1. 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 .

2. 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 .

3. 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

4. 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

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

6. 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.

7. 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

8. 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.

9. 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 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.

10. 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 .

11. 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

12. 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

13. 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

14. 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

15. 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,

16. allergies
Anesthetics
Antibiotics
Analgesics
Aatex

17. preoperative prophylactic antibiotic
1st generation cephalosporin
Vancomycin