General Surgery Pre-Operative Preparations PDF 2025

Dr/ Ahmed Kamel  General Surgery Pre-operative Preparations Pre-oPerative PreParations  The rationale of pre-op preparation: ① Determine a...

Dr/ Ahmed Kamel  General Surgery Pre-operative Preparations Pre-oPerative PreParations  The rationale of pre-op preparation: ① Determine a patient’s fitness for surgery ② Reduce morbidity and mortality. ③ Anticipate difficulties. ④ Make advanced preparation and organize facilities, equipment and expertise. ⑤ Enhance patient safety and minimize chances of errors. ⑥ Alleviate any relevant fear/anxiety perceived by the patient.  The extent of pre-operative preparation depends on:- 1. Classification of surgery (Elective – Scheduled – Urgent - Emergency) 2. Nature of the surgery (Major, major plus) 3. Location of the surgery (A& endoscopy, minor theatre, main theatre) 4. Facilities available  Classification of surgery: According to National Confidential Enquiry into Patient Outcome & Death (NCEPOD)  Mutually convenient timing. ① Elective  Lower complication rate. Scheduled ②  Early surgery under time limits e.g. 3 weeks for malignancy. (or semi-elective)  As soon as possible after adequate resuscitation & within 24  Urgent hours.  Resuscitation concomitant with immediate operative ④ Emergency intervention.  Higher complication rate. Surgery To Be Simple with Dr/A. Kamel 1  General Surgery Pre-operative Preparations Patients may be... ▪ Emergency: o Admitted from A&E. o Admitted from clinic. ▪ Elective: o Scheduled admission from home, usually following pre- COMPLICATION RATES assessment.  It includes: ① Preoperative assessment. ② Preoperative Laboratory testing & imaging. ③ Preoperative consent & counselling. (A) Assessment of ④ Identification & documentation. fitness for surgery ⑤ Patient optimization for elective surgery. ⑥ Resuscitation of the emergency patient. ⑦ The role of prophylaxis. ⑧ Preoperative marking. ① Preoperative medications ② Preoperative management of cardiovascular disease ③ Preoperative management of respiratory disease ④ Preoperative management of endocrine disease (B) Preoperative ⑤ Preoperative management of neurological disease management of ⑥ Preoperative management of liver disease coexisting disease ⑦ Preoperative management of renal failure ⑧ Preoperative management of rheumatoid disease ⑨ Preoperative assessment and management of nutritional status ⑩ Risk factors for surgery and scoring systems Surgery To Be Simple with Dr/A. Kamel 2  General Surgery Pre-operative Preparations Assessment of fitness for surgery Pre-assessment clinics ⎚ The preassessment clinic aims to assess surgical patients 2–4 weeks preadmission for elective surgery. ⎚ Preassessment is timed so that the gap between assessment and surgery is:  Long enough so that a suitable response can be made to any problem highlighted.  Short enough so that new problems are unlikely to arise in the interim. ⎚ The timing of the assessment also means that:  Surgical team can identify current pre-op problems.  High-risk patients can undergo early anaesthetic review.  Perioperative problems can be anticipated, and suitable arrangements made:  E.g. Book Intensive Therapy Unit [ITU] / High-Dependency Unit [HDU] bed for the high-risk patient.  Medications can be stopped or adapted:  E.g. Anticoagulants, drugs that increase risk of deep vein thrombosis [DVT].  There is time for assessment by allied specialties:  E.g. dietitian, stoma nurse, occupational therapist, social worker.  The patient can be admitted to hospital closer to the time of surgery, thereby reducing hospital stay.  The patient should be reviewed again on admission for factors likely to influence prognosis and any changes in their pre-existing conditions:  E.g. new chest infection, further weight loss. I Preoperative Assessment  Preoperative Assessment Includes: 1- History. 2- Physical examination. 3- Investigations as indicated: e.g. A. Blood tests B. Urinalysis C. ECG D. Radiological investigations E. Microbiological investigations F. Special tests 4- Consent & counselling. Surgery To Be Simple with Dr/A. Kamel 3  General Surgery Pre-operative Preparations 1 Surgical history  Parts of history taking: ⎚ Dictate the urgency. Presenting ① ⎚ It can influence the anaesthetic management & any associated complaint systemic effects of presenting pathology. Systemic ⎚ Careful assessment of each body system about its function ② assessment To rule out if any other is involved. 1. Many diseases have direct effect on general & anesthetic Past medical & treatment and outcome.  surgical history 2. Any previous operations or bleeding tendency. 3. Any previous reaction to anesthetic agents. 1. Interaction with anesthetics. → e.g., MAO inhibitors. 2. Related to sudden withdrawal → Steroids. Drug history & 3. Drugs to be continued over the perioperative period → E.g., ④ allergies drugs for HTN & IHD. 4. Anticoagulant drugs (Aspirin, Warfarin) 5. Hormone Replacement Therapy (HRT) ⎚ Smoking: How much and for how long? ⑤ Social history Short term Long term ▪  Myocardial oxygen demand ▪  immune function ▪  oxygen delivery ▪  clearance 1. Malignant hyperthermia. ⑥ Family history 2. Pseudocholinesterase deficiency. 3. Bleeding disorders. Principles of history taking... 1. Listen: What is the problem? (Open questions). 2. Clarify: What does the patient expect? (Closed questions). 3. Narrow: Differential diagnosis (Focused questions). 4. Fitness: Comorbidities (Fixed questions). Surgery To Be Simple with Dr/A. Kamel 4  General Surgery Pre-operative Preparations 2 Physical Examination  General principles:  Detailed descriptions of physical examination methods can only be learnt by observation and practice. ‫ تتحسن بالممارسة‬-  Don’t rely on the examination of others.. ‫ افحص بنفسك‬-  Surgical signs may change, and others may miss important pathologies.  Patients should be: ‫ حق المريض عليك‬- A. Be treated with respect and dignity. B. Receive a clear explanation of the examination undertaken. C. Be kept as comfortable as possible.  A chaperone should be present, especially for intimate examinations. ‫ مرافق العيان‬-  This is will often be part of a local guideline or policy.  Items of physical examination: ① General examination including vital signs. ② Cardiac examination; including JVP and heart sounds. ③ Respiratory examination; tracheal position, accessory muscles or respiration. ④ Abdominal examination. ⑤ CNS. ⑥ Musculoskeletal system. ⑦ Peripheral vascular. ⑧ Local examination. ⑨ Body orifices. If you don’t put your finger, you will put your foot. Emergency Physical examination ⎚ The routine examination must be altered to fit the circumstances. ⎚ Air way, Breathing, Circulation, Disability, Exposure. (A, B, C, D, E) ⎚ Secondary survey (head to toe) after patient becomes stable. ⎚ When a number of emergency is present at the same time - Triage. Surgery To Be Simple with Dr/A. Kamel 5  General Surgery Pre-operative Preparations II Preoperative Investigations  When to perform a clinical investigation: “Rationale or value of preoperative investigations” ① To confirm a diagnosis. ② To exclude a differential diagnosis. ③ To assess the appropriateness of surgical intervention. ④ To assess fitness for surgery.  When deciding on appropriate investigations for a patient, you should consider: 1. Simple investigations first 2. Safety (non-invasive investigation before invasive investigation if possible) 3. Cost VS benefit 4. Sensitivity & specificity of the investigation: the likelihood of the investigation providing an answer. 5. Ultimately, will the investigation change your management?  Investigations needed: ⎚ Major surgery can lead to organ system dysfunction needing ① Type of surgery most investigations. ⎚ For example, sickle cell test for patients of Afro-Caribbean ② Patient origin with family history of sickle cell disease ③ Comorbidities ⎚ For example, peak flow rates for severe asthmatics Surgery To Be Simple with Dr/A. Kamel 6  General Surgery Pre-operative Preparations 1 Blood Tests ⎚ When to perform a preoperative FBC? In practice almost all surgical patients have an FBC measured but it is particularly important in the following groups: 1. ALL emergency pre-op. cases especially abdominal conditions, trauma, sepsis. 2. ALL elective pre-op. cases aged > 60 years. ① FBC 3. ALL elective pre-op cases in adult women. 4. If surgery is likely to result in significant blood loss (major surgery). 5. If there is suspicion of: ▪ Blood loss ▪ Haematopoietic disease ▪ Anaemia ▪ Cardiorespiratory disease ▪ Sepsis ▪ Coagulation problems ⎚ When to perform? 1. ALL preoperative cases > 65 years 2. ALL patients with: ▪ Cardiopulmonary disease ▪ or taking diuretics or steroids. 3. ALL patients with: Urea and ▪ History of Renal/liver disease. ② ▪ or abnormal nutritional state. electrolytes 4. ALL patients with history of: ▪ Diarrhea. ▪ Vomiting. ▪ Other metabolic/endocrine disease. Incident of unexpected abnormality in apparently fit patient under 40 yrs is < 1% ⎚ When to perform? ③ Amylase  ALL adult emergency admissions with abdominal pain, prior to consideration of surgery. ⎚ When to perform? Random Blood 1. Acute abdomen ④ Glucose 2. Elective cases with DM, malnutrition, obesity 3. Elective cases > 60 years Surgery To Be Simple with Dr/A. Kamel 7  General Surgery Pre-operative Preparations ⎚ When to perform? 1. History of: Bleeding disorder - Liver disease - Excessive alcohol use. 2. Patients receiving anticoagulants: Coagulogram  PT/INR done on the morning of surgery for patients ⑤ studies instructed to discontinue warfarin. 3. Cardiothoracic surgery. 4. Vascular surgery. 5. Angiographic procedures. 6. Craniotomy procedures. ⎚ When to perform? 1. ALL patients with: ▪ Upper abdominal pain. Liver function ⑥ ▪ Jaundice. tests ▪ Hepatic disease. 2. Alcoholic 3. Screening for Hepatitis B & Hepatitis C ⎚ When to perform? Blood group / 1. Emergency preoperative case. ⑦ Cross match 2. Suspicion of blood loss, anemia, coagulation defects. 3. Procedure on pregnant ladies. 2 Electrocardiogram (ECG) ⎚ When to perform?  Within 12 weeks of surgery (or less if condition warrants) For patients with known cardiac disease  Within 6 months prior to surgery For all patients > 50 years Surgery To Be Simple with Dr/A. Kamel 8  General Surgery Pre-operative Preparations 3 Imaging ⎚ When to perform? 1. All elective pre-op cases aged > 60 years 2. All cases of: ▪ Cervical, thoracic or abdominal trauma. ▪ Acute respiratory symptoms or signs. 3. Previous cardiorespiratory disease & no recent chest Chest ① radiograph radiograph 4. Thoracic surgery. 5. Patients with malignancy. 6. Suspicion of perforated intra-abdominal viscus 7. Recent history of tuberculosis (TB) 8. Recent immigrants from areas with a high prevalence of TB 9. Thyroid enlargement (retrosternal extension). 1. Ultrasound. Other ② 2. CT scan. Performed according to requirement investigations 3. MRI. Investigating special cases coexisting disease ① Chest radiograph for patients with severe rheumatoid arthritis:  They are at risk of disease of the odontoid peg, causing subluxation and danger to the cervical spinal cord under anesthesia. ② Specialized cardiac investigations:  e.g.. echocardiography, cardiac stress testing, MUGA scan.  Used to assess pre-op cardiac reserve  They are increasingly used routinely before major surgery. ③ Specialized respiratory investigations:  e.g. spirometry to assess pulmonary function and reserve. Surgery To Be Simple with Dr/A. Kamel 9  General Surgery Pre-operative Preparations III Assessment of risk of surgery ⎚ There are few patients who have no risk for surgery. ⎚ It is important to quantify the risks involved so they be discussed with the patients. ⎚ Two main prognostic scoring systems which are in current use are: 1. Acute Physiology And Chronic Health Evaluation (APACHE) scoring system 2. American Society of Anaesthesiologists (ASA) scoring system. 1 APACHE system ⎚ Helps to predict the outcome of patients admitted to ICU. ⎚ It has subsequently been applied to patients undergoing surgery ⎚ APACHE II: APACHE II Classification Includes 12 acute physiological variables 1. Body Temperature (rectal) 2. Blood pH Acute 3. Heart Rate (HR) 4. Serum sodium A Physiology 5. Respiratory Rate (RR) 6. Serum potassium Score 7. Mean Arterial Pressure (MBP) 8. Serum creatinine 9. FiO2 (alveolar arterial O2 gradient) 10. Hematocrit 11. Glasgow Coma Scale (GCS) 12. WBCs count B Age points Graded from ≤ 44 to ≥ 75 years Chronic ▪ 2 Points for elective post operative admission. C Health ▪ 5 points for emergency op. nonoperative admission, Problems immunocompromised pts, CLD, CVD, respiratory or renal disease. Score is A+B+C ⎚ APACHE III:  Introduced in 1991.  Includes: o 5 More physiological variables: - Blood Urea Nitrogen. - Urine Output. - Albumin. - Bilirubin. - Glucose. o Modified version of Glasgow Coma Scale (GCS). Surgery To Be Simple with Dr/A. Kamel 10  General Surgery Pre-operative Preparations 2 ASA system ⎚ It is very simple and widely accepted. ⎚ 50% patients presenting for elective surgery are in ASA Grade I. ⎚ Operative mortality rate for these patients is less than 1 in 10,000. ⎚ ASA Grading & Predictive mortality: ASA Grade Definition Mortality I ▪ Normal healthy patient. 0.06% II ▪ Mild systemic disease and doesn’t limit activity. 0.4% III ▪ Severe systemic disease that limits activity. 4.5% IV ▪ Severe systemic disease that is a constant threat to life. 23% ▪ Moribund, not expected to survive 24 hours with or V 51% without surgery Surgery Related Risk High Risk Surgery (>5%) Intermediate Risk (