Pre-operative Preparation: Key Considerations

• Optimal preparation for an operation leads to a successful result, protecting both the patient and the physician involved.
• A primary risk factor for postoperative morbidity is pre-existing preoperative conditions
• These conditions can potentially affect the operation itself, influence anesthesia, and impact the postoperative course, potentially precluding the procedure.
• Glucocorticoids are taken continuously by approximately 0.5% of the general population and 1.5% of women over 55 years of age.
• Adult women experience perioperative anaphylactic reactions to latex in 12% of cases in comparison to children at 70%.
• Health care workers, women who self-catheterize, and women with spinal cord injuries, are at a higher risk for latex allergy.
• Three basic questions that a preoperative physical examination should address:

Change in Disease Process

• Determine whether the primary gynecologic disease process has shifted following the initial diagnosis.

Effects On Other Organ Systems

• Evaluation of how the primary gynecologic disease is influencing other organ systems.

Deficiencies

• Identification of deficiencies in other organ systems which could affect the proposed surgery and hospitalization.
• Physical examinations conducted while the patient is under anesthesia can yield extra information and minimize surgical surprises, effectively guiding surgical plans.
• Approximately 60% of routinely conducted tests are performed irrespective of indications from a patient's history or physical exam.
• Preoperative tests devoid of clinical justification or specific purpose should not be performed, according to the American Society of Anesthesiologists (ASA) Practice Advisory for Preanesthesia Evaluation.
• Most major gynecologic surgeries require a preoperative complete blood cell count, as well as blood typing and antibody screening.
• Individualized preoperative lab tests should be customized to the woman, surgical procedure, and detailed history and exam.
• Evaluating the preoperative creatinine or blood urea nitrogen level is important if the woman will be given antibiotics cleared by the kidneys.
• Consider a pregnancy test, especially with teen patients because menstrual history is unreliable, and incorporate PREG criteria for women 18 years or older

Electrolyte Levels

• If the patient is taking any diuretics or presents any history of either renal disease or heart disease then electrolyte levels should be checked.
• Serum electrolyte levels should be evaluated in women with vomiting, diarrhea, ileus, bowel obstruction, or any condition that affects electrolyte balance.
• Routine radiographs have typically little effect on preoperative management
• Chest radiographs should be ordered for current or former smokers, women with cardiac or pulmonary symptoms, immigrants without recent chest films, and women surpassing 70 years.
• Baseline preoperative electrocardiograms are cost effective for asymptomatic women 60 years and older without risk factors or a history of cardiac disease.
• Legal issues tend to arise if informed consent is not obtained. Standardized preoperative orders and electronic order sets are recommended.
• In an enhanced recovery pathway, solid foods may be consumed until midnight prior to the procedure, while clear liquids can be ingested until 30 minutes before the surgery.
• Enhanced recovery after surgery (ERAS) protocols facilitate solid food consumption up to six hours before surgery to prevent hypoglycemia.

ASA Risk Classes

• Anesthesiologists classify surgery procedures according to five ASA risk classes.
• Mortality risks for ASA classes 1–3 are doubled during emergency operations, mortality rises slightly in class 4, and it remains unchanged in class 5.
• Enhanced recovery is a bundled process designed to reduce stress and attenuate changes from surgery, replacing untested practices while hastening recovery.
• Enhanced recovery protocols have decreased the length of stay by about 2.5 days on average, and decreased complications by almost 50%.
• Greatest complex cytoreduction was achieved within enhanced recovery for ovarian cancer patients, about 57% undergoing colonic or small bowel resection.
• Thoracic epidural anesthesia (TEA) effectively controls pain after major open gynecologic surgeries and promotes a quicker return of bowel function, contributing to its popularity.
• Using TEA might not align with some ERAS goals, decreasing its use in ERAS, and it has been associated with more interventions.
• Hypotension, longer hospital stays and more complications came as a result of TEA in a series of early stage endometrial cancer patients.
• Surgical Site Infection (SSI) is a common complication after surgery that can cause dissatisfaction, increased costs and morbidity as well as increased mortality.
• Three classifications of SSIs according to the Centers for Disease Control and Prevention and the American College of Surgeons National Quality Improvement Program:
  • Superficial Incisional, Deep Incisional, and Organ/Space.
• SSI reduction elements regularly include preoperative smoking cessation, antiseptic showering, and chlorhexidine preparation, and glycemic control.
• Hair clippers are preferrable to razors and appropriate preoperative selection and normothermia.
• Abundant literature supports prophylactic antibiotics usage in gynecology, which is shown to reduce febrile morbidity approximately from 40% to 15%.
• Also, the rate of pelvic infection went roughly from 25% to 5%.

Antimicrobial Prophylaxis

• Use first or second generation cephalosporins of cefazolin, cefotetan, cefoxitin, or ampicillin-sulbactam for vaginal or abdominal hysterectomy.

Women with B-Lactam Allergy

• Recommended combinations are (1) clindamycin or vancomycin plus an aminoglycoside, or (2) aztreonam, or (3) a fluoroquinolone, metronidazole, and aminoglycoside, or (4) a fluroquinolone alone.
• For antibiotic administration, single-dose therapy is equally effective to 24 hours of antibiotics.
• No advantages are apparent by continuing antibiotics past immediate operative period.
• Vaginal surgery carries lowest SSI risks, and remains preferrable when feasible.
• Up to 16-fold reduction of SSI risk can occur if minimally invasive hysterectomy approaches replace laparotomy.
• Evidence documents there is roughly a 2-3-fold increase in SSI rate that is typically associated with perioperative shaving.
• Clipping is the better approach if hair removal is required.
• Using chlorhexidine gluconate in conjunction with 70% isopropyl alcohol can lead to 40% reduction in SSIs versus a 10% povidone-iodine solution.
• Refrain from smoking patients to prevent postoperative complications for 21% in smoking cessation cohorts, versus 41% in controls.

Hypothermia

• Preventing hypothermia is important to improving surgical outcomes.
• Elevates risk of wound infections
• Increases post-operative myocardial events and periopertaive blood loss
• Impairs drug metabolism
• Prolongs postoperative recovery
• Two-fold rise in SSI occurs with increased glucose levels past 180 mg/dL for all individuals irrespective history.
• It's optimal to maintain appropriate perioperative blood glucose levels less than 200 mg/dL for all patients.
• Tight glucose control (80–130 mg/dL) is shown not to have an impact on SSI rates compared with tighter glucose levels lower than 200 mg/dL as well as detrimental effects.
• About 25% of all SSIs are caused by Staphylococcus aureus. Pulmonary emboli cause about 40% of deaths following gynecologic surgery.
• About 15% of symptomatic emboli will not present until first week after discharge, despite the injury typically happening at the operation time.
• Use Caprini score to determine those at risk, as women in the very low risk group show <3% of venous thromboembolism, moderate risk shows 10–30% and high risk shows >30%.
• Low-molecular-weight heparin (LMWH) is much more effective than standard heparin due to high bioavailability, consistent anticoagulation, and dose independence.
• LMWH administration works equally effectively both perioperatively and postoperatively.
• Warfarin should be held for about five days and the international normalized ratio should be under 1.5 before incision.
• Hold therapeutic dose aspirin held before surgery for seven days.
• Once daily baby aspirin can typically be continued. Factor Xa inhibitors should be held for about 2 to 3 days.
• Individual drug half-life determines holding period of Factor Xa inhibitors
• Depending on renal function, direct thrombin inhibitors should be held for roughly 2-4 days.
• Bleeding disorders typically present themselves early. Approximately 1–2% may have a bleeding diathesis such as von Willebrand disease.
• Patients experiencing chronic steroid therapy is essential to their preoperative dose to be taken on the day they are undertaking surgery.
• Stress-dose steroid administration has little risk compared with adrenal crisis.
• Only women with history of pulmonary disease, pulmonary functions test of lung volumes and rates of flow are indicated.
• Increase in atelectasis occurs because of morbid obesity, smoking, pulmonary disease, and increasing age, while pain, position, function of the distention, diaphragm, and sedation also decrease measurements.

Rate Increase

• Excessive noncardiac operative procedure within 3 months of acute myocardial infarct is likely to be 27% to 37%.
• Reinfarction chance is typically shown to be 4% to 6% after six months, with elective operations.
• Perioperative beta-blockers are no longer used with the reason given of elevated death risk.
• Prophylactic antibiotics administration solely to prevent endocarditis is gone of because there is no need to the GI tract procedures.
• Successful preparation for surgery depends on evaluation.
• The patient should be safe.
• Evaluate the gyneclogic diagnosis.
• Prep the team for procedure.
• Make sure the patients privacy is valid.
• Establish formed and consented care.
• Ensure patient's fears and anxiety are put at ease.
• Determine the general of woman and surgery procedure.
• Prepare to have complications.
• Use the patients in open questions.
• Ask if the any surgery has caused bleeding and/or issues.
• Ask the patient for possible viruses.
• Conduct physical observations well.
• Preoperative testing helps find unsymptomatic signs before surgery.
• Discuss mammography, pap tests, and colonoscopy before any surgery is performed.
• Preoperative tests should guide.
• Discuss any tests before you do them.
• Evaluate the surgery with a gynecologic surgeon.
• Reduce Postoperative Complications
• Mark what the patient has with a universal protocol.
• Make preoperative more efficient.
• Team needs to brief before surgery.
• The positioning needs to be reviewed more.
• Prevent surgical site infections.
• The causes of surgical site infections.
• Surgical Site Infection Reduction Bundles.
• Use prophylactic.
• Minimally Invasive Surgery.
• Shaving of an area.
• Chlorhexidine/Alcohol Skin Preparation.
• Smoking isn't healthy.
• Normothermia.
• It needs controlled.
• Screen: Staphylococcus aureus.
• Try to eliminate death.
• Test the heart for any issues present.
• Do not inject infective endocarditis.

This material covers why vaginal surgery is often preferred and hair removal recommendations. It also addresses the benefits of chlorhexidine gluconate, managing steroid therapy, and when pulmonary function tests are needed. Guidelines for patients on Thrombin Inhibitors and ways to reduce atelectasis are also covered.