Preoperative Management

Allie Martin
General Surgery
Department of Surgery
UHWI
Objectives
What is the general approach to
patient preparation?
Important organ systems to consider
Laboratory and radiological adjuncts
Preoperative counseling/consent and
physiotherapy
Antibiotic prophylaxis
A look at the emergency patient
General Approach
Are there any risks involved with the
proposed operation?
If so, what are they?
Can they be optimized or eliminated?
These risks may be anaesthetic
related or procedure related. Risks
may overlap both areas.
General Approach
Common risks
Chronic illnesses
Cardiovascular/Cerebrovascular
Ischaemic or other heart disease
History of Stroke
Hypertension
Diabetes
Asthma
Sickle Cell Disease
Renal Disease
General Approach
Common Risks
Poor nutrition
Drug allergies
Drugs that can cause adverse
interactions or interfere with normal
physiologic responses
Anticoagulants or antiplatelet meds
Beta blockers
Smoking or alcohol abuse
General Approach
Common Risks
Deep vein thrombosis and pulmonary
embolism.
Post-operative infection
Acute lung aspiration and pneumonia
Haemorrhage secondary to coagulation
or clotting disturbance
General Approach

Some chronic problems may be

subclinical.
The patients primary surgical problem
may imply the presence of a risk factor
which should be looked for/anticipated,
assessed and optimized appropriately.
Metastatic cancer
Peripheral arterial disease
Assessing Risk
The information obtained from a thorough
history and examination cannot be
overstated. It comprises the major part of
our method of assessment and is the sole
method of assessment used in many cases.
If there is a positive history or examination
finding suggesting or confirming a risk
factor, the risk factor may need further
assessment.
Blood and radiological assessment.
Investigations
Complete Blood Count
Haemoglobin (Hb)
White Cell Count
Platelet Count
Electrolytes, Urea and Creatinine
PT, PTT
ECG, Chest X-Ray, Echocardiogram
Lung function tests
ABG, FEV1, VC
Specialized tests depending on specific diseases, eg.
Endocrine disturbances
Liver Disease eg. obstructive jaundice
Investigations
Done to assess known disease
processes or chronic illnesses
Done when there is no clear evidence
of a problem, but there is reasonable
risk of a problem existing but is not
clinically detectable.
Patient Optimization
Eliminating or optimizing problems found
Electrolyte abnormality
Dehydration
Uncontrolled Diabetes or Hypertension
URTI
Malnourished state
This may involve referrals for the
involvement of other specialties, such as
cardiology, haematology, nutritionists.
Preoperative Counseling
Informed consent
Involves a full explanation of the problem and
the proposed procedure.
Complications of the proposed procedure are
explained.
If there are alternative forms of therapy, these
are explained with reasons for not choosing
them
What would happen without treatment or if an
alternative form of treatment is offered instead?
Preoperative Counseling
Reducing anxiety reduces pain and
improves the postoperative course.
What to expect afterwards.
Preoperative physiotherapy to
reduce chest complications, DVT and
venous thrombo-embolism. This also
introduces the physiotherapist and their
role in management prior to surgery.
Immediate Preoperative Care
Fasting for 6 hours
Maintain medication for chronic diseases. May be
given with sips of water.
Sedative to reduce anxiety
Supplemental hydration may be necessary
in some diseases.
Pharmacologic DVT prophylaxis commenced
Antibiotic prophylaxis given as needed
Preop Management of Emergencies
Surgical risk is often higher since there is not
enough time for full preparation.
The life threatening problems are rectified as
best as possible with a compromise, after
considering the risk of further delays.
AMPLE History
Allergies, Medication, Past medical history, Last meal,
Events prior.
Correction of electrolyte imbalance or
dehydration
Assume a full stomach
Summary
Preoperative preparation involves an
assessment of perioperative risks, an
assessment of risks and the elimination or
optimization of these risks.
Preoperative counseling and physiotherapy
is important.
Emergency patients can be challenging and
preoperative risk assessment and
optimization is often truncated in the
interest of carrying out prompt surgery.