36. RENAL SYSTEM
• About 5% of popln has some degree of renal dysfunction which may
affect multiple organ system and increase perioperative morbidity
• Preoperative creatnine levels of >2mg/dl is an independent risk factor
for cardiac complications
– LAB INVESTIGATIONs
– Serum Cr; BUN
– Serum e-
– Hematocrit
– U/A
– Fractional excretion of sodium
– CXR
– ECG
9/20/2019 by dr dawit y 36

37. Preoperative Optimisation
• Anemia is treated with erythropoietin or darbepoietin
• Mgt electrolytes
• Replacement of calcium for symptomatic hypocalcaemia
• Use of phosphate binding antacids for hyperphosphatemia
• Correction of metabolic acidosis ( sod bicarbonate is given
i/v if levels fall below 15meq/l
• Hyponatremia is treated by fluid restriction
• Avoid nephrotoxic drugs
• DIalysis
9/20/2019 by dr dawit y 37

38. Endocrine and metabolic disorders
Hyperthyroidism:
• Elective surgery deferred until euthyroid state achieved
• Preop ECG and serum electrolytes done
• Anithyroid drugs and beta blockers/digoxin continued on the
day of surgery
• In case of emergency surgery in thyrotoxic patient at risk of
thyroid storm, a combination of beta blocker and glucocorticoids
used
Hypothyroidism:
• Severe hypothyroidism can cause MI, coagulation defects
and electrolyte imbalance
• Elective surgery to be deferred until euthyroid state achieved
9/20/2019 by dr dawit y 38

39. Malnutrition
• 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
•
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40. Obesity
• BMI > 35 (other defiitions exist)
• is associated with increased risk of postoperative complications
– Diffucult intubation
– Aspiration
– Myocardial infarction
– Cerebrovascular incident
– DVT
– Respiratory compromise
– Poor wound healing
– Mechanical-lifting,transfering
•
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41. • Delay procedure until the patient is more
active and has lost weight
• preventative measures for acid aspiration and
DVT
DM next seminar
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42. Patients with hx of steroid use
– Patients who have taken > 5mg of prednisolone or
equivalent for > 3 weeks are at risk when under going major
surgery
– Minor procedures: no additional steroid required
– Moderate operation: 50-75 mg/day of hydrocotisone (or eq)
for 1 -2 days
– Major operation: 100-150 mg/day hydrocortisone (or eq)
9/20/2019 by dr dawit y 42

43.  Pheochromocytoma :
– Require preoperative pharmacologic Mx to
prevent intraoperative hypertensive crisis or
vascular collapse
– A combination of alpha and beta adrenergic
blockade started 1-2 weeks before surgery
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44. DVT prophylaxis
• DVT is common in surgical
patients
• Can cause PE which carries a
high mortality
• Surgery, trauma and
immobilization are responsible
for 50% of DVT
 RISK FACTORS FOR DVT:
• Age
• Obesity
• Immobility
• Malignancy
• Trauma
• Surgery
• Dehydration
• Past hx thromboembolism
• Oral contraceptives(COC,etrogen
only)
• HRT
• Pregnancy, peurperium
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45.  PROPHYLAXIS:
• Graded elastic compression stocking
• Intermittent pneumatic calf
compression
• Postoperative early ambulation
• Heparin prophylaxis
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47. Pts on Anticoagulants
• Require preoperative reversal of anticoagulant effect
• Warfarin should be witheld for 5 scheduled doses
preoperatively to reduce the INR to 1.5 or less
• Patients at risk of thromboembolic event are
recommended to have full bridging while off
anticoagulation
• For those on LMWH last dose should be given 20 -24 hours
prior to surgery and restarted approx. 12-24 hours
postoperatively
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48. • In patients on heparin:
• Elective procedure- discontinue heparin 6
hrs before surgery.
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49. Antibiotic Prophylaxis
 Appropriate antibiotic prophylaxis depends upon:
– the most likely pathogen encountered
– Class of the operative procedure( clean, clean contaminated,
contaminated , dirty)
 Class I -- don’t require antibiotic prophylaxis, except in cases of
indwelling prosthesis placement or bone incision
 Class II--- only single preoperative prophylactic dose
 Class III & IV -- mechanical preparation plus parenteral antibiotics
with aerobic and anaerobic coverage
9/20/2019 by dr dawit y 49

50. • Perioperative Medications
– Use drugs that control the patient’s medical
conditions
– while minimizing the risk associated with
anesthetic drug interactions or hematologic or
metabolic effects of drugs;
– Two groups
• Drugs that need to be continued (PO /Parentral )
• Drugs that should be discontinued
9/20/2019 by dr dawit y 50

51. Drugs that need to be continued
– Drugs with rebound effects
• Anti hypertensives- clonidine
• β blockers & α agonists
• Anti convulsants-Barbiturates & opoids
– Steroids
– Anti arrhythmias
– Psychiatric drugs
9/20/2019 by dr dawit y 51

52. • Drugs that need to be stopped
– ASA
• D/c 7 days before surgery
• Platelet transfusion in significant risk
• NSAIDS
– Inhibit platelet aggregation.
– Discontinue 1–3 days before surgery
• ACE inhibitors
• Cause hypotension
• postoperative renal dysfunction
9/20/2019 by dr dawit y 52

53. • Tamoxifen & estrogen
• 2-4 fold increases in thromboembolism
• Discontinue for 4weeks
• Lipid lowering agents
– predispose patients to myositis and
rhabdomyolysis
– discontinue before surgery
– resume when the patient is able to eat
postoperatively
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54. • Herbal medications
– Adverse drug interactions
– To minimize the risk to stop herbal medications
1week before surgery
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55. • Summary of medications usually continued
– Beta adrenergic & Calcium channel blockers,
– Antiarrhythmics
– Bronchodilators
– Thyroid hormone &Antithyroid drugs
– Insulin ,Corticosteroids ,Anticonvulsants
– Carbidopa/levodopa
– Drugs for myasthenia gravis
– Selective serotonin reuptake inhibitors
– Tricyclic antidepressants
– Antipsychotic drugs
– Benzodiazepines &Opioid analgesics
9/20/2019 by dr dawit y 55

56. • Medications usually stopped
– Aspirin and antiplatelet drugs
– NSAIDs (unselective and COX-2 inhibitors)
– Diuretics
– Lipid lowering drugs
– Estrogens
– Dopamine receptor agonists
– Monoamine oxidase(MAO) inhibitors
– Herbal products
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57. • NPO
–If possible in all patients;
–MR for grossly evident aspiration=50%
• Protective effect of the gastro esophageal
& pharyngeo esophageal sphincters is
lost
–Increased risk in
• GERD ,Full stomach, obese, Comatose
• Intestinal obstruction
• Pregnant
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58. ASA recommendation
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59. • NGT decompression/ lavage
– Patients with small bowel obstruction
– Paralytic ilieus
– GOO/ gastric surgery
– Achalasia
Iv access
– In all patients
– Maintenance fluid in patients kept NPO,
– Rehydrate patients who are dehydrated,
– Resuscitate shocked patients,
– Pre operative medications & anesthetic drugs
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60. • Urinary catheter
– Indicated for monitoring of output
– Response of resuscitation in shock
– Patients expected to develop post op urinary
retention
– Pelvic surgery
– Prolonged surgery expected
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61. consent
• Get Informed consent
– Get a signature ; patient knows about
disease & surgery; has agreed to it
– A patient has a right to postpone or refuse the
surgery
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62. Pre medications
– Anxiolytics
– Prophylactic antibiotics
– Prophylactic anti coagulants
– Continued medications
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63. References
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• internet
63

64. Thank you !
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