Preoperative Preparation DR. WALID AL - MEKHLAFI 2023 INTRODUCTION Preoperative preparation is the preparation of a patient requiring surgery to optimize postoperative outcomes The preparation begins from the time of contact of the patient with the surgeon and ends on the day of surgery in the preoperative room The approach is multidisciplinary It involves participation of anesthetic and surgical teams, radiologists, pathologists, specialist nursing staff and Operating Room staffs To obtain satisfactory results in general surgery requires a careful approach to preoperative preparation of patients Specific patient groups have specific needs High risk patients should be identified early, and appropriate measures taken to reduce complications The preoperative consultation and evaluation is an important interaction between the patient and physician It allows the surgeon to : • Carefully access the medical condition • Evaluate the patient ’ s overall health status • Determine risk factors against procedures • Educate the patient • Discuss the procedure in detail It helps the patient to : • Gain a realistic understanding of the proposed surgery • Consider alternative treatment options • Realize the possible complications during perioperative period SITUATIONS o Emergency : life - threatening condition requiring immediate action ( e.g. ruptured aneurysm, penetrating trauma, peritonitis) o Urgent : surgery required within few hours (e.g. intestinal obstruction, appendicitis, wound debridement ) o Elective : there is time for further evaluation (e.g. hernia, varicose vein, breast malignancy ) The complication rate is higher with ................................. Routine preparation for surgery • History • Physical examination • Special investigation • Informed consent • Marking the site/side of operation • Thromboembolic prophylaxis • Antibiotic prophylaxis History What are the items of history? Examination What are the items of physical examination? The routine examination must be altered to fit the circumstances in emergency situations ( primary survey - Secondary survey ) When a number of emergencies present at same time ( T ri a ge ) Investigations: o Complete blood count o Blood group o Coagulation profile o Renal function test o Liver function test o Virology o Blood sugar level o Chest x - ray, ECG and Echo o Others e.g., Electrolytes and U/S or CT ASSESSMENT OF RISK OF SURGERY o There are few patients who have no risk for surgery o It is important to quantify the risks involved so they be discussed with the patients o Two main prognostic scoring systems which are in current use are • APACHE System • ASA System APACHE System Acute Physiology And Chronic Health Evaluation Helps to predict the outcome of patients admitted to ICU and has subsequently been applied to patients undergoing surgery APACHE II 12 acute physiological variables Patient ’ s age Chronic health points APACHE III ASA System American Society of Anesthesiologist It is very simple and widely accepted 50 % patients presenting for elective surgery are in ASA Grade 1 Operative mortality rate for these patients is less than 1 in 10,000 MORTALITY RISK Clinical Predictors of Increased risk • Major predictors • Intermediate predictors • Minor predictors Surgery related risk • High risk • Intermediate risk • Low risk THROMBOEMBOLIC PROPHYLAXIS • DVT is common in surgical patients • It can cause PE which carries a high mortality • Surgery, trauma and immobilization are responsible for 50 % of DVT RISK FACTORS FOR DVT: Age – Obesity – Immobility – Malignancy - Trauma - Dehydration Past history thromboembolism - Oral contraceptives - HRT - Pregnancy PROPHYLAXIS: Elastic compression stocking - Intermittent pneumatic calf compression Postoperative early ambulation - Heparin prophylaxis Heparin dose: • Baseline aPTT • Loading dose 80 mg/kg • Maintenance dose 18 mg/dl • Doubling the aPTT • Heparin can lead to HIT syndrome