PREOPERATIVE PREPARATION

BY DR NIKHIL AMEERCHETTY

MS general surgery RESIDENTE- MAIL : nikhilameerchetty@gmail.com

AIMS AND OBJECTIVES

Gather and record all the information

Optimise the patient condition

Choice of surgery

Prepare for the adverse effects

Inform the concerned

History taking

Open questions Closed questions Focussed questions Fixed questions

EXAMINATION

General

Surgery related

Systemic

Specific

INVESTIGATIONS

Minor and intermediate procedures require no investigations unless the patient is having comorbidities

• MAJOR OPERATIONS • Full blood count• Urea and electrolytes• Electrocardiography• Clotting screen• Chest radiography• Urinalysis• Beta-Human chorionic gonadotrophin• Blood glucose and HbA1c• ABG,LFT OTHERS

SPECIFIC PREOPERATIVE PROBLEMS,REFERRALS AND MANAGEMENT

CAPACITYBase line

organ function

OPTIMISATION

Medication ,lifestyle ,re

fferal

ALTERNATIVE

Minimally impacting

procedures

THEATRE PREPARATIO

NSTiming and teamwork.

CARDIOVASCULAR DISEASE• Flight Of Stairs• Myocardial Infarction (MI),IHD,VHD : Postpone Surgery For 4-6weeks. • Stents : Patients On Asprin And Clopidogrel , Surgery After 6weeks Of

Stoppage• For Cases Of Low Risk Bleeding And Surgery Cannot Be Postponed Can Go

Ahead With Surgery .• For High Risk and surgery cannot be postponed Stop Clopidogrel And

Continue Asprin . • Percutaneous Coronary Intervention With Stenting postpone surgery For 4

To 6 Weeks.• B blocker

• Warfarin for atrial fibrillation stopped 5 days preoperatively (INR <1.5)• warfarin for a case of mechanical heart valves stop 5

days prior when INR <1.5 start unfractionated heparin .• Blood pressure to be kept below160/90mmhg .

WHEN TO REFER 1. A Murmur Is Heard And The Patient Is Symptomatic.2. Poor Left Ventricular Function Or Cardiomegaly.3. Ischaemic Changes Can Be Seen On Ecg Even If Patient Is Not

Symptomatic (Silent Mi).4. Abnormal Rhythm On The Ecg, Tachy/Bradycardia Or A Heart

Block That May Lead To Cardiovascular Compromise5. Decreasing The Adrenergic6. Surge Associated With Surgery And Halting Platelet Activation

And7. Microvascular Thrombosis.

RESPIRATORY DISEASE• Current Respiratory Status Should Be Compared With Their

‘Normal State’• Steroid Use : If > 10 Mg Of Prednisolone And Undergoing High-

risk Surgery Will Need Perioperative Steroid Supplements. • COPD : Fev1 <80%• Infections : Postpone 4-6 Weeks

OPTIMIZATION

• Smoking Cessation (Within 2months Before The Planned Procedure)• Antibiotic Therapy For Preexisting Infection• Pretreatment Of Asthmatic Patients With Steroids and bronchodilators can be

used till the induction time .• Exercise (3 Miles In Less Than 1 Hour Several Times Weekly).

REFFERAL• There is a severe disease or significant deterioration

from usual condition.• Major surgery is planned in a patient with significant

respiratory comorbidities.• Right heart failure is present: dyspnoea, fatigue,

tricuspid regurgitation, hepatomegaly and oedema of the feet.• The patient is young with COPD (indicates a rare and

lifethreatening condition).

GASTROINTESTINAL DISEASE• NPO For Solid Food 6hrs , Water 2 Hrs• In Infants Clear Drink 2hrs , Breast Feed Upto 3 Hrs ,Formula

Feeds 6hrs • Intravenous Fluids In Cases Children, Elderly And Diabetics If

Surgery Is Delayed .

• The Presence Of Ascitis, Oesophageal Varices, Hypoalbuminaemia,

•HEPATOBILIARY SYSTEM

PREPARATION OF JAUNDICE PATIENT

• Admit at least 72 hours before surgery for preparation• Use of lactulose and bowel preparation reduce risk of hepatic

encepalopahty• Prophylactic antibiotics necessary because stagnant bile is a good

culture medium• Adequate hydration ( four liters daily to prevent hepatorenal syndrome

and reduce risk of hepatic encephalopathy from dehydration )• Intravenous fluid should be normal saline alterating with 5 or 10%

dextrose , avoid ringers lactate.

•High calorie because risk of hypoglycemia by taking glucose drinks•High protein diet •Correct anemia by transfusion with packed cells•Correct coagulopathy with intravenous vitamin K, fresh frozen plasma , fresh whole blood )•Other Vitamin  supplements : vitamin B Co, vitamin C

CHILD-PUGH SCORING SYSTEM

GENITOURINARY DISEASE

• GOAL• Identification of coexisting cardiovascular, circulatory, hematologic, and

metabolic derangements • creatinine level of 2.0 mg/dL or higher is an independent risk factor for

cardiac complications. • Anemia, treated with erythropoietin or darbepoietin

• DIABETES MELLITUS,• HYPERTENSION • ISCHAEMIC HEART DISEASE,• ACIDOSIS• HYPOCALCAEMIA • HYPERKALAEMIA• UTI

ESRD • Replacement Of Calcium For Symptomatic Hypocalcaemia,• Phosphate-binding Antacids For Hyperphosphatemia • Sodium Bicarbonate Below 15 Meq/Liter. It Can Be

Administered In Intravenous (IV) fluid As One To Two Ampules In One Liter Of 5% Dextrose Solution. • Hyponatremia Is Treated By Volume Restriction

  ENDOCRINE AND METABOLIC DISORDERS

DIABETES MELLITUS

• AIM: •Optimize Blood sugar control prior to surgery• MONITORING:• Check Blood Glucose every 4 hours prior to surgery• Perioperative Blood Sugar Monitoring frequency per anesthesia

protocol• Prefer perioperative mild Hyperglycemia to Hypoglycemia

• Insulin

• Long acting Insulin (Lantus, Levemir)• Take full Lantus dose the night before the procedure• Take 80% of the usual morning dose on the day of the procedure

• Intermediate Insulin (NPH Insulin)• Take full NPH dose the night before the procedure• Take 66% of the usual morning dose on the day of the procedure

• Mixed-Insulin (e.g. Insulin 70/30)• Do not take mixed Insulin on the morning of surgery• Give NPH at 66% of the usual morning dose (NPH component only of the mixed Insulin) on the day of the

procedure• Insulin Pump

• Insulin Pumps should only deliver basal rate (not bolus)• Consider Running at 50% of the rate

• Short-Acting, Rapid-acting or bolus Insulin (e.g. Lispro, Regular, Aspart, Glulisine)• Do not take bolus Insulin (short-acting Insulin) on the morning of the procedure

 ORAL HYPOGLYCEMIC DRUGS

1.Hold long-acting Sulfonylureas 2-3 days before surgery

2.Hold short-acting Sulfonylureas on the night before surgery

3.Hold Metformin on day before surgery (risk of Lactic Acidosis)

4.Thiazolidinediones may be continued

• For a case of hyperthyroidism postpone the surgery till euthyroid state is achieved • Patient of hyperthyroidism under medication can continue till the day of surgery •Hypothyroidism usually does not require correction but severe case need to be optimised •Hypothyroidism increase the sensitivity of the other medications • Pheochromocytoma is controlled by alpha and beta blockade

COAGULATION DISORDERS•The Progesterone-only Pill Can Be Continued.• Combined Pill ( Risk Of Significant Thrombosis)• Hormone Replacement Therapy (HRT) Should Be Stopped 6 Weeks Prior To Surgery.

•Warfarin•Hold for 5 doses and maintain INR <1.5• For high risk cases replace with LMWH and hold upto 24hrs before surgery • For intravenous heparin hold before 6hrs of start of operation • Postponed for 4 weeks after an episode of venous or arterial thromboembolism.

GUIDELINES FOR BLOOD TRANSFUSION

NEUROLOGICAL AND PSYCHIATRIC DISORDERS

•Anticonvulsant and antiparkinson medication is continued perioperatively to help early mobilisation of the patient.•Lithium should be stopped 24 hours prior to surgery .

RISK FACTORS

RISK ASSESSMENT AND CONSENT

Six key steps

■ Referral from primary care: involvement of the GP.

■ Pre-operative care by the hospital team.

■ Admission to hospital.

■ Care during the operation by the surgeon and the anaesthetist.

■ Post-operative care in the hospital.

■ Follow-up – rehabilitation and going home.

NEW ELEMENTS OF CARE IN ERP

1. Nutrition: A key part of enhanced recovery is keeping you well fed. carbohydrate nutritious drinks to be drunk before you arrive at the hospital.

2. Drinks : safe to drink water until just two hours before your operation.

3. Preparation of the bowel if undergoing colo-rectal surgery: traditional methods of flushing out the bowel before operations on the bowel are not always necessary.

4. Discharge planning

THANK YOU ….