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Pre-op AssesmentSivesha Nandakumaran

Lalitha Jaya Raman

Nithiyah Devaraju

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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

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Patient assessment

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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)

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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

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Other relevant history

• Alcohol

• Recreational drugs

• Allergies

• Risk for DVT

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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

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Investigations

• FBC • major surgery, elderly, anaemia

• BUSE • major surgery, elderly, medication eg. diuretics

• ECG • elderly, CVS

• Chest x-ray • cardiac problems, pulmonary diseases

• β-HCG • rule out pregnancy

• Blood glucose & HbA1c• LFT

• jaundice, suspected hepatitis, cirrhosis, malignancy

• Others

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Specific preoperative problems, referrals and

management

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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 can’t 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• β-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 mother’s milk within 3 hours• No cow’s/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 + ½ 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 patientExplore How much does the patient knowDiagnosis Why the operation is being proposedTreatment Explain whether the treatment is within the

protocolsOptions Discuss all the optionsResults Explain the likely outcome including pain, mobility,

work, diet and return to normal dietEventualities Eg. The possibility of removing the testis in a hernia

operationAdverse events

Eg. Bleeding

Sound mind Ask if they understoodOpen question

Check if further clarification is needed

Notes Documentation

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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:

Patient Surgical

Perioperative care

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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)

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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:

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Specific strategies:

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Consider admission to a critical care facility

postoperatively

CARE IN THE OPERATING ROOM

Nithiyah Devaraju

PREOPERATIVE PREPARATION RIGHT BEFORE THE SURGERY

The patient should be seen by both the surgeon and the anaesthetistbefore any pre-medication is given.

1. The patient’s identity should be confirmed and the patientshould be asked to confirm what surgery is being carried out.

The case notes should agree with this and with what is writtenon the operating schedule.

2. A check should be made that there has been no change in thepatient’s condition since they were last seen and, if the

patient’s 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 beasked whether they have any questions and whether they arehappy 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 undertakenand preferably recorded in the notes.6. A check should be made for any sepsis (skin, teeth, urine andchest).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 indeliblepen.9. The surgical area should be shaved either at this time orimmediately before the incision is made.

Surgeon’s 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 patient’s 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 priorto donning a gown and gloves, to minimise the microbial loads onparts of the surgical staff that might come into contact with thepatient. Time spent scrubbing varies from unit to unit but as ageneral rule surgeons in training should usually start scrubbingbefore, 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 ofthe skin with an increased risk of infection.

Gowning

• The folded gown is lifted away from the surrounding wrappingand kept away from the trolley.• The gown is grasped firmly at the neckline and allowed tounfold completely, with the inside facing the wearer.• The arms are inserted into the armholes simultaneously (thefront 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 theneck and waist.• If a wrap-around type of gown is worn, these ties are securedwith the help of the circulating nurse once gloves are on.

Gloving

External sources of contamination in the operatingtheatre

■ Poor scrubbing up, gowning and gloving technique ■ Excessive inappropriate movement into and out of

theoperating room

■ Too many people in the operating room – excessivemovement

■ Unnoticed perforation of a glove ■ Contamination of instruments by an unscrubbed

person

Universal precautionsUniversal precautions are based on the concept that blood, bloodproducts and body fluids of all persons are potential sources ofinfection, 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 TherapySurgical patients need •Maintenance volume requirements•On going losses•Volume excess/deficits•Maintenance electrolyte requirements•Electrolyte excess/deficits

1. Maintenance RequirementsThis includes: insensible

urinarystool losses

Body weight Fluid required0-10Kg 100ml/kg/dnext 10-20Kg 50 ml/kg/dsubsequent Kg 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 mls /d

2. On Going Losses• NG

• 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 lossesdeficits

Fluid and Electrolyte Therapy

Normal maintenance requirementsOn going losses

measure all losses in I/O chart estimate third space losses

Deficits estimate using vital signs estimate using HCT

Fluid and Electrolyte Therapy

The best estimate of the volume required is the patients response

After therapy started observe vital signsUrine output (0.5mls/Kg/hr)Central venous pressure

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References:

• Bailey and Love’s 26th edition• http://www.moh.gov.my/images/gallery/

Garispanduan/Anaesthethic_clinic_protocols.pdf

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THANK YOU