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preopereative care.pptx

1. Preoperative evaluation determines if a patient is optimized for planned surgery and helps identify risks. It involves assessing the surgery, patient health, and making recommendations. 2. A multidisciplinary team evaluates surgical risk, urgency, and the patient's medical conditions and functional status. Testing may be needed depending on risk. 3. The goals are to optimize management of acute/chronic illnesses, treat untreated conditions, and identify high-risk patients needing further optimization before surgery.

Health & Medicineâ—¦
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Preoperative care Presenter-Dr. Abdurahman(OSR1) Moderator- Dr Yemane (Consultant Anethiologist )
outline â—Ź Objective â—Ź Overview â—Ź Approach â—Ź Diagnostics â—Ź Medication management â—Ź Informed consent â—Ź Take home message
Objectives â—Ź Approach to preop patient â—Ź Optimize patients for operation
Preop Evaluation Preoperative evalutation is performed to determine whether a patient is in optimal health for a planned surgical procedure Its extent depends on the urgency of the surgery
Approach 1. Confirming the surgical procedure and indication for the surgery 2. Evaluate surgical procedural risk based on the surgery type and urgency 3. Evaluate patient health and indivisual risk of perioperative complications 4. Make recommnenation for the surgical team 5. Coordinate perioperative preparation steps
Multidisciplinary team roles ● Medical practitioner ○ determines if the patient is medically optimized ○ initiates measures to optimize the patient’s health if necessary ○ alerts the perioperative team to special health concerns and abnormal test results ● Surgeon ○ obtains consent ○ determines if surgery can be delayed for further optimization ● Anesthesiologist ○ Chooses the appropriate anesthetic technique
Evaluating surgical procedural risk Type of surgical procedure â—Ź intraperitoneal,intrabdominal,intrathoracic,major vascular surgery â—Ź greater blood loss,longer procedures,emergency procedures Perioperative mortality by type of surgery Risk Examples Low(<1%) Knee Arthroscopy Intermediate(1-5%) Total hip arthroplasty High(>5%)
Urgency of the surgery Urgency Timing Perioperative mortality at 30 days Emergency surgery as soon as possible 3.7% Urgent surgery 24-48hrs 2.3% Time-sensitive surgery 1-6 weeks Elective surgery 12 months 0.4%
evaluating patient health Goals 1. assess whether acute or chronic illnessess are being optimally managed 2. begin treatment of untreated or undertreated medical conditions 3. identify high risk patients who may benefit from â—‹ advanced diagnostic testing â—‹ medical specialist referral â—‹ delay in surgery â—‹ higher levels of postoperative care
Full history and physical examination â—Ź previous anesthetic hx â—Ź allergies â—Ź regular medications â—Ź presenting complaint â—Ź past medical history â—Ź airway assesment â—‹ malampati score
Perioperative functional assesment â—Ź Subjective patient reporting of exercise capacity â—Ź Duke activity status index â—Ź Cardiopulmonary exercise testing
Risk stratification tools Validated risk stratification tools identify which patients may benefit from â—Ź medical intervention â—Ź perioperative daignostic testing â—Ź consultation
Thirty day mortality <0.1% <1% 1-2% ~10% >50% N/A E Emergency surgery(appended to grades I-IV)
Emergency perioperative evaluation â—Ź simaltenous rescutiation and managment â—Ź focus on clinical evaluation on conditions associated with high morbidity â—Ź order diagnostic test that reflects dual roles of assesment and resucitation â—‹ CBC,CMP â—‹ ABG,Lactate â—‹ ECG â—‹ coagulation â—Ź Notify members of the perioperative team of urgent finding
Rationale for preoperative testing â—Ź establish a new diagnosis â—Ź impact decision on surgery â—Ź influence choice of anesthetic tecnique â—Ź alter intraoperative monitoring or managment â—Ź change postoperative disposition
Diagnostic â—Ź Low risk surgery â—‹ low risk patients-no routine diagnostic test is required â—‹ high risk patients-consider testing as routine managment for chronic conditions â—Ź High risk or intermediate risk surgery â—‹ All patients â—‹ High risk patients-consider additional specialist consultation
Study Indication cbc surgery associated with significant blood loss age >65 and major procedure RFT age > 50 with intermediate or high risk surgery known renal, cardiac or dm medications that impair renal function nephrotoxic drug blood glucose,HgbA1c DM liver function test cld coaugulation studies anticoagulant use urine analysis pregnancy test women of child bearing age ECG BMI>40 with risk factor,High risk surgery CXR BMI>40 with syptoms,high risk surgery
Cardiovascular system perioperative cardiac risk-MI,heart failure , arrythmias, stroke , death â—Ź existing cardiovascular disease â—Ź poor functional status â—Ź older age â—Ź diabetes â—‹ ECG â—‹ Echocardiography â—Ź Blood pressure- <160/100 â—Ź MI - delay 2 month
Respiratory system procedure related risk factors 1. surgical site 2. duration of surgery 3. type of anesthesia investigation chest xray -age > 50 with high risk surgery
Evaluation and managment of other systems â—Ź Malnourishment consult a dietitian 1. BMI<18.5 2. Unplanned weightloss >10% in 6 month 3. decrease in dieatry intake of 50% in the last week 4. serum albumin <3g/dl
Hepatic disorders â—‹ Acute hepatitis- delay surgery until there is documented improvement in liver function tests â—‹ Chronic liver disease-Child score â—Ź Hematologic disorders â—‹ Venous thromboimbolism-minimum 1 month ideally 3 month â—‹ Anemia Endocrine â—‹ DM-Hemoglobin A1C-<8
Neurological disorders â—‹ Cerebrovascular accidents- delay 9 month Renal disorders CKD- increased risk for akI
Medications managment â—Ź Cardiac â—‹ Coutinue- Beta blockers,calcium channel blockers, nitrates, statins â—‹ Hold- ACEI,ARB for 24 hrs â—‹ hold morning dose-Diuretics â—Ź Hematologic â—‹ Vit K antagonist -hold 7 days and bridge â—‹ aspirin- hold only in high risk bleeding procedures â—Ź Endocrine â—‹ Insulin â–  Short acting- skip Morning dose â–  Intermediate acting- 50% in morning â–  Long acting and insulin pump- 60-80% â–  Premixed(NPH 70:Regular 30) - BG> 200 give 50% ,BG < 200 give 50% of long or intermediate componet
Oral antidiabetics - Hold morning dose except SGLT-2 inhibitors hold 3-4 days Estrogen,progestrons,androgens - continue,/one month corticosteroids- continue Throid hormones - continue â—Ź CNS - â—‹ Parkinsons, antiepelpetics,Psycotropic - continue â—‹ MAOI - 2-3 weeks â—Ź NSAIDS â—‹ Short acting - 24 hrs â—‹ Intermediate acting - 4 days â—‹ Long acting - 10 days
Preoperative preparation measures â—Ź Lifestyle modification â—‹ Smoking cessation - 4-8 weeks â—‹ Alchol - 4 weeks ,avoid abrupt withdrawal 1-3 days â—Ź Fasting â—‹ 2hrs-NPO â—‹ 4hrs-Breastmilk â—‹ 6hrs-non human milk, solid food, infant formula â—‹ 8hrs - meat, fried food, fatty food â—Ź Antibiotic â—‹ 30-60minutes prior to skin incision
Informed consent ● patient is informed of all medical issues ● patient is informed of recommendations and all options of care ● patient is aware of the benefits and risks of options of care ● patients personal expectations and concerns are considered ● providers consider the patient’s viewpoints ● providers answer all the patient question’s ● patient actively participates in all decisions
Take home message â—Ź Routine perioperative testing of healthy indivisuals undergoing elective surgery is not recommended. â—Ź Patients with high disease burden and having high risk surgery often require extensive testing and possible postponment of surgery. â—Ź Patients having emergency surgery still require evaluation eventhough managment beyond rescusitation is typically limited.