Pre-Operative Assessment

1. Pre-Operative Assessment DrAhmed Badrek-AlAmoudi

2. 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? A Badrek-Amoudi

3. 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 A Badrek-Amoudi

4. The DiagnosisThis can be established by a combination: • The Patient’s 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. A Badrek-Amoudi

5. 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. A Badrek-Amoudi

6. 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 A Badrek-Amoudi

7. 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% Obesity BMI> 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 Risk Factors II A Badrek-Amoudi

8. 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. Risk Factors IIICardiovascular Diseases A Badrek-Amoudi

9. 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. Risk Factors IVRespiratory diseases A Badrek-Amoudi

10. 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. Risk Factors VGastro intestinal diseases A Badrek-Amoudi

11. Interest to the surgeon: Patients are more sensitive to protein depletion, U&E& 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 Risk Factors VDiabetes A Badrek-Amoudi

12. 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 Risk Factors VRenal & haematological Disorders A Badrek-Amoudi

13. 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. A Badrek-Amoudi

14. Risk Factors ASA ( American Society of Anaesthesiologist) A Badrek-Amoudi

15. 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 A Badrek-Amoudi

16. Prophylaxis IIThrombo-Embolism 1 A Badrek-Amoudi

17. 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% A Badrek-Amoudi

18. Prophylaxis IIIOthers A Badrek-Amoudi

19. 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. A Badrek-Amoudi

20. Nursing Preparations • Bathing • Removal of jewellery • Removal of dentures • Skin preparation and shaving on morning of surgery • Administration of medications prescribed. A Badrek-Amoudi

21. 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 A Badrek-Amoudi

22. 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. • G+S blood. • ICU & tracheostomy for possible tracheomalacia. A Badrek-Amoudi

23. Special ConsiderationsOthers A Badrek-Amoudi

24. 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. A Badrek-Amoudi

25. 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. A Badrek-Amoudi

26. 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 (< 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 oxygenation…Avoid hypoxia • S/C Heparin…….Avoid hypercoagulable status A Badrek-Amoudi

27. 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. A Badrek-Amoudi

28. 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. Scenario 2 preop A Badrek-Amoudi

29. 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. A Badrek-Amoudi

30. 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 it’s 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 Scenario 3 preop A Badrek-Amoudi

31. 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. A Badrek-Amoudi

32. Scenario 4 preop • Collect evidence of diagnosis • Thyroid function • Autoantibodies • Nuclear /USS scans • Histology excluding Ca • Normalise the thyroid function: • Iodine, β 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 A Badrek-Amoudi

33. 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. A Badrek-Amoudi

34. Scenario 5 preop • Diagnose • Check for possible underlying and associated problems • Stage • Map and check for synchronous tumours • Correct electrolyte abnormalities and CBC • Improve the nutritional status. • Assess the need for neoadjuvent treatment ( involve the oncology, radiology, endoscopy teams) • Check for integrity of L ureter and L kidney hydrnephrosis • Full clinical assessment ( lung, heart and liver) • Bowel preparation • Stoma location • Prep the abdomen • Prophylactic AB and bowel sterilisation. • Prophylactic thromboeblism. • Informed consent A Badrek-Amoudi

35. Scenario 6 A 20 year old gentleman involved in an RTA. Patient’s 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. A Badrek-Amoudi

36. Scenario 6 preop • Primary and secondary survey • AMPLE • Cross match and basic laboratory work up • CXR, C-Spine, Pelvis x-rays • Consent • Inform OR and shift • Administer AB en-rout to OR A Badrek-Amoudi

37. 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. A Badrek-Amoudi