preoperative preparation.pdf

Preoperative Preparation Mostafa Farag Lecturer of Surgery Department of Surgery Faculty of Medicine...

Preoperative Preparation Mostafa Farag Lecturer of Surgery Department of Surgery Faculty of Medicine University of Alexandria Learning Objectives 1. How to asses surgical, medical and anaesthetic aspects 2. How to optimize patient condition 3. How to take consent 4. How to organize operating list Definition : is the preparation of the patient requiring surgery to optimize Post-operative outcomes The preparation begins at the time of contact of the patient with the surgeon and ends at the day of surgery The approach is multidisciplinary, it involves participation of anaesthetic and surgical teams, radiologist, pathologists, specialist nursing stuff and operating room stuff. 1. Review of patient data medical records: History History of underlying disease, medication, functional capacitance, previous anesthetic history, family history, smoking and alcoholic use, review of systems, psychological support Airway evaluation  2.Examination: General: Positive findings even if not related to the proposed procedure should be explored further Surgery related: Type and site of surgery, complications occurred due to underlying pathology Systemic: Comorbidities and extent of limitation of each organ function Specific: For example, suitability for positioning during surgery. General: Anaemia, jaundice, cyanosis, nutritional status, sources of infection (teeth, feet, leg ulcers) Cardiovascular: Pulse, blood pressure, heart sounds, bruits, peripheral edema Respiratory: Respiratory rate and effort, chest expansion and percussion note, breath sounds, oxygen saturation Gastrointestinal: Abdominal masses, ascites, bowel sounds, hernia, genitalia Neurological: Consciousness level, cognitive function, sensation, muscle power, tone and reflexes Airway assessment Examination specific to surgery At preoperative assessment, the clinical findings, site, side, specific imaging or investigation findings related to the pathology for which the surgery is proposed should be noted. Suitability of the patient for the proposed surgical option and vice versa should also be assessed. For example, laparoscopic procedures are less invasive and are therefore preferred in most; however, not all patients can tolerate pneumoperitoneum and positioning. 3. Investigations: The National Institute of Health and Care Excellence, UK (NICE) guidelines lay out the investigations needed for various categories of surgery. Full blood count (FBC) is needed for major operations, in the elderly and in those with anaemia or pathology with ongoing blood loss and chronic disease. Urea and electrolytes (U&Es) are needed before all major operations, in most patients over 65 years of age especially with cardiovascular, renal and endocrine disease, or if significant blood loss is anticipated. Electrocardiography (ECG) is required for those patients over 65 years of age and symptomatic patients with a history of rheumatic fever, diabetes, cardiovascular, renal and cerebrovascular disease, with and without severe respiratory problems. Chest radiograph should be restricted to specific patients, such as those with cardiac failure, severe chronic obstructive pulmonary disease (COPD), acute respiratory symptoms, pulmonary cancer, metastasis or effusions or those who are deemed to be at risk of active pulmonary tuberculosis. Clotting screen If a patient has a history suggestive of a bleeding diathesis, liver disease, eclampsia, or has a family history of bleeding disorder, or is on antithrombotic or anticoagulant agents then coagulation screening will be needed. Urine analysis: Dipstick testing of urine should be performed on all patients to detect urinary infection, biliuria, glycosuria and inappropriate osmolality Arterial blood gases: A low-cost tool that can give quick and vital information in acute or chronic severe respiratory conditions. Liver function tests: These are indicated in patients with jaundice, known or suspected hepatitis, cirrhosis, malignancy or in patients with poor nutritional status Q- SPECIFIC PREOPERATIVE PROBLEMS : Cardiovascular disease:  Hypertension, ischaemic heart disease (IHD) and coronary stents  Dysrhythmias   implanted pacemakers and cardiac defibrillators  Valvular heart disease. Gastrointestinal disease: Nil by mouth and regular medications Patients are advised not to take solids within 6 hours and clear fluids within 2 hours before anaesthesia to avoid the risk of acid aspiration syndrome. Regurgitation risk  Patients with hiatus hernia, obesity, pregnancy and diabetes are at high risk of pulmonary aspiration, even if they have been NBM before elective surgery.  Clear antacids, H2-receptor blockers, e.g. ranitidine, or proton pump inhibitors, e.g. omeprazole, may be given at an appropriate time in the preoperative period. Respiratory disease: The patient should be referred to a respiratory physician if:  There is a severe disease or significant deterioration.  Major surgery is planned in a patient with significant respiratory comorbidities.  Right heart failure is present – dyspnoea, fatigue, tricuspid regurgitation, hepatomegaly and edematous feet.  The patient is young and has severe respiratory problems (indicates a rare condition) Genitourinary disease: Renal disease Urinary tract infection Endocrine and metabolic disorders:  Malnutrition  Obesity  Diabetes mellitus  Coagulation disorders : Patients with a strong family history or previous personal history of thrombosis should be identified. They will need thromboprophylaxis in the perioperative period. Consider stopping estrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before surgery (NICE guidance). Patients with a low risk of thromboembolism can be given thromboembolism- deterrent stockings to wear during the perioperative period. High-risk patients with a history of recurrent DVT, pulmonary embolism and arterial thrombosis will be on warfarin. This should be stopped before surgery and replaced by low molecular weight heparin or factor Xa inhibitors.  4. Airway assessment The ability to intubate the trachea and oxygenate the patient are basic and crucial skills of the anaesthetist. The ease or difficulty encountered when performing airway manoeuvres can be predicted by simple examination findings of full mouth opening (modified Mallampati class), jaw protrusion, neck movement and thyromental distance. When more than one of the above tests are positive, the chances of experiencing difficulty in obtaining and securing the airway become greater. To obtain the modified Mallampati class, the anaesthetist sits in front of the patient who is asked to open their mouth and protrude the tongue. Q- Patient factors that predispose to high risk of morbidity and mortality:  Previous severe cardiorespiratory illness, e.g. acute myocardial infarction, COPD or stroke  Late stage vascular disease involving aorta  Age >70 years with limited physiological reserve in one or more vital organs  Extensive surgery for carcinoma Acute abdominal catastrophe with haemodynamic instability (e.g. peritonitis)  Acute massive blood loss >8 units  Septicaemia  Positive blood culture or septic focus  Respiratory failure: PaO2 0.4 or mechanical ventilation >48 h  Acute renal failure: urea >20 mmol or creatinine >260 mmol/L 5. preoperative patient counseling: Preoperative counseling refers to an educational intervention before surgery which aims at improving patient’s knowledge, health and outcome. Principles Discuss the diagnosis and treatment options at a time and place at which the patient is best able to understand and retain the information. Discuss with the patient the intraoperative and immediate and late postoperative complications that should happen. Where possible, explain the up to date, relevant information in a way that the patient will understand; and allow time for the patient to process information and ask any questions You should not present information in a way that might influence patients’ decision making- explain the options fully Make sure to document what was said and decided. Most cases will also require a separate consent form to be signed. Emphasis that signing a consent form is not final and decision can be reversed at any time. 6. Consent - Consent should be both voluntary and informed. - The guidance outlines the key principles of consent and how the discussion should:  give the patient the information required to make a decision  be tailored to the individual patient  explain all reasonable treatment options  discuss all material risks  should be written and recorded on a form  the key points of the discussion should be recorded in the case notes.  For consent to be given, the patient must have capacity, which includes the ability to understand the information provided, to retain and use the information to make a decision and to indicate what that decision is  Clearly in certain emergency situations, it may not be possible to follow all of the key principles 7. Arranging theatre list  The date, place and time of operation should be matched with availability of personnel.  Appropriate equipment and instruments should be made available.  The operating list should be distributed as early as possible to all staff who are involved in making the list run smoothly: - Ward, theatre and specialist nursing staff - Anaesthetic and surgical teams - Radiology, pathology involvement - Rehabilitation and social care workers - Specific personnel in individual cases