PREOPERATIVE

PREPARATION OF THE
PATIENT

Dr. Hiwa Omer Ahmed

Assistant professor in General
Surgery

LECTUR 1 & 2
 LECTURE 1
PREOPERATIVE PREPARATION OF THE
PATIENT
• convergence of the art and
science of the surgical discipline.
• in outpatient office visit to
hospital inpatient
• Approaches to preoperative evaluation
differ significantly, depending on the
1.nature of the complaint
2. the proposed surgical intervention
3. patient health
4. assessment of risk factors
5.the results of directed investigation
6. interventions to optimize the patient's
overall status
7. readiness for surgery.
 Determining the Need for
Surgery
confirmation of relevant physical
findings and review of the
clinical history and laboratory
and investigative tests that
support the diagnosis.
 Perioperative Decision
Making
• Once the decision has been made to
proceed with operative management, a
number of considerations must be
addressed regarding the
1.timing and site of surgery
2. the type of anesthesia
3. the preoperative
preparation necessary
to understand the patient's risk and
optimize the outcome.
 Preoperative Evaluation
• The aim is to identify and
quantify any comorbidity that
may have an impact on the
operative outcome. The goal is
to uncover problem areas that
may require further
investigation or be amenable to
preoperative optimization ..
• The preoperative evaluation is
determined in light of the
1.planned procedure (low, medium, or
high risk),
2. planned anesthetic technique,
3. the postoperative disposition of the
patient (outpatient or inpatient, ward
bed, or intensive care).
4. to identify patient risk factors for
postoperative morbidity and mortality.
• consultation with an internist or
medical subspecialist may be
required to facilitate the workup
and direct management. In this
process, communication between
the surgeon and consultants is
essential to define realistic goals
for this optimization
process and to expedite
surgical management
 The aim of a preoperative
evaluation
to assess the fitness of the individual for
anesthesia and surgery.
A well-conducted history and physical
examination answer several important
questions:
• Is this a healthy patient?
• What is the indication for surgery?
• Is the surgical procedure low risk,
intermediate risk, or high risk?
• What is the functional status of the
patient?
• What is the effect of the present
condition on the patient?
• What improvement is expected after
surgery?
Answers to these questions should then direct
preoperative testing and management.
1.The tests selected should therefore evaluate
existing illness, screen for conditions that could
affect outcomes in the perioperative period, and
help to determine perioperative risks.
Existing illnesses that need evaluation and possible
treatment include hypertension, diabetes
mellitus, cardiac, vascular, pulmonary, renal, and
hepatic diseases.
The pregnant patient, the geriatric patient, the
patient with oncologic disease, malnutrition, or
coagulation disorders also needs directed
evaluations
 THE HEALTHY
PATIENT
The initial preoperative evaluation of a
patient should be supplemented by a
complete assessment of the patient’s
general health. This involves a thorough
*history
*physical examination.
1.Complete blood counts
2.Blood urea and electrolytes

3.An electrocardiogram (ECG) is indicated over 40 years,.

4.Posteroanterior and lateral chest x-rays

5. Hb%

6.GUE
• The history should include information
regarding any known medical problems and
ongoing treatment, previous surgical procedures,
and problems if any during previous anesthesia.
These can include difficult intubation, bleeding
tendencies, and anesthetic jaundice.
• Family history of problems during anesthesia or
surgery should be obtained. These can make the
anesthesiologist aware of potential problems such
as malignant hyperthermia, bleeding tendencies,
or thrombophilia.
• In addition to routine information about family
history, a strong family history of allergies should
alert the surgeon to the possibility of
hypersensitivity to drugs.
• An exhaustive history of drug allergies,
sensitivities, and current or recently taken
medications should be obtained. Medications
such as digitalis, insulin, and corticosteroids
should be maintained and their doses
carefully regulated in the perioperative
period.
• If the patient is on corticosteroids or if it has
been discontinued within a month of surgery,
he or she may have a hypofunctioning
adrenal cortex resulting in impaired
physiologic responseM to surgical stress
 Consent for surgical
treatment
Objectives
• Recognize the need to establish trust and
confidence in patients under your care.
• Understand that a signature on a consent form is
not legal proof that informed consent has been
given.
• Realize that you must warn patients of the hazards
as well as the benefits of surgical treatment.
• Identify and deal appropriately with difficulties in
gaining consent. Respect the confidentiality of
your dealings with patients.
 THE MORAL IMPORTANCE
OF
INFORMED CONSENT
• • The moral unacceptability of
anyone exercising unlimited
power over others is at the heart
of many of our liberal values.
What is informed consent?

• to be able to make a considered

choice about what is in their personal
interests - they must receive
sufficient accurate information
about their illness, the proposed
treatment and its prognosis.
 DO & DONT
1. Describe the procedure itself, including
information about its practical implications
and probable prognosis.
2. Reveal the probability of specific associated
risks or complications.
3. Do not assume that the patient already knows the
risks of other aspects of the proposed surgical
procedure, such as the complications that might
result from a general anaesthetic, bed rest,
intravenous fluids or a catheter.
4. Outline other surgical or medical alternatives to the
proposed treatment, including non-treatment,
along with their general advantages and
disadvantages.
 Good consenting practice

1. As much as possible, ensure that

the physical surroundings during the
discussion between you and your
patient are conducive to easy, quiet
conversation.
2. Use the simplest possible language,
avoiding needless technicalities.
Appropriate leaflets or booklets can be
helpful, as is innovative work using
audiorecording of interviews;
patients can be encouraged to take
the recording home to discuss with
others.
3. Having attempted to provide clear
information, now determine whether
or not the patient has actually
understood it.
 The consent form

• 1. In principle, the consent form signed by the

patient before operation
• You should also sign the form after obtaining
consent to indicate that, to the best of your
knowledge, the patient has both received and
understands the information necessary to
make a considered judgment.
2. However, it is unnecessary for a competent patient to
sign for all surgical interventions. A simple investigative
procedure such as venepuncture, involving minimal risk,
can be undertaken after oral explanation of, and consent
to, what it physically entails. Consent can be assumed to
be implied if the patient then accepts the procedure.

3. The consent form is not legal proof that consent has

been given. Always bear this in mind if you are tempted
to cut corners as regards good practice in obtaining
consent. It is merely one piece of evidence that some
attempt was made to obtain informed consent, not that it
was a morally or legally satisfactory attempt.
 unconscious
Here, there is a clear duty to treat, despite
the fact that it is impossible to obtain the
patient's consent, and there would be no
risk of battery if operation proceeded.
The only circumstance that justifies surgery
without consent is the dramatic need of
patients, coupled with their inability to give
consent.
 Children
Ordinarily, obtain consent for elective surgery on young
children from someone - usually the parent - deemed
competent to make informed choices about the child's
best interests. However, this does not suggest that you
must always be guided solely by parental wishes. If you
believe such a decision is necessary to save the child's
life, the parents' wishes can be overridden. If there is
time, apply to the court for the appropriate order. If
not, you can still proceed.
 LECTURE 2
Preoperative preparation
for
surgery
 ROUTINE PREOPERATIVE
PREPARATION

Evaluation
1. Take a full history and exclude any
significant
medical problems
2. Check clinical signs against the planned
surgical procedure, in particular noting the
side involved. Confirm that the planned
operative procedure is appropriate.
3. Take a full drug history with specific
enquiry regarding allergic responses to
drugs, latex and skin allergies. Continue
medication over the perioperative
period, especially drugs for
hypertension, ischaemic heart disease
and bronchodilators. Give patients on
oral steroid therapy intravenous
hydrocortisone. Stop oral warfarin
anticoagulation 3 days preoperatively
and check the prothombin time prior to
surgery.
Patients taking aspirin or other
antiplatelet medication (e.g.
clopidogrel) may have an increased
risk of bleeding; stop these drugs for
at least 48 h preoperatively for major
surgery.
Stop drugs, over the perioperative period, that
may interfere with anaesthetic agents, including
monoamine oxidase inhibitors, lithium, tricyclic
antidepressants and phenothiazines.
If possible, stop the oral contraceptive pill 4
weeks prior to any major surgery.
Postmenopausal patients on hormone
replacement therapy do not need to have their
medication stopped before an operation.
4. There is a clear correlation between malnutrition
in
the preoperative period and an increased morbidity
and
mortality from surgery .
5. Young and fit patients undergoing minor
procedures do not require any
preoperative investigations

In older patients or those with significant

medical problems, standard investigation
would include a full blood count, urea
and electrolytes, chest X-ray and
electrocardiogram.
Routine preoperative measures

1. Adhere to the protocol followed by

your firm
2. Prohibit solid diet to adult patients
for 6 h, and clear fluids for 4 h, prior
to an elective general anaesthetic.
Fasting times for children vary in
different hospitals and they are also
age dependent.
Babies under 1 year
No breast milk for 2-3 h before anaesthesia
No formula feed for 6 h before anaesthesia
Clear fluids may be given up to 3 h before anaesthesia

Children over 1 year

No food/milk for 6 h before anaesthesia
Clear fluids up to 3 h before anaesthesia

3. The operation site must be prepared by the removal of

hair, if this is necessary for access, using a depilatory
cream. Shaving or clipping hair from the operation site
increases the risk of infection, unless the skin
preparation is carried out immediately prior to surgery.
4.Mark a unilateral operation site on the
skin with an indelible marker pen.

5. Explain to the patient (or guardian) the

procedure and any likely complications,
answer questions the patient may have, and
only then have them sign the consent form. If
you are unable to answer the patient's
questions, seek help from a senior colleague.
6. It is good practice for the operating
surgeon to obtain the patient's
consent; not immediately before an
operation but some time ahead, so
that they may have a period of
reflection, and an opportunity to ask
further questions that may arise.
7. Antibiotic administration is guided by
the surgical procedure involved and is
discussed below, as is prophylaxis
against deep vein thrombosis.
8. If specific services, such as frozen
section histopathology or
intraoperative radiography are likely to
be required during the operation,
organize these in advance.
9. PROPHYLAXIS AGAINST DEEP VEIN
THROMBOSIS AND PULMONARY EMBOLI
Pulmonary emboli are a major cause of
mortality for surgical patients, accounting
for 10% of inpatient deaths in the United
Kingdom.
Recent operation, immobilization and trauma
were responsible for 50% of deep vein
thrombosis (DVT) in a review by Cogo et al
(1994), but there are other important
predisposing factors,
such as the high oestrogen content oral
contraceptive pill, and significant obesity .
Many risk factors cannot be avoided, but take
measures to avoid propagation of any
thrombosis:
• Subcutaneous heparin may reduce the
incidence of DVT by 50%; it is generally well
tolerated Systemic anticoagulation effects of
low dose subcutaneous heparin are minimal
and haemostasis is not impaired.
• Newer low molecular weight heparins
(LMWHs), as effective as standard heparin,
need only once a day dosage.
 Risk factors for deep vein
thrombosis

• Recent surgery
• Immobilization
• Trauma
• Oral contraceptive pill
• Obesity
• Heart failure
• Arteriopathy
• Cancer
• Age > 60 years
 SYSTEMS APPROACH TO
PREOPERATIVE EVALUATION
• Cardiovascular
• Cardiovascular disease is the leading cause
of death in the industrialized world, and its
contribution to perioperative mortality
during noncardiac surgery is significant.
• Consequently, much of the preoperative
risk assessment and patient preparation
centers on the cardiovascular system.
 ASA classification
•   I—Normal healthy patient  
•   II—Patient with mild systemic disease  
•   III—Patient with severe systemic disease that
limits activity but is not incapacitating   
• IV—Patient who has incapacitating disease
that is a constant threat to life   
• V—Moribund patient not expected to survive
24 hours with or without an operation
• The optimal timing of a surgical procedure after
myocardial infarction (MI) is dependent on the
duration of time since the event and assessment of
the patient's risk for ischemia, either by clinical
symptoms or by noninvasive study. Any patient can
be evaluated as a surgical candidate after an acute
MI (within 7 days of evaluation) or a recent MI
(within 7-30 days of evaluation). The infarction
event is considered a major clinical predictor in the
context of ongoing risk for ischemia. The risk for
reinfarction is generally considered low in the
absence of such demonstrated risk. General
recommendations are to wait 4 to 6 weeks after MI
to perform elective surgery
 Preoperative evaluation of
pulmonary function
• may be necessary for either thoracic or
general surgical procedures.
• Necessary tests include forced expiratory
volume in 1 second (FEV1), forced vital
capacity, and the diffusing capacity of carbon
monoxide. Adults with an FEV1 of less than
0.8 L/sec, or 30% of predicted, have a high
risk for complications and postoperative
pulmonary insufficiency; nonsurgical
solutions are sought. Pulmonary resections
need to be planned so that the postoperative
FEV1 is greater than 0.8 L/sec, or 30% of
predicted..
• Preoperative interventions that may
decrease postoperative pulmonary
complications include
1.smoking cessation (>2 months before
the planned procedure),
2.bronchodilator therapy,
3.antibiotic therapy for preexisting
infection,
4.pretreatment of asthmatic patients with
steroids.
5.Perioperative strategies include the use
of a.epidural anesthesia,
b. vigorous pulmonary toilet and
rehabilitation, c. continued
bronchodilator therapy
 Renal

• Approximately 5% of the adult

population have some degree of
renal dysfunction
• . In fact, a preoperative
creatinine level of 2.0 mg/dL or
higher is an independent risk
factor for cardiac complications.
• Patients with chronic end-stage
renal disease undergo dialysis
before
 Hepatobiliary

• . A patient with liver dysfunction

requires careful assessment of
the degree of functional
impairment, as well as a
coordinated effort to avoid
additional insult in the
perioperative period
• A patient with liver dysfunction
undergoes standard liver function
tests.
• can be investigated by serologic
testing for hepatitis A, B, and C.
• Alcoholic hepatitis is suggested by
lower transaminase levels and an
aspartate/alanine transaminase
ratio (AST/ALT) greater than 2.
 Endocrine
• A patient with an endocrine condition
such as diabetes mellitus,
hyperthyroidism or hypothyroidism,
or adrenal insufficiency is subject to
additional physiologic stress during
surgery.
• The preoperative evaluation
identifies the type and degree of
endocrine dysfunction to permit
preoperative optimization.
 DM
• A diabetic patient requires special attention to
optimize glycemic control perioperatively.
• Non–insulin-dependent diabetics need to
1.discontinue long-acting sulfonylureas such as
chlorpropamide and glyburide
• 2.a shorter-acting agent or sliding-scale insulin
coverage may be substituted in this period.
• The use of metformin is stopped preoperatively
because of its association with lacticacidosis in
the setting of renal insufficiency.
• An insulin-dependent diabetic is told to withhold
long-acting insulin preparations (Ultralente
preparations) on the day of surgery; lower
dosages of intermediate-acting insulin (NPH or
Lente) are substituted on the morning of
surgery.
• These patients are scheduled for early morning
surgery, when feasible.
• During surgery, a standard 5% or 10% dextrose
infusion is used with short-acting insulin or an
insulin drip to maintain glycemic control. A
patient with diabetes mellitus that is well
controlled by diet or oral medication may not
require insulin perioperatively,
• but those with poorer control or patients taking
insulin may require preoperative dosing and
both glucose and insulin infusion during surgery
• Frequent assessments of glucose levels are
continued through the postoperative period.
Current recommendations are to maintain the
perioperative glucose level between 80 and
150 mg/dL, even in patients not previously
diagnosed as being diabetic.
• Adequate hydration must be maintained with
avoidance of hypovolemia.
• Postoperative orders include frequent (every
2-4 hours) finger stick glucose checks and the
use of short-acting insulin in the form of
sliding-scale coverage
 Immunologic
• The approach to a patient with suspected
immunosuppression is the same, regardless of whether
this state results from antineoplastic drugs in a cancer
patient or immunosuppressive therapy in a transplant
patient or is the result of advanced disease in patients
with acquired immunodeficiency syndrome. The goal is to
optimize immunologic function before surgery and to
minimize the risk for infection and wound breakdown.
• Preoperative assessment includes a thorough history of
the patient's underlying disease and current functional
status; a history of immunosuppressive treatment,
including names of medications and duration of treatment;
and a history of recent changes in weight.
 Hematologic

• Hematologic assessment may lead to the

identification of disorders such as anemia,
inherited or acquired coagulopathy, or a
hypercoagulable state.
• Substantial morbidity may derive from
failure to identify these abnormalities
preoperatively. The need for perioperative
prophylaxis for venous thromboembolism
must be carefully reviewed in every surgical
patient
• Anemia is the most common
laboratory abnormality
encountered in preoperative
patients. It is often
asymptomatic and can require
further investigation to
understand its cause
 bleeding risk
• All patients undergoing surgery are questioned to assess
their bleeding risk.
• . The inquiry begins with direct questioning about a
personal or family history of abnormal bleeding.
Supporting information includes a history of easy bruising
or abnormal bleeding associated with minor procedures
or injury. A history of liver or kidney dysfunction or recent
common bile duct obstruction needs to be elicited, as well
as an assessment of nutritional status. Medications are
carefully reviewed, and the use of anticoagulants,
salicylates, nonsteroidal anti-inflammatory drugs
(NSAIDs), and antiplatelet drugs are noted.
• Physical examination may reveal bruising,
petechiae, or signs of liver dysfunction. Patients
with thrombocytopenia may have qualitative or
quantitative defects as a result of immune-
related disease, infection, drugs, or liver or
kidney dysfunction. Qualitative defects may
respond to medical management of the
underlying disease process, whereas
quantitative defects may require platelet
transfusion when counts are less than 50,000 in
a patient at risk for bleeding
• Although coagulation studies are not
routinely ordered, patients with a history
suggestive of coagulopathy undergo
coagulation studies before surgery.
Coagulation studies are also obtained before
the procedure if considerable bleeding is
anticipated or any significant bleeding would
be catastrophic. Patients with documented
disorders of coagulation may require
perioperative management of factor
deficiencies, often in consultation with a
hematologist.
 Special
preparations