preoperative assessment

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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