Preoperative care by Dr .A. Aljohari assistant professor general sur

1. Preoperative care by Dr .A. Aljohari assistant professor general surgery K . A . U . H

2. Preoperative care:it is the care of the patient with major surgical problem as the ultimate outcome will be largely dependent on measures taken as a result of the preoperative assissmentpreoperative assissment :an overall assessment and evaluation of the patient general health , operative risk , and fitness for general anaesthesia that might influence recovery

3. Preoperative care consists of the following:* assisssment of the operative risk and fitness for GA* adequate explanation of the nature of the operation* correction of nutritional , blood volume , fluid &electrolyte  deficincies* institution of prophylactic measures against common post operative complications* estimation of amount of blood required to cover the operation* general preparation of patient for surgery* assissment of the likely postoperative course and the need for I . C . U or H . D . U

4. General health assissment: history: * chief surgical complaint * systemic review * pervious surgery * previous experience of anaesthetic  complications * smoking , alchol * other medical disorders * current medications examination : * general and systemic examination * nutritional and mental status * abnormalities of the jaw and neck * presence of dentures

5. Investigations : routine invx mandatory discretionary unnecessary according to the type of the operation and the status of the patient CBC , U & E , LFT , sickle cell screening , ECG neck X ray , chest X ray , thoracic inlet X ray special invx PFT ecchocardiogram coagulation profile

6. Consultation :it is important if the patient has abnormal findings inthe field of competence medical anaesthesia cardiac other surgical specialitiespreoperative note :it is a summary of the evaluation , the diagnostic workup , decision made , and the discussed risks andcomplications 

7. Assissment of the operative risk : specific factors affects the operative risk * age * systemic organ dysfunctions CV diseases RESP diseases GIT disease hematological conditions * obesity * DM * drugs * delayed wound healing * risk of thromboembolism * immune competence * operative severity and operating surgeon

8. Age : pediatric elderlyCV diseases: * MI and CHF are the most common cause of perioperative death in patient undergoing non cardiac surgery * clinical predictors of increased perioperative  cardiovascular riskRESP diseases: COPD , RAWD  smoking ( type , duration , when to stop ) abnormal blood gas , CXR , or PFT

9. GIT problems: malnutrition: * dietary HX * biochemical parameters ( Alb , transferrin ) * nutritional support ( PPT , TPN ) jaundice : * sepsis * liver failure * bleeding tendancy * renal failure * fluid & electrolytes  disturbances

10. Hematological conditions: * anemia * bleeding disordersDM: * NIDDM * IDDM preoperative diabetic managementobesity: increased risk of : * respiratory complications pulmonary failure sleep apnea * DVT  * wound dehiscence and infections

11. Delayed wound healing : factors affecting wound healingthromboembolism: * age > 45 years * cancer pt * obesity * myocardial dysfunction * prior HX of thromboembolismimmune competence: ( old age , trauma , cancer , burn , HIV ) * infectious complications  * universal precautions

12. drugs : * drug allergy * drug inturractions * drug effect that can precipitated by the operation or the anaesthesia * drugs that should be maintained ( steroids) or their doses should be adjusted ( insulin) or those that should be stopped ( warfarin or OC )

13. Operative severity and operating surgeon : minor LA procedures , uncomlicated hernia repair or varicse vein operation moderate appendectomy , cholecystectomy mastectomy , TURP major  laparotomy , bowel resection major amputations major + any aortic procedures , AP resection oesophagectomy operative severity score POSSUM

14. Skill of operative surgeon Risk assissment scoring system : * A S A * APACHE * POSSUM appropriate explanation of the nature of the  procedure : * informed consent * possible complications related to the surgery or the anaethesia

15. prophylactic measures : prevention of infective endocarditis i.v amoxycillin combination of amoxycillin & gentamicin against  bowel organism in pt with artificial valves or who have had endocarditis vancomycin or teicoplanin or clindamycin for those allergic to penicillin

16. Chemoprophylaxis against surgical infections * principles of prophylactic antibiotics * nature of the procedure clean clean_contaminated contaminated dirtyprevention of renal failure: high risk group : jaundiced pt cardiopulmonary bypass significant hypovolemia hydration mannitol

17. Prophylaxis against DVT:the need for the prophylaxis depends on the operative risk low risk moderate risk high riskprotocols: chemical prophylaxis s.c heparin ( low & high moleular )  oral anticoagulants dextran 70 mechanical methods compression stocking intermittent pneumatic compression

18. The amount of blood required : cross match group and save maximum surgical blood ordergeneral preparations for surgery: * respiratory >>>> incentive spirometry * nursing procedures void bathing shaving * GIT  NPO bowel perp ( mechanical , chemical ) NGT * bladder catheterization * premedications anxiolytics

19. Management of patients with medical disorders :hypertension * essential * secondarymost common complication: * CAD * myocardial ischemiaclinical assessment should be focused on : * is the BP is well controlled by the current medical treatment or is there is need for additional therapy * presence oof organ damage ( ventricular hypertrophy or renal failure ) * exclusion of secondary causes in not been DX

20. * Mild to moderate essential HTN :if systolic < 180 mmHg and diastolic < 110 mmHg , there is a minimal risk for cardiac complication .* treated HTN :the antihypertensive medications should not be stopped and should be continued in the perioperative period in order to maintain the control and to prevent rebound hypertension * sever or poorly controlled HTN :high risk of cardiac failure or stroke , surgery should be cancelled till the BP is appropriately treatedmore urgent surgery needed , control the BP for minutes or hours by rapidly acting agents ( eg i.v B blockers ) 

21. Myocardial ischemia:risk assessment * the surgeon has to balance the need for the surgery against the risk of the surgery * cardiac complications are two to five times more likely to occure with emergency surgery than with elective surgery * the risk is related to the likelihood of a serious perioperative cardiac event : MI , heart failure or death

22. High risk pts :should their surgery cancelled or delayed until cardiac problem has been investigated and treated  coronary angiography coronary angioplasty CABG before surgeryIntermediate risk pts : exercise ECG ecchocardiogram myocardial perfusion scanabnormal results �� optimization of the medical therapy before surgery or coronary revascularizationLow risk pts :non invasive cardiac tests are not needed if the pt is going for either low risk or an intermediate risk surgical procedure.Pt with poor function capacity , even with no clinical risk predictor , should have non invasive cardiac tests

23. Diabetic pts : * pts on OHG agents shuold be stopped 1 day before surgery * if there is significant loss of BS control , soluble insuline by 4 hourly injections or low dose contineous infusion ( 3_ 4 u / h ) is administered. * resume OHG when the pt is tolerating solid food * pts on insulin , start i.v ( D5% 0.5 NS ) the day of surgery 50 _70 cc / hr * give one third of the usual dose of insulin SQ the morning of surgery  * continue i.v infusion of regular insulin according to the reading of the BS * postoperatively , continue i.v dextrose * follow BS 4-6 hrs by finger stick and use sliding scale ( 100 _180 mg / dl ) * adjust the insulin dose with resumption of oral intake or convert to the previous insulin dose.

24. Steroids :guides to steroids coverage :* hydrationd , correction of the BP and electrolytes problems* hydrocortisone phosphate 100 mg i.v oncall to OR * hydrocortisone phosphate 100 mg i.v in recovery and Q6 hourly for the 1st 24 hrs * if the progression is satisfactory , reduce the dose over 3_5 days * resume previous oral steroids or fluorocortisone when pt is tolerating oral intake* maintain or increase hydrocortisone dose to 200_400 mg / 24 h if there is fever or hypotension* if k wasting occure switch to methylprednisolone.

25. Liver cirrhosis : child�s classificationchild�s A = 5_7 points ( 2 % mortality )child�s B = 8_10 points ( 10 % mortality )child�s C > 11 points ( > 50 % mortality )prophylaxis :* ensure fluids & electrolytes RX  na _water restriction cautious diuresis* maintain nutritional status*prevent GI bleeding ( H2 blockers )* reduce GI flora to reduce bacterial production of ammonia ( noemycicn , lactulose )* correct abnormal clotting  vit K i.v FFP during operation

26. Respiratory problems :* preoperative physiotherapy & incentive spirometry* drug therapy bronchodilators antibiotics ( abdominal surgery ) theophylline to asthmatic pts* stop smoking ( at least 4 weeks before surgery )* alternative methods of anaethesia ( local , regional or spinal )* early post operative physiotherapy* perioperative administration of i.v steroids

27. hematological diorders :* inherited clotting disorders hemophilia A , Badministration of the deficient clotting factor before and for up to 2 weeks after surgery until the danger of secondary hemorrhage is over  VW disease  FFP cryoprecipitatae dismopressin* anticogulant therapy : warfarin to be stopped 4 days before operation and to start i.v heparin infusion ( VHD ) or prophylactic low Hematological disorders : dose heparin ( DVT )Aspirin should be stopped 2 weeks before surgery

28. THANK YOU