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CME Preoperative assessment final.pptx
- 1. PRE-OPERATIVE ASSESSMENT Presenters : Hemeshwary , Aisyah Supervisor : Dr Isma
- 2. OUTLINE • INTRODUCTION • SYSTEMS OF PREOPERATIVE ASESSMENT • SYSTEMIC APPROACH TO PRE OP EVALUATION • PREOPERATIVE CHECKLIST • TAKE HOME MESSAGE
- 3. INTRODUCTION • Preoperative assessment process to ensure that the proposed procedure remains appropriate – that the presenting complaint still warrants an operation and that the patient has made an informed decision to proceed. • Early identification of these patients allows time to optimize their pre-existing medical illness and plan perioperative management so as to reduce risk.
- 4. • In addition, preoperative assessment offers an opportunity to perform routine clerical tasks and also to advise patients about fasting, how to manage their routine medications and what will happen on the day of surgery. • Patients scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery.
- 6. SYSTEMIC APPROACH TO PRE OP EVALUATION HISTORY TAKING • A standard history should be taken. A set of fixed questions are needed to determine 'fitness' for surgery. • Surgery specific symptoms ( including features not present), onset , duration and exacerbating and relieving factors should also be documented
- 7. • Cardiovascular history : High blood pressure , chest pains palpitations, syncope, dyspnoea, and poor exercise tolerance • Respiratory system history : History of smoking , productive cough, wheeze, dyspnoea, or stridor present. • Drug history: A full drug history - some medications require stopping or altering prior to surgery • Past Surgical and Anaesthetic History
- 8. EXAMINATION General • Anemia , jaundice, cyanosis, nutritional status , sources of infection • Airway assesment • The airway examination is completed by systematic inspection of the mouth opening, thyromental distance, neck mobility, and the size of the tongue in relation to the oral cavity • The patient is observed in frontal and profile views . The size of the tongue in relation to the oral cavity can be graded by using the Mallampati classification.
- 10. (REVISED CARDIAC INDEX LEE CRITERIA) • Cardiovascular • Pulse , blood pressure , bruits, peripheral oedema • Stress ECG, stress echocardiogram, myocardial scintigraphy- IHD • Patients with any suggestion of valvular heart disease or poor left ventricular function, an echocardiogram should be done : EF < 30% is associated with poor patient outcomes
- 11. Respiratory • Respiratory rate and effort, chest expansion, and percussion note, breath sounds, oxygen saturation • Lung function test- assess individuals with known or suspected respiratory disease Neurological • Consciousness level, cognitive function, sensation, muscle power, tone and reflexes Renal disease • Underlying conditions leading to chronic renal failure such as diabetes mellitus, hypertension and IHD – should be stabilized before elective surgery • Appropriate measures should be taken to treat acidosis , hypocalcemia and hypercalcemia
- 13. PRE OPERATIVE INVESTIGATIONS • FBC • Renal profile and electrolytes • ECG • CXR • Clotting screen • LFT, TFT • Other indicated investigations; HbA1c, glucose, urinalysis, ABG
- 14. ANTIBIOTICS • Appropriate antibiotic prophylaxis in surgery depends on the most likely pathogens encountered during the surgical procedure. • The expected wound classification of the planned operative procedure is helpful for deciding the appropriate antibiotic spectrum and is considered before ordering or administering any preoperative medication.
- 16. • Prophylactic antibiotics are not generally required for clean (class I) cases except in the setting of indwelling prosthesis placement or when bone is incised. • Patients who undergo class II procedures benefit from a single dose of an appropriate antibiotic administered before the skin incision. • Contaminated (class III) cases require mechanical preparation or parenteral antibiotics with aerobic and anaerobic activity. • Dirty or infected cases often require the same antibiotic spectrum, which can be continued into the postoperative period in the setting of ongoing infection or delayed treatment • The appropriate antibiotic is chosen before surgery and administered within 60 minutes before surgical incision
- 17. PRE OP FASTING • 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. • If the surgery is delayed, oral intake of clear fluids should be allowed until 2 hours before surgery or intravenous fluids should be started, especially in vulnerable groups of patients,e.g. children, the elderly and diabetics. • Patients can continue to take their specified routine medications with sips of water in the NBM period.
- 18. REVIEW OF MEDICATION • Patients taking cardiac drugs including beta blockers and antiarrhythmics, anticonvulsants, antihypertensives, or psychiatric drugs are advised to take their medications with a sip of water on the morning of surgery. • Oral hypoglycaemics should be withold to avoid hypoglycaemic episodes during preoperative fasting. • Drugs that are associated with an increased risk for perioperative bleeding are withheld before surgery. • Clopidogrel (Plavix) is withheld for 7 to 10 days, • Aspirin stopped 1 week before surgery. • Warfarin usually stopped 5 days before surgery
- 19. CONSENT Consent should be both voluntary and informed. The discussion between the surgeon and patient should: ● give the patient the information required to make a decision; ● be tailored to the individual patient; ● explain all reasonable treatment options; ● should be written and recorded on a form; ● the key points of the discussion should be recorded in the case notes.
- 20. • For consent to be given, the patient must have capacity, which includes the ability to understand the information provided, to retain and use the information to make a decision and to indicate what that decision is. • The surgeon should presume the patient has capacity for consent unless during the process it is demonstrated that this is not the case. The person obtaining consent must be appropriately experienced to do so. • Consent from children below 18 should be obtain from the caretaker
- 21. ARRANGING AN OPERATIVE ROOM • 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 as early as possible to all staff who are involved in making the list run smoothly. • Prioritise patients, e.g. children and diabetic patients should be placed at the beginning of the list; life- and limb-threatening surgery should take priority; cancer patients need to be treated early.
- 22. TAKE HOME MESSAGE Assess the risks and benefits of the proposed surgery 1 Identify any condition that may require intervention prior to admission and surgery and take appropriate actions 2 Perform necessary investigation and review the results 3 Obtain informed consent and prepare pre op documentation 4
- 23. SOURCES • Bailey and Love’s Short Practice of Surgery 27th Edition • Sabiston Textbook of Surgery 20th Edition
- 24. THANK YOU
Editor's Notes
- A brief history of why the patient first attended and what procedure they have subsequently been scheduled for. One should also confirm the side on which the procedure will be performed (if applicable)
- Cardiovascular disease, including hypertension; exercise tolerance is a useful indicator of cardiovascular fitness and, particularly for patients undergoing major surgery, can help predict their risk of post-operative complications and level of care needed post-operatively. Screening questions may elucidate undiagnosed disease and prompt further investigation, e.g. the presence of exertional chest pain, syncopal episodes, or orthopnoea (sensation of breathlesness in the recumbent position relieved by sitting or standing) Respiratory disease, as adequate oxygenation and ventilation is essential in reducing the risk of acute ischaemic events in the peri-operative period. Questions including whether the patient is able to lie flat for a prolonged period or has a chronic cough are key as these may preclude spinal anaesthesia; also screen for symptoms and signs of obstructive sleep apnoea, if the patient has any risk factors . Increasing severity of symptoms generally indicates worsening of the condition. A full drug history is required, as some medications require stopping or altering prior to surgery EXAMPLE. Ask about any known allergies, both drug and non-drug allergies Past Surgical History: Has the patient had any previous operations? If so, what, when, and why? If the patient is having a repeat procedure, this can significantly change both the surgical time and ease of operation, and hence influence the anaesthetic technique used Past Anaesthetic History Has the patient had anaesthesia before? If so, for what operation and what type of anaesthesia? Were there any problems? Did the patient experience any post operative nausea and vomiting?
- The Mallampati examination is performed with the patient sitting and the head in a neutral position, the mouth opened as wide as possible, and the tongue protruded maximally. The observer views the oral and pharyngeal structures that are evident. In general, patients in whom the uvula, tonsillar pillars, and soft palate are visible (class I) are easy to mask ventilate and intubate. Patients in whom only the hard palate is visible, a class IV airway, have a higher likelihood of being difficult to mask ventilate and intubate. However, the Mallampati classification is only one component of the airway examination and must be used in conjunction with other aspects of the airway examination and the patient’s history to provide a complete airway assessment.
- The airway examination is completed by systematic inspection of the mouth opening, thyromental distance, neck mobility, and the size of the tongue in relation to the oral cavity The patient is observed in frontal and profile views . The size of the tongue in relation to the oral cavity can be graded by using the Mallampati classification. The Mallampati examination is performed with the patient sitting and the head in a neutral position, the mouth opened as wide as possible, and the tongue protruded maximally. The observer views the oral and pharyngeal structures that are evident. In general, patients in whom the uvula, tonsillar pillars, and soft palate are visible (class I) are easy to mask ventilate and intubate. Patients in whom only the hard palate is visible, a class IV airway, have a higher likelihood of being difficult to mask ventilate and intubate. However, the Mallampati classification is only one component of the airway examination and must be used in conjunction with other aspects of the airway examination and the patient’s history to provide a complete airway assessment.
- Systemic approach to pre op evaluation Cardiovascular It is important to identify the patients who have a high perioperative risk of major adverse cardiovascular events (MACE) including myocardial infarction (MI), and make appropriate arrangements to reduce this risk. Patients at high risk are those with ischaemic heart disease (IHD), congestive cardiac failure (CCF), arrhythmias, severe peripheral vascular disease, cerebrovascular disease or 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). In patients with any suggestion of valvular heart disease or poor left ventricular function, an echocardiogram should be obtaine; an ejection fraction of less than 30% is associated with poor patient outcomes.
- Pulmonary Postoperative respiratory complications, such as pneumonia, are a major cause of morbidity and mortality especially after major abdominal and thoracic surgery. A patient’s current respiratory status should be compared with their ‘normal state’. A preoperative chest radiograph or scan is useful in a patient with known emphysematous bullae, pulmonary cancer, metastasis or effusions. 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 (for age, weight and height), have severe disease are at risk of pneumonia and respiratory failure in the postoperative period. Neurological In patients with a history of stroke, pre-existing neurological deficit should be recorded. These patients may be on anti-platelet or anticoagulant Renal 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&Es. In the acute setting, patients who have a stable volume status can undergo surgery without preoperative dialysis, provided that no other indication exists for emergency dialysis Diabetic patients Diabetes and associated cardiovascular and renal complications should be controlled to as near normal level as possible before a surgery. Any history of hyper- and hypoglycaemic episodes, and hospital admissions, should be noted. HbA1c levels should be checked. For elective surgery, HBA1c of <69 mmol/mol is recommended. Lipid-lowering medication should be started in patients who are in a high risk group for cardiovascular complications of diabetes. If the operation is in the morning, patient is advised to omit the morning dose of medication and breakfast. Though tight control of blood sugar is not needed, the patient’s blood sugar levels should be checked 2 hourly. For those on the afternoon list, breakfast can be given with half their regular dose of intermediate-acting insulin (or full dose oral antidiabetic agents) and then managed with regular blood sugar checks 2hourly. 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.