Transcript Document

Preoperative Care
By: Dr. Muath Mustafa
Department of Surgery, BMC
OUTLINES
-Introduction:
-Evaluation:
-Routine preoperative measures:
-The use of Antibiotic:
-Prophylaxis against Deep Vein Thrombosis and Pulmonary Emboli:
-Grades of Surgery:
-ASA Grades:
-Preparation of Hypertensive Patient:
-Preparation of Diabetic Patient:
Introduction:
To obtain satisfactory results in surgery, a careful preoperative preparation of the
patient is vital.
The importance of this preparation becomes more evident as the surgical
procedure performed becomes more complex.
Evaluation:
-Take a full history and exclude any significant medical problems
(DM,HTN,COPD,Asthma).
-Check clinical signs against the planned procedure, in particular noting the side
involved.
-Take a full drug history with specific enquiry regarding allergic responses to drugs,
latex, and skin allergies.
=Medications to be continued over the preoperative period:
Anti HTN
IHD Drugs
Bronchodilators
DM Medications
Stop oral Warfarin (Anticoagulant) 3-4 days preoperatively and check the
prothrombin time prior to surgery. If prothrombin time remains unacceptably
high, the patient may require an infusion of Fresh Frozen Plasma‫ز‬
Patients on Warfarin who have had a life-threatening thrombotic episode
(Pulmonary Embolus) with in the previous 3 months should be switched to
heparin intravenously until 6 hrs before surgery. The heparin can usually be
restarted 4 hrs after surgery.
=Medications to be stopped:
Aspirin,Clopedogrel (Antiplatelets). Stop 48 hrs before surgery. If not stopped the
patient is at increased risk of bleeding.
Monoamain oxidase inhibitor.
Lithium.
They may interfere with anaesthitic agents.
Tricyclic antidepresent
Phenothiazine.
Stop OCPs 4 weeks before surgery.
-Take history of nutritional status. Improve if needed.
-Take investigations:
CBC: all patients.
U & E: all patients.
ECG: all patients > 40 years.
Chest x-ray: all patients >30 years
Liver functions: all patients.
Hepatitis: ? All patients
Echocardiogram: abnormal ECG, ischemic heart, heart failure.
Clotting screen (Coagulation profile): anticoagulants, abnormal LFTs
Calcium: Thyroid and Laryngectomy.
Pulmonary functions: abnormal chest x-ray, partial Laryngectomy,
Oesophagectomy.
Note: Young and fit patients do not require ant preoperative investigations.
Routine preoperative measures:
-Each surgical procedure has a standard protocol for patient preparation. Adhere
to the protocol and use a checklist; you will not leave out an important step.
-Prohibit solid diet to adult patients for 6 hrs and clear fluids for 4 hrs prior to an
elective general anaesthetic. Fasting time for children vary. We instruct the
patient to fast to reduce the risk of pulmonary aspiration.
Summary of Fasting Recommendations to Reduce the Risk of Pulmonary
Aspiration:
Ingested Material
Clear liquids
Breast milk
Infant formula
Non-human milk
Light meal
Minimum Fasting Period (hours)
2
4
6
6
6
-Operation site must be prepared by marking, and removal of hair if needed.
Ask the patient to shower and clean the operation site with antiseptic solution if
available.
 Avoid hair shaving or clipping long time before the surgery. Instead it is done at
the time of surgery to avoid bacterial colonization.
-Explain to the patient or guardian the procedure, and any likely complications,
answer questions the patients may have, and only then have them sign the
consent form.
Keep in mind that operating surgeon should obtain the consent form. Seek help
from a senior colleague if you are unable to answer patient`s questions.
Also, consent should ideally be taken from patients not immediately before an
operation but sometime ahead, so that they may have a period of reflection, and
an opportunity to ask further questions that may arise
-If specific services, such as frozen section histopathology, or intraoperative
radiotherapy are likely to be required during the operation, organize these in
advance.
-Before going to the operating room:
He/she will have to remove:
1. Dentures/partial plates
2. Glasses/contact lenses
3. Appliances/prosthesis
4. Makeup/nail polish
5. Hairpins/hairpiece
6. Undergarments
The use of Antibiotic:
-As a general rule, treat patients with clinical infection using systemic antibiotics
before they undergo operation.
-Antibiotic prophylaxis for an elective operation depends the procedure being
performed.
RISK OF WOUND INFECTION BY TYPE OF WOUND.
Clean
Clean-contam.
Contaminated
Dirty
2%
10%
20-40%
All
-Clean procedures, as varicose veins, do not require antibiotic prophylaxis.
Abdominal operations not associated with significant contamination, such as
cholecystectomy, demand only a single dose of prophylactic antibiotic given on
induction of anaesthesia.
-Procedures in a contaminated field, such as appendicitis, require a preoperative
dose and two postoperative doses. This regimen is also satisfactory for most
other gastrointestinal tract procedures, including gastric surgery, and colonic
operations on prepared bowel.
-The choice of antibiotic prophylaxis is determined by the surgical procedure itself.
Operations potentially contaminated by skin flora require prophylaxis against
staphylococcal infection with Flucloxacilline 500mg I/V.
Procedures involving the bowel require broad-spectrum cover for Gram-positive
and Gram-negative organisms and anaerobes. (Cephalosporine with
Metronidazol).
Biliary tract procedures rarely involve anaerobic contamination. Cephalosporin
alone is satisfactory.
Prophylaxis against Deep Vein Thrombosis and Pulmonary Emboli:
Pulmonary Emboli are a major cause of mortality for surgical patients.
Risk factors for DVT:
Age >40 years
Obesity
Varicose veins
High oestrogen pill
Previous DVT or PE
Malignancy
Infection
Heart failure / recent infarction
Polycythaemia /thrombophilia
Immobility (bed rest over 4 days)
Major trauma.
Risk factors for DVT:
Incidence of DVT and fatal pulmonary embolism in hospital patients:
Risk
Low risk =
Moderate risk =
High risk =
DVT
<10%
14%
40-80%
PE
<0.01%
0.5%
5%
Incidence of fatal pulmonary embolism in high risk patients increases 500 folds.
Prophylaxis against DVT:
Treatment of DVT:
I/V Heparin
Oral Warfarin after 3days of i/v heparin
Grades of Surgery:
ASA Grades:
Preparation of Hypertensive Patient:
-If systolic blood pressure > 160 mmhg and diastolic pressure > 110 mmhg, the
elective surgery should be rescheduled.
-Moderate or marked, longstanding, untreated hypertension increases
perioperative morbidity and mortality, and it is significant risk factor for the
production of coronary atherosclerosis.
-Stabilize patients with sustained systemic arterial hypertension (systolic > 160
mmhg, diastolic > 110 mmhg) on antihypertensive therapy before proceeding
with long duration elective surgery.
-Untreated or inadequately treated hypertensives respond in an exaggerated
manner to the stress of surgery, with resultant increase in the operative
morbidity and mortality.
-Assume that patients with long standing moderate to marked hypertension have
coronary atherosclerosis and manage them appropriately, even in the absence of
overt signs and or symptoms of ischemic heart disease.
-Do CXR, ECG, treadmill test and Coronary Angiography with the possibility of
recanulation of the blocked artery if needed.
Preparation of Diabetic Patient:
-Take a detailed history regarding the DM status, and the cardiovascular system
status of the patient, and before surgery, the cardiovascular status of the patient
should be reviewed.
Regimes for surgery on diabetic patients
Type of surgery
Minor
Intermediate/Major
Controlled by diet
No specific precautions
Measure blood glucose 4-hourly, if >
12mmol start glucose-potassiuminsulin sliding scale regimen.
Controlled by oral
agents
Omit medication on the morning of
operation and start when eating
normally postoperatively
Omit medication and monitor blood
glucose 1-2 hourly, if > 12mmol start
glucose-potassium-insulin sliding scale
regimen.
Controlled by insulin
Unless very minor procedure (omit insulin when nil by mouth) give glucosepotassium-insulin sliding scale regimen during surgery and until eating normally
postoperatively.
-Patient taking long-acting insulin preoperatively should be converted to Actrapid
insulin, and surgery should be scheduled for the early morning if possible.
-Infuse 10% glucose 500ml + 10 mmol potassium chloride (KCL) at 100 ml per hour.
Prepare a 50ml syringe containing 50 units of Actrapid(Short acting) insulin in 50
ml normal saline(=1 unit per ml) and connect to a 3-way tap to a glucose infusion.
Adjust the rate of the syringe driver according to the following sliding scale:
Blood glucose(mmol)
Rate of syringe driver (ml/h)
<5
Switch off
5-7
1
2
7-10
10-20
3
>20
4
-If two successive blood glucose values are > 20 mmol, consult the duty doctor.
ANY QUESTIONS?