Preoperative Preparation and Classification

Preoperative Preparation Rationale

• Determining a patient's fitness for surgery is crucial
• Preparing facilities and equipment in advance is important
• Ensuring patient safety and reducing errors is a key objective
• Addressing patient fear or anxiety contributes to a better experience
• Lowering morbidity and mortality is a priority

Classification of Surgery

• Elective surgeries are scheduled at a mutually convenient time
• Scheduled surgeries have time limits, such as 3 weeks for malignancy cases
• Urgent surgeries are performed ASAP with adequate resuscitation, ideally within 24 hours
• Emergency surgeries require immediate resuscitation along with intervention

Preassessment Clinics

• The goal is to evaluate surgical patients 2–4 weeks prior to elective surgery
• Preassessment timing should balance problem identification and preventing new issues
• Adequate time is required to address problems, but not so long that new issues arise

Preoperative Assessment

• History, physical examination, consent, and counseling are all key

Investigations as indicated

• Blood tests
• Urinalysis
• ECG
• Radiological, microbiological, and special tests

Surgical History

• Urgency is a key factor
• Anesthetic management can be influenced along with system effects of presenting pathology

Systemic Assessment

• Careful assessment of each body system is required

Past Medical and Surgical History

• Any diseases that directly affect general and anesthetic management and outcome
• Previous operations
• Bleeding tendencies
• Hospital admissions
• Reactions to anesthetic agents

Drug History and Allergies

• List all drugs, dosages, and times taken
• Inquire about drugs related to sudden withdrawal
• Note drugs to be continued during the perioperative period, like those for hypertension and ischemic heart disease
• List all allergies and their reactions
• Ask about oral contraceptives and antiplatelet meds like aspirin/clopidogrel

Social History

• Smoking and drinking habits should be noted (how much and for how long?)
• Recreational drug abuse
• Living situation: Who is at home? Who cares for the patient?

Family History

• Bleeding disorders
• Malignant hyperthermia

Physical Examination: General Principles

• Detailed observation and practice are key
• Don't rely on others' examinations, as surgical signs can change
• Treat patients with respect and dignity
• Provide clear explanation
• The patient should be kept as comfortable as possible
• A chaperone should be present, especially for intimate examinations.
• Check local guidelines on protocol

Physical Examination: Items

• General examination including vital signs
• Cardiac examination including JVP and heart sounds
• Respiratory examination: tracheal position, accessory muscles or respiration
• Abdominal examination
• CNS
• Musculoskeletal system
• Peripheral vascular
• Local examination
• Body orifices

Preoperative Laboratory Testing and Imaging

• Used to confirm a diagnosis
• To exclude a differential diagnosis
• To assess the appropriateness of surgical intervention
• To assess fitness for surgery

When to perform Preoperative Lab Tests

• Major surgery or in neonate
• Males older than 70
• Females older than 45
• Chronic renal, liver, or lung disease
• Anemia or malignancy
• Poor nutritional states
• Vascular aneurysms

Serum Creatinine & Electrolytes: Indications

• Kidney disease
• Hypertension
• Diabetes
• Stroke
• Poor nutritional states
• Certain medications (Digoxin, diuretics, steroids)
• Chemotherapy

Glucose: Indications

• Diabetes
• Family history of diabetes
• Obesity
• Stroke
• Poor nutritional status
• Steroid use
• Cushing’s syndrome
• Addison’s disease

ECG: Indications

• Diabetes
• Cardiac disease
• Hypertension
• Chronic lung disease
• Thyroid disease
• Morbid obesity
• Taking Digoxin
• Makes older than 45
• Females older than 55

X-ray Chest: Indications

• Heavy smoker
• Aortic aneurysm
• Chronic lung disease
• Radiation therapy
• Cardiomegaly

Coagulation Studies: Indications

• Liver disease
• Renal dysfunction
• Family history of bleeding disorder
• Taking anticoagulant drugs

ASA Classification

• Used to Assess the risk of surgery
• ASA I: Normal healthy patient
• ASA II: Patient with mild systemic disease
• ASA III: Patient with severe systemic disease
• ASA IV: Patient with severe systemic disease that is a threat to life
• ASA V: Moribund patient not expected to survive without the operation
• ASA VI: Declared brain-dead patient

ASA I Examples

• Healthy
• Non-smoker
• No or minimal alcohol use

ASA II Examples

• Mild diseases only, without substantive functional limitations
• Current smoker, light alcohol drinker
• Pregnancy
• Obesity (30

ASA III Examples

• Substantive functional limitations; one or more moderate to severe diseases.
• Poorly controlled DM or HTN, COPD
• Morbid obesity (BMI ≥40), active hepatitis
• Alcohol dependence or abuse
• Implanted pacemaker, moderate reduction of ejection fraction
• ESRD undergoing regularly scheduled dialysis
• History (>3 months) of MI, CVA, TIA, or CAD/stents

ASA IV Examples

• Recent (

Preoperative Consent and Counseling

• The decision to operate should be based on all available information from history, examination, and investigative tests
• Recognizing that all patients are different is crucial
• Consider the age, belief, and worry of patient
• Discuss diagnoses and treatment options when the patient is best able to understand
• Use up-to-date written, visual, and other aids
• Provide sufficient information
• Details of diagnosis
• Prognosis if the condition is left untreated and if it is treated
• Options for further investigations if diagnosis is uncertain
• Options for treatment or management of the condition
• The option not to treat
• Common and serious side effects

Identification of the Patient and Documentation

• Patient identification is essential
• All patients should have an identity wristband stating name, date of birth, ward, and consultant
• There also should be a red wristband that documents allergies
• Patient identification is checked by the nursing team on admission to the theatre.
• Medical documents (medical notes, drug and fluid charts, consent forms, and operation notes) are legal documents
• All entries to the notes should be written clearly and legibly.
• Always write the date and time and your name and position at the beginning of each entry.
• Record as much information as possible in the format described above for history and examination
• The source of information should also be stated (eg from patient, relative, old notes, clinic letter, GP)

Patient Optimization for Elective Surgery

• Optimizing the patient's condition gives them the best possible chance of a good surgical outcome
• Do not forget that this includes nutrition
• Morbidity and mortality increases in patients with comorbidity
• Optimisation of surgery by ensuring:
• An appropriate grade of surgeon (to minimize operative time and blood loss)
• Adequate preoperative resuscitation
• Provision of on-table monitoring critical-care facilities are available

Resuscitation of the Emergency Patient

• It is essential that the acutely ill surgical patient is adequately resuscitated and stabilized before theatre
• In extreme and life-threatening conditions this may not be possible and resuscitation should not delay definitive treatment
• Most emergency patients fall into one of two categories: Hemorrhage and Sepsis

Resuscitation Principles

• Correct dehydration through IV fluids to restore electrolyte balance
• Use urinary catheter to monitor fluid balance carefully with hourly measurements
• Correct anaemia
• Give pain control before anesthesia to decrease cardiac workload
• Treat sepsis with antibiotics guided with blood and pus cultures
• Insert a nasogastric (NG) tube to decompress the stomach and lower risk of aspiration

Role of Prophylaxis

• Reduction or prevention of a known risk
• Stopping potentially harmful factors
• This includes stopping medications like Aspirin 3-5 days and Clopidogrel for 2 weeks before surgery
• stopping smoking before surgery
• Prescribing drugs known to reduce risks
• Use of Heparin to reduce the risk of DVT.
• Give Cardiac medications to reduce cardiovascular risk through drugs like preoperative ẞ blockers, statins, and Enzyme [ace] angiotensin-converting inhibitors

Thromboembolic Prophylaxis

• Incidence
• Deep Vein Thrombosis (DVT) is common in surgical patients. DVT can cause Pulmonary Embolism (PE)
• Risk Factors Responsible for 50% of
• Trauma
• Surgery
• Immobility
• Age
• Obesity
• Malignancy and Dehydration
• Past history of thromboembolism
• Oral contraceptives
• Hormone Replacement Therapy (HRT).
• Pregnancy and Puerperium

Prophylaxis

• Graded elastic compression stocking
• Intermittent pneumatic calf compression
• Postoperative early ambulation
• Heparin prophylaxis

Surgical Wound Classifications

• Clean wound
• Without opening of any body cavity
• an example is hernia, thyroidectomy, or breast surgery
• Incidence of infection: <5%
• Prophylactic: None
• Clean contaminated
• With opening of abdominal cavity with little spillage of contents.
• an example is appendectomy, or cholecystectomy
• Incidence of infection: 5-10%
• Prophylactic: One dose of 2nd generation cephalosporine
• Contaminated wound
• With opening of abdominal cavity with major spillage of contents.
• Traumatic wound <4hrs, and acute abdominal conditions. Perforated duodenal ulcer
• Incidence of infection: 20% >35%
• Prophylactic: One dose of 2nd generation cephalosporine.+ Metronidazole
• Dirty wound
• Traumatic wound > 4hrs. Gangrenous wound, pus
• Wet gangrene and/or Fecal peritonitis and Pyocele
• Prophylactic: Therapeutic Antibiotic according to culture and sensitivity

Cardiac Disease Preoperative Considerations

• Known risk factors must be identified in the history like smoking, hypertension, hyperlipidemia, diabetes, and positive family history
• Of the heart and lungs must be performed
• Recent myocardial infarction (MI increases the risk of re-infarction
• First 3 weeks has risk of 80%
• First 3 months has risk of 25-40%
• 3-6 months has risk of 10-15%
• After 6 months has risk of only 5%

Preoperative Management of Diabetes

• Always avoid both hypo- and hyperglycemia
• Good glycemic control can decrease the risk of of cerebral damage, and osmotic diuresis
• Supply enough insulin to prevent ketoacidosis
• Be aware of increased risks of postoperative complications as infection
• Full pre-op history and examination
• Place first on operating list
• Reduce period of starvation and risk of hypoglycemia
• Avoidance of hypoglycemia in an anaesthetized patient.
• Prevention of ketosis and acidaemia, Electrolyte abnormalities and Volume depletion
• Protect pressure areas, especially in PVD and neuropathy
• Take care! A postoperative diabetic patient is at risk of infection, and arteriopathic disease
• Involve patients themselves in the management of their diabetes during this period

Preoperative Management of Steroid Therapy

• Complications of steroid therapy increase the risk of poor wound healing and may mask sepsis.
• Deficiency may present as cardiac failure or Addisonian crisis.
• Side effects of steroid therapy : Includes impaired glucose tolerance, fragile skin, osteoporosis, peptic ulceration, altered fluid retention and metabolic alkalosis
• The nature of the surgery should be performed according to level of previous steroid use
• Minor Use- 50 mg hydrocortisone IM/IV preoperatively.
• Intermediate Use- 50 mg hydrocortisone IM/IV with premed & 50 mg hydrocortisone every 6 h for 24 h
• Major Use- 100 mg hydrocortisone IM/IV with premed & 100 mg hydrocortisone every 6 h for at least 72 h after surgery.