PREOPERATIVE ASSESSMENT AND
PREPARATION
1. Doctor know your patient
Creating Rapport
Patients illness
Surgical procedure planned for
Physical examination
Review investigations
Consent for the procedure
2. ASA Classification
a) A healthy patient with no systemic disease
b) Mild to moderate systemic disease
c) Severe systemic disease imposing functional limitation
on patient
d) Severe systemic disease which is a constant threat on
patient
e) Moribund patient who is not expected to survive with
or without the operation
f) A brainstem dead patient whose organs are being
removed for donor purposes
3. Description of Surgery
Elective: Intervention planned or booked in
advance of routine admission to
Hospital. Timing to suit patient,
hospital and staff.
Expected: Patient requiring early treatment where the
condition is not an immediate threat to life,
limb or organ survival. Normally within days
of decision to operate.
Urgent: Intervention for acute onset or clinical
deterioration of potentially life threatening
conditions, for those conditions that may
threaten the survival of a limb or organ for
fixation of many fractures and for relief of
pain or other distressing symptoms.
Normally within hours of decision to operate.
Immediate: Immediate life, limb organ saving intervention.
Resuscitation simultaneous with intervention
Normally within minutes of decision to operate
A) Life saving
B) Other e.g. limb or organ saving
Preoperative Tests
Routine: TBC Total Blood Count
U & E – creatinine
Blood sugar
Other tests: Indicated by disease severity
Offer pregnancy tests to all women who
say they may be pregnant. Ask for LMP date
Sickle cell test
Chest X-ray, lung, heart or renal disease or if
postoperative recovery in critical care unit expected.
Premedication Drugs
1. Sedatives: 1 hour preoperatively
Temazepam
Lorazepam
Midazolam
2. Gastric PH increasing Drugs
H2 Antagonists Ranitidine Oral - night before
and 2 hrs preop.
Proton pump inhibitors Omeprazole
Oral- night before and
I/V infusion over 30 min.
Antacid Sodium Citrate Oral 10 min preop
3. Analgesic Drugs
Opioids Morphine IM
Pethidine IM
NSAIDS Diclofenac Oral PR
Paracetamol Oral PR
4. Prokynetic Drugs - Metaclopramide
Fasting
- Aims at reducing volume of gastric contents and
hence the risk of pulmonary aspiration
- Aspiration associated with significant - morbidity and
mortality.
- Factors predisposing to regurgitation and pulmonary
aspiration.
Inadequate anaesthesia
Pregnancy
Obesity
Difficult airway
Emergency surgery
Full stomach
Altered gastrointestinal motility.
Fasting Guidelines
Ingested material minimum fast
Clear fluids 2 hours
Breast milk 4 hours
Light meal, infant formula, other milk 6 hours
Delayed Gastric emptying
Metabolic causes - Diabetic mellitus, renal failure, sepsis
Decreased gastric motility - head injury
Pyloric obstruction - pyloric stenosis
Gastro oesophageal reflux - emptying of solids
Raised intra abdominal pressure – obesity, pregnancy
(predisposes to passive regurgitation)
Opioids
Trauma
Prophylaxis of venous Thrombo embolism
- Pulmonary embolism responsible for 10% of all hospital
deaths.
- Without prophylaxis 40-80% of high risk patients
develop detectable DVT and up to 10% die of PE.
Increased risk of venous thromboembolism
- Hypercoagulability caused by surgery, cancer or
hormone therapy.
- Stasis of blood in venous plexuses of the legs during
surgery and postoperatively.
- Interference with venous return (pregnancy, pelvic
surgery and pneumoperitoneum.
- Dehydration.
- Poor cardiac output.
- Any patient confined to bed especially the elderly.
Categories of risk for Thromboembolism
1. Duration and type of operation
Long surgical procedure - hip and knee.
2. Patient factors
- Previous history of DVT or PE, Thrombophilia.
- Pregnancy, puerperium, oestrogen therapy
(contraceptive pill or HRT).
- Age > 40 years.
- Obesity and immobility.
- Varicose veins
3. Associated Diseases
- Malignancy.
- Trauma (spinal cord injury, lower limb fracture).
- Heart failure, recent myocardial infarction.
- Systemic infection
- Lower limb paralysis (e.g. after stroke).
- Hematological diseases (polycythaemia,
leukaemia,
paraproteinaemia).
Other diseases - nephrotic syndrome, inflammatory
bowel disease
Methods of Prophylaxis
1. General measures
- Avoidance of prolonged immobility (early mobilization).
- Avoidance of dehydration.
2. SC Heparin.
3. Lower dose unfractionated heparin.
Start 2 hours before surgery 5000 u 12 hourly.
8 hourly for high risk patients.
4. LMW Hs (low molecular weight heparins)
5. Graduated compression stockings (antiembolism
stockings)
Use with SC heparin
6. Intermittent pneumatic compression devises used in
orthopaedic practice.
CONSENT
1. Valid Consent must be obtained from a competent and informed
adult, guardian - 16 yrs age
- mental illness
2. Known risks should be disclosed, alternative treatments
should be discussed.
3. If a competent adult who understands everything
decides against surgery, this choice must be respected.
Advance refusal of treatment i.e. living wills must be
respected.
4. Emergency – verbal consent is adequate
5. Treatment without consent in life threatening situations
is allowed.
6. Documentation is mandatory - signed consent form.
ANAESTHETIC RISK
Perception of risk modified by a number of factors
Probability of occurrence - Size of sample
- Regional Bias - catastrophic
- dramatic over publicity
- Underestimation of large risks
- Overestimation of small risks
Perception of the anaesthetist important in communication
Controllability – informed consent with a choice of Anaesthetist and
anaesthetic options
Severity - high risk – death, paraplegia, permanent organ failure.
Answer all the patients questions.
BRAN - Benefits
- Risks
- Alternatives
- Nothing done
Peri-operative Mortality
Elective surgery 1 : 200 All patients 1 month after
Emergency 1 : 40
Major surgery doubles the risks
Death associated with anaesthesia ASA 1 & 2
1 : 100000 increased to 5 – 10 times
For high risk ASA 3 – 4
1 : 10000 (caesarean section difficult intubation)
Emergency
Factors that contribute to Anaesthetic Mortality
1. Inadequate preoperative assessment
2. Inadequate preparation and resuscitation
3. Inappropriate Anaesthetic technique
4. Inadequate peri-operative monitoring
5. Lack of supervision
6. Poor postoperative care
Peri-operative Morbidity
CVS - High risk surgery
HX ischaemic heart disease, CCF
HX cerebrovascular disease
Respiratory - pneumonia, respiratory arrest
CNS - Nerve injury - ulnar neuropathy,
brachial plexus
Lumbosacral root injury
Spinal cord injury
Minor - Pain, nausea, vomiting
