PREOPERATIVE PREPARATION

1. PREOPERATIVE PREPARATION
DR.RAGHU NATH KARMAKER
PHASE B RESIDENTS
PAEDIATRIC SURGERY
MMCH

2. INTRODUCTION
Preoperative and postoperative care are both important and in general ,are
responsibility of surgeon
The preoperative period should be used for relevant investigations and for
preparation for surgery .
The risk of surgery and GA are increased in patient who has poor perfusion and
oxygen delivery to vital tissue .
Many patient requiring emergency surgery in this compromised state leading to
hypovolemia ,CF, anemia , sepsis, or respiratory failure.

3. Definition
Preoperative preparation is the preparation of a patient requiring surgery to
optimize postoperative outcomes.
The preparation start from the time of contact of the patient with the surgeon
and ends on the day of surgery in the preoperative room .

4. OBJECTIVES
Surgical, medical and anaesthetic aspects of assessment
Optimize the patients condition
Consent
To organize operating list

5. AVAILABLE TIME FOR PREOPERATIVE
OPTIMISATION
1.
2.
3.
4.
5.
General preoperative preparation of patient is highly variable and divided into –
The 4 minutes window
The 4 hour window
The 4 day window
The 4 week window
The over 4 month window

6. The 4 minutes window – immediate surgery eg; cardiothoracic trauma ,
exsanguinating haemorrhage .
The 4 hour window – gastrointestinal surgical emergency .
The 4 day window – delays of several days allows more formal preparation for
surgery eg; laparotomy for non strangulating bowel obstruction , surgery for
obstructive jaundice .
The 4 week window – most cancer surgery can be delayed for several weeks .
The over 4 month window – truly elective surgery postponed if the risk of surgery
significant .

7. Preoperative plan for the best patient
outcomes :
Gather and record all relevant information
Optimise patient condition
Choose surgery that offers minimal risk and maximum benefit
Anticipate and plan for adverse events
Inform everyone concerned

8. PATIENT ASSESSMENT
HISTORY TAKING : A standard history should be taken . A set of fixed question
are needed to determine fitness for surgery .surgery specific symptoms ,onset,
duration , exacerbating and relieving factors should also be documented.
Principles of history taking are :
Listen
Clarify
Narrow (Differential diagnosis)
Fitness

9. PATIENT ASSESSMENT
CVS history : Blood pressure , chest pain , palpitation , syncope , dyspnea and
poor exercise tolerance.
Respiratory system history : history of productive cough , wheeze , dyspnea ,
hoarseness of voice or stridor present .increasing sevearity of symptoms
indicates worsening of the condition .
Past history : past surgery and anaesthesia can reveal problems that may
present during current hospitalization .
Drug history

10. Examination :
General examination
CVS
Respiratory
Gastrointestinal
Neurological
Airway assessment

11. Examination specific to surgery :
The clinical findings , site , side , specific imaging or investigation findings
related to the pathology for which the surgery is proposed should be noted .

12. INVESTIGATIONS
FBC and Blood grouping
Serum creatinine
Chest radiography
Blood glucose
Urinalysis
On special situations : Echocardiogram like ARM, Cleft lip ,palate etc .
Others : clotting screening , beta HCG , LFT, Investigation to assess capacity of
specific organ system and risk associated .

13. Preoperative assessment in emergency
surgery :
The principles of preoperative assessment is the same as in elective surgery ,
except that the opportunity to optimize the condition is limited by time
constraints.
Medical assessment and treatment should be – ATLS protocol
Some risks may be reduced but some may persist and whenever possible these
need to be explained to the patient .

14. RISK ASSESSMENT AND CONSENT:
Risks : Related to the co-morbidities , anaesthesia and surgery
Explain : advantages , side effect , prognosis
Language : simple , use daily life comparisons to explain risks
Consent : valid consent is necessary ( from legal guardian under 16 years )
except in life savings circumstances .

15. THE OPERATIVE TEAM
Ward , theatre and specialist nursing staff
Anaesthetic and surgical teams
Radiology , pathology involvement
Rehabilitation and social care workers
Specific personnel in individual cases

16. DUTIES OF NURSES
To provide information and emotional support for patients and their family
members .
To ensure that all preoperative data have been accumulated
To maintain patients baseline haemodynamic statuses

17. ARRANGING THE THEATRE LIST
The date , place and time of operation should be matched with availability of
personnel.
Appropriate equipment and instruments should be made available.
The operating list should be distributed all staffs who are involved in making the
list run smoothly.
Priorities patients selected by team leader .

18. SPECIAL CONSIDERATIONS :
Preoperative fasting :
Aim : prevent acid aspiration syndrome
Children : 2 hours for clear fluid , 6 hour for solids .
Infants : clear fluid up to 2 hours , mothers milk up to 3 hours , cow or formula
milk up to 6 hours before anaesthetic .

19. PATIENT WITH OBSTRUCTIVE JAUNDICE
PREPARATION :
Correction of dehydration and electrolyte imbalance .
Correction of coagulation profile ( inj. Vitamin k 10 mg once daily for 3 days, if
not corrected FFP Before and during operation ).
Prevention of hepato-renal shut down
Avoid hepatotoxic drugs as possible
Prophylactic antibiotics
Avoid constipation to prevent translocation of gut organism .

20. PREPARATION FOR HAEMOPHILIA
PATIENT
Coagulation profile : BT, CT, PT, APTT
Factor eight and nine assay
Aim : for minor surgery factor level should be at least 50 %,
for major surgery factor level should be 100%
operation should be done under GA.
Calculated amount of recombinant factor eight concentrate transfuse 12 hourly ,
and factor nine once daily .

21. GUT PREPARATION :
Aim : reduce faecal load
reduction of number of bacteria .
Objective : To reduce chance of anastomotic leakage
To reduce chance of postoperative infection .
Preparation : 2 days before surgery – low residual diet and laxatives
One days before surgery ( liquid diet , laxative and rectal wash )
On the day of surgery : enema simplex at morning .

22. INTRAVENOUS ACCESS
1.
2.
3.
4.
Sometimes intravenous access is challenging for preoperative preparation part ,
several method of IV access are :
Percutaneous peripheral vein cannulation
Peripheral vein “cut down “
Interosseous access
Central venous catheterization .

23. CONCLUSION
The anticipated outcome of preoperative preparation is a patient who is
informed about the surgical course and copes with it successfully. The goal is to
decrease complication and promote recovery .