Pre-operative care assessment and

preparations

by Aburi Godfrey James and Rahima

Abdulaziz

5th/09/16
 Objectives
• To understand the general principles of
preoperative care
• To understand principles of preparation in
specific types of operations.
• To understand how to take informed consent
Definition
• Preoperative care is the preparation and
management of patient prior to surgery
• It includes both physical and psychological
preparation of the patient for surgery
 Patient assessment
Stages of preoperative patient assessment
• Begin at point of referral
• Surgical outpatient;
– the first contact of the patient with the surgical team
– Risks and potential benefits of surgery weighed against
those of alternatives and no treatment
– the decision to offer surgery is made once diagnosis is
known
– Patient should be made to understand the nature of the
illness, implications of the surgery and the prognosis.
 Early admission
• To have full clerking and adequate relevant
investigations done particularly those which
were not completed when he was still an
outpatient.
• to allay the patients anxiety before a major
surgery, to give a full explanation on the type of
operation and hence seek informed consent
from the patient.
 Patient history
• Layout of standard history:
– Patient demographics
– Presenting complaint
– History of presenting complaint
– Review of other systems
– Past medical and surgical history
– Family history
– Social history
 Clinical examination
• Key points to note ;
• General examination
– Anemia, jaundice, cyanosis, finger clubbing, lymphadenopathy, nutritional status,
teeth, feet, leg ulcers
• Cardiovascular
– pulse, Bp, heart sounds, bruits, peripheral edema
• Respiratory
– Respiratory rate, chest expansion, percussion note, breath sounds, oxygen saturation
• Gastrointestinal
– Abdominal masses, ascites, bowel sounds, bruits, hernia, genitalia
• Neurological
– Consciousness level, any pre-existing cognitive impairment or confusion, deafness,
neurological status of limbs
 Preoperative investigations
• These are undertaken to assess;
– fitness for anesthesia
– Identify problems amenable to correction prior to surgery.

• They are based on:

– A good history and thorough examination
– Factors apparent from the clinical assessment
– The likelihood of asymptomatic disease
– The type of surgery and anesthesia planned
– Surgical unit protocols guiding the use of preoperative
investigations
Preoperative Investigations
Haematocrit, blood sugar, blood urea, serum
creatinine, electrolytes, chest-Xray, ECG,
blood grouping, blood-gas analysis, cardiac
assessment.
 Cont’d
• Investigations commonly done include;
– hematological;
• Full blood count:
• Coagulation screen
• Cross matching
– Biochemical:
• Liver function tests
• Urea and electrolytes
• urinalysis
– Cardiac investigations
• Electrocardiography
• Echocardiography
• Exercise testing
 Cont’d
• Respiratory investigations
– Chest x-ray
– Sputum culture and drug sensitivity
– Pulmonary function tests
– Arterial blood gases
• Other investigations;
– b-Human chorionic gonadotropin
– Hepatitis /HIV virus serology
– MRSA screening
 Indications for routine preoperative
investigations
investigations indications
CBC most patients, young women with menorrhagia, patient whose
surgery may involve significant blood loss, old patients with
undiagnosed anemia

Coagulation screen suspected abnormal clotting, on anti-coagulation treatment,

consideration of epidural anesthesia

Urea and electrolytes Patients over 65yrs, history of cvs, pulmonary, or renal
problems

LFTs Jaundice, known/suspected hepatitis, cirrhosis, malignancy,

portal hypertension, malnutrition

ECG Patients over 65yrs, history of cvs, pulmonary and anesthetic

problems, expectation of significant blood loss

Chest x-ray In case of significant cardiac history or respiratory problems

 Management
• Management plan
– Drawn up in discussing with the patient using
language the patient understands.
The discussion involves;
– The specific surgical diagnosis or diagnoses .
– Confounding issues e.g. medical comorbidities that
will complicate the management plan
Key points in 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
 Psychological preparation
• Patients are often fearful or anxious about having
surgery
• Variety of fears cause operational anxiety. They
include fear of:
• The unknown
• Surgical failure
• Anesthesia
• Pain
• Unsuccessful recovery
• Incisions with needles or knives
• Death, Unsuccessful recovery
 Cont’d
• Effects of preoperative anxiety:-
– Physiological responses such as
tachycardia,
hypertension,
elevated temperature, s
weating, nausea, heightened senses such as smell,
touch and Peripheral vasoconstriction.
– Psychological effects: behavioral and cognitive changes
resulting in increased tension, apprehension,
nervousness and aggression.
 Cont’d
• Ways of psychological preparation;
– Preoperative patient teaching or tours
– Providing accurate and thorough information about the
operation
– Permitting family members to be present before the
operation and involving them in psychological preparation
– Creating a good patient-doctor relationship.
Patient concerns should be expressed and the surgeon notified.
Children; should be allowed to have parents around as much as
possible. Use of puppets in a play activity to demonstrate
medical procedures and should be encouraged to bring favorite
toys on the day of surgery
 Cont’d
• Benefits of psychological preparation:
– Patients and families tend to cope better with the
patient’s postoperative course
– Goals of recovery are known ahead of time which
leads to superior outcomes, and the patient is able
to manage postoperative pain more effectively.
 The preoperative ward round
• Purpose; to ensure that the patient has been adequately assessed
and prepared for surgery
Surgical staff
• Re-examine the patient to ensure the operation proposed is still
appropriate
• Records are checked to make sure that all essential investigations
have been completed.
• Address patient questions and fully explain surgical procedure,
anesthesia, postoperative analgesia, use of catheters, drains and
postoperative monitoring.
• Should also take the responsibility that the patient has understood
the nature of the operation and its implications.
 Cont.’
Nursing staff
• Responsible for removing and safeguarding the dentures, rings and
other jewellery, giving premedication, testing urine and fixing a
band around a patients wrist which indicates name, religion and
dose and time of administration of premedication.

Anaesthetic staff
• Should be alerted early enough to any likely problems during
anaesthesia and surgery.
• Give premedication whose main aim is to sedate, relieve anxiety,
and remove pain. It should remembered that drugs are no
substitutes for explanation and reassurance.
 Informed 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
 Informed consent
• Competence
– Adults (over 18) deemed competent
– Require that they can comprehend and retain the
information discussed with them, believe it, and
weigh up and choose from an array of treatment
options
 cont’d
• Patients who are mentally impaired, heavily
sedated, or critically ill are not considered
legally able to provide consent.
• The next of kin (spouse, adult child, adult sibling
or person with medical power of attorney) may
act as a surrogate and sign the consent form.
• Children under 18 must have a parent or
guardian sign.
 The preoperative checklist
• Completed prior to induction of anesthesia
• WHO recently introduced surgical safety checklist
• It covers; patient identity, proposed surgery and
site, availability of clinical records, investigation
results, consent, patient allergies, equipment
availability and anesthesia concerns.
• Purpose; guard against incorrect and wrong site
surgery, prevent poor planning and adverse events.
The WHO surgical safety checklist
 Systematic preoperative assessment
• Cardiovascular risk
• Risk factors are:
–Recent MI,
–Clinical heart failure,
–Systemic HTN,
–History of arrhythmia.
• The risks are highest in the 1st 3 months following infarct. But gradually
decreases in the next 6 months. So elective surgery can be considered 6
months later.
• Always consult with a cardiologist regarding these patients before
surgery.
• ECG should be performed as a routine investigation for this group.
• Respiratory risk
• The most common respiratory condition to encounter
preoperatively are COPD & Asthma.
• Significant lower respiratory tract infections should be
treated before surgery except when the surgery is life-saving.
• The patient’s usual inhalers should be continue
• Guidance should be given preoperatively on breathing
exercise.
• Antibiotic should be given preoperatively to prevent
postoperative chest infection.
• Renal risk
• CKD is the most common renal risk that is encountered
preoperatively in this group.
• Blood Urea & S. Creatinine should be done.

• Moderate elevation of urea & Creatinine can be considered in

elderly patient.
• Patient on dialysis should be dialyzed preoperatively to
ensure good fluid balance & to correct any hyperkalemia.
 Cont.’

• Patient on renal transplants require to have

their immunosuppressant preoperatively.
• Ensure adequate hydration to avoid
precipitating renal failure in frail & critically ill
patient.
• Always consult with a nephrologist.
 Rational use of antibiotics
• Antibiotic use depends on whether it is going to be
clean or contaminated operation and type of flora
likely to cause infection.
• Patient with clinical infection should be treated with
broad spectrum antibiotics prior to surgery.
• Clean procedure (e.g. varicose vein surgery) do not
need antibiotic prophylaxis.
• Abdominal surgery, which is not associated with
significant contamination (e.g. elective
cholecystectomy) requires only a single dose of
prophylaxis given on the induction of anaesthesia.
 Cont.’
• Procedures with a contaminated field (e.g.
Appendicitis, Peritonitis, Perforation etc.) should be
treated with a preoperative dose and two post
operative doses.
• The most common antibiotics used preoperatively
are:
– Cephalosporins;
– Floroquinolones;
– Metronidazole;
– Anti staphylococcal penicillin;
– Co amoxyclav etc.
Prophylaxis against DVT & pulmonary emboli

• Pulmonary emboli and DVT are two major

causes of death of surgical patients.
Prophylaxis should be taken for all patients
preoperatively to minimize post operative
morbidity & mortality.
• Risk factors: recent surgery, trauma, diabetes,
immobilization, old age, cancer, obesity, heart
failure
 Cont.’
• The risk factors can be minimized
preoperatively by:
1. Pre and post operative subcutaneous
heparin administration.
2. Graduated compression stockings.
3. Intraoperative intermittent pneumatic calf
compression.
Preoperative anxiolytic medication
• Aim: patient to arrive in the anaesthetic room
in a relaxed, pain-free state.
• For very anxious patients
• Oral benzodiazepines are commonly used
as they have a relatively long duration of
action.
 Preoperative fasting
• Purpose: to try to ensure an empty stomach and
minimize the risk of regurgitation and aspiration
during induction of anaesthesia.
• patients should be starved of food for 6 hours and
of clear fluids for 2 hours.
• NGT indicated in situations where an empty
stomach cannot be guaranteed despite fasting
e.g.. Pregnancy, gastric outlet or bowel
obstruction.
 Preparation for surgery in special groups
• Bowel surgery:
- Bowel preparation is considered prior to bowel surgery.
- For elective surgery, bowel preparation is most commonly
achieved by placing the pt on liquid diet 3-5 days prior to
surgery & administering oral purgatives or enema on the day
prior to surgery.
- Specially for small bowel surgery, proper hydration &
nutrition should be maintained.
- If there is evidence of obstruction, an NG tube should be
inserted to prevent aspiration
• Preparation for jaundiced patient:
 The risk of surgery in a patient with obstructive jaundice
can be reduced significantly by careful preoperative
management.
 Preoperative drainage by a Biliary endoprosthesis should
be considered in elderly patients who are deeply
jaundiced or all patients with biliary tract sepsis.
 Cont.’
 Vitamin K should be given to all patients with
obstructive jaundice prior to surgery.
 A coagulation profile should be checked.
 Adequate hydration should be done to prevent
hepato-renal syndrome.
 Antibiotic prophylaxis should be given to combat
high infective complications in a jaundiced patient.
• Thoracic surgery:
- Assessment of respiratory function is the most important aspect of
preoperative preparation.

- Active preoperative physiotherapy, treatment of any respiratory

infections with antibiotics and good post operative analgesia

minimize the risk of postoperative respiratory failure.

- Subcutaneous heparin is routine to prevent pulmonary embolus.

• Endocrine surgery:

-For thyrotoxicosis patients, a period of antithyroid drug

& beta blockers is given to prevent thyrotoxic crisis.

- Patients with pheocromocytoma may require admission

a week before surgery to evaluate & block the alpha &
beta adrenergic effects of catecholamines.
 References
• Bailey & Love Short practice of Surgery (25th
edition)
• Principles and practice of surgery (6th edition)
• General Surgical Operations – R. M. Kirk (5th
edition)
• Clinical Surgery in general – R M Kirk (3rd
edition)