Preoperative assessment

1. Preoperative assessment Done by: dr. Fatima Khajah

2. The goal of medical preoperative evaluation: • To assess medical problems in surgical patients. • To determine how best to manage these problems during surgery. • To provide recommendations for post-operative care.

3. Pre-op Assessment • Preoperative risk assessment starts by identifying: • The type of surgery to be performed. • The "type" of patient who is to have it. • It is these two factors which determine the risk of complications.

4. Surgery-specific risk: • High risk: cardiac risk often > 5% • Aortic repair (aneurysmal, dissection) • Noncarotid major vascular (infrainguinal and intraabdominal) • Peripheral vascular surgery • Anticipated prolonged surgical procedures with large fluid shifts and/or blood loss • Major emergency procedures, particularly in the elderly

5. Cardiac Risk • Intermediate risk: cardiac risk generally < 5% • Major intraabdominal (nonvascular) • Intrathoracic (nonendoscopic) • Major orthopedic • Carotid endarterectomy • Major head and neck • Radical prostatectomy • Low risk: cardiac risk generally < 1% • Ophthalmologic (excluding prolonged retinal) • Minor head and neck • Minor prostate (such as cystoscopy or TURP) • Biopsies and superficial procedures

6. ASA classification: • I : normal healthy patient. • II: patient with mild systemic disease. • III: patient with sever systemic disease that limits activity but is not incapacitating. • IV: patient who has incapacitating disease that is a constant threat to life • V: moribund patient not expected to survive 24 hours with or without an operation.

7. General evaluation components: • History: • Pre-existing medical condition that increase operative risk. • Personal habits increasing operative risk. • Family history. • Functional status. • Review of systems.

8. General evaluation components • Physical examination: • Vital signs • Head & neck • Lung • Cardiac • Abdominal • Neurologic • Peripheral vascular • Routine diagnostic testing

10. Specific consideration in pre-operative management: • cardiovascular: • The cardiovascular disease is the leading cause of death in the industrialized world, & its contribution to perioperative mortality during non-cardiac surgery is significant. • The functional capacity of the pt’s cardiovascular system should be evaluated preoperatively, starting by taking history, examination.

11. Functional Capacity:

12. Cardiac Risk Indices of Goldman and Detsky:

13. Specific Recommendations • If pt has recent MI the surgery should be delayed for 4-6 weeks from the events. • Pts who have undergone a perctaneous coronary intervention with stenting, the elective surgery should be delayed for 4-6 weeks. • If the pt is medium to high risk undergoing major to intermediate risk surgery, pt should receive ß blockers as early as possible preoperatively.

14. Pulmonary system: • Routine preoperative pulmonary function testing is not recommended: Insensitive and Expensive • Procedure-specific risk factors: • the surgical site. • the duration of surgery. • the type of anesthesia. • the type of neuromuscular blockade.

15. General factors that increase risk for postoperative pulmonary complications: • Increasing age • Lower albumin level • Dependent functional status • Weight loss & possibly obesity • Stroke • Congestive heart failure • Acute renal failure • Blood transfusion • Chronic steroid use

16. Specific pulmonary risk factors: • COPD. • Smoking. • Preoperative sputum production. • Pneumonia. • Dyspnea. • Obstructive sleep apnea

17. Pulmonary risk reduction • Preoperative: • encourage smoking cessation for at least eight weeks • treat airflow obstruction in patients with COPD or asthma • administer antibiotics and delay surgery if respiratory infection is present • begin patient education regarding post-operative lung-expansion maneuvers • Intraoperative: • limit duration of surgery to less than three hours • use spinal or epidural analgesia* • avoid use of pancuronium • use laparascopic procedures when possible • Postoperative: • use deep-breathing exercises or incentive spirometry • use continuous positive airway pressure (CPAP) • use epidural analgesia* • use intercostal nerve blocks*

18. Renal system: • 5% of the of the adult population have some degree of renal dysfunction that can affect the physiology of multiple organ systems & cause additional morbidity in the preoperatively period. • A pt with end stage renal disease frequently required additional attention in the preoperative period. • Dialysis is commonly required within preoperative period for control of volume & electrolyte abnormalities • In the acute setting pts who have stable volume status can undergo surgery without preoperative dialysis

19. Renal Function • Prevention of secondary renal insults in the peri operative period include to avoidance nephrotoxic agents & maintenance of adequate intravascular volume throughout this period. • Nonsteroidal agents are avoided in pts with renal insufficiency.

20. Hepatobiliary system: • A pt with liver dysfunction requires carful assessment of the degree of functional impairment as well as a coordinated effort to avoid additional insult in the preoperative period. • pt with liver cirrhosis, should be assessed with the child classification, which stratifies operative risk according to a score. • Child’s class had a mortality rates according to the classes • A 10%. • B 31%. • C 76%. • Several recent reports have showed decreased rates of complication with laparoscopic procedures performed in cirrhotic pts.

21. Endocrine system: • A pt with an endocrine condition such as DM, HTN, hypo or hyperthyroidism or adrenal insufficiency is subject to additional physiologic stress during surgery. • Careful monitoring identifies signs of metabolic stress related to inadequate endocrine control during surgery & throughout the postoperative course.

22. DM: • The evaluation of diabetic pt for surgery assesses the adequacy of glycemic control & identifies the presence of diabetic complications. • A diabetic pt requires special attention to optimize glycemic control preoperatively & post operatively. • The adequacy of preoperative glycemic control has an impact on wound healing & the risk for the surgical site infection.

23. Thyroid disease: • A pt with known or suspected thyroid disease is evaluated with a TFT. • If the physical examination suggests signs of airway compression, further imaging may be warranted. • If pt has hypo or hyperthyroidism, should be treated before any surgery.

24. Immunologic: • The goal is to optimize immunologic function before surgery & to minimize the risk for infection & wound breakdown. • Pts who are immunocompromised may be at risk for wound complication, especially if receiving exogenous steroid therapy. • When taken within 3 days of surgery, steroids reduce the degree of wound inflammation, epitheliazation & collagen synthesis, which can lead to wound breakdown & infection.

25. Hematologic: • Hematologic assessment may lead to the identification of disorders which were uncovered before. • Pts with normovolmicanemia without significant cardiac risk or anticipated blood loss during surgery can be managed safely without transfusion, with most healthy pts tolerating Hb levels of 6 or 7 g/dl • Coagulopathy may result from inherited or acquired platelet or factor disorders or may be associated with organ dysfunction or medications. • All surgical pts are assessed for their risk for venous thromboembolism & recieve adequate prophylaxis according to current guidelines.

26. Risk factors of DVT: • Age. • Type of surgical procedure. • Pervious thromboemboliism. • Cancer. • Obesity. • Varicose veins. • Cardiac dysfunction. • Indwelling central venous catheters. • IBD. • Nephrotic syndrome. • Pregnancy. • Estrogens. • Tamoxifen use.

27. Additional preoperative consideration: • Age. • Nutritional status. • Obesity.

28. Airway assessment: • How easy or difficult it will be to intubate a patient depends on the following points: • Are they obese? • Do they have a short neck and small mouth? • To what extent can they open their mouth? • Is there any soft tissue swelling at the back of the mouth or any limitations in neck flexion or extension?

29. Mallampati scoring system

30. In summary: • It is important to evaluate the pt preoperatively to decrease the rate of post operation morbidity & mortality. • History, physical examination & lab test are the basic in pre operative assessment. • pre operative evaluation depend on type of the surgery & pt. • Each system in the body should be clearly evaluated. • The airway should be assess preoperatively.

31. Thank you