Pre-op Assesment

Sivesha Nandakumaran
Lalitha Jaya Raman
Nithiyah Devaraju

Contents
Patient assessment
Specific preoperative problems, referrals and
management
Risk assessment and consent
Perioperative management of the high risk
surgical patient
Care in the operating theatre
Nutrition and fluid therapy

Patient assessment

Aim
To look for risks and manage patients accordingly,
to enable safe surgery

History
Principles of history taking
Listen: problem & expectations (open)
Clarify: diagnosis (close)
Narrow: differential diagnosis (focused)
Fitness: comorbidities (fixed)

Key topics in past medical hx

Cardiovascular
Ischaemic heart disease
Hypertension

Respiratory
Asthma, COPD

Gastrointestinal
GERD, PUD

Genitourinary tract
Renal dysfunction

Endocrine/Metabolic
DM, thyroid

Locomotor
Arthritis

Previous surgery
Problems encountered

Other relevant history

Alcohol
Recreational drugs
Allergies
Risk for DVT

Examination
Examination

General

Surgery related: Site of surgery, possible

complications due to underlying pathology

Systemic: comorbidities and severity

Specific: Eg. Suitability for positioning during

surgery; potential bacteraemia

Investigations
FBC
major surgery, elderly, anaemia

BUSE
major surgery, elderly, medication eg. diuretics

ECG
elderly, CVS

Chest x-ray
cardiac problems, pulmonary diseases

-HCG
rule out pregnancy

Blood glucose & HbA1c

LFT
jaundice, suspected hepatitis, cirrhosis, malignancy

Others

Specific preoperative
problems, referrals and
management

Cardiovascular diseases
Identify patients with high pre-op risk of MI
CAD, CCF, arrhythmias, severe peripheral vascular
disease, cerebrovascular disease.

Refer to cardiologist

Murmur heard, symptomatic

Cardiomegaly, known poor left ventricular function
Ischemic changes on ECG, asymptomatic
Abnormal ECG rhythm

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Hypertension, IHD, stents

BP
<160/90

Angina- not well controlled

Cardiologist, thrombolysis, CABG

MI
Elective surgery postpone 3 - 6 months

Coronary stents
Antiplatelet therapy- effectiveness
If cant delay surgery and bleeding risk is low, antiplatelet
therapy can be continued.
Risk of bleeding, stop clopidogrel and continue with
aspirin; consult cardiologist
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Dysrhythmias
Atrial fibrillation
-blockers, digoxin, CCB started preoperatively
Warfarin
Stopped 3 - 4 days before surgery
Restart normal dosage level on the evening after surgery.
Check that the INR has dropped to 1.5 or lower before surgery.

Implanted pacemaker/ cardiac defibrillator

Reprogrammed to turn off cardioversion
Bipolar diathermy activity during surgery sensed as ventricular
fibrillation

Switch on after surgery

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Valvular heart disease

Valvuloplasty before elective surgery
Mechanical heart valves

Stop warfarin 5 days before

Replace with heparin infusion
Stop 2 hours before surgery
Start heparin + warfarin immediately post-op
Close monitoring of APTT
Stop heparin after 5 days

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Anaemia and blood transfusion

Iron supplements
HB <8g/dL in chronic anaemia
Suspect excessive bleeding
Group and save

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Respiratory disease
Encourage compliance to medication; stop
smoking
Regular medication with additional dose of
bronchodilators given prior to surgery
Patients on prednisolone + high risk surgery
to take perioperative steroid supplement

Acute exacerbations
Postpone elective surgery

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 Refer to respiratory physician

Significant deterioration from usual
Major surgeries planned in patients with significant
respiratory comorbidities
Right heart failure
Young patient with COPD

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Gastrointestinal
Nil by mouth
No solids within 6 hours
No fluids within 2 hours
Infants
No clear drinks within 2 hours
No mothers milk within 3 hours
No cows/formula milk within 6 hours

Bowel prep
Lower bacterial load
Reduce spillage and contamination intraop
Contraindicated in complete bowel obstruction and
perforation
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Genitourinary disease
Chronic renal failure
Dialysis a few hours before surgery
FBC & BUSE done after final dialysis before
surgery

UTI
Elective op
Treat infection beforehand

Emergency op
Start antibiotic
Ensure good urine output
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Endocrine and metabolic disorders

Diabetes mellitus
Near normal blood glucose level
Morning: omit breakfast and morning dose
Afternoon: breakfast + insulin dose/ normal oral
anti-diabetic drugs

BMI <18.5
Nutritional support minimum 2 weeks prior

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 BMI >30
Reduce weight
Continue CPAP if they have OSA
Cholesterol reducing agents
Problems of surgery in the obese
Increased risk of:
Difficulty intubating
Aspiration
Deep vein thrombosis and pulmonary embolism
Respiratory compromise
Poor wound healing/infection
Pressure sores
Mechanical problems lifting, transferring, operating table
weight limits
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Risk assessment
and consent
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Risk assessment and consent

Risks: Related to comorbidities, anaesthesia
and surgery
Explain: Advantages, side effects, prognosis
Language: Simple
Consent: Valid consent is necessary except in
life-saving circumstances

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Taking consent (LED TO REASON)

Lead in

Introduce yourself and identify the

patient

Explore

How much does the patient know

Diagnosis

Why the operation is being proposed

Treatment

Explain whether the treatment is within

the protocols

Options

Discuss all the options

Results

Explain the likely outcome including pain,

mobility, work, diet and return to normal
diet

Eventualiti
es

Eg. The possibility of removing the testis

in a hernia operation

Adverse
events

Eg. Bleeding

Sound
mind

Ask if they understood

Open

Check if further clarification is needed

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Perioperative
management of the
high risk surgical
patient

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Introduction:

Operative mortality

Size of the population and mortality rate.

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A practical approach to perioperative

care for the high risk patient:
Identify the high risk patient
Assess the level of risk
Detailed preoperative assessment
Optimise medical management
Intraoperative considerations
Specific strategies
Consider admission to a critical care
facility postoperatively.
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Identify the high risk

patient:

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Assess the level of risk:

Risk score systems:
- ASA
- METs
- CEPT
- RCRI

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American society of
anaesthesiologist (ASA)

29

Metabolic equivalent of task

(METs)

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Cardiopulmonary exercise
testing (CPET)

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Revised cardiac risk index

(RCRI)

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Detailed preoperative
assessment:

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Optimise medical management and

intraoperative considerations:

34

35

36

Specific strategies:

37

Consider admission to a
critical care facility
postoperatively

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CARE IN THE OPERATING

ROOM
Nithiyah Devaraju

PREOPERATIVE PREPARATION RIGHT

BEFORE THE SURGERY
The patient should be seen by both the surgeon and the anaesthetist
before any pre-medication is given.
1. The patients identity should be confirmed and the patient
should be asked to confirm what surgery is being carried out.
The case notes should agree with this and with what is written
on the operating schedule.
2. A check should be made that there has been no change in the
patients condition since they were last seen and, if the
patients condition has changed, this needs to be recorded.
3. Consent. The patient should be asked if they want the consent
process to be repeated and, even if not, they should be
asked whether they have any questions and whether they are
happy to proceed with surgery. This should be recorded in the
notes.
.

4. All relevant results, investigations and imaging must be available.

5. Adequate preoperative planning should have been undertaken
and preferably recorded in the notes.
6. A check should be made for any sepsis (skin, teeth, urine and
chest).
7. If there is the possibility of any neurovascular complications,
the neurovascular status should also be recorded at this stage.
8. The side to be operated on should be marked with indelible
pen.
9. The surgical area should be shaved either at this time or
immediately before the incision is made.

Surgeons preparation for the

operation
All surgeons will have an envelope or ceiling
to their surgical abilities, which is unique to
them. A surgeon should only operate if he/she
is capable of performing the surgery safely in
the circumstances.
The surgeon must aim to optimise the
patients procedure by adequate preparation.
This is highlighted in the traditional military
saying: the seven Ps prior
preparation and planning prevents
profoundly poor performance..

Scrubbing
Scrubbing up is the process of washing the hands and arms prior
to donning a gown and gloves, to minimise the microbial loads on
parts of the surgical staff that might come into contact with the
patient. Time spent scrubbing varies from unit to unit but as a
general rule surgeons in training should usually start scrubbing
before, and finish after, the senior surgeon.
The commonest solutions used for hand-washing in the UK are 2%
chlorhexidin gluconate or 7.5% povidone-iodine.
Excessive time or vigour in scrubbing may cause breakdown of
the skin with an increased risk of infection.

Gowning
The folded gown is lifted away from the surrounding wrapping
and kept away from the trolley.
The gown is grasped firmly at the neckline and allowed to
unfold completely, with the inside facing the wearer.
The arms are inserted into the armholes simultaneously (the
front of the gown is not be touched with ungloved hands).
Hands should stay inside the cuffs while gloving.
The circulating theatre nurse should secure the gown at the
neck and waist.
If a wrap-around type of gown is worn, these ties are secured
with the help of the circulating nurse once gloves are on.

Gloving

External sources of contamination in the

operating
theatre
Poor scrubbing up, gowning and gloving
technique
Excessive inappropriate movement into and out
of the
operating room
Too many people in the operating room
excessive
movement
Unnoticed perforation of a glove
Contamination of instruments by an unscrubbed
person

Universal precautions
Universal precautions are based on the concept that blood, blood
products and body fluids of all persons are potential sources of
infection, independent of diagnosis or perceived risk
Universal precautions include:
wearing of protective gloves, ideally with double layers;
wearing of protective eyewear and mask;
wearing of protective apron and gown;
using safe sharp instrument handling techniques
undertaking hepatitis B vaccination for staff;
covering open wounds that are clean;
staff with infected wounds or active dermatitis should stay
off
work.

NUTRITION AND FLUID

THERAPY

Introduction
Malnutrition is common. It occurs in about 30% of
surgical patients with gastrointestinal disease and
in up to 60% of those in whom hospital stay has
been prolonged because of postoperative
complications.
It is frequently unrecognised and consequently
patients often do not receive appropriate support.
There is a substantial body of evidence to show
that patients who suffer starvation or have signs of
malnutrition have a higher risk of complications
and an increased risk of death in comparison with
patients who have adequate nutritional reserves.

Nutrition Support and Methods of

Feeding
Surgical treatment requires added
nutrition support for tissue healing and
rapid recovery.
To ensure optimal nutrition for surgery
patients, diet management may involve
enteral and/or parenteral nutrition
support.

Poor Nutritional Status

Has been associated with:
Impaired wound healing
Increased risk of postoperative infection
Reduced quality of life, increased
mortality rate
Impaired function of gastrointestinal
tract, cardiovascular system, respiratory
system
Increased hospital stay, cost

General Dietary Management

Routine IV fluids supply hydration
and electrolytes, but not energy and
nutrients
Methods of feeding
Oral
Enteral: Nourishment through regular
gastrointestinal route, either by regular
oral feedings or by tube feedings
Parenteral: Nourishment through small
peripheral veins or large central vein

Fluid and Electrolyte

Therapy
Surgical patients need
Maintenance volume
requirements
On going losses
Volume excess/deficits
Maintenance electrolyte
requirements
Electrolyte excess/deficits

1. Maintenance
Requirements
This includes:

Body weight
0-10Kg
next 10-20Kg
subsequent Kg

insensib
le
urinary
stoolrequired
Fluid
losses
100ml/kg/d
50 ml/kg/d
20ml/kg/d
15ml/Kg/d for elderly

70 Kg Man
Needs
1st 10kg x 100mls =
1000mls
2nd 10kg x 50mls =
500mls
Next 50kg x 20mls=
1000mls
TOTAL

2500

 NG

2. On Going
Losses

drains
fistulae
third space losses
Concentration is similar to
plasma
Replace with isotonic fluids

3. Volume Deficit Acute

vital signs changes
Blood pressure
Heart rate
CVP

tissue changes not

obvious
urine output low

3. Volume Deficit Chronic

Decreased skin
turgor
Sunken eyes
Oliguria
Orthostatic
hypotension
High Creatine ratio

4. Volume
Excess

Over hydration
Mobilisation of third space
losses
Signs
weight gain
pulmonary edema
peripheral edema
S3 gallop

Fluid and Electrolyte

Therapy
Goal
normal haemodynamic parameters
normal electrolyte concentration
Method
replace normal maintenance
requirements
ongoing losses
deficits

Fluid and Electrolyte

Therapy
Normal maintenance
requirements
On going losses
measure all losses in I/O
chart
estimate third space
losses

Deficits
estimate using vital signs

Fluid and Electrolyte

Therapy
The best estimate of the volume
required
is the patients response
After therapy started observe
vital

signs
Urine output (0.5mls/Kg/hr)
Central venous pressure

References:
Bailey and Loves 26th edition
http://www.moh.gov.my/images/gallery/G
arispanduan/Anaesthethic_clinic_protocol
s.pdf

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THANK YOU
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