Transcript Pre-operative Assessment and Preparation

Pre-operative Assessment and
Preparation
By
Dr.Rashad Al-Kashgari
Associate Professor of Surgery
2001
Pre-operative Assessment and Preparation
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Why ?
How ?
When ?
What ?
Pre-operative Assessment and Preparation
WHY ?
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Elective operation should be performed under
optimal condition with full physical and
psychological preparation of a fully informed
patient.
Emergency operation may have to be done in
less than ideal circumstances .
Pre-operative Assessment and Preparation
HOW ?
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History
Physical exam
Investigation
Pre-operative Assessment and Preparation
WHEN ?
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Out patient visit
Pre-operative ward round
ER
Pre-operative Assessment and Preparation
WHAT TO DO ?
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Six tasks
To explain to the patient / relative the nature of the
illness , implications of surgery and prognosis
Identification of potential operative mortality and
postoperative morbidity
To assess the fitness for operation
Identification of the risks of potential postoperative
complications and prophylactic measures .
Planning of operation and consent
Task one
To explain to the patient / relative
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Nature of surgery
Implication of surgery
Alleviate fear/anxiety of the patient
Prognosis
Task two
Identification of potential operative
mortality and morbidity
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Look for the risk factors?
Risk factors of mortality and morbidity
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Myocardial infarction
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Pregnancy
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Thrombogenic drugs
Smoking
Previous anesthetics
Allergies
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Avoid op.whenever possible for at
least 6 months
Elective op. is avoided.Risk of
miscarriage & teratogenicity
Steroids & pills
Suxamthonium/halothane
Penicillin/Iodine-containing drugs
Task three
To assess the fitness for operation
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Assessment of general condition
Assessment of metabolic state
Assessment of cardiovascular system
Assessment of respiratory system
Assessment of renal system
Assessment of general condition
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Careful clinical exam.
Pulse rate
B.P.
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Full blood count
Serum urea & electrolytes
Blood group & save serum
X-match blood if needed
Assessment of metabolic state
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Height
Weight
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Problems associated
with obesity :
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Venepuncture
Anatomical landmarks
Respiratory problems
Thromboembolism
Wound infection
Wound dehiscence
Assessment of cardiovascular
system
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Clinical exam of heart
and vessels
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ECG
Echocardiogram
Cardiovascular conditions
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 Increase risk of CVA/MI
Hypertension
Myocardial ischaemia  Avoid techniques /drugs which
increase heart rate/diastolic
B.P/perfusion gradient
Cardiac arrhythmias
 Discuss with cardiologist pre-op
Valve disease/septal
 Cover with antibiotics
defect
Hypovolemia
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Restore blood volume pre-op
Assessment of respiratory system
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Clinical exam of chest
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CXR
Sputum for bacteriological
exam
Blood gases
Pulmonary function tests:
FEV1
FVC
Respiratory conditions
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Chronic bronchitis
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Suffer HYPOXEMIA.DO blood gases High
risk patients-consider only for urgent op
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Asthma
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Brochiectasis
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Common cold
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At risk of post-op respiratory failure.Give
bronchodilator. Best index: FEV1/FVC X100
Physiotherapy + Antibiotics (use local
blocks instead of general anaesthesia)
Cancel op. in acute phase
Assessment of renal system
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Clinical examination
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Urinanalysis & microscopy
Urine for microbiological
examination
Serum urea
Serum creatinine
Renal disorders
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Chronic retention
Task four
Identification of risks of potential post
operative complications and prophylaxis
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Pulmonary collapse and Pre-op breathing exercises
infection
Cardiac complications  Avoid excessive fluid post-op in
all patients with cardiac
ischemia or valvular disease
 Major causes are hypovolemia,
Acute renal failure
sepsis, jaundice and
characterized by:
(oliguria, dilute urine , & mismatched blood
urea conc.<300 mmol/l)
Task four (continue)
Identification of risks of potential postoperative
complications and prophylaxis (continue)
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Venous Thrombosis
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Wound infection
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Avoid compression of legs
during and after op.
If necessary,use graded
compression stocking / low
dose heparin 5000 I.u Q.12
hrs OR a single dose of LMW
heparin
Prophylactic antibiotics
(Bactericidal best guess for
offending organism,high
doses,three doses..when?
Task five
Planning of the operation
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The operation should be properly named after
full explanation to the patient and the side of
operation is marked in case of bilateral parts.
He/she should consent for it.
The duration of hospital stay,convalescense
and time off work should be indicated.
CONSENT
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Explain to the patient in simple non medical
language what is going to be done.
Alleviate his/her fears.
Do not deceive the patient.
Reassure the patient
Task six
Pre-operative orders
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Keep NPO (Nil per Oral) from ??:00 hrs
Medications
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Essential
Prophylaxis
Prepare area for surgery
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Cleaning
Shave
Enema
Etc