Pre-operative Assessment and Management Dr. Muhammad Adil Khan Dr. Fatima Zahid Butt Surgical Unit-I Lahore General Hospital

Learning Outcomes Describe the principles involved in pre- operative assessment ofa patient Enumerate the Specific pre-operative problems in preparing a patient for surgery Identify the stages in the consent process

Definition The preoperative period runs from the time the patient is admitted to the hospital or surgicenter to the time that the surgery begins. 3

Pre-operative plan  Documentation of the condition(for which surgery is needed).  Assessment of the patient.  Uncovering of hidden co-morbidities.  Perioperative risk determination.  Optimization of the patient’s condition.  Development of an appropriate perioperative care plan.  Education of the patient.  Reduction of costs, shortening of hospital stay, reduction of cancellations and increase of patient satisfaction.

Steps of P.O.P ’ s History Examinations Investigations Preoperative treatments Documentation Patient Education

Principles of History taking  Listen: What is the problem? (Open questions) Clarify: What does the patient expect  (Closed questions)  Narrow: Differential diagnosis (Focused questions)  Fitness: Comorbidities (Fixed questions)  Past Hx: Medical & Surgical  Drug Hx

Examination General: findings even if not related to the proposed procedure should be explored Surgery related: Type and site of surgery, complications which have occurred due to underlying pathology Systemic: Comorbidities and their severity Specific: For example, suitability for positioning during surgery.

General Ex: To check fitness for anesthesia & surgery. GPE Systemic: -CVS -CNS -GIT -Respiratory system

Specific Surgical Ex:  Its aim: to confirm previous findings & diagnosis, to determine severity & to gauge extent.  E.g. in inguinal hernia confirm it ’ s inguinal not femoral, reducible or not & whether there are any signs of bowel obstruction.

Specific Medical Ex:  Its aim: to evaluate the presence & severity of other problems.  E.g. Diabetic patient undergoing surgery need careful examination for sepsis, neuropathy or microvascular disease

Investigations – Routine Every hospital and ward has its own protocols. The tests which normally performed on most patient prior to surgery: *Baseline (CBC, PT, APTT, RFTs, LFTs, S/E) *Serology (HBsAg, AntiHCV) *Chest Radiography *ECG

Investigations – Disease Oriented Echocardiography: All those patients with Age>6o and previous H/O VHD, IHD Urinalysis: used for determination of renal function, inflammation, infection & metabolic disorders. Pregnancy Test: ( β-HCG ) HBsAg& HIV testing. BSR, & HbA1c : Diabetes Aterial Blood Gas Analysis Pulmonary Function Tests Thyroid Function Tests

Management plan – Key points Provide all information and take an informed consent. Understanding of the patient about the disease and procedure. Use common language. Discuss the procedure with the alternatives. Give the patient time to think things over. Encourage discussion.

Specific Pre-op problems Anesthesia Fitness

Cardiovascular System: Hypertension. IHD / Recent MI. Arrhythmias. Cardiac failure. Valvular Heart Disease Anaemia & Blood transfusion.. BP > 160 systolic or > 95 diastolic - surgery deferred till control of BP (atleast 2 weeks) MI – No surgery – 6 mths. Consider transfusion if Hb% < 8 g/dl (Major Surgery).

Respiratory System – Pulmonary Toilet – Antibiotics – Stop smoking prior 4 wks & continue inhalers – Avoid respiratory suppressants (narcotics) Lower Respiratory Tract Infection – to be treated Smoking Asthma COPD Pulmonary fibrosis

Renal Disease Renal impairment (Avoid nephrotoxic agents e.g Abx and Radiocontrasts dyes) UTI Categorize – Pre-renal / Renal & Post-renal Hemodialysis within 24 hrs of the procedure. Monitoring of Intravascular volume status. Start antibiotics – UTI Care taken – maintain good urine output

Metabolic disorders Diabetes Adrenocortical suppression Risk-reduction strategies for Diabetic pts Extra dose steroids to avoid crisis

Specific P.O.P – Coagulation disorders X clotting cascades Acq. Coagulopathy Thrombophilia Thromboprophylaxis for High risk groups / Stopping of anticoagulant drugs Complex bleeding disorders – consult haematologist Correct hypothermia

Specific P.O.P – Other disorders – Neuropathies / myopathies – need prolonged ventilation – Psychiatric pts – need GA – Inflammatory arthropathies to be identified Neurologic Psychiatric Locomotor

Specific P.O.P – Remote infection >Sources of bacteraemia – Artificial material – Jt replacement surgery / arterial grafting Infected toes / teeth > Prophylactic antibiotics best administered just prior to induction.

Documentation History – presented logical manner Investigations & Management plan – listed for action Drug chart – routine / prophylactic

Taking Consent - Stages Lead in Explore Diagnosis Treatment Options Introduce yourself and identify the patient How much does the patient know Why the operation is being proposed Explain whether the treatment proposed is in accordance with protocols Discuss all the options

Taking Consent -Stages – Results Eventualities – Adverse events – Sound mind – Open question – Notes Explain likely outcome For example, the possibility of needing to remove the testicle in a hernia operation Myocardial infarction, stroke and embolus & bleeding Ask if they have understood Check if further clarification Document everything discussed and agreed

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