preoperative preperation

History

Principles of history-taking
■ Listen: what does the patient see as the problem? (Open questions)
■ Clarify: what does the patient expect? (Closed questions)
■ Narrow the differential diagnosis. (Focused questions)
■ Fitness: what other comorbidities exist? (Fixed questions

History of the presenting complaint

Past medical history
Drug history
Social history

Cardiovascular

■ Ischaemic heart disease – angina, myocardial infarctiona
■ Hypertensiona
■ Heart failure
■ Dysrhythmias
■ Peripheral vascular disease
■ Deep vein thrombosis and pulmonary embolisma
■ Anaemia


Respiratory
■ Chronic obstructive pulmonary disease
■ Asthmaa
■ Fibrotic lung conditions
■ Respiratory infections
■ Malignancy

Gastrointestinal

■ Peptic ulcer disease and gastro-oesophageal reflux
■ Bowel habit – bleeding per rectum, obstruction
■ Malignancy
■ Liver disease – jaundice, alcohol, coagulopathy

Genitourinary tract

■ Urinary tract infection
■ Prostatism
■ Renal dysfunction

Neurological

■ Epilepsy
■ Cerebrovascular accidents and transient ischemic
attacks
■ Psychiatric disorder


Endocrine/metabolic
■ Diabetes
■ Thyroid dysfunction
■ Phaeochromocytoma
■ Porphyria

Locomotor system

■ Osteoarthritis
■ Inflammatory arthropathy such as rheumatoid arthritis,
including neck instability

Infectious diseases

■ Human immunodeficiency virus
■ Hepatitis
■ Tuberculosis

Previous surgery

■ Types of anesthetic and any problems encountered
■ Have any members of the patient’s family had particular
problems with anesthesia?


Examination
General
■ Anaemia, jaundice, cyanosis, nutritional status, teeth, feet,
leg ulcers (sources of infection)
Cardiovascular
■ Pulse, blood pressure, heart sounds, bruits, peripheral
pulses, peripheral oedema
Respiratory
■ Respiratory rate and effort, chest expansion and
percussion note, breath sounds, oxygen saturation
Gastrointestinal
■ Abdominal masses, ascites, bowel sounds, bruits, herniae,
genitalia
Neurological
■ Conscious level, any pre-existing cognitive impairment or
confusion, deafness, neurological status of limbs

Investigations

1-Full blood count young woman with menorrhagia and older patient
2-Urea and electrolytes
- over the age of 65
- lose a significant amount of blood in theatre
- history of cardiovascular, pulmonary or renal problems.
- diuretic taking patients


3- Liver function testsThese are indicated in patients with jaundicehepatitis, cirrhosis, malignancy, portal hypertension, poor nutritional reserves or clotting problems

4-Clotting screen

or any patient on anticoagulants, with compromised liver function tests or evidence of a bleeding diathesis.
.
5-Arterial blood gases
assessment of some respiratory conditions,

6-Electrocardiography

-anyone over the age of 65 ???, 40year?
- in all patients in whom significant blood loss is possible
- All patent with a history of cardiovascular, pulmonary or anesthetic problems.

7-Chest radiography

This is not usually required unless the patient has a significant
cardiac history (including hypertension) or respiratory problems.
in IRAQ is different due to TB.

8- Human chorionic gonadotrophin

- in blood or urine and used to confirm pregnancy. It is essential in all female patients of childbearing age with abdominal pain to exclude an ectopic pregnancy and in any
unconscious female patient of childbearing age.
9-Sickle cell test
Usually the patient with sickle cell disease will know that they have this and inform the surgical team
10-Hepatitis/human immunodeficiency virus serology
Testing should be undertaken in any patient with a past history of high-risk exposure to infected body fluids, hepatitis or disorders associated with acquired immunodeficiency syndrome. .
11- Other radiological investigations
Patients with rheumatoid arthritis may have an unstable cervical spine, in which case the spinal cord can be injured during intubation. radiographs should be obtained preoperatively to check for instability.


Orthopaedic surgery often requires careful planning on the basis of recent radiographs.

.
12-Further cardiac evaluation
Previous discussion with the anesthetist and/or a cardiologist is advisable if there are cardiac problems. A resting ECG does not reliably predict ischemic perioperative events. ECHO, A ventricular ejection fraction of less than 35%, however, indicates a high risk of cardiac complications.

13- Further respiratory evaluation

Thoracic surgery usually requires a thorough respiratory work-up preoperatively. Otherwise, this is only indicated in patients with severe chronic obstructive airways disease [forced expiratory volume in 1 s (FEV1) of < 40%] or poorly controlled asthma in
which preoperative optimization might be possible.

14-Temperature
Patients with a pyrexia should not be operated on until the cause
has been identified and corrected if possible.
15-Urinalysis
Dipstick testing of urine is usually carried out preoperatively. It can detect urinary infection, biliuria, glycosuria and inappropriate osmolality. More detailed microscopic or biochemical analysis is indicated if the patient has a history of urinary tract problems or

management plan

Key points in the management plan discussion
■ Provide all of the information necessary for the patient to
make an informed decision
■ Use language that the patient will understand
■ Discuss the options rather than telling the patient what
will be done
■ Give the patient time to think things over
■ Encourage the patient to discuss things with a trusted
friend/partner
■ Suggest that the patient write down a list of points that he
or she wishes to discuss


SPECIFIC PREOPERATIVE PROBLEMS
Cardiovascular disease
Hypertension
.- systolic pressures ≥ 160 mmHg
diastolic pressures ≥ 95 mmHg
elective surgery deferred until their blood pressure is under control.
- Newly diagnosed hypertension may need further investigation look for an underlying cause; the medical team may need to be involved.
-For an acute admission requiring urgent surgery the blood pressure may need to be controlled more rapidly.
- It can be dangerous for a patient’s blood pressure to drop precipitously and
this should be carried out with the assistance of the medical team.
.

Ischaemic heart disease, including recent myocardial

infarction
Recent myocardial infarction is a strong contraindication to elective anaesthesia. There is a significant mortality rate from anaesthesia within 3 months of infarction and elective procedures should ideally be delayed until at least 6 months have elapsed.

Significant or worsening angina needs investigation by acardiologist before elective surgery

If urgent surgery isrequired, aggressive medical therapy is indicated and meticulous optimisation of oxygenation and fluid balance throughout the
perioperative period must be obtained


Dysrhythmias
Fast atrial fibrillation must be controlled before surgery
.Pace maker required preoperatively,in particular second- or third-degree heart block. If a pacemaker
Most standard pacemakers are stable during anaesthesia but
only bipolar diathermy should be used whenever possible.
Cardiac failure
This needs careful work-up preoperatively and will require specialist medical input. Oxygenation and fluid balance are of critical importance in these patients and must be meticulously monitored and documented
Anaemia and blood transfusion
. Preoperative transfusion should be considered if the preoperative haemoglobin concentration is below 8 g dl–1 or if the patient is symptomatic or actively losing blood

Respiratory disease

Infection
-Significant lower respiratory tract infections should be treated before surgery .
-Patients with bronchiectasis and chronically infected sputum may need appropriate antibiotics combined with intensive
physiotherapy..
Asthma
The patient’s usual inhalers should be continue , may need oral steroid cover. .
Chronic obstructive pulmonary disease
The anaesthetist must be informed if the chronic obstructive pulmonary disease (COPD) is significant, as regional anaesthetic techniques may need to be considered. Appropriate postoperative
- intensive therapy unit (ITU) bed.
Pulmonary fibrosis
There is no evidence that any treatment alters the course of disease but inform anaesthetist
. If the patient smokes they should be
asked to stop at least 4 weeks before the surgery


Gastrointestinal disease
Malnutrition
In the malnourished patient, treatment with nutritional support
for a minimum of 2 weeks before surgery is required to have any
impact on subsequent morbidity. l.
Obesity
Obesity is defined as a BMI of more than 30. These patients are
at an increased risk of a number of postoperative complications.
In some cases it might be better for the patient to delay surgery
until they have lost weight.

Problems of surgery in the obese

Increased risk of:
■ Difficulty intubating
■ Aspiration
■ Myocardial infarction
■ Cerebrovascular accident
■ Deep vein thrombosis and pulmonary embolism
■ Respiratory compromise
■ Poor wound healing/infection
■ Pressure sores
■ Mechanical problems – lifting, transferring, operating table


Regurgitation risk
Pulmonary aspiration can lead to acid pneumonitis, severe bronchospasm,
pneumonia and death. .

A frequently used regime is ‘no solids for 6 hours’ and ‘no clear

fluids for 4 hours’ before surgery. .
Other management strategies may include the preoperative
use of H2-receptor blockade,
a nasogastric tube to empty a significantly
distended stomach
and specific anaesthetic techniques.

Surgery in the jaundiced patient

Causes of jaundice:
■ Secondary complications of surgery:
■ Clotting disorders need vitamin k
■ Hepatorenal syndrome need hydration
■ Infection need antiboitic

Renal impairment

■ Prerenal:
Dehydration
Poor perfusion
■ Renal:
Acute – volume depletion, platelet function,
immunosuppression
Chronic – fluid balance, ?dialysis, ?transplantation
■ Postrenal:
Obstruction – calculi, prostate, blocked
Catheter


Urinary tract infection

Metabolic disorders

Diabetus
Surgical risks for the diabetic patient
■ Increased risk of sepsis – local and general
■ Neuropathic complications – pressure care
■ Vascular complications – cardiovascular, cerebrovascular,
peripheral
■ Renal complications
■ Fluid and electrolyte disturbances

Adrenocortical suppression

Patients receiving oral adrenocortical steroids regularly (including up to 2 months before surgery) will have a degree of adrenocortical suppression. They will require extra doses of steroids around the time of surgery to avoid an Addisonian crisis

Coagulation disorders

Patients taking drugs that interfere with the clotting Cascades
For simple atrial fibrillation, warfarin can usually be stopped 3–4 days before surgery and then restarted at the normal dosage level on the evening after surgery.
Check that the international normalised ratio (INR) has dropped to 1.5 or lower before surgery

DVT

Deep vein trombosis
Risk factors for thrombosis
■ Increasing age
■ Significant medical comorbidities (particularly malignancy)
■ Trauma or surgery (especially of the abdomen, pelvis and
lower limbs)
■ Pregnancy/puerperium
■ Immobility (including a lower limb plaster)
■ Obesity
■ Family/personal history of thrombosis
■ Drugs, e.g. oestrogen, smoking


Risk groups for thrombosis according to surgery
Low risk
■ Minor surgery (less than 30 min), no risk factors, any age
■ Major surgery (more than 30 min), no risk factors, less
than age 40
■ Minor trauma or medical illness
Moderate risk
■ Major surgery (not orthopaedic or abdominal cancer), age
40+ or other risk factor
■ Major medical illness, trauma or burns
■ Minor surgery, trauma or illness in patient with a
family/personal history
High risk
■ Major surgery (elective or trauma orthopaedic, cancer) of
the pelvis, hip or lower limb
■ Major surgery, trauma or illness in a patient with a
family/personal history
■ Lower limb paralysis/amputation

Prophylaxis against thrombosis

Mechanical
■ Early mobilisation
■ Neuraxial anaesthesia
■ Leg compression stockings
■ Calf and foot pumps
Pharmacological
■ Heparin and low molecular weight heparin
■ Warfarin
■ Aspirin
■)


Neurological and psychiatric disorders
Peripheral neuropathies and myopathiesmay require prolonged
ventilation postoperatively and this should be anticipated.

Anticonvulsants need to be continued perioperatively and

may need to be changed to intravenous forms if starvation is prolonged.

Psychiatrically disturbed patients may require general rather

than regional anaesthesia.

Locomotor disorders

Specific complications of the inflammatory arthropathies should
be identified preoperatively.
The commonest, and potentially most catastrophic, of these is the unstable cervical spine in the patient with rheumatoid arthritis
If not handled carefully during intubation these patients can sustain
significant spinal cord damage

CONSENT

Stages in the consent process
■ Ensure competence (ensure that the patient can take in,
analyse and express their view)
■ Check details (correct patient)
■ Make sure that the patient understands who you are and
what your role is
■ Discuss the treatment plan and sensible alternatives
■ Discuss possible risks and complications (especially those
specific to the patient)
■ Discuss the type of anaesthetic proposed
■ Give the patient time and space to make the final decision
■ Check that the patient understands and has no more
questions
■ Record clearly and comprehensively what has been agreed


Multiprofessional team members
For theatre
■ Ward staff
■ List organiser and circulator
■ Theatre nursing staff
■ Anaesthetic staff, including operating department
practitioners (ODPs)
■ Other members of the surgical team
■ Radiology department
■ Pathology department

For postoperative recovery

■ Rehabilitation staff
■ Social care workers
■ Children’s ward staff
■ ITU/high-dependency unit staff
■ Specialist nurse counsellor (stoma/amputation)