2. In the last 10 years there has been a major shift from
in-patient to out-patient surgery. Many patients requiring major
in-patient elective surgery now arrive in hospital on the day of
surgery. Preoperative assessment and optimisation important part of
modern surgical practice. The modern preparation of a patient for
operation characterizes the convergence of the art and science of
the surgical discipline.
3. Important aspects of pre-op. preparation are : 1. GATHER AND
RECORD 2. PLAN 3. BE PREPARED 4. COMMUNICATE
4. Aim : not to screen broadly for undiagnosed disease but
rather to identify and quantify comorbidity that may impact
operative outcome. Driven by findings on history and physical
examination suggestive of organ system dysfunction. The goal is to
uncover problems areas that may require further investigation or be
amenable to preoperative optimization. If significant comorbidity
or evidence of poor control of an underlying disease process,
consultation with a specialist
5. ROUTINE PREOPERATIVE PREPARATION FOR SURGERY History
Physical examination Special investigation Informed consent Marking
the site/side of operation Antibiotic prophylaxis
6. SURGICAL HISTORY Hx taking is detective work. Preconceived
ideas, snap judgment and hasty conclusions have no place in this
process. Do not be in any doubt that a good hx is not vital. If you
embark on surgical treatment concentrating on a localized lesion
you will be unprepared if complications developed. If you take the
wrong diagnostic path all the rest of your activities
misdirected.
7. PRINCIPLES OF HISTORY-TAKING Listen: what does the patient
see as the problem? (Open questions) Clarify: what does the patient
expect? (Closed questions) Narrow the differential diagnosis.
(Focused questions) Fitness: what other comorbidities exist? (Fixed
questions) LAYOUT OF A STANDARD HISTORY Presenting complaint
History of the presenting complaint
8. SORE POPE Symptoms, including features not present Onset
Relieving factors Exacerbating factors Pain, nature of the pain,
any radiation, etc. Other therapies Planned surgery
Expectations
9. PAST Hx H/O DM, TB, HTN Any previous op.or bleeding tendency
Any previous reaction to anaesthetic agent DRUGS Hx Interaction
with anesthesia (MAOI) Drugs for HTN ,IHD to be cont.over
preoperative period Anticoagulant drugs (aspirin, warfarin)
10. Social history Smoking Alcohol Occupation Diet Identify
problems early to formulate a sensible postoperative plan and
prevent delays in discharge. Family History HTN, DM , TB, ALLERGIC
DISORDER , CA , etc
11. PHYSICAL EXAMINATION This include a full physical exam Dont
rely on the examination of others Surgical signs may change and
others may miss important pathology One should acquire the habit of
performing a complete exam in exactly the same sequence; No step is
omitted and added advantage of familiarizing what is normal so that
abnormalities can be more recognized
13. SYSTEMIC EXAMINATION Cardiovascular Pulse, blood pressure,
heart sounds, bruits, peripheral pulses, peripheral oedema
Respiratory Respiratory rate and effort, chest expansion and
percussion note, breath sounds, oxygen saturation Gastrointestinal
Abdominal masses, ascites, bowel sounds, bruits, herniae, genitalia
Neurological Conscious level, any pre-existing cognitive impairment
or confusion, deafness, neurological status of limbs
14. INVESTIGATIONS 1) FULL BLOOD COUNT (WHEN TO PERFORM ?) All
emergency Pre-operative cases All elective Pre-operative cases over
60 years All elective Pre-operative cases in adult females If
surgery likely to result in significant blood loss Suspicion of
blood loss, anemia,sepsis,CRD,coagulation problems 2.) UREA &
ELECTROLYTES(WHEN TO PERFORM?) All Pre-operative cases over 65
Positive result from U/A All pt with cardiopulmonary dis. or taking
diuretics, steroids All pt with H/O renal/liver dis.or abn.
nutritional state All pt with H/O diarrhea/vomiting or other
metabolic/endocrine dis. All pt with IVF for more than 24hrs
15. 3) LIVER FUNCTION TESTS Jaundice Known Or Suspected
Hepatitis Cirrhosis Malignancy Portal Hypertension Poor Nutritional
Reserves Or Clotting Problems 4) CLOTTING SCREEN Patient On
Anticoagulants Compromised Liver Function Tests Or Evidence Of A
Bleeding Diathesis. Surgery May Involve Heavy Blood Loss.
16. 5) ELECTROCARDIOGRAPHY All above age of 65 All patients in
whom significant blood loss is possible All those with a history of
cardiovascular, pulmonary or anaesthetic problems. 6) CHEST X-RAY
All elective pre-operative cases over 60 yrs All cases of
cervical,thoracic or abdominal trauma. Acute respiratory symptoms
or signs Previous CRD and no recent CXR Thoracic surgery Malignant
dis. Viscus perforation Recent H/O TB Thyroid enlargement
17. 7) GROUP AND SAVE /CROSSMATCH Emergency pre-operative case
Suspicion of blood loss,anemia,coagulatin defect Procedure on
pregnant ladies 8) BLOOD SUGAR - All diabetic pts - All above 40
yrs of age - Family hist
18. SYSTEMS APPROACH TO PREOPERATIVE EVALUATION I)
CARDIOVASCULAR Cardiovascular disease is the leading cause of death
in the industrialized world, and its contribution to perioperative
mortality for noncardiac surgery is significant. Nearly 30% have
significant coronary artery disease or other cardiac comorbidities.
As such, much of the preoperative risk assessment and patient
preparation centers on the cardiovascular system.
19. CARDIAC RISK INDICES 1) Goldman Cardiac Risk Index, 1977 2)
Detsky Modified Multifactorial Index, 1986 3) Eagle's Criteria for
Cardiac Risk Assessment, 1989 Revised Cardiac Risk Index 1.
Ischemic heart disease 1 Each increment in points increases the
risk for postoperative myocardial morbidity 2. Congestive heart
failure 1 3. Cerebral vascular disease 1 4. High-risk surgery 1 5.
Preoperative insulin treatment of diabetes 1 6. Preoperative
creatinine >2 mg/dL 1
20. CLINICAL PREDICTORS OF INCREASED PERIOPERATIVE
CARDIOVASCULAR RISK LEADING TO MYOCARDIAL INFARCTION, HEART
FAILURE, OR DEATH Major Risk Factors Unstable coronary syndromes
Acute or recent myocardial infarction with evidence of considerable
ischemic risk as noted by clinical symptoms or noninvasive studies
Unstable or severe angina (Canadian class III or IV) Decompensated
heart failure Significant arrhythmias High-grade atrioventricular
block Symptomatic ventricular arrhythmias in the presence of
underlying heart disease Supraventricular arrhythmias with an
uncontrolled ventricular rate Severe valve disease
21. Minor Risk Factors Advanced age Abnormal electrocardiogram
(e.g., left ventricular hypertrophy, left bundle branch block, ST-T
abnormalities) Rhythm other than sinus (e.g., atrial fibrillation)
Low functional capacity (e.g., inability to climb one flight of
stairs with a bag of groceries) History of stroke Uncontrolled
systemic hypertension Intermediate Risk Factors Mild angina
pectoris (Canadian class I or II) Previous myocardial infarction
identified by history or pathologic evidence Q waves Compensated or
previous heart failure Diabetes mellitus (particularly insulin
dependent) Renal insufficiency
22. - Weigh the benefits of surgery versus the risk and
determine whether perioperative intervention will reduce the
probability of a cardiac event. - Coronary revascularization using
coronary artery bypass or percutaneous transluminal coronary
angioplasty - Sx delayed upto 4-6 wks after coronary
intervention
23. - Any patient can be evaluated as a surgical candidate
after an acute MI (within 7 days of evaluation), or a recent MI
(between 7 and 30 days of evaluation). -There is a significant
mortality rate from anaesthesia within 3 months of infarction and
elective procedures should ideally be delayed until at least 6
months have elapsed. - Systolic pressures > 160 mmHg &
diastolic pressures >95 mmHg ----postpone surgery -Newly
diagnosed hypertension may need further investigation to look for
an underlying cause; the medical team may need to be involved.
24. *Perioperative risk for cardiovascular morbidity and
mortality was decreased by 67% and 55%, respectively, in patients
receiving blockade in the perioperative period versus those
receiving placebo. *Benefit noticeable in the 6 months following
surgery, better in the group that received blockade up to 2 years
after surgery.
25. II) PULMONARY -Preoperative evaluation of pulmonary
function may be necessary for either thoracic or general surgical
procedures. -Extremity, neurosurgical, and lower abdominal surgical
procedures do not routinely require pulmonary function studies,
-Thoracic and upper abdominal procedures can decrease pulmonary
function and predispose to pulmonary complications. As such, it is
wise to consider assessing pulmonary function for - all lung
resection cases, -thoracic procedures requiring single-lung
ventilation, and -major abdominal and thoracic cases in patients
>60 years of age, -have significant underlying medical disease -
smoke -have overt pulmonary symptomatology.
26. Necessary tests include 1) the forced expiratory volume at
1 second (FEV1), 2) the forced vital capacity, and 3)the diffusing
capacity of carbon monoxide. Adults with an FEV1 of less than 0.8
L/second, or 30% of predicted, have a high risk of complications
and postoperative pulmonary insufficiency; nonsurgical solutions
should be sought. General factors that increase risk for
postoperative pulmonary complications include : -Increasing Age,
-Lower Albumin Level, -Dependent Functional Status, - Weight Loss,
-Obesity
28. That may decrease postoperative pulmonary complications,
include -Smoking Cessation (2 mths) -Bronchodilator Therapy,
-Antibiotic Therapy For Preexisting Infection, And -Pretreatment Of
Asthmatic Patients With Steroids. Perioperative strategies include
-The Use Of Epidural Anesthesia, -Vigorous Pulmonary Toilet And
Rehabilitation, And -Continued Bronchodilator Therapy.
29. III) RENAL Approximately 5% of the adult population have
some degree of renal dysfunction .The identification of
cardiovascular, circulatory, hematologic, and metabolic
derangements secondary to renal dysfunction should be the goal of
preoperative evaluation of these patients. The patient should be
questioned about prior MI and symptoms consistent with ischemic
heart disease. Cardiovascular examination should seek to document
signs of fluid overload.
30. Diagnostic testing for patients with renal dysfunction
should include -Electrocardiogram (ECG), -Serum Chemistry Panel
(Na,k,cl,urea,creatinine,ca,p Etc.) - Complete Blood Count (CBC). -
Urinalysis And Urinary Electrolyte Studies - Blood Gas
Determination - Prothrombin Time (PT) And Partial Thromboplastin
Time - Bleeding Time
31. -Pharmacologic manipulation of * hyperkalemia, *replacement
of calcium for symptomatic hypocalcemia, and *the use of
phosphate-binding antacids for hyperphosphatemia -Sodium
bicarbonate is used in the setting of metabolic acidosis when serum
bicarbonate levels are below 15 mEq/L. This can be administered in
intravenous (IV) fluid as 1 to 2 ampules in 5% dextrose solution.
-Hyponatremia is treated with volume restriction, although dialysis
is often required within the perioperative period for control of
volume and electrolyte abnormalities.
32. -Patients with chronic end-stage renal disease should
undergo dialysis prior to surgery, to optimize their volume status
and control the potassium level. -Intraoperative hyperkalemia can
result from surgical manipulation of tissue or the transfusion of
blood. Such patients are often dialyzed on the day after surgery as
well. - In the acute setting, patients who have a stable volume
status can undergo surgery without preoperative dialysis, provided
that no other indication exists for emergent dialysis.
34. *The prevention of secondary renal insult in the
perioperative period must be the focus of the anesthesia and
surgical teams. *This includes the avoidance of nephrotoxic agents
and maintenance of adequate intravascular volume throughout this
period. *In the postoperative period, the pharmacokinetics of many
drugs may be unpredictable, and adjustments of dosages should be
made. *Notably, narcotics used for postoperative pain control may
have prolonged effects, despite hepatic clearance. *NSAIDs should
be avoided.
35. IV) HEPATOBILIARY -Hepatic dysfunction may reflect the
common pathway of a number of insults to the liver, including
viral-, drug-, and toxin-mediated disease. - careful assessment of
the degree of functional impairment as well a coordinated effort to
avoid additional insult in the perioperative period. Evidence of
hepatic dysfunction include : -Jaundice and scleral icterus -Skin
changes include spider angiomas, caput medusae, palmar erythema,
and clubbing of the fingertips. - Abdominal examination may reveal
distention, evidence of fluid shift,and hepatomegaly. -
Encephalopathy or asterixis may be evident - Muscle wasting or
cachexia can be prominent
36. INVESTIGATIONS -LFT -Albumin levels -Coagulation profile.
-Serologic testing for hepatitis A, B, and C. -Alcoholic hepatitis
is suggested by lower transaminase levels and an AST/ALT ratio
greater than 2 -The patient with acute hepatitis with elevated
transaminases should be managed nonoperatively, when feasible,
until several weeks beyond normalization of laboratory values.
-Urgent or emergent procedures in these patients are associated
with increased morbidity and mortality. -The patient with evidence
of chronic hepatitis may often safely undergo operation. -The
patient with cirrhosis may be assessed using the Child-Pugh
classification.
37. CHILD-PUGH SCORING SYSTEM POINTS 1 2 3 Encephaopathy None
Stage I or II Stage III or IV Albumin(g/dl) >3.5 2.8-3.5 10
g/dL, transfusion rarely required. Measure vital signs/tissue
oxygenation when hemoglobin is 6 to 10 g/dL and extent of blood
loss is unknown. Tachycardia and hypotension refractory to volume
suggest the need for transfusion; O2 extraction ratio > 50%, VO2
decreased, suggest that transfusion usually is needed
59. All patients undergoing surgery should be questioned to
assess bleeding risk. Coagulopathy may result from inherited or
acquired platelet or factor disorders or may be associated with
organ dysfunction or medications. Assessment includes : -personal
or family history of abnormal bleeding. - history of easy bruising
or abnormal bleeding associated with minor procedures or injury.
-nutritional status. -Review of medications and the -Use of
anticoagulants, salicylates,NSAIDs, and antiplatelet drugs should
be noted -coagulation studies
60. Physical examination may reveal bruising, petechiae, or
signs of liver dysfunction. Patients with thrombocytopenia may have
qualitative or quantitative defects, due to immune-related disease,
infection, drugs, or liver or kidney dysfunction. Qualitative
defects --medical management of the underlying disease process,
whereas Quantitative defects -- platelet transfusion when counts
are less than 50,000 in a patient at risk for bleeding. Although
should not be routinely ordered, patients with a history suggestive
of coagulopathy should undergo coagulation studies prior to
operation
61. *Patients taking warfarin, the drug can be held for several
days preoperatively to allow the International Normalized Ratio
(INR) to fall to the range of 1.5 or less. *Patients with a recent
history of venous thromboembolism or acute arterial embolism often
require perioperative IV heparinization due to increased risk of
recurrent events in the perioperative period.
62. *Systemic heparinization can often be stopped within 6
hours of surgery and restarted within 12 hours postoperatively.
*When possible, surgery should be postponed in the first month
after an episode of venous or arterial thromboembolism. *Patients
on anticoagulation for less than 2 weeks for pulmonary embolism or
proximal DVT should be considered for inferior vena cava filter
placement prior to operation
63. Level of Risk Definition of Risk Level Calf DVT (%) Proxim
al DVT (%) Clinica l PE (%) Fatal PE (%) Prevention Strategy Low
Minor surgery in patients < 40 yr with no additional risk
factors 2 0.4 0.2 0.002 No specific measures Moderate Minor surgery
in patients with additional risk factors: nonmajor surgery in
patients aged 4060 yr with no additional risk factors; major
surgery in patients < 40 yr with no additional risk factors 1020
24 12 0.10.4 LDUH q 12 hr, LMWH, ES or IPC High Nonmajor surgery in
patients > 60 yr or with additional risk factors; major surgery
in patients > 40 yr or with additional risk factors 2040 48 24
0.41.0 LDUH q 8 hr, LMWH or IPC Highest Major surgery in patients
> 40 yr plus prior VTE, cancer, or molecular hypercoagulable
state; hip or knee arthroplasty, hip fracture surgery; major
trauma; spinal cord injury 4080 1020 410 0.25 LMWH, oral
anticoagulants, IPC/ES + LDUH/LMWH or ADH
64. NATIONAL RESEARCH COUNCIL CLASSIFICATION OF OPERATIVE
WOUNDS CLASS I (CLEAN) Nontraumatic No inflammation No break in
technique Respiratory, alimentary, or genitourinary tract not
entered CLASS II (CLEAN -CONTAMINATED) Gastrointestinal or
respiratory tract entered without significant spillage CLASS III
(CONTAMINATED) Major break in technique Gross spillage from
gastrointestinal tract Traumatic wound, fresh Entrance of
genitourinary or biliary tracts in presence of infected urine or
bile CLASS IV ( DIRTY) Acute bacterial inflammation encountered,
without pus Transection of clean tissue for the purpose of surgical
access to a collection of pus Traumatic wound with retained
devitalized tissue, foreign bodies, fecal contamination, or delayed
treatment, or all of these; or from dirty source
65. -The appropriate antibiotic should be chosen prior to
surgery and administered before the skin incision is made. -Repeat
dosing should occur at an appropriate interval,generally 3 hours
for abdominal cases or twice the half-life of the antibiotic.
-Perioperative antibiotic prophylaxis should generally not be
continued beyond the day of operation. - With the advent of minimal
access surgery, the use of antibiotics seems less justified because
the risk of wound infection is extremely low.
66. ANTIMICROBIAL PROPHYLAXIS FOR SURGERY sabiston 18th edition
NATURE OF OPERATION COMMON PATHOGENS RECOMMENDED ANTIMICROBIALS
ADULT DOSAGE BEFORE SURGERY Gastrointestinal Esophageal,
gastroduodenal Enteric gram-negative bacilli, gram-positive cocci
High risk[ only: cefazolin 1-2 g IV Biliary tract Enteric
gram-negative bacilli, enterococci, clostridia High risk only:
cefazolin 1-2 g IV Colorectal Enteric gram-negative bacilli,
anaerobes, enterococci Oral: neomycin + erythromycin base OR
metronidazole Parenteral: cefoxitin] 1-2 g IV OR cefazolin 1-2 g IV
+ metronidazole 0.5 g IV OR ampicillin/sulbactam 3 g IV
Appendectomy, non-perforated Enteric gram-negative bacilli,
anaerobes, enterococci Cefoxitin 1-2 g IV OR cefazolin 1-2 g IV +
metronidazole 0.5 g IV OR ampicillin/sulbactam 3 g IV Genitourinary
Enteric gram-negative bacilli, enterococci High risk* only:
ciprofloxacin 500 mg PO or 400 mg IV * Urine culture positive or
unavailable, preoperative catheter, transrectal prostatic biopsy,
placement of prosthetic material
67. * Parenteral prophylactic antimicrobials can be given as a
single IV dose begun 60 minutes or less before the operation. * For
prolonged operations (>4 hours) or those with major blood loss,
additional intraoperative doses should be given at intervals 1-2
times the half-life of the drug for the duration of the procedure
in patients with normal renal function. * If vancomycin or a
fluoroquinolone is used, the infusion should be started 60-120
minutes before the initial incision in order to minimize the
possibility of an infusion reaction close to the time of induction
of anesthesia and to have adequate tissue levels at the time of
incision.
68. -For patients allergic to penicillins and cephalosporins,
clindamycin with gentamicin, ciprofloxacin, levofloxacin, or
aztreonam is a reasonable alternative. -For a ruptured viscus,
therapy is often continued for about 5 days. Ruptured viscus in
postoperative setting (dehiscence) requires antibacterials to
include coverage of nosocomial pathogens.
69. REVIEW OF MEDICATIONS A careful review of the patients home
medications should be a part of the preoperative evaluation prior
to any operation. - In general, patients taking *cardiac drugs,
including blockers and antiarrhythmics; *pulmonary drugs such as
inhaled or nebulized medications; or *anticonvulsants,
*antihypertensives, or *psychiatric drugs, should be advised to
take their medications with a sip of water on the morning of
surgery. - Medications such as lipid lowering agents or vitamins
can be omitted on the day of surgery.
70. - Drugs that affect platelet function should be held for
variable periods: * aspirin and clopidogrel should be held for 7 to
10 days, *NSAIDs should be held between 1 day (ibuprofen and
indomethacin) and 3 days (naproxen and sulindac), depending on the
drugs half-life. - Estrogen use has been associated with an
increased risk of thromboembolism and should be withheld for a
period of 4 weeks preoperatively.
71. PREOPERATIVE CHECKLIST The preoperative evaluation
concludes with a review of all pertinent studies and information
obtained from investigative tests. Documentation should be made in
the chart of this review, which represents an opportunity to ensure
that all necessary and pertinent data have been obtained and
appropriately interpreted. Informed consent should be documented in
the chart, which represents the result of discussion(s) with the
patient and family members regarding the indication for the
anticipated surgical procedure, as well as its risks and proposed
benefits. Preoperative orders should be written and reviewed as
well. The patient should receive written instructions regarding
time of surgery and management of special perioperative issues such
as bowel preparation or medication usage.
72. I ) COLORECTAL CARCINOMA A) BOWEL PREPARATION It is
important to obtain physical clearance of the bowel. Many surgeons
have changed from traditional methods of bowel preparation to using
purgative (sodium citric acid 12g, magnesium oxide 3.5 g). A
suitable regime is : Preoperative days 4 and 3: low residue diet
Preoperative days 2 and 1: liquid only diet Day of admission: 1
sachet Picolax in morning, repeated in afternoon These methods are
contraindicated in complete intestinal obstruction
73. On-table lavage -An appendicectomy is performed and a large
calibre (30 F) Foley catheter is brought through the anterior
abdominal wall and inserted into the caecum and retained in place
by inflation of the balloon and insertion of a purse string suture
on the bowel. -After removal of the operative specimen, the divided
colon is then intubated by wide bore corrugated anaesthetic tubing
which is draped over the patients side into a bucket. -The Foley
catheter is connected to a iv infusion set and normal saline is
infused until the bowel is clean. The anaesthetic tubing is removed
and the operation is completed. -The Foley catheter is left as an
intubated caecostomy for 10 days postoperatively after which it is
removed
74. B) Antibacterial agents *The postoperative wound infection
rate is reduced by intravenous antibacterial agents; giving them
for 24h during and around the time of surgery is as effective as
any other regimen. *Any combination of agents should include
metronidazole which is active against anaerobic bacteria.
Metronidazole (500mg i.v.) is given on induction of anaesthesia and
repeated at 8 and 16 h postoperatively. *Many surgeons add an
antibiotic such as an aminoglycoside (e.g. tobramycin, gentamicin)
or a cephalosporin to metronidazole giving it at the same frequency
and for the same duration. *Antibiotics are given for no more than
24h in the non-infected case. A full 57 day course should be given
where sepsis or toxicity is already present, e.g. diverticular
abscess, colonic abscess.
75. C) Stomas Preoperative education may include discussion of
the proposed surgical option, demonstration of appliances, and
description of the type of stoma and how it will be managed. It is
helpful to describe the stoma appearance, the usual consistency and
quantity of drainage, gas and odor control, diet, fluid and
electrolytes, clothing, sexuality, recreation, and return to work.
The location of the site must be (a) within the rectus muscle, (b)
outside of abdominal creases and scars, and (c) within the
patient's line of vision The site should be marked preoperatively
with waterproof ink and later scratched with a sterile needle.
76. If a midline incision is used, it is best if the stoma can
be located at least two to three fingerbreadths (about 2.5 in.)
away from the incision, as this will allow for an adequate barrier
to be placed around the stoma postoperatively. It is best to stay
at least two to three fingerbreadths away from the iliac crest to
avoid interference with appliance adherence.
77. II) OBSTRUCTIVE JAUNDICE A) Correction of coagulation
abnormalities The shortage of vitamin K impairs the synthesis of
prothrombin . If prothrombin time is elevated, vitamin K should be
given in the form of K1 intravenouslyhe. A dose of 20mg is followed
by a rapid return to a normal prothrombin time within 12 24 ft if
the liver is normal. Vitamin K1 in a dose of 1020mg should be given
daily intravenously or intramuscularly until operation takes place.
It is usually unnecessary to continue the administration of vitamin
K postoperatively.
78. When there is severe hepatocellular damage fresh plasma
frozen should be given. Prothrombin activity is retained in these
plasma fractions for several months. Stored whole blood contains
little or no prothrombin. B) Prevention of renal failure Jaundiced
patients undergoing surgery have an increased tendency to develop
renal impairment due to renal tubular damage and hepatorenal
syndrome. It is important to keep the patient well hydrated before
operation. Use of nephrotoxic antibiotics should be avoided. C)
Antibiotics Increased susceptibility to infection Metronidazole
combined with cephalosporins or aminoglycosides D) Avoid
constipation
