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Preoperative Preparation for Surgery

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dr gm kan on Jun 16, 2009 Says :

another exceelant presentation from author

tareq on Jun 11, 2009 Says :

thanx

tareq on Jun 11, 2009 Says :

thanx

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Notes

Show Notes

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Preoperative Preparation for Surgery Prepared by Dr. ibrahim zabiri SUP BY; DR FIAZ FAZILI

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Slide 4 :

Preoperative preparation for surgery Contents Introduction Pre-operative care Pre-operative investigation Assessment of risk for surgery Preparation for surgery of specific patient groups Consent

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Preoperative Preparation for Surgery Introduction To obtain satisfactory results in general surgery requires a careful approach to the preoperative preparation of patients . Specific patients groups have specific needs high risk patients should be identified early and appropriate measures taken to reduce complication

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Preoperative Preparation for Surgery Prior to consideration of surgical intervention,it is necessary to prepare the patient as fully as possible. The extent of pre-operative preparation will depend on the:

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Pre-operative preparation situation Nature of surgery (minor or major) Location of surgery Facilities available

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Preoperative Preparation for Surgery Situation Emergency :life-threatening condition requiring immediate action,(e.g. ruptured aneurysm, penetrating trauma) Urgent: surgery required within a few hours (e.g. appendicitis , wound debridement) Elective (e.g. hernia ,varicose vein)

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Preoperative Preparation for Surgery The rational for pre-operative preparation is to Anticipated difficulties Make advance preparation and organize facilities, equipment and expertise Enhance pt safety and minimize chance of errors Relive any relevant fear/anxiety perceived by pt

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Routine Preoperative Preparation for Surgery History Physical examination Special investigation Informed consent Marking the site/side of operation Thromboembolic prophylaxis Antibiotic prophylaxis

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Surgical History Surgical History Hx taking is detective work. Preconceived ideas, snap judgment and hasty conclusions have no place in this process. Do not be in any doubt that a good hx is not vital. If you embark on surgical treatment concentrating on a localized lesion you will be unprepared if complications developed. If you take the wrong diagnostic path all the rest of your activities misdirected.

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Surgical history Presenting complaint this dictates the urgency and can influence anesthetic management Any associated systemic effects of presenting pathology Systemic assessment carefully assess each body system about its function. Rule out any other system may be involved

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Surgical history Past medical &surgical Hx Many diseases have direct effect on the general and anesthetic treatment and outcome ( cardiovascular and respiratory system) Any previous op.or bleeding tendency Any previous reaction to anaesthetic agent Drugs &allergic Hx Interaction with anesthesia (MAOI) Related with sudden withdrawal (steroids) Drugs for HTN ,IHD to be cont.over preoperative period Anticoagulant drugs (aspirin, warfarin) CCP HRT

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Surgical history Family Hx Malignant hyperthermia Pseudochlinesterase deficiency. SCA Bleeding disorders Social Hx Smoking Short-term nicotin inc. myocardial o2 demand &co dec o2 delivery Long-term dec immune function , dec clearance of secretion

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The physical examination This include a full physical Ex. Don’t rely on the examination of others One should acquire the habit of performing a complete Ex.in exactly in the same sequence; No step is omitted and added advantage of familiarizing what is normal so that abnormalities can be more recognized Surgical signs may change and others may miss important pathology. What mind doesn't know eyes don’t see.

Slide 16 :

The physical examination General Ex. Cardiac Ex.(JVP, HS) Respiratory Ex.(trachea, accessory ms,percussion ,auscultation) Abdominal Ex. CNS Musculoskeletal Ex Peripheral vasculature Local Ex Body orifices If u don’t put your finger u will put your foot

Slide 17 :

The emergency physical examination Routine Ex.must be altered to fit the circumstances A, B,C,D,E,F Secondary survey(head-to-toe) When no. of emergencies present at the same time you must apply triage Loss of life is more important than loss of a limb.

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Pre-operative investigations It is worthwhile when its requested in order to answer a specific question or confirm an important clinical impression prior to intervention Investigations are performed for a number of reasons ,but all should share the feature of directing management

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Pre-operative investigations Exclusion of alternative dx Confirmation of dx Risk to others Assessment of fitness for surgery Medicolegal consideration To know the extent of disease

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Pre-operative investigations Blood tests Full blood count (when to perform ?) All emergency Pre-operative cases All elective Pre-operative cases over 60 years All elective Pre-operative cases in adult females If surgery likely to result in significant blood loss Suspicion of blood loss, anemia,sepsis,CRD,coagulation problems

Slide 22 :

Pre-operative investigations Blood tests Urea &electrolytes(when to perform?) all Pre-operative cases over 65 Positive result from U/A All pt with cardiopulmonary dis. Or taking diuretics,steroids All pt with H/O renal/liver dis.or abno.nutrational state All pt with H/O diarrhea/vomiting or other metabolic/endocrine dis. All pt with IVF for more than 24hr’s Incidence of unexpected abnormality in apparently fit pt under 40 yr’s is <1%

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Pre-operative investigations Blood tests Amylase Perform in all adult emergency admission with abdominal pain,prior to consideration surgery. RBG Acute abdomen Elective case with DM,malnutrition, obesity Elective cases over 60 Abn. U/A

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Pre-operative investigations Blood tests Clotting ; PT inc. with warfarin , liver diseases; , DIC APTT inc Heparin Hemophilia A and B BT inc .platelet low or dysfunction Liver function test All pt with upper abdominal pain ,jaundice, hepatic dis. alcoholic

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Pre-operative investigations Blood tests Group and save /crossmatch Emergency pre-operative case Suspicion of blood loss,anemia,coagulatin defect Procedure on pregnant ladies

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Pre-operative investigations Imaging Chest x-ray (when to perform) All elective pre-operative cases over 60 yr’s All cases of cervical,thoracic or abdominal trauma. Acute respiratory symptoms or signs Previous CRD and no recent CXR Thoracic surgery Malignant dis. Viscus perforation Recent H/O TB Thyroid enlargement

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Assessment of risk for surgery There are few pts who have no risk factor for surgery It is important to quantify the the risks involved so they can be discussed with the pt; Two main prognostic scoring system which are in current use are: APACHE SYSTEM ASA SYSTEM

Slide 28 :

Prognostic scoring system Predict the outcome of patients admitted to ICU and subsequently been applied to pt under going surgery APACHE II system Recently APACHE III has been introduced include 5 more physiological variables ( blood urea nitrogen, urine op,albumin, bilirubin and glucose ) and modified version GCS ; 12 acute physiological variables Pt’s age Chronic health points

Slide 29 :

APACHE II classification Score is A+B+C A acute physiology score (APS) 1 recent temp. 2 MBP 3 HR 4 RR 5 Fio2 (alveolar arterial o2 gradient 6 Ph 7 serum Na 8 serum k 9 serum creatinine 10 WBC 11HCT % 12GCS B age points graded from <44 to >75 years C chronic health points 2 points for elective post-op admission 5points for Emergency op Non-operative admission Immunocompromised pt Chronicliver,CVD,respiratry or renal disease.

Slide 30 :

Prognostic scoring system ASA system; It is very simple and has been widely adopted 50% of pts presenting for elective surgery are ASA grade I Operative mortality rate for these pts is less than 1 in 10,000

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American Society of anesthesologists ASA grade and predicated mortality

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prognostic scoring systemGOLDMAN cardiac risk in non -cardiac surgery

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Peri-operative management Consent Details of the diagnosis and prognosis,and prognosis if condition is left untreated Options for management, include the option not to treat A detailed explanation of the proposed procedure,including common and serious side effects (>1%) For each option explanation of risk and benefits The name of dr. who will have responsibility for treatment An opportunity for pts and relatives to ask questions A reminder that pts may change their minds and or seek further opinions

Slide 34 :

Preparation for surgery of specific patient groups Thormboembolic prophylaxis

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Thormboembolic prophylaxis DVT is common in surgical patients. Can cause PE which carries a high mortality should be prevented. 10% of in-patient deaths. Recent surgery, immobilization and trauma were responsible for 50% of DVT(1994) Risk factors

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Risk factors for DVT Age Obesity Immobility Malignancy Trauma ,post-surgical Dehydration Thorombophilic pt (def. Of protein c,s) ,lupus anticoagulant +ve Past hx of thorombo- embolism Oral contraceptives HRT Pregnancy, puerperium

Slide 37 :

prophylaxis Graded elastic compression stocking Intermittent pneumatic calf compression Electrical calf muscle stimulation Post-operative leg elevation and early ambulation Heparin prophylaxis Other agents affecting blood coagulation (aspirin)

Slide 38 :

Further reading Current surgical practice;2003 Clinical surgery by R.M.Kirk MRCS essential revision notes 2002 The Mont Reid surgical handbook

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Discussion Discussion

Slide 40 :

Thank you Thank you Thank you Thank you

	fiazfazili 1 Years ago. Category: Anesthesiology

Tags:	Anesthesiology

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