SEMINAR TITLE: PRE OPERATIVE CARE FOR GYNECOLOGIC PATIENT

Prepared by :mekonnen mengistu and mengistu kassa

Moderator: Dr samartha

OUTLINE

• INTRODUCTION• PREOPERATIVE EVALUATION

HISTORYPHYSICAL EXAMINATIONANESTHESIOLOGIC EXAMINATION INVESTIGATION

• PREOPERATIVE PREPARATION

INTRODUCTION

• Preoperative care is the preparation and management of a patient prior to surgery.

• It includes both physical and psychological preparation.

• Surgical treatment of the patients with gynecologic diseases is warranted only when all the conservative treatment approaches have been exhausted.

• Many postoperative problems can be anticipated preoperatively, and eliminated or minimized.

• There are two groups of indications for gynecological surgery: Absolute - when surgery must be undertaken,

when its cancellation is life threatening.Relative - when surgery can be postponed till the

most appropriate occasion for its performing.

• The surgeon is obliged to introduce to the patient all the reasons of the surgical treatment.

INFORMED CONCENT:• The patient must submit an informed written

consent to confirm that she takes the risk of the planned surgical treatment.

• discussion regarding consent should be held with a qualified interpreter present.

• The presence of an interpreter should be included in the documentation.

• The informed consent discussion should include the following:– Rationale– Complications– Unexpected findings at surgery– Personnel who will be involved in the surgery.– Documentation

PREOPERATIVE EVALUATION

• Used to addresses issues that will potentially affect the woman during her surgical procedure and recovery.

• The surgeon should use this time to review:– the patient's history – physical examination– identify physical limitations

– gather information required to plan surgery– optimize medical status, and – educate about what to expect from the

procedure and during the recovery period.Patient history• A comprehensive history is the first step

helping surgeons to determine the scope of general physical examination, laboratory, and radiologic tests.

• The patients undergoing minor surgery can be examined by their surgeon and anesthesiologist on the operation day during preoperative preparation but

• those with more serious conditions should be examined at least a week before surgery, allowing the time for risk assessment, specialist consultations, and preparation.

General medical history: includes • Personal and family diseases• History of drug use• Allergies to drugs, foods, and other environmental allergens• Hospitalizations• Earlier diseases (including previous operations and

tolerance of anesthetics).• Important family data refer to malignancies, cardiovascular

diseases, diabetes mellitus, cerebrovascular diseases, and osteoporosis.

Gynecologic and obstetric history • should contain the data about major

complaints of the current disease (beginning, duration, symptoms).

• past pregnancies (description of each, duration, complications, type of delivery)

• menstrual cycle data (intervals, duration, copiousness, dysmenorrhea, premenstrual syndrome, intermenstrual bleeding)

• menarche; data on the last menstruation• if the patient is age at menopause, recent

vaginal bleeding, vasomotor symptoms, hormone replacement therapy.

• birth control (if sexually active - active contraception, methods in the past; if sterilized - time and mode of sterilization).

• sexual history• birth control (conception difficulties, infertility

treatment)• infections (vaginal discharge, previous vaginal

infections, sexually transmitted diseases).

Clinical (physical) examination• The aim of the physical examination is to

establish the physical, health status, in view of history and medical condition.

• Full physical examination is needed.• detailed exam of the abdomen and pelvis, as

the main component of the procedure.

Anesthesiologic preoperative examination • An anesthesiologist has to examine the patient before

her operation.why?– b/c it helps him to get an insight into the

general health condition, and– to assess whether the patient is able to tolerate

the risks and duration of anesthesia for the planned surgery.

• A special stress is put on the state of consciousness and vital functions of the heart, blood vessels, liver, and kidneys.

Anesthesiologic surgical risk is assessed based on the assessment of physical status created by the American Society of Anesthesiology – ASA:

• Group I- original disease, if it is without a systemic im-pact

• Group II - moderate systemic disease without functional impediments

• Group III - severe systemic disease with serious functional impediments

• Group IV- severe systemic life-threatening disease

• Group V- moribund patient, with 24 hours; and

• Group VI- confirmed brain death INVESTIGATION• Preoperative indications for laboratory tests

– Patient age– diagnosis of the disease and – risk of the procedure with careful and detailed

history and physical examination.

• blood group determination• complete blood count with the leukocyte

formula, sedimentation, bleeding and coagulation time, thrombocytes, fibrinogen.

• Renal function test• liver function test• Blood glucose level• General analysis of the urine and urine culture

• Pregnancy test Pregnancy testing should be performed shortly

before surgery on all fertile women who could be pregnant.

• Imaging studies are often performed to select patients who will not

benefit from surgery (eg, metastatic disease) or to help biopsy tissue for diagnosis of suspicious

masses

• Imaging study includes An intravenous pyelogram (IVP) Computed tomography (CT) magnetic resonance imaging (MRI), and Ultrasound

NB:Preoperative chest x-rays should not be routinely performed.

• Investigation specific to patients problem.

PREOPERATIVE PREPARATION

• It is important to allow adequate time for preparation prior to surgery. This includes:

1-Correction of anemia: Strategies to correct anemia preoperatively are:-

Iron supplementation Medical treatment of abnormal uterine

bleeding Erythropoiesis-stimulating agents Blood transfusion

2-Smoking cessation: Patients undergoing elective surgery should be

advised to stop smoking at least eight weeks before surgery.

Preoperative smoking cessation may decrease wound complications, particularly wound infection.

3-Medical consultation and stabilization The consultant should be asked specific

questions, such as is thyroid replacement adequate hypertension well controlledCHD optimally managed, and diabetes under control

4-Bowel preparation: The gynecologic surgery literature does not

address the safety and efficacy of mechanical bowel preparation.

In general, you can expect to: Modify the dietTake a laxative or bowel preparation medication Increase fluid intake

5-preoperative antibiotics: Provision of optimal local immunity to infection

is primarily a surgical task. A single dose of antibiotic immediately before

the operation is sufficient for most surgical procedures.

If the operation is going to take more than 3 hours, administration of antibiotics should be repeated.

• In time consuming interventions intramuscular administration of antibiotics is preferred.

• Prophylactic use of antibiotics have been demonstrated to be more successful for vaginal compared to abdominal operations.

• Adequate use of antibiotics is able to reduce the rate of infections, as well as morbidity and associated costs .

Recommendation for choosing antibiotcs in postoperative infection prophylaxis:

• Cephalosporins first generation: up to 2,0 grammes

• Metronidazole 0,5 - 1,0 grammes + gentamicin 1,5 mg/kg iv.

• Clindamycin 600 - 900 mg iv + Gentamicin 1,5 mg/kg

• Ciprofloxacin 400 mg iv

Thromboprophylaxis: reduces the incidence of symptomatic DVT or

pulmonary embolism. Types of thromboprophylaxis —

pharmacologic or mechanical

Pharmacologic prophylaxis includes Low-dose unfractionated heparin (LDUH) —

5000 units subcutaneously (SC) every 8 to 12 hours.

Low molecular weight heparin (LMWH) — Dalteparin 2500 units or enoxaparin 40 mg SC daily.

NB: The use of aspirin for prophylaxis is NOT recommended, as other measures are more efficacious.

• Mechanical methods of thromboprophylaxis are placed on the patient just prior to the start of surgery and used continuously until hospital discharge.

• Most commonly used methods in gynecologic surgery are:Intermittent pneumatic compression boots (IPC)Graduated compression stockings (GCS)

Which patients need thromboprophylaxis? The ACCP recommendations for women undergoing

gynecologic surgery are:Low risk (ie, minor surgery in mobile patients) AND/OR

entirely laparoscopic procedures with NO additional VTE risk factors — Do not require specific prophylaxis, but early and frequent ambulation is advised.

Entirely laparoscopic procedures WITH additional VTE risk factors — Mechanical, pharmacologic thromboprophylaxis, or both.

Major gynecologic surgery for benign disease with NO additional risk factors — IPC or pharmacologic thromboprophylaxis.

Major gynecologic surgery for malignancy AND/OR in patients WITH additional risk factors — Pharmacologic therapy (LDUH should be given every eight hours).

Patients who have undergone major surgery for malignancy AND/OR have a previous history of VTE should continue LMWH for up to 28 days.

CONCLUSION

• Preoperative patient preparation for gynecologic surgery is

to avoid or minimize both intra and postoperative complications, and

enabling a successful outcome of surgery.

Reference

• Up to date 19.3; Preoperative evaluation and preparation of women for gynecologic surgery. Author:William J Mann, Jr, MD.

• Danforth's Obstetrics & Gynecology, 9th Edition

• Clinic of Gynecology and Obstetrics• Bailey & Love’s short practice of surgery 25th

ed

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