The document discusses preoperative care and evaluation for emergency and elective patients. It covers topics like preoperative evaluation, assessment of surgical risk, optimizing patient medical conditions, and specific considerations for organ systems like cardiovascular, respiratory, hepatic, and endocrine systems. The goal of preoperative care is to minimize risks and complications by identifying and addressing any medical issues before surgery.

1. PREOPERATIVE CARE AND EVALUATION
IN EMERGENCYAND ELECTIVE PATIENTS
Presenter :Berhanu(GSR1)
Moderator :Dr .Obsa (General
surgeon,asst professor of surgery)

2. Outline
Introduction
Preoperative evaluation
Pre-operative investigation
Assessment of risk for surgery
Specific Preoperative Problems & Mgt
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3. Objectives
To be able to organize Pre-op care & List
Understanding of pre-op care
Surgical, Medical Assessment
Optimization of the Pt.
Identification & Care for Higher risk Pts.
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4. Introduction
 Every successful surgery will in a large part be dependent on
adequate material/non-material preparation prior to “knife on
skin”.
 Careful pre-op planning minimizes the unwanted effects
physiological changes post operatively
 Reduce post-op complications
 Helps to decide whether to offer operative Rx, when to offer
& which operation is suitable.
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5. Introdu…
Surgical Objectives
 Achieving a joint understanding of surgical objectives and
expectations between patient and surgeon is paramount to improve
patient satisfaction and outcomes.
 3 broad potential objectives of surgical intervention
 disease prevention
 disease control
 symptom palliation
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6. Procedural urgency
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7. PREOPERATIVE CARE IN EMERGENCY PATIENT
ABC of life
Resuscitation and stabilization of patient
Pertinent history, P/E, Investigations
Informed consent
Manage the patient accordingly
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8. PREOPERATIVE CARE IN ELECTIVE OPERATIONS
 Approaches to preoperative evaluation differ significantly
 Depending on the nature of complaints
 Proposed surgical intervention
 Patient’s risk factors,
 Laboratory investigation results
 interventions to optimise the patient’s overall status and
readiness for surgery
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9. HISTORY
History of the presenting complaint
 The time course and severity of the patient’s symptoms.
 Symptoms, onset, relieving/aggravating factors
Past medical history
Respiratory: COPD , asthma, fibrotic lung conditions, respiratory infection,
malignancy
Cardiovascular system: IHD, HTN, HF, Dysrhythmia, PVD, DVT, PTE, aneamia
Gastrointestinal system: PUD and GERD, Bowel habit , jaundice, alcohol,
coagulopathy
Genitourinary tract: UTI, renal dysfunction
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10. Past medical history…
• Locomotor system- Osteoarthritis, RA
• Neurological- Epilepsy, CVA and TIA, psychiatric
disorders
• Endocrine/metabolic- Diabetes, thyroid dysfunction
• Infectious diseases-HIV, TB, hepatitis
• Previous surgery- previous anaesthesia, problems
encountered
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11. Detailed Hx and P/Exams
Focused on
Operative, anesthetic and pt. healing factors
CVS and Respiratory fitness
Pre-existing Medical Conditions
Current medications and Allergies
Past Medico-Surgical/Anesthetic Hx
Individualized Pt. preparation
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12. Diagnostic workup
Baseline investigation
Practice in generally included
 age >40yrs CBC, serum electrolyte
 age>50yrs chest x-ray and electrocardiogram
Focused workup to the presenting illnes
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13. Assessment Of Risk Of Surgery
ASA SYSTEM
It is very simple and widely accepted
50% Pts. presenting for elective surgery are
in ASA Grade I
Operative mortality rate for these patients is
less than 1 in 10,000
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14. ASA physical status classification
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15. Pre op care
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16. Pre op care
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17. Cardiovascular disease
Major cause of nonsurgical perioperative deaths.
 Generally speaking, anesthesia reduces cardiac output by
20%..
 Increased circulating catecholamines or
sympathetic nervous system activity may
precipitate arrhythmias and increase heart rate and
blood pressure.
Pre op care
SYSTEMS APPROACH TO PREOPERATIVE EVALUATION
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18.  Anesthesia and medications have direct effects on
myocardial contractility, automaticity, and conduction.
 The greatest risk occurs in the 72 hours following
operation
 The best approach to minimizing cardiac complications is
to maintain one's awareness of the presence and severity
of preexisting heart disease
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19. Risk factors
Patient factors
Procedure related factors
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20. Assessment tools
Goldmann cardiac index, 1977
 Detsky modified multifactorial index, 1986
-Eagle criteria for cardiac risk assessment,
1989
 Revised cardiac index
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21. Pre op care
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22. Revised cardiac risk index
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23. Functional Status
 can be quantified in terms of metabolic equivalents (METs)
 Patients with poor functional status are at significantly
elevated risk of perioperative cardiac events
 can be categorized as
 Excellent, >10 METs
 Good 7 to 10 METs;
 Moderate 4 to 6 METs
 poor< 4
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24. Short Simple Screen for Functional
Assessment
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25. Preexisting Cardiac Disease
Ischemic heart disease
Following an acute MI, the rate of subsequent
postoperative ischemia and MI decreases as the
time interval to surgery increases.
 The risk of perioperative stroke was also
increased with surgery occurring within 6 months
of MI.
 In the absence of myocardial revascularization,
noncardiac surgery should be delayed for 60 days
or more after acute MI.
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26.  Elective procedures- after 6 months.
 Significant/worsening angina -investigation by a cardiologist before
elective surgery
 If urgent surgery is required
o Aggressive medical therapy
o Meticulous optimization of oxygenation and fluid balance
 Beta blocker therapy
-decrease MI, cardiac death, CV arrest
- increase- stroke, total mortality
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27. Patient scheduled for surgery with known or
have risk factor for CAD
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28. Patient with Heart failure
Cardiac complications is doubled when
clinical signs of HF are present preoperatively
Decompensated HF should be evaluated and
treated before surgery.
Postponement of surgery is often appropriate
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29.  Preservation of left ventricular ejection fraction is an
independent predictor for patients undergoing elevated-risk
surgery
 LVEF ≤29% were identified as having higher risk in
vascular surgery
 suspected valvular heart disease should have review of
echocardiography evaluation performed within 1 year prior
to surgery
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30. Dysrhythmia
 Fast atrial fibrillation must be controlled before surgery.
 The intervention necessary depends on the physiological state of the
patient and the urgency of the surgery required.
 Regular measurement of serum potassium is essential, particularly
if digoxin is being used.
 Most standard pacemakers are stable during anaesthesia but only
bipolar diathermy should be used whenever possible
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31. Hypertension
most common pre-existing medical disease in
patients presenting for surgery
major risk factor for renal, cerebrovascular,
peripheral vascular, and coronary artery diseases
should be treated medically to render them
normotensive before elective surgery
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32. HTN
 BP should be stabilised ,<140/90mmHg in most patient
<130/80mmHg in DM ,CKD patients
 SBP ≥160 mmHg and DBP ≥ 110 mmHg should have elective
surgery deferred until their blood pressure is under control
 2weeks should be allowed if new anti-HTN is introduced.
 Ongoing treatment with beta blockers and statins is known to
reduce periop morbidity and mortality.
 HTNsives should receive their morning dose before surgery in
elective cases
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33.  Newly diagnosed hypertension may need further
investigation to look for an underlying cause
 most medical centers now recommend withholding
ACE-Is/ARBs the morning of surgery
 Patients on concomitant diuretic therapy are at
greatest risk for intraoperative hypotension requiring
treatment.
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34. Patients on chronic antihypertensive
therapy
Continue the drug up to the time of surgery
ACEI
Continue the drug if Rx is for HTN
Stop if Rx is for CHF in whom base line BP is
low- hypotension
 Centrally acting sympatholytics & β-blockers are associated with
acute withdrawal syndrome -Angina , MI, Sudden cardiac death
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35. Respiratory disease
Pulmonary risk factors;
 Age,
Asthma,COPD
Smoking
Pneumonia
Obst.sleep apnea
Concurrent comorbid conditions
Incisions closest to the diaphragm
Respiratory infection
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36. Preoperative predictors
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37. Effect of surgery on PFT
 FRC decreases by
10% to 15% after lower abdominal operations,
30%after upper abdominal operations ,and
35% after thoracotomies
Functional residual capacity (FRC) has been recognized for
decades as the single most important lung volume
measurement associated with the development of pulmonary
complications after most types of operations.
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38. Respiratory Tests
FEV per1 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
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39. pre-op interventions
Infection - treat before surgery
Asthma
 Give 2-4 puffs of β-agonists before 30 min of
ETT
Steroid therapy, continue bronchodilators
Control of infection
Vigorous pulmonary toilet &rehabilitation
Use epidural anesthesia as much as possible
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40. COPD
Aggressive treatment to achieve best possible base line level of pulmonary function .
Before operation, instruct patients
 Techniques of coughing, deep breathing, and use of one of the incentive
spirometry devices that increase inspiratory effort.
 Smoking cessation- 2 months before the planned procedure.
 Antibiotic therapy for preexisting infection.
 Encouraging exercise preoperatively.
 vigorous pulmonary toilet and rehabilitation
 Systemic steroid
 Bronchodilators
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41. Hepatobiliary system
Ixs
LFT
Coagulation profile
Blood glucose
Viral markers
Urea & electrolyte
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42. 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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43. Pre op care
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44. Mgt for patient with liver disease
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45. Renal system
~5% of popn has some degree of renal
dysfunction
May affect multiple organ system
Increase perioperative morbidity
Preoperative Cr ≥ 2.0 mg/dL- an
independent risk factor for cardiac
complications
Evaluation (Hx, P/E, Ix)
Ix- CBC, ECG, e-s, RFT, CXR, U/A
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46. Preventing perioperative renal dysfunction
Risk factors:- Pt and procedure related
Incr. RFT,
CHF,
Advanced age
Intraoperative hypotension
Sepsis
Intravascular volume contraction
Use of nephrotoxic and Radionuclide agents.
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47. Preoperative Optimization
Rx of Anemia with erythropoietin
Correcting electrolytes Imbalances
Acid/base imbalances correction
Avoid nephrotoxic drugs
Dialysis
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48. Endocrine and metabolic disorders
Hyperthyroidism
Achieving Euthyroid state
Pre-op ECG and serum electrolytes
Anithyroid drugs and beta blockers continued
on theday of surgery
In emergency surgery, use beta blocker +
glucocorticoids in Pts. at risk of thyrotoxic
storm
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49. Hypothyroidism
Severe hypothyroidism can cause MI,
coagulation defects
and electrolyte imbalance
 Elective surgery to be deferred until Euthyroid
state is achieved
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50. DIABETICS;
 Marked hyperglycemia should be avoided during surgery;
the greater danger, however, is from severe unrecognized
hypoglycemia
 Diabetics on diet control only; treat as normal for minor
surg
 Those on biguanides eg metformin; discontinue and start
shortacting sulphonylureas for minor surg.
 For type II dm(major surg), stop oral hypoglycemics on
day of op. Start soluble insulin
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51. preoperative workup of patients with
diabetes mellitus
Thorough physical examination, with special
care to discover occult infections;
ECG for myocardial infarction
 Chest x-ray for hidden pneumonia or
pulmonary edema.
 A complete urinalysis
Serum potassium
 serum creatinine assess renal function.
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52. DIET CONTROLLED DM
There are no specific precautions
Check on the blood sugar
Short acting insulin subcutaneous sliding scale
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53. Type 2 (Non-Insulin-Dependent) DM
If the serum glucose level is below 250 mg/dL on
the morning of surgery, sulfonylureas should be
withheld;
long-acting sulfonylurea drugs should be
discontinued on the day before surgery; and 5%
glucose solution should be administered
intravenously at a rate of about 100 mL/h.
 If the fasting glucose level is above 250-300
mgadd 5 units of insulin directly to each liter of 5%
glucose solution being given at 100 mL/h
The goal is to maintain glucose levels between 100
and 200 mg/dL,
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54. B. Type 1 (Insulin-Dependent) Diabetes
Mellitus
 Type 1 patients require insulin during surgery. It can be
administered by any of the following methods:
(1) subcutaneous administration of long-acting insulin;
(2) constant infusion of a mixture of glucose and insulin; or
(3) separate infusions of glucose and insulin.
• With either technique, blood glucose levels should be
monitored at least every 2 hours during the procedure to
avoid hypoglycemia below 60 mg/dL and hyperglycemia
above 250 mg/dL.
• Blood glucose levels can be measured rapidly during
surgery with a portable electronic glucose analyzer.
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55. Mgt con..
Early placement on the operating list
Minor procedure- continue with SC insulin
Procedures where breakfast & possibly lunch is
missed- Omit any short acting insulin & give ½-
intermediate or long acting to provide basal insulin
OR 1/3-1/2 of total morning dose as intermediate
insulin only
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56. APPROACH TO ANEMIA IN THE SURGICAL PATIENT
• should undergo a thorough workup to identify and
treat the underlying cause before elective
procedures are undertaken.
• A detailed history should be obtained to identify
any symptoms of blood loss from the
genitourinary and gastrointestinal tracts.
• A history of renal, hepatic, hematologic, or
endocrinologic disorders and a medication history
should be elicited.
• A complete laboratory evaluation including CBC,
reticulocyte count, peripheral smear
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57. • Generally, blood transfusion in surgery is only indicated if the:
i) Pre-operative Hb is <7gm/dl with minimal blood loss expected
at operation.
ii) Pre-operative Hb is <9gm/dl if greater then 500ml of surgical
blood loss is anticipated.
iii) Pre-operative Hb is <10gm/dl in patients with cardiac disease,
respiratory disease or with uraemia
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58. BMI <18.5 indicates nutritional impairment
BMI <15 is associated with significant hospital
mortality
Hx of weight loss >10% of body weight over a
6-months period or 5% over a month is
significant
 erative morbidity and mortality for over 70 years. Quantification of thedegree of malnutrition and thecorrection of severe malnutritionpreoperatively remain an important part of surgical management. Assessment of nutriti
Nutritional support for a minimum of 2 weeks
before surgery is required
Delay procedure until an optimum Wt. is
achieved
Pre op care
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59. Surgical risks associated with Obesity
Diffucult intubation
Aspiration
Myocardial infarction
Cerebrovascular incident
DVT
Respiratory compromise
Poor wound healing
Mechanical-lifting,transfering
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60. Adrenocortical Problems
Patients on steroid therapy needs stress dose
before undergoing major or minor surgery
Pheochromocytoma
• Pre-op Rx 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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61. perioperative supplemental
glucocorticoid regimens
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62. DVT prophylaxis
DVT is common in surgical patients
Can cause PTE which carries a high mortality
Surgery, trauma and immobilization are
responsible for 50% of DVT
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63. Caprini Risk assessment model for
venous thromboembolisim in general
surgical pt
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64. Venous thromboembolisim
prophylaxis
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65. Pts. On Anticoagulants
 Pre-op reversal of anticoagulant effect
 Warfarin should be withheld for 5 scheduled doses
preoperatively to lower INR to 1.5 or less
 Pts. on LMWH, give last dose 20-24hrs prior to
surgery & restart ~12-24hrs postoperatively
 For an elective procedure, discontinue heparin 6 hrs
before surgery
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66. Pre op care
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67. Cont..
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68. Prophylactic antibiotics
depends on
Most likely pathogen encountered
Class of the operative procedure
(clean, clean contaminated,
contaminated , dirty)
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69. Peri operative medication
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70. Pre op care
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71. Pre op care
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72. Preoperative Fasting
The standard order of “NPO after midnight”
for pre-op pts. is based on the theory of
reducing volume and acidity of the stomach’s
contents during surgery
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73. ASA recommendation for NPO time in Hours
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74. PREOPERATIVE PREPARATIONS
1. Psychological preparation
2. Take written informed consent.
3. Discuss with patient and the family about the risks,
benefits and alternatives
4. Skin preparation-bathing and shaving.
5. Keep NPO after mid night and MF
6. Optimize patient medically.
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75. 7. Preoperative incentive spirometry.
8. Prophylactic antibiotics …
9. Bowel preparation as necessary …
10. DVT prophylaxis where indicated …
11. Catheterize or insert NG tube as indicated
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76. Summary
• Preoperative care is targeted to the best out
come of surgical procedures
• Full assessment of the patient is important for
minimizing the risks.
• Optimize patient condition
• Choose surgery that offers minimal risk and
maximum benefit
• Anticipate and plan for adverse events
• Inform everyone concerned
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77. References
• Sabiston Textbook of Surgery, 20th edition,
Courtnet et al.
• Short practice of surgery(Bailey and Love ),
26th edition, Normal S.W et al.
• Washington manual of surgery 20th edition
• Fishers Master of surgery
• Greenfield’s surgery scientific principles and
practice 6th edition
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