PREOPERATIVEPREPARATION OFTHEPATIENT

Dr.HiwaOmerAhmed AssistantprofessorinGeneral Surgery

PREOPERATIVEPREPARATIONOFTHEPATIENT convergenceoftheartandscienceofthe surgicaldiscipline. inoutpatientofficevisittohospitalinpatient

 Approachestopreoperativeevaluationdiffer significantly,dependingonthe 1.natureofthecomplaint 2. theproposedsurgicalintervention 3. patienthealth 4. assessmentofriskfactors 5.theresultsofdirectedinvestigation 6. interventionstooptimizethepatient's overallstatus 7. readinessforsurgery.

DeterminingtheNeedforSurgery
confirmationofrelevantphysicalfindingsand reviewoftheclinicalhistoryandlaboratory andinvestigativeteststhatsupportthe diagnosis.

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Perioperative DecisionMaking
Oncethedecisionhasbeenmadetoproceed withoperativemanagement,anumberof considerationsmustbeaddressedregarding the 1.timingandsiteofsurgery 2.thetypeofanesthesia 3.thepreoperative preparationnecessary tounderstandthepatient'sriskandoptimize the outcome

PreoperativeEvaluation
Theaimistoidentifyandquantifyany comorbidity thatmayhaveanimpactonthe operativeoutcome.Thegoalistouncover problemareasthatmayrequirefurther investigationorbeamenabletopreoperative optimization ..

 Thepreoperativeevaluationisdeterminedin lightofthe 1.plannedprocedure(low,medium,orhigh risk), 2. plannedanesthetictechnique, 3. thepostoperativedispositionofthepatient (outpatientorinpatient,wardbed,or intensivecare). 4. toidentifypatientriskfactorsfor postoperativemorbidityandmortality.

 consultationwithaninternistormedical subspecialist mayberequiredtofacilitate theworkupanddirectmanagement.Inthis process,communicationbetweenthe surgeonandconsultantsisessentialtodefine realisticgoals forthisoptimization processandtoexpedite surgicalmanagement

Theaimofapreoperativeevaluation
toassessthefitnessoftheindividualforanesthesia andsurgery. Awellconductedhistoryandphysicalexamination answerseveralimportantquestions:

Isthisahealthypatient? Whatistheindicationforsurgery? Isthesurgicalprocedurelowrisk,intermediate risk,orhighrisk? Whatisthefunctionalstatusofthepatient? Whatistheeffectofthepresentconditionon thepatient? Whatimprovementisexpectedaftersurgery?

Answerstothesequestionsshouldthendirectpreoperative testingandmanagement. 1.Thetestsselectedshouldthereforeevaluateexistingillness, screenforconditionsthatcouldaffectoutcomesinthe perioperative period,andhelptodetermineperioperative risks. Existingillnessesthatneedevaluationandpossibletreatment includehypertension,diabetesmellitus,cardiac,vascular, pulmonary,renal,andhepaticdiseases. Thepregnant patient,thegeriatricpatient,thepatientwith oncologic disease,malnutrition ,orcoagulationdisordersalso needsdirectedevaluations

THEHEALTHYPATIENT
Theinitialpreoperativeevaluationofapatient shouldbesupplementedbyacomplete assessmentofthepatientsgeneralhealth. Thisinvolvesathorough *history *physicalexamination. 1.Completebloodcounts

2.Bloodureaandelectrolytes

3.Anelectrocardiogram(ECG)isindicatedover40years,.

4.Posteroanteriorandlateralchestxrays 5.Hb%

6.GUE

Thehistoryshouldincludeinformationregardinganyknown medicalproblemsandongoingtreatment,previoussurgical procedures,andproblemsifanyduringpreviousanesthesia. Thesecanincludedifficultintubation,bleedingtendencies, andanestheticjaundice. Familyhistoryofproblemsduringanesthesiaorsurgery shouldbeobtained.Thesecanmaketheanesthesiologist awareofpotentialproblemssuchasmalignanthyperthermia, bleedingtendencies,orthrombophilia. Inadditiontoroutineinformationaboutfamilyhistory,a strongfamilyhistoryofallergiesshouldalertthesurgeonto thepossibilityofhypersensitivitytodrugs.

 Anexhaustivehistoryofdrugallergies,sensitivities, andcurrentorrecentlytakenmedicationsshouldbe obtained.Medicationssuchasdigitalis,insulin,and corticosteroidsshouldbemaintainedandtheirdoses carefullyregulatedintheperioperative period. Ifthepatientisoncorticosteroidsorifithasbeen discontinuedwithinamonthofsurgery,heorshe mayhaveahypofunctioning adrenalcortexresulting inimpairedphysiologicresponseM tosurgicalstress

Whatisinformedconsent?
tobeabletomakeaconsideredchoiceabout whatisintheirpersonalinterests theymust receivesufficientaccurateinformationabout theirillness,theproposedtreatmentandits prognosis.

1. Describe theprocedureitself,including informationaboutitspracticalimplications andprobableprognosis. 2.Revealtheprobabilityofspecificassociated risksorcomplications. 3.Donotassumethatthepatientalreadyknowsthe risksofotheraspectsoftheproposedsurgical procedure,suchasthecomplicationsthatmight resultfromageneralanaesthetic,bedrest, intravenousfluidsoracatheter. 4.Outlineothersurgicalormedicalalternativestothe proposedtreatment,includingnontreatment,along withtheirgeneraladvantagesanddisadvantages.

Goodconsentingpractice
1.Asmuchaspossible,ensurethatthephysical surroundingsduringthediscussionbetween youandyourpatientareconducivetoeasy, quietconversation.

2.Usethesimplestpossiblelanguage,avoiding needlesstechnicalities. Appropriateleafletsorbookletscanbehelpful, asisinnovativeworkusingaudiorecording of interviews;patientscanbeencouragedto taketherecordinghometodiscusswith others.

3.Havingattemptedtoprovideclear information,nowdeterminewhetherornot thepatienthasactuallyunderstoodit.

ROUTINE PREOPERATIVE PREPARATION

Evaluation 1.Takeafullhistoryandexcludeanysignificant medicalproblems 2.Checkclinicalsignsagainsttheplannedsurgical procedure,inparticularnotingthesideinvolved. Confirmthattheplannedoperativeprocedureis appropriate.

3.Takeafulldrughistorywithspecificenquiry regardingallergicresponsestodrugs,latex andskinallergies.Continuemedicationover theperioperative period,especiallydrugsfor hypertension,ischaemic heartdiseaseand bronchodilators.Givepatientsonoralsteroid therapyintravenoushydrocortisone.Stoporal warfarin anticoagulation3days preoperativelyandchecktheprothombin timepriortosurgery.

Patientstakingaspirinorotherantiplatelet medication(e.g.clopidogrel)mayhavean increasedriskofbleeding;stopthesedrugs foratleast48hpreoperativelyformajor surgery.

Stopdrugs,overtheperioperative period,that mayinterferewithanaesthetic agents, includingmonoamineoxidase inhibitors, lithium,tricyclic antidepressantsand phenothiazines. Ifpossible,stoptheoralcontraceptivepill4 weekspriortoanymajorsurgery. Postmenopausalpatientsonhormone replacementtherapydonotneedtohave theirmedicationstoppedbeforeanoperation.

4.Thereisaclearcorrelationbetweenmalnutritionin thepreoperativeperiodandanincreasedmorbidityand mortalityfromsurgery.

5.Youngandfitpatientsundergoingminor proceduresdonotrequireanypreoperative investigations Inolderpatientsorthosewithsignificant medicalproblems,standardinvestigation wouldincludeafullbloodcount,ureaand electrolytes,chestXrayand electrocardiogram.

Routinepreoperativemeasures
1.Adheretotheprotocolfollowedbyyourfirm 2.Prohibitsoliddiettoadultpatientsfor6h, andclearfluidsfor4h,priortoanelective generalanaesthetic. Fastingtimesforchildrenvaryindifferent hospitalsandtheyarealsoagedependent.

Babiesunder1year Nobreastmilkfor23hbeforeanaesthesia Noformulafeedfor6hbeforeanaesthesia Clearfluidsmaybegivenupto3hbeforeanaesthesia Childrenover1year Nofood/milkfor6hbeforeanaesthesia Clearfluidsupto3hbeforeanaesthesia 3.Theoperationsitemustbepreparedbytheremovalof hair, ifthisisnecessaryforaccess,usingadepilatory cream.Shavingorclippinghairfromtheoperationsite increasestheriskofinfection,unlesstheskin preparationiscarriedoutimmediatelypriortosurgery.

4.Markaunilateraloperationsiteontheskin withanindeliblemarkerpen.

5.Explaintothepatient(orguardian)the procedureandanylikelycomplications, answerquestionsthepatientmayhave,and onlythenhavethemsigntheconsentform.If youareunabletoanswerthepatient's questions,seekhelpfromaseniorcolleague.

6.Itisgoodpracticefortheoperatingsurgeon toobtainthepatient'sconsent;not immediatelybeforeanoperationbutsome timeahead,sothattheymayhaveaperiodof reflection,andanopportunitytoaskfurther questionsthatmayarise.

7.Antibioticadministrationisguidedbythe surgicalprocedureinvolvedandisdiscussed below,asisprophylaxisagainstdeepvein thrombosis. 8.Ifspecificservices,suchasfrozensection histopathologyorintraoperative radiography arelikelytoberequiredduringtheoperation, organizetheseinadvance.

9.PROPHYLAXISAGAINSTDEEPVEIN THROMBOSISANDPULMONARYEMBOLI

Pulmonaryemboliareamajorcauseofmortality forsurgicalpatients,accountingfor10%of inpatientdeathsintheUnitedKingdom. Recentoperation,immobilizationandtraumawere responsiblefor50%ofdeepveinthrombosis (DVT)inareviewbyCogo etal(1994),butthere areotherimportantpredisposingfactors,

suchasthehighoestrogen contentoral contraceptivepill,andsignificantobesity. Manyriskfactorscannotbeavoided,buttake measurestoavoidpropagationofany thrombosis: Subcutaneousheparinmayreducetheincidence ofDVTby50%;itisgenerallywelltolerated Systemicanticoagulationeffectsoflowdose subcutaneousheparinareminimaland haemostasis isnotimpaired. Newerlowmolecularweightheparins(LMWHs), aseffectiveasstandardheparin,needonlyonce adaydosage.

Riskfactorsfordeepveinthrombosis
Recentsurgery Immobilization Trauma Oralcontraceptivepill Obesity Heartfailure Arteriopathy Cancer Age>60years

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ASAclassification
INormalhealthypatient IIPatientwithmildsystemicdisease IIIPatientwithseveresystemicdisease thatlimitsactivitybutisnotincapacitating IVPatientwhohasincapacitatingdisease thatisaconstantthreattolife VMoribundpatientnotexpectedto survive24hourswithorwithoutan operation