preoperative evaluation and prepration assessment of overall risks that may complicate operative peroid and post operative recovery throught Hx ( PMHx, FHx, SHx, SurgHx), Px , basic labs , EKG are all needed , at minimum most critical systems to be mindful of are cardiac , pulmonary , hepatic and nutritional . know the major risk factors for operative / post-operative complications .

cardiac assessment In general , all pts should have an EKG before surgery , to check for any subclinical arrhythmias. Major cardiac risk factors are : CHF , recent MI ( within 6 m ) , HTN , and arrhythmia Pts w / documented or symptomatic CHF should have their EF assessed (echocardiography). EF < 35 % is an absolute contraindication to surgery. Pts w / CHF should have their EF optimized via traditional medical tx ( ACEI, BB , DIURETICS OR DIGITALIS) Hx of MI IN THE PAST 3 M is an major CI for surgery . preferably , the pt should be 6 m past their last MI .

Cardiac Assessment It is preferable for HTN to be tightly controlled prior to surgery . HTN increase the risk of heeding and hematoma. Pts w / valvular heart disease have an increased risk of post - operative endocarditic. Pts w/ implanted pacemakers :Should consult w/ their cardiologist regarding the use of electrocaudery during surgery

Goldmans Cardiac Risk Index JVB = 11 POINTS MI = 10 POINTS PVCs , Non sinus rhythm = 7 POINTS Age > 70 = 5 POINTS any emergent surgery = 4 POINTS Aortic valvular stenosis , poor condition , surgery to thrax or abdomen = 3 POINTS

risk of complication / mortality 0.5 = < 1 % 6-12 = 5 % 13 -25 = 11 % 25+ = 22%

pulmonary assessment Centers around the presence or absence of copd All smokers and COPD pts should have PFTs performed (FEV1) If the FEV1 is low ( < 80 % predicted) you should do ABGs ( looking for Pco2) If the Pco2 is high ( > 45 mmhg) , the pt should stop smoking for 8 weeks , do pulmonary exercise , and recheck.

hepatic assessment Hepatic disorder can directly increase the risk of bleeding ( low factors) and reduce wound healing Liver function panels should be obtained as part of any pts basic lab workup (cmp ,Pt ) should be obtained Focusing on four parameters , T bill , albumin , ammonium and Pt) As a general rule of thumb , if any of these are abnormal , they should be corrected before surgery . especially ammonium , hepatic encephalopathy is an absolute CI for surgery . One significant exception , if the T.bill IS HIGH to a suspected obstruction may proceed

nutritional support In practice , relatively obvious most of the time based on outward appearance and hx Significant unintended wt loss ( > 20%) in past 3 months Lab parameters suggesting nutrional deficiency: Albumin (low) HB (low) , iron studies (high TF) presence of anergy to skin antigens pts w/ suggestive nutrional deficiency should receive PO nutritional support , inpatient , for 5 to 10 days prior to surgery.

metabolic assessment and prepration Focusing primarily on DM and complications. DKA is an absolute CI for surgery. this should be addressed before any surgical endeavor. In general , DM presents complications w/wound healing and a propensity toward post op infections Glucose level- 6-10 mmol /L . Omit oral hypoglycaemic on morning of surgery, monitor sugar level postop until eating freely (mild cases). If glucose > 10mmol/L- start glucose/insulin/K⁺ infusion Insulin dependent: Start glucose/ insulin/ K⁺ prior to surgery. Convert to- sc short acting insulin then regular insulin as the diet is introduced.

The use of epinephrine for surgical purposes should be avoided in these pts . If pts is on corticosteroids (hypoadrenalism) will need increased dosage during and after surgery .

Neurological Assessment pts w/ hx of stroke : most are on anticoagulants . accelerated HTN is an absolute INDICATION to terminate surgery pts with seizure disorders :inform anesthesia sleep apnea/snoring : inform anesthesia

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

Hematological Assessment It is generally advised to normalize pt and ptt prior to surgery . have ffp , platelets . rbcs on hand Preoperative haemoglobin around 10 G/ dl Anti platelet drugs: should be withdrawn only after cardiology consultation. Warfarin: Stopped 4-5 days before surgery, started on IV unfractionated heparin or subcutaneous low molecular weight heparin DVT prophylaxis- SC heparin 5000 IU 2 hours preoperatively and 8 hours postoperatively

Dialysis dependent: Careful IV fluid administration. Chronic renal failure Dialysis dependent: Careful IV fluid administration. Preoperative dialysis to optimize patient. Non-dialysis dependent: Reasonable renal function. Avoid nephrotoxic drugs , control B.p

obs and skin Post pone all elective surgery until after surgery Remember , surgery is a stressor . it can cause exacerbations of herpes , discoid lupus , psoriasis,

allergies Anesthetics Antibiotics Analgesics Aatex

preoperative prophylactic antibiotic 1st generation cephalosporin Vancomycin