Preoperative evaluation of surgical patients Part 1

Dr. Piyush Giri

Introduction

• Preoperative preparation is the preparation of a patient requiring surgery to optimize postoperative outcomes

• Begins from the time of contact of the patient with the surgeon and ends on the day of surgery

• The approach is multidisciplinary

Preoperative patient preparation

1. Gathering and recording: History, examination, investigation, conclusion and treatment plan

2. Planning to minimize risk and maximize benefit for the patient

3. Being prepared for adverse events and plan to how to deal with them

4. Communicating with patient and all other members of the team

Patient assessment

• History • Examination• Investigations

History

• Presenting illness• History of presenting illness• Past medical history• Drug history• Social history

Examination

• General examination• Cardiovascular system• Respiratory system• Gastrointestinal• Neurological

• Explaining to the patient: discussing the proposed management plan

Investigations

• Commonly needed investigations are1. Full blood count : clinical diagnosis, anaemia,

blood loss 2. Urea and electrolyte: >65 yrs, h/o of CVS, Pulmonary or renal

problems

3. Liver function tests: Jaundice, Infection, cirrhosis, clotting

problems, Portal Hypertension

• Hepatic risk: • Predictors of mortality: Bilirubin (>2mg/dl),

Serum albumin (<3gm/dl), PT (>16secs), Encephalopathy

• 40% mortality : if either of these present• 80-85% mortality if 3 or more are present or if

bilirubin alone >4, albumin alone<2gm/dl, or ammonia concentration > 150mg/dl

Investigations Contd.

4. Clotting screen: Anti coagulant therapy, Abnormal LFT, bleeding disorder

5. Arterial blood gases: Acid- base abnormality suspected or respiratory conditions

6. EKG: > 65 years, Past h/o of CVS, pulmonary or anesthetic problems

7. Chest radiography: CVS and Pulmonary problems

• Cardiac risk:• Ejection fraction: <35% = incidence of MI 75-

85% and mortality 55-90%• Goldman’s index: 11 points to raised JVP,• 7 points to Premature ventricular contraction,• 4 points to emergency surgery• 3 points each to: Aortic valve stenosis, poor

medical condition, surgery within chest or abdomen

• Interpretation of Goldman index and cardiac complication

• <5 – 1%• <12 – 5%• <25 – 11%• >25 – 22%

8. Urinalysis: detects infections, glycosuria, osmolarity, Haematuria

9. Beta- Human chorionic gonadotrophin: in all female patients of childbearing age with

abdominal pain or if she is unconscious

10. Viral Serology: Hepatitis/ Human immunodeficiency

NICE guidelines

• Guideline help guide appropriate routine preoperative investigations

• Based on ASA grading and Surgery Grading

ASA Grading

• ASA Grade 1: Normal healthy patient• ASA Grade 2 : A patient with mild systemic

disease• ASA Grade 3 :A patient with severe systemic

disease• ASA Grade 4 :A patient with severe systemic

disease that is a constant threat to life

• Grade 1 (minor): Excision of lesion of skin

• Grade 2 (Intermediate): Primary repair of inguinal hernia

• Grade 3 (Major): Endoscopic resection of prostate

• Grade 4 (Major +): Colonic resection;

SPECIFIC PREOPERATIVE PROBLEMS

1. Cardiovascular:• Hypertension: BP: >160/95 mmHg: elective

surgery should be deferred• Ischaemic heart diseases: recent MI is stong

contraindication, significant mortality rate from anaesthesia if

within 3 months elective surgery can be delayed upto 6

months

• Dysrhythmias: AF to be controlled, Heart block: preoperative pacing, bipolar diathermy should be used when possible

• Cardiac failure: Oxygenation and fluid balance

• Anaemia and blood transfusion: transfusion if Hb < 8gm/dl

2. Respiratory Problems:• Infection: LRTI should be controlled before

surgery

• Asthma: Inhalers to be continued

• Chronic obstructive pulmonary disease: regional anesthesia

3. Gastrointestinal system.BMI CLASSIFICATION• <16 Severe malnutrition• 16–16.99 Moderate malnutrition• 17–18.49 Mild malnutrition• 18.5–24.9 Normal• 25–29.9 Overweight• 30–34.9 Obese class 1• 35–39.9 Obese class 2• ≥40 Obese class 3

• Malnutrition: Nutritional support for minimum 2 weeks,

MUST (Malnutrition Universal Screening) Tool: BMI , Weight loss and Acute disease effect

Total: 6 0: low risk of undernutrition: routine clinical care1: Medium risk: Observe2 or more : Treat: dietician or local policies, later

food fortification

• Obesity: BMI > 30 Advice to lose weight for elective procedure

• Regurgitation risk: in Hiatus hernia, bowel obstruction, Paralytic ileus

decresed by Nil per oral: solid food 6 hours and 2 hours for liquids

and also by: H2 receptor blockers and Nasogastic tube insertion

• Jaundice: increased secondary complications:Impaired clotting: Vitamin KRenal failure: patient kept well hydrationIncreased infection: prophylactic antibiotics

3. Metabolic Disorder:• Diabetes Mellitus: Are at high risk for

Complications, • Improving Diabetic control• Lipid lowering drugs• Treating significant vascular stenosis• For minor surgery: omiting morning dose, and

in insulin dependents: IV insulin given

• Adrenocortical Suppresion: adrenocoritcal steroid> 2 months, need extra

doses at the time of surgery.

4. Coagulation disorder: INR to be < 1.5: Warfarin: stopped 3-4 days earlier in Atrial

Fibrillation. Is replaced with heparin where thrombosis is

significant, eg. Mechanical heart valve. Asprin and Clopidogrel to be stopped before 1

week of surgery.

• Disseminated intravascular coagulation and haemophilia to be treated accordingly.

• Prophylaxis against thrombosis:• Mechnical: Early mobilisation, stockings, calf

and foot pumps.• Pharmacological: Heparin and low molecular

weight heparin, Warfarin, Asprin

5. Neurological and psychiatric disorder:Anticonvulsant: to be continuedPsychiatrically disturbed: may require general

rather than regionalTricyclic antidepressents and Monoamine

oxidase inhibitor to be discontinued: may have unwanted interaction

6. Locomotor disorder:Most catastrophic being unstable cervical spine.Disease modifying drugs may be continued in

Rheumatoid Arthritis

7. Remote site infection: from teeth or toe, to be treated preoperatively

or given appropriate antibiotic prophylaxis

Documentation

It should include:• Clinical notes• Investigations• Management plan

Consent to be obtained, from person fully conversent on planned surgery, alternative and complication

Multiprofesional team Members

• For Theatre:• Ward staff• List organiser and circulator• Theatre nursing staff• Anaesthetic staff• Radiology department• Pathology department

• For Postoperative recovery:• Rehabilitation staff• Social care worker• ITU/ High dependency unit staff• Specialist nurse counsellor (stoma/

amputation)

• THANK YOU