Pre-Operative Assessment

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Pre-Operative Assessment

• Dr Ahmed Badrek-AlAmoudi

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IntroductionIn admitting a patient for surgery
the following questions should be answered

• Is the diagnosis firmly established?
• Has the disease and the procedure been adequately
  explained
• Is there a need for further assessments to stage
  the disease or to deal with other diseases?
• How risky is the operation?
• Are corrections of blood volume, nutritional
  status or electrolyte imbalances needed?
• What are the prophylactic measures needed?
• What are the particular preparations required
  prior or during the surgery ?
• Is a cross match needed?
• What is the likely course immediately post-op?

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The preoperative Assessment

• History
• CVS ( MI), RS, Smoking, BP, DM, Bleeding
  diathesis, CVA.
• Drugs, Allergies and Alcohol.
• Reactions to Anaesthesia.
• Examination
• CVS, RS, nutritional status, mental status.
• Neck, Jaw and presence of dentures.
• Investigations
• Routine
• Special

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The DiagnosisThis can be established by a
combination

• The Patients Document
• The Chronology of OPD notes.
• The Chronology of correspondence or
  consultations.
• Report of lab., radiological histopathological
  investigations.
• The Patient
• Complete history and physical examinations
• Note any changes in symptoms or signs.
• The family or relatives
• Complete any missing links.
• Ask for any voluntary information.

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Risk assessmentImportance Aims

• Patient selection
• Finding the balance between benefit vs risk
• Provides a guide to the degree of support
  required in post-op period.
• Provides a data base for risk adjusted outcomes.

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Risk AssessmentRisk Factors I

• Age
• Cardiovascular
• Respiratory diseases
• Smoking
• GI malnutrition, Jaundice Adhesions
• Renal dysfunction
• Haematological disorders
• Obesity
• Diabetes
• Surgeon and Operative severity
• Emergency
• Drugs

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Risk Factors II

• Obesity
• BMIgt 30
• Increased risk in
• DVT,
• Wound infections Dehiscence
• Respiratory complications sleep apnoea.
• Intercurrent diseases.
• Operative difficulty
• Relative risk of mortality 3-5
• Advise controlled wt reduction
• Arrange ICU post-op

• Age
• Distinction must be made between physiological
  state and chronological age.
• Are less mobile, intercurrent disease, less
  physiological reserve.
• Caution with regards to
• IVF Narcotic analgesia.
• More likely to have wound infection.
• In 65 CVA 1, In 80 CVA 3

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Risk Factors IIICardiovascular Diseases

• Predictors CPCEN
• Major
• Unstable coronary syndrome.
• Decompensated CCF.
• Significant Arrhythmias
• Severe valvular disease
• Intermediate
• Mild angina
• PMH MI
• Compensated CCF
• DM
• Minor
• Age, abnormal ECG..etc

• Action
• Evaluation
• Clinical, Specialist opinion, ECG, Stress ECG,
  CXR, Echo
• ..others
• IF Major
• Cancel unless life threatening
• Consider CABG prior to elective surgery.
• If intermediate
• Objective performance.
• Hypertension
• Indicates CAD
• More likely to develop hypotension during
  surgery.
• Control prior to surgery.

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Risk Factors IVRespiratory diseases

• Estimate function
• Clinical and Specialist opinion.
• ABG
• CXR
• Spirometry FEV1/FVC, PEFR
• Chest infection
• Postpone for 2 weeks
• Antibiotics Physio.
• COAD
• Leis with specialist
• Reschedule surgery.
• Plan to transfer to ICU for mechanical
  ventilation pending
• Lung function, type duration of surgery.

• Smoking
• 10 cigr.6 fold increase in post-op respiratory
  complications.
• Respiratory and CVS effects
• Carbon monoxide has higher affinity for O2 than
  Hb.
• Nicotine increases heart rate and BP.
• Hypersecretion of thick mucus
• Immunosuppressive
• Stop 3 months improve pulmonary functions
• Stop 1-2 days Decreases CO levels.

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Risk Factors VGastro intestinal diseases

• Malnutrition
• Loss o15-20 of body wt is associated with severe
  impairment of physiological function
• No evidence of benefit of preop feeding.
• Adhesions
• Higher risk of bowel injury and subsequent
  fistula formation
• Longer duration of surgery

• Jaundice poses a risk for
• Sepsis
• Clotting disorders
• Renal failure
• Liver failure
• Fluid and electrolyte abnormalities
• Drug metabolism
• Management
• Vit k FFP
• Adequate hydration and diuretics oral Lactulose
• Antibiotics
• Nutrition.

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Risk Factors VDiabetes

• Interest to the surgeon
• Patients are more sensitive to protein depletion,
  UE glucose imbalance.
• Surgical stress can precipitate DKA.
• DKA is a cause of acute abdomen
• Decreased phagocytosis, neutrophil activation and
  antibody production
• Small vessel disease
• Peripheral vascular disease
• Peripheral neuropathy
• Autonomic neuropathy
• Recognition of hypo/Hyperglycaemic attacks

• Management
• Specialist Opinion required

NSC Minor LA
4 hourly close observations Omit dose in mane. Either low dose infusion or fixed dose insulin Type II GA
GIK G 500 ml 10 dextrose I Insulin sliding scale K Potassium 10 mmol Continue till first light meal Type I GA
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Risk Factors VRenal haematological Disorders

• Renal
• Identify the cause
• Pre-renal, eg cardiac, hypovolaemia
• Renal, eg acute tubular necrosis( drug induces)
• Post renal, eg obstructive uropathy.
• Identify pt for renal dialysis.
• Check K levels
• Accurate fluid balance
• Look for signs of fluid overload.
• Do not misinterpret poly ureamic phase

• Anaemia
• Correction 1 week pre-op
• Correction day preop is undesirable
• Haemodilution
• Thrombocytopaenia
• In splenomealy, Platelets must be transfused
  immediately preop and on ligating the arterial
  supply.
• Sickle cell disease
• Crisis caused by dehydration, infection,
  hypoxia, hypothermia.
• Jaundice anaemia
• Splenic infarctions sepsis
• Prevention Warm, well hydrated, well analogised
• Consider exchange transfusion in SS
• Correction of coagulopaties

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Risk Factors Operative Severity

• Minor
• Procedures under LA, Uncomplicated hernia
• Moderate
• Appendicectomy, Cholecystectomy
• TURP
• Major
• Laparotomy, Bowel resection
• Major
• AP resection, hepatioco-pancreatic surgery
• Emergency surgery.

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Risk Factors ASA ( American Society of
Anaesthesiologist)
Physical Status Class
Normal healthy individual 1
Mild-moderate systemic disease eg DM, BP 2
Severe systemic disease, NOT incapacitating eg CCF with limited exercise tolerance 3
Incapacitating disease, constant threat to life. with or with out surgery eg Uncontrolled angina 4
Moribund pt not expected to live, surgery is the last resort. 5
Patient requiring emergency surgery. E
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Prophylaxis IWound Infection

• Indications
• When the risk of infection is high
• Clean- contaminated or dirty surgery
• When the results of infection is serious
• e.g. cardiopulmonary bypass
• When there is proven benefit for prophylaxis.
• Principles
• MIC must be achieved and maintained through the
  op.
• Bacteriocidal with high tissue penetration.
• The agent used depends on the likely pathogen

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Prophylaxis IIThrombo-Embolism 1
Patient Group DVT Risk level
Minor surgery Major surgery, agelt40, no PMH lt 10 Low
Major agegt40 and/or major medical conditions. PMH of DVT/PE. Lower limb paralysis 10-40 Moderate
Major abd. Or pelvic surgery for cancer. Major PMH of DVT/PE Major lower limb amputations 40-80 High
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Prophylaxis IIThrombo-Embolism 2

• Recommended Protocols
• Low risk Graduated
  compression stockings, early
  mobilization.
• Moderate-High risk GCS, EM, Unfractionated
  Heparin UFH, Low Molecular
  weight heparin LMWH,
  Intermittent Pneumatic compression IPC.
• UFH s/c . 5000 bd, start 2 hours preop, continue
  till disharge.Contraindicated in Neurosurgery,
  TURP and ? Epidurals.
• Complications Haematoma bleeding
• Must be used with GCS
• LMWH Od, Less risk of bleeding
• GCS/IPC reduction of DVT by 65

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Prophylaxis IIIOthers
Education, counselling and behavioural techniques Preoperative sedation Psychological prophylaxis
40 no previous valvular abnormalities. At risk Valvular disease, Alcoholics, DM, drug addicts, immunosuppressed. Cover for Strep.viridans and Staph. AB regime variable. Infective Endocarditis
Good hydration. Improved renal perfusion using osmotic or loop diuretics. Renal
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Prophylaxis IVBowel Preparation

• Mechanical Bowel Prep.
• Low residue liquid diet 2-3 days pre-op,
  Purgatives and Phosphate enemas 2-3 times the day
  preop.
• Osmotic and oral purgatives using Poly-ethelene
  Glycol PEG.
• Balanced isotonic solutions
• 2 L, 1 day pre-op.
• Well tolerated.
• Intra-operative colonic irregation
• In emergency stenotic lesions
• Upper GI
• Fasting pre-op is usually sufficient.
• NGT insertion and wash out may be necessary.
• Bowel Sterilization
• Effective reduction of colonic bacteria
• Erythromycin and metronidazole.

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Nursing Preparations

• Bathing
• Removal of jewellery
• Removal of dentures
• Skin preparation and shaving on morning of
  surgery
• Administration of medications prescribed.

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Blood Transfusions

• Group Saves
• Simple breast surgery
• Cholecystectomy
• Ileostomy
• Anorectal surgery
• Thyroidectomies.
• Cross matched
• Mastectomy 2U
• AP Colorectal 3-4U
• Gatrectomy 2U
• Splenctomy 2U
• AAA 6U
• Oesophageal-gastrectomy 4U

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Special ConsiderationsThe Thyroid

• Flexible laryngoscopy by ENT check the vocal
  cords
• Recent TFT
• Control of thyrotixicosis
• Beta blockers.
• Lugol Iodine treatment
• Anti-thyroid drugs.
• Anesthetic assessment for the possability of
  difficult intubation.
• GS blood.
• ICU tracheostomy for possible tracheomalacia.

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Special ConsiderationsOthers
Arrange with path lab for Fresh Frozen Section Arrnge ICU for post-op ventilation Vaccination 2 weeks pre-op Platelets pre and during surgery Intra-operative Flouroscopy Increase dose of steroids Neck Xray preintubation Lumbar views Mark site preop Parathyroid. Thoraco-Abd Surgery Spleen Biliary Surgery Pt on Steroids Rheumatoids Elderly for spinal Stoma
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Special ConsiderationsEmergency Surgery

• Time factor is more critical
• In 35-40 of cases the diagnosis is uncertain.
• Resuscitation if needed must be combined with the
  above assessment.
• Patients with acute surgical emergencies are more
  likely to have physiological upsets.
• Broad decisions must be made
• Shock
• Serious injuries to the chest or abdomen
• Acute abdomen Peritonitis
• Abscesses
• GI haemorrhage
• Certain conditions require immediate surgical
  intervention
• Do not compromise the patient by requesting
  investigations.
• Help is at hand when you need it.

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Scenario 1

• A 20 year old male patient with sickle
  cell disease was diagnosed with calcular
  cholecystitis. Laparoscopic cholecystectomy was
  planned.

Outline the steps needed to assess and prepare
this man for the planned surgery and the issues
to be discussed on obtaining an informed consent.
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Scenario 1 preop

• Read-up the condition.
• A clinical general assessment
• Haematological considerations
• Degree of anaemia.
• Sickle test
• Electrophoresis
• Quantify Hb S, Hb A
• Quantify Hb S (lt 40), Hb A post exchange
  transfusion
• Specific assessment of cardiac, liver and renal
  functions
• Preparation
• NBM and IVI avoid dehydartion
• IV AB..Avoid sepsis
• Analgesia.Avoid Pain.
• Keep warm..Avoid hypothermia
• Keep good oxygenationAvoid hypoxia
• S/C Heparin.Avoid hypercoagulable status

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Scenario 2

• A 50 year old non insulin dependant
  diabetic is planned for a right inguinal hernia
  repair. He is on warfarine for past hx of DVT.

Outline the steps needed to assess and prepare
this man for the planned surgery and the issues
to be discussed on obtaining an informed consent.
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Scenario 2 preop

• General consideration
• Clinical assessment
• Check for possible risk factors for the hernia.
• Cardiac, renal, hypertension and nutritional
  assessment
• Prophylaxis IV antibiotics
• Skin preparation
• Keep good hydration
• Always recognise the state of hypo/hyper glycemic
  coma

• Specific considerations
• Position on the operation list.
• Requirements of insulin sliding scale.
• In emergencies check for acetone and acidotic
  status.

NSC Minor LA
4 hourly close observations Omit dose in mane. Either low dose infusion or fixed dose insulin Type II GA
GIK G 500 ml 10 dextrose I Insulin sliding scale K Potassium 10 mmol Continue till first light meal Type I/II GA
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Scenario 3

• A 55 year old obese lady who is a smoker
  and hypertensive recently diagnosed with cancer
  of the left breast. L mastectomy is planned.

Outline the steps needed to assess and prepare
this lady for the planned surgery and the issues
to be discussed on obtaining an informed consent.
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Scenario 3 preop

• Obesity
• Assess BMI
• Assess comorbid factors
• BP, cardiac and respiratory function, DM,
  hyperlipidaemia, hormonal profile if indicated.
• Thromboembolic prophylaxis
• Hypertension
• Insure adequate smooth control
• Check for myocardial cerebral ischaemia
• Check medication and its side effects.
• Smoking
• Stop it and assess comorbid factors.

• Specific measures
• Histological evidence
• Staging CT, bone scan
• Localisation
• LFT, Ca, CBC
• Tumour markers
• Risk assessment
• E/P receptor status
• X-match
• Involvement of oncology, radiology, pathology,
  plastics, specialist nurse teams.
• Timing neoadjuvent chemo/radio therapy

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Scenario 4

• A 30 year old lady with graves disease
  failed to respond to medical treatment.
  Thyroidectomy is planned.

Outline the steps needed to assess and prepare
this lady for the planned surgery and the issues
to be discussed on obtaining an informed consent.
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Scenario 4 preop

• Collect evidence of diagnosis
• Thyroid function
• Autoantibodies
• Nuclear /USS scans
• Histology excluding Ca
• Normalise the thyroid function
• Iodine, ß blockers, benzodiazepines
• Evidence of normal TFT post treatment
• General clinical and objective assessment of
  cardiac status
• Check CBC ( aplastic anaemia)
• Group and save.
• Flexible laryngoscopy vocal cords
• Consent issues
• premedication

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Scenario 5

• A 70 year old gentleman recently diagnosed
  with cancer of the rectum 8 cm from the anal
  margin. Anterior resection is planned. He is on
  steroids for COAD.

Outline the steps needed to assess and prepare
this gentleman for the planned surgery and the
issues to be discussed on obtaining an informed
consent.
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Scenario 5 preop

1. Diagnose
2. Check for possible underlying and associated
   problems
3. Stage
4. Map and check for synchronous tumours
5. Correct electrolyte abnormalities and CBC
6. Improve the nutritional status.
7. Assess the need for neoadjuvent treatment (
   involve the oncology, radiology, endoscopy teams)
8. Check for integrity of L ureter and L kidney
   hydrnephrosis
9. Full clinical assessment ( lung, heart and liver)
10. Bowel preparation
11. Stoma location
12. Prep the abdomen
13. Prophylactic AB and bowel sterilisation.
14. Prophylactic thromboeblism.
15. Informed consent

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Scenario 6

• A 20 year old gentleman involved in an
  RTA. Patients abdomen is distended and he is
  shocked.
• Emergency laparotomy was deemed necessary.

Outline the steps needed to assess and prepare
this gentleman for the planned surgery and the
issues to be discussed on obtaining an informed
consent.
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Scenario 6 preop

1. Primary and secondary survey
2. AMPLE
3. Cross match and basic laboratory work up
4. CXR, C-Spine, Pelvis x-rays
5. Consent
6. Inform OR and shift
7. Administer AB en-rout to OR

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Scenario 7

• A 67 year old man with a septic diabetic
  foot presented to the ERD.
• He is IDDM for 5 years , with IHD for 2
• P 130/ minute, BP 90/60, T 38.5, O2 Satu. 82

Outline the steps needed to assess and prepare
this gentleman for the planned surgery and the
issues to be discussed on obtaining an informed
consent.