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Syed Alam Zeb
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Preoperative preparation!!
Dr.Syed Alam Zeb
Role of Surgeon during preoperative preparations:
Gathering & recording information; Minimizing risk, maximizing
success; Contingency plans for adverse
events; Communications
Steps of P.O.P’s :
History Examinations Investigations Preoperative treatments Communications Informed consent Operating lists On arrival to OT table
Types of patients:
Out-Patient Department
Usually seen 1-2 weeks before surgery at preadmission clinic
Emergency department
Need initial assessment & immediate resuscitation
History:
A- listen to ur patient complains B- clarify his problem by questions C- try to reach to a diagnosis by
confirming & excluding. D- determine the fitness of ur
patient for a surgery physically & psychologically.
Examinations:
General medical examinations Specific surgical examinations Specific medical examinations
General Medical Ex:
To check fitness for anesthesia & surgery.
GPE Systemic: - CVS- CNS- GIT- Respiratory system
Specific Surgical Ex:
Its aim: to confirm previous findings & diagnosis, to determine severity & to gauge extent.
e.g. in inguinal hernia confirm it’s inguinal not femoral , reducible or not & whether there are any signs of bowel obstruction.
Specific Medical Ex:
Its aim: to evaluates the presence & severity of other problems.
e.g. Diabetic patient undergoing surgery need careful examination for sepsis , neuropathy or microvascular disease
Investigations:
I. Routine Investigation Every unit and ward has its own protocol. The tests which normally performed on
most patient coming to surgery: * Full Blood Count * Basic Biochemistry * Chest Radiography
Investigations: II. Targeted Surgical Tests:
Hematology : to exclude anemia, for platelets count & to assess the amount of blood may be needed during or after operation.
Creatinine & Electrolytes: state of dehydration & renal insufficiency.
Liver Function Tests: Alb & Protein guide to nutritional status & shows any clotting problems.
Investigations: ECG : It’s recommended in all patient
>65years, pt. with blood loss & cardiovascular/pulmonary problems.
Urinalysis: used for determination of renal function, inflammation, infection & metabolic disorders.
Pregnancy Test: ( B- human chorionic gonadotrophin )
HBsAg, HCV Antibodies & HIV testing.
Communication: Information for the patient : He should be aware of his surgeon,
procedure, stuff & what is going on. Information for stuff : Team work is the main key for success. Recording : All important information should be
recorded clearly in patient notes because it is the reference database.
Preoperative Treatments:
Antibiotics : should be at peak level when surgery starts.
Transfusion : sort anemia well in advance.
Nutrition : improve situation whatever possible.
Thromboprophylaxis : needs for high risk patient only.
Prophylactic Antibiotics: The commonest infective organism is
Staphylococcus aureus. Some surgeon use flucloxacillin , but
most used broad spectrum antibiotics which cover S. aureus, streptococci & anaerobes.
In GIT surgery combination of cephalosporin & metronidazole.
Prophylactic antibiotic best administered just prior to induction.
Anemia & Blood Transfusion:
Preoperative transfusion should be considered if major blood loss is anticipated during surgery or if Hb% < 8 g/dl.
Malnutrition : Malnourished patient is at high risk of
morbidity & mortality following surgery.
Nutritional support is required for a minimum of 2 weeks prior to surgery.
Malabsorption overcome by vitamins & enzymes while obstructive conditions N/G feed, I/V fluids, surgical bypass & formal enterostomy.
Thromboprophylaxis:
Methods of anticoagulation : I. Pharmaceutical : Aspirin is the best choice. II. Mechanical : Foot & calf pumps believed to prevent
stasis. III. Physical : Early mobilization & minimizing length of
stay in hospital reduce stasis & DVT.
Preoperative Tx for special cases:
Diabetes:- If controlled orally: omit morning
dose of oral hypoglycemic- Insulin-dependent: managed on I/V
infusion of dextrose & insulin- Extra K needed
Preoperative Tx for Special cases:
Respiratory disease: - Blood gases & pulmonary function tests
needed to assess severity.- Stop smoking & continue inhalers- Involve physiotherapists & anesthetists.- Avoid respiratory suppressants (narcotics)- Mobilize early- Give O2
Preoperative Tx for special cases:
Hypertension :- BP > 160 systolic or > 95 diastolic their
surgery postpone till controlling of BP.- Plasma Potassium (K) checking is
necessary in Pt. with diuretics. Routine Medication: - Most can be given as usual- Stop aspirin if bleeding is suspected- Discuss ACE inhibitors or unusual drugs
with anesthetists.
Informed Consent:
STAGES OF INFORMED CONSENT:- I. Preparation- II. Explanation- III. Competence- IV. Closure
I. Preparation: A. Introduction: - Ur name- Pt name- Explain what are u doing & by which
authority B. Background:- Check what pt knows- Explore how much he/she actually want
to know.
II. Explanation: A. What is wrong: Explain the diagnosis is
simple language.
B. Action : what is the proposed action? Is it differ from national or other guidelines ? justify
C. Outcome: describe the likely short & long outcome
D. Choices: describe all viable choices, including doing nothing
II. Explanation: E. Complications:- Explain in clear language all serious
complications & those with a risk > 1%- Describe actions that will be taken to
prevent each- Explain how they will managed them if
they do occur F. Right of Refusal:- Make it clear that the final decision is the
patient’s alone- Give the patient time to think about the
decision
III. Competence:
Check the ability of patient to take in, retain & consider the information provided & articulate the decision.
Can be achieved by recording the patient’s answer to the questions “ Tell me what you have understood”.
IV. Closure:
A. Open question : e.g. “ Is there anything else you
would like to discuss?”. B. Record: Record & write every thing was
discussed & what was agreed.
Operating List: Diabetic patients first. Day cases early Major cases before minor “ Dirty” cases last Operating lists final check:- Patients: name, number & location correct- Side written & marked- Radiographs & results available- Blood cross-matched & ready- Consent is taken- Nurses informed of timing- Theatres informed of special needs
On Arrival for Surgery:
The patient:- Confirm identity, notes, problem, tests
result & blood if ordered. The operating theatre & team:- Good communication with stuff- All required instruments is ready- Surgeon not usually the leader
References:
Bailey & Love’s Short Practice of Surgery 24th edition.
Internet websites.