1. Preparing Patients for the Operating Room Sugong Chen June 22, 2015

2. When does it start? As soon as you meet the patient! Remember we are surgeons so every patient is a potential surgical candidate

3. Why is it important? Identifies patients who might require a more extensive preoperative evaluation Predicts post operative complications and morbidity/mortality

4. Top patient risk factors most predictive of post operative mortality VARIABLEODDS RATIO95% CI 14 Private Sector Hospitals (N = 54,450; C-index = 0.934) ASA 4/58.16.0-11.0 ASA 33.52.7-4.7 Albumin g/dL0.620.56-0.69 Emergency operation 2.62.2-3.1 Age/yr1.041.03-1.04 Platelet count <150,000 1.91.6-2.2 Disseminated cancer 2.92.3-3.7 Dyspnea at rest1.61.3-2.0 Dyspnea with minimal exertion 1.31.0-1.5 DNR3.92.6-5.8 BUN >40mg/dL1.31.0-1.6 Work RVU/unit1.021.01-1.03 128 VA Hospitals (N = 129,546; C-index = 0.900) ASA 4/55.34.3-6.6 ASA 32.62.2-3.2 Albumin g/dL0.60.57-0.63 Emergency operation 2.01.9-2.2 Disseminated cancer3.32.9-3.8 Age/yr1.041.03-1.04 Work RVU/unit1.051.04-1.05 Dyspnea at rest1.41.2-1.6 Dyspnea with minimal exertion 1.31.2-1.5 DNR2.82.4-3.3 Ascites2.31.9-2.7 BUN >40mg/dL1.41.2-1.6

5. ASA Classification I -- Normal healthy patient II -- Patient with mild systemic disease III -- Patient with severe systemic disease that limits activity but is not incapacitating IV -- Patient who has incapacitating disease that is a constant threat to life V – Moribound patient is not expected to survive 24 hours with or without an operation

6. Key components Chief Complaint and History Past medical and surgical history Allergies Medications Review of Systems Physical Exam Appropriate Labs and Studies

7. Is patient stable ABC Vitals Monitors Imaging Resuscitate as needed

8. Key Component: History Get the details and summarize pertinent details LOCATES Don’t forget pertinent negatives PMHx PSHx SocHx

9. Key Component: Allergies Drugs Contrast Latex

10. Key Component: Medications Important to know for peri-op care – Cardiac – Glucose control – Antihypertensives – Anticoagulation – Anti-platelet therapies

11. Key Component: Review of Systems Constitutional/ General Eyes Ear, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/ lymphatic Allergic/ immunology

12. Exam Heart Lungs Pulses Abdomen – Scars, bowel sounds, distension, tenderness, location, peritoneal signs (guarding, rebound) Etc. Imaging Labs

13. Informed consent Blood – Pre printed forms that detail the risks of blood transfusion Operative/ Invasive – Generic forms – Procedure specific forms – Must list the risks associated with the procedure and generalized risks as well as benefits

14. Pre-op Note PRE-OP DIAGNOSIS: PROCEDURE: planned surgery. LABS: CBC, chemistries, PT/INR, urinalysis, etc. CHEST X-RAY: note findings. EKG: note findings. ADDITIONAL STUDIES: echo, imaging, etc. BLOOD: not needed, type/screen or type/cross 2 units packed RBCs, etc. ORDERS: NPO, preoperative antibiotics, skin or colon preps, etc. CONSENT: signed and on chart / CSOC.

15. Pre-op Orders/ Considerations CXR EKG Labs Type and screen/cross Anticoagulation reversal Diet- NPO after midnight versus Hold tube feeds on call to OR. Maintenance IVF while NPO Special orders- bowel preps, ostomy site marking etc.

16. Prior to going to the OR, all patients need… Full H&P within 30 days of the operation – Unless they are an inpatient Interval H&P morning of surgery Consent for the operation/blood Type and screen Pre-op orders – NPO – MIVF – Antibiotics on call to OR (if needed) – Appropriate labs