pre-operative assessment

Pre-Operative AssessmentDr Ahmed Badrek-AlAmoudi

04/19/23A Badrek-Amoudi2

IntroductionIn admitting a patient for surgery the following questions should be answered:

Is the diagnosis firmly established? Has the disease and the procedure been

adequately explained Is there a need for further assessments to stage

the disease or to deal with other diseases? How risky is the operation? Are corrections of blood volume, nutritional status

or electrolyte imbalances needed? What are the prophylactic measures needed? What are the particular preparations required prior

or during the surgery ? Is a cross match needed? What is the likely course immediately post-op?


The preoperative Assessment

History CVS ( MI), RS, Smoking, BP, DM, Bleeding diathesis,

CVA. Drugs, Allergies and Alcohol. Reactions to Anaesthesia.

Examination CVS, RS, nutritional status, mental status. Neck, Jaw and presence of dentures.

Investigations Routine Special


The DiagnosisThis can be established by a combination: The Patient’s Document:

The Chronology of OPD notes. The Chronology of correspondence or consultations. Report of lab., radiological & histopathological

investigations. The Patient:

Complete history and physical examinations Note any changes in symptoms or signs.

The family or relatives Complete any missing links. Ask for any voluntary information.


Risk assessmentImportance & Aims:

Patient selection:Finding the balance between benefit vs risk

Provides a guide to the degree of support required in post-op period.

Provides a data base for risk adjusted outcomes.


Risk Assessment

Risk Factors I Age Cardiovascular Respiratory diseases Smoking GI: malnutrition, Jaundice & Adhesions Renal dysfunction Haematological disorders Obesity Diabetes Surgeon and Operative severity Emergency Drugs


Risk Factors II

Age Distinction must be made

between physiological state and chronological age.

Are less mobile, intercurrent disease, less physiological reserve.

Caution with regards to: IVF & Narcotic analgesia.

More likely to have wound infection.

In 65 CVA 1%, In 80 CVA 3%

Obesity BMI> 30 Increased risk in:

DVT, Wound infections &

Dehiscence Respiratory complications

& sleep apnoea. Intercurrent diseases. Operative difficulty

Relative risk of mortality 3-5

Advise controlled wt reduction

Arrange ICU post-op


Risk Factors IIICardiovascular DiseasesPredictors: CPCENMajor: Unstable coronary

syndrome. Decompensated CCF. Significant Arrhythmias Severe valvular diseaseIntermediate: Mild angina PMH MI Compensated CCF DMMinorAge, abnormal ECG..etc

Action: Evaluation:

Clinical, Specialist opinion, ECG, Stress ECG, CXR, Echo..others

IF Major: Cancel unless life

threatening Consider CABG prior to

elective surgery. If intermediate:

Objective performance. Hypertension:

Indicates CAD More likely to develop

hypotension during surgery. Control prior to surgery.


Risk Factors IVRespiratory diseases Estimate function:

Clinical and Specialist opinion.

ABG CXR Spirometry: FEV1/FVC, PEFR

Chest infection: Postpone for 2 weeks Antibiotics & Physio.

COAD Leis with specialist Reschedule surgery.

Plan to transfer to ICU for mechanical ventilation pending:Lung function, type & duration of surgery.

Smoking 10 cigr.=6 fold increase in

post-op respiratory complications.

Respiratory and CVS effects Carbon monoxide has higher

affinity for O2 than Hb. Nicotine increases heart rate

and BP. Hypersecretion of thick

mucus Immunosuppressive Stop 3 months= improve

pulmonary functions Stop 1-2 days= Decreases CO

levels.


Risk Factors VGastro intestinal diseasesMalnutrition Loss o15-20% of body wt is

associated with severe impairment of physiological function

No evidence of benefit of preop feeding.

Adhesions: Higher risk of bowel injury

and subsequent fistula formation

Longer duration of surgery

Jaundice poses a risk for: Sepsis Clotting disorders Renal failure Liver failure Fluid and electrolyte

abnormalities Drug metabolismManagement: Vit k & FFP Adequate hydration and

diuretics & oral Lactulose Antibiotics Nutrition.


Risk Factors VDiabetes

Interest to the surgeon: Patients are more sensitive

to protein depletion, U&E& glucose imbalance.

Surgical stress can precipitate DKA.

DKA is a cause of acute abdomen

Decreased phagocytosis, neutrophil activation and antibody production

Small vessel disease Peripheral vascular disease Peripheral neuropathy Autonomic neuropathy Recognition of

hypo/Hyperglycaemic attacks

Management:Specialist Opinion required

Minor LANSC

Type II GA

4 hourly close observationsOmit dose in mane.Either low dose infusion or fixed dose insulin

Type I GAGIKG: 500 ml 10% dextrose I : Insulin sliding scaleK : Potassium 10 mmolContinue till first light meal


Risk Factors VRenal & haematological DisordersRenal: Identify the cause:

Pre-renal, eg: cardiac, hypovolaemia

Renal, eg: acute tubular necrosis( drug induces)

Post renal, eg: obstructive uropathy.

Identify pt for renal dialysis.

Check K levels

Accurate fluid balance Look for signs of fluid

overload. Do not misinterpret

poly ureamic phase

Anaemia Correction 1 week pre-op Correction day preop is

undesirable Haemodilution

Thrombocytopaenia In splenomealy, Platelets must be

transfused immediately preop and on ligating the arterial supply.

Sickle cell disease Crisis caused by : dehydration,

infection, hypoxia, hypothermia. Jaundice & anaemia Splenic infarctions: sepsis Prevention: Warm, well hydrated,

well analogised Consider exchange transfusion in

SS

Correction of coagulopaties


Risk Factors Operative Severity Minor:

Procedures under LA, Uncomplicated hernia Moderate:

Appendicectomy, Cholecystectomy TURP

Major: Laparotomy, Bowel resection

Major+: AP resection, hepatioco-pancreatic surgery Emergency surgery.


Risk Factors ASA ( American Society of Anaesthesiologist)

ClassPhysical Status

1Normal healthy individual

2Mild-moderate systemic disease eg: DM, BP

3Severe systemic disease, NOT incapacitating eg: CCF with limited exercise tolerance

4Incapacitating disease, constant threat to life. with or with out surgery eg: Uncontrolled angina

5Moribund pt not expected to live, surgery is the last resort.

EPatient requiring emergency surgery.


Prophylaxis IWound InfectionIndications:1. When the risk of infection is high

Clean- contaminated or dirty surgery2. When the results of infection is serious

e.g. cardiopulmonary bypass3. When there is proven benefit for prophylaxis.

Principles: MIC must be achieved and maintained through the op. Bacteriocidal with high tissue penetration. The agent used depends on the likely pathogen


Prophylaxis IIThrombo-Embolism 1

Risk level

% DVT

Patient Group

Low< 10Minor surgeryMajor surgery, age<40, no PMH

Moderate

10-40

Major+ age>40 and/or major medical conditions.PMH of DVT/PE.Lower limb paralysis

High40-80

Major abd. Or pelvic surgery for cancer.Major+ PMH of DVT/PEMajor lower limb amputations


Prophylaxis IIThrombo-Embolism 2Recommended Protocols:Low risk: Graduated compression stockings,

early mobilization.Moderate-High risk: GCS, EM, Unfractionated Heparin

UFH, Low Molecular weight heparin LMWH, Intermittent Pneumatic compression IPC.

UFH: s/c . 5000 bd, start 2 hours preop, continue till disharge.Contraindicated in Neurosurgery, TURP and ? Epidurals.Complications: Haematoma & bleedingMust be used with GCS

LMWH: Od, Less risk of bleeding GCS/IPC reduction of DVT by 65%


Prophylaxis IIIOthers

Psychological prophylaxis

Education, counselling and behavioural techniques Preoperative sedation

Infective Endocarditis

40% no previous valvular abnormalities. At risk: Valvular disease, Alcoholics, DM, drug addicts, immunosuppressed. Cover for Strep.viridans and Staph. AB regime variable.

Renal Good hydration. Improved renal perfusion using osmotic or loop diuretics.


Prophylaxis IVBowel Preparation

Mechanical Bowel Prep. Low residue liquid diet 2-3 days pre-op, Purgatives and

Phosphate enemas 2-3 times the day preop. Osmotic and oral purgatives using Poly-ethelene Glycol PEG.

Balanced isotonic solutions 2 L, 1 day pre-op. Well tolerated.

Intra-operative colonic irregation: In emergency stenotic lesions

Upper GI: Fasting pre-op is usually sufficient. NGT insertion and wash out may be necessary.

Bowel Sterilization: Effective reduction of colonic bacteria Erythromycin and metronidazole.


Nursing Preparations

Bathing Removal of jewellery Removal of dentures Skin preparation and shaving on morning of surgery Administration of medications prescribed.


Blood Transfusions

Group & Saves: Simple breast surgery Cholecystectomy Ileostomy Anorectal surgery Thyroidectomies.Cross matched: Mastectomy 2U AP + Colorectal 3-4U Gatrectomy 2U Splenctomy 2U AAA 6U Oesophageal-gastrectomy 4U


Special ConsiderationsThe Thyroid Flexible laryngoscopy by

ENT: check the vocal cords

Recent TFT Control of thyrotixicosis:

Beta blockers. Lugol Iodine treatment Anti-thyroid drugs.

Anesthetic assessment for the possability of difficult intubation.

G+S blood. ICU & tracheostomy for

possible tracheomalacia.


Special ConsiderationsOthers

Parathyroid.Thoraco-Abd SurgerySpleen

Biliary SurgeryPt on Steroids

RheumatoidsElderly for spinal Stoma

Arrange with path lab for Fresh Frozen SectionArrnge ICU for post-op ventilation

Vaccination 2 weeks pre-opPlatelets pre and during surgeryIntra-operative FlouroscopyIncrease dose of steroids

Neck Xray preintubationLumbar viewsMark site preop


Special ConsiderationsEmergency Surgery

Time factor is more critical In 35-40% of cases the diagnosis is uncertain. Resuscitation if needed must be combined with the above

assessment. Patients with acute surgical emergencies are more likely to have

physiological upsets. Broad decisions must be made:

Shock Serious injuries to the chest or abdomen Acute abdomen & Peritonitis Abscesses GI haemorrhage

Certain conditions require immediate surgical intervention Do not compromise the patient by requesting investigations.

Help is at hand when you need it.


Scenario 1

A 20 year old male patient with sickle cell disease was diagnosed with calcular cholecystitis. Laparoscopic cholecystectomy was planned.

Outline the steps needed to assess and prepare this man for the planned surgery and the issues to be discussed on obtaining an informed consent.


Scenario 1 preop Read-up the condition. A clinical general assessment Haematological considerations:

Degree of anaemia. Sickle test Electrophoresis Quantify: % Hb S, Hb A Quantify: % Hb S (< 40%), Hb A post exchange

transfusion Specific assessment of cardiac, liver and renal

functions Preparation:

1. NBM and IVI…… avoid dehydartion2. IV AB……………..Avoid sepsis3. Analgesia……….Avoid Pain.4. Keep warm……..Avoid hypothermia5. Keep good oxygenation…Avoid hypoxia6. S/C Heparin…….Avoid hypercoagulable status


Scenario 2

A 50 year old non insulin dependant diabetic is planned for a right inguinal hernia repair. He is on warfarine for past hx of DVT.

Outline the steps needed to assess and prepare this man for the planned surgery and the issues to be discussed on obtaining an informed consent.


Scenario 2 preop

General consideration:1. Clinical assessment2. Check for possible risk

factors for the hernia.3. Cardiac, renal,

hypertension and nutritional assessment

4. Prophylaxis IV antibiotics

5. Skin preparation6. Keep good hydration7. Always recognise the

state of hypo/hyper glycemic coma

Specific considerations:1. Position on the operation list.2. Requirements of insulin sliding

scale.3. In emergencies: check for

acetone and acidotic status.

Minor LANSC

Type II GA

4 hourly close observationsOmit dose in mane.Either low dose infusion or fixed dose insulin

Type I/II GA

GIKG: 500 ml 10% dextrose I : Insulin sliding scaleK : Potassium 10 mmolContinue till first light meal


Scenario 3

A 55 year old obese lady who is a smoker and hypertensive recently diagnosed with cancer of the left breast. L mastectomy is planned.

Outline the steps needed to assess and prepare this lady for the planned surgery and the issues to be discussed on obtaining an informed consent.


Scenario 3 preopA. Obesity

Assess BMI Assess comorbid factors:

BP, cardiac and respiratory function, DM, hyperlipidaemia, hormonal profile if indicated.

Thromboembolic prophylaxis

B. Hypertension: Insure adequate smooth

control Check for myocardial cerebral

ischaemia Check medication and it’s side

effects.

C. Smoking Stop it and assess

comorbid factors.

Specific measures1. Histological evidence2. Staging CT, bone scan3. Localisation4. LFT, Ca, CBC5. Tumour markers6. Risk assessment7. E/P receptor status8. X-match9. Involvement of oncology,

radiology, pathology, plastics, specialist nurse teams.

10. Timing neoadjuvent chemo/radio therapy


Scenario 4

A 30 year old lady with graves disease failed to respond to medical treatment. Thyroidectomy is planned.

Outline the steps needed to assess and prepare this lady for the planned surgery and the issues to be discussed on obtaining an informed consent.


Scenario 4 preop1. Collect evidence of diagnosis

Thyroid function Autoantibodies Nuclear /USS scans Histology excluding Ca

2. Normalise the thyroid function: Iodine, β blockers, benzodiazepines Evidence of normal TFT post treatment

3. General clinical and objective assessment of cardiac status

4. Check CBC ( aplastic anaemia)5. Group and save.6. Flexible laryngoscopy: vocal cords7. Consent issues8. premedication


Scenario 5

A 70 year old gentleman recently diagnosed with cancer of the rectum 8 cm from the anal margin. Anterior resection is planned. He is on steroids for COAD.

Outline the steps needed to assess and prepare this gentleman for the planned surgery and the issues to be discussed on obtaining an informed consent.


Scenario 5 preop1. Diagnose2. Check for possible underlying and associated problems3. Stage4. Map and check for synchronous tumours5. Correct electrolyte abnormalities and CBC 6. Improve the nutritional status.7. Assess the need for neoadjuvent treatment ( involve

the oncology, radiology, endoscopy teams)8. Check for integrity of L ureter and L kidney

hydrnephrosis9. Full clinical assessment ( lung, heart and liver)10. Bowel preparation 11. Stoma location12. Prep the abdomen13. Prophylactic AB and bowel sterilisation.14. Prophylactic thromboeblism.15. Informed consent


Scenario 6

A 20 year old gentleman involved in an RTA. Patient’s abdomen is distended and he is shocked.

Emergency laparotomy was deemed necessary.



Scenario 6 preop

1. Primary and secondary survey2. AMPLE3. Cross match and basic laboratory work

up4. CXR, C-Spine, Pelvis x-rays5. Consent6. Inform OR and shift7. Administer AB en-rout to OR


Scenario 7

A 67 year old man with a septic diabetic foot presented to the ERD. He is IDDM for 5 years , with IHD for 2P: 130/ minute, BP 90/60, T 38.5, O2 Satu. 82%


pre-operative assessment

Documents

increased risk

risk assessmentimportance

risk factors iiagedistinction

elective surgery

specialistreschedule

nutritional status

abnormal ecg

specialist opinion