6-Pre-Operative Care Assessment and Preparations-1
6-Pre-Operative Care Assessment and Preparations-1
6-Pre-Operative Care Assessment and Preparations-1
preparations
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.
Urea and electrolytes Patients over 65yrs, history of cvs, pulmonary, or renal
problems
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.