1 Pre-operative Management Pre-operative Assessment
1
"People don't die of their diseases,
they die of the pathophysiological effects of disease" Sir William Osler 1897. Pre-operative assessment should aim to identify risk factors which could be optimised to minimize complications, improve outcome and ensure patient safety and comfort.
AIMS
. Establish rapport with the patient and family, and allay anxiety
Assess functional status, optimise and balance risk and benefit. Plan peri-operative management according to the risk factors. Explain all procedures, establish communication and obtain informed consent.
HISTORY
Vital and most informative and cannot be substituted for by investigations
Age: biological age is more important than chronological age Profession, lifestyle, effort tolerance and metabolic equivalents (see page 10.1) • Presenting complaint, its complications and surgery planned • Current and past medical discases, drug therapy, sepsis, allergies • Coagulopathy : gum bleeding, bruises, knee swellings Menstrual and obstetric history
• Previous anaesthesia, date and nature of surgery and complications Family history of medical illnesses, anaesthetic complications • Social habits : smoking, alcoholism, drugs, high risk behaviour
SYSTEM REVIEW
Nutrition CVS RS CNS Liver Kidney Oral GIT
: appetite, weight loss / gain, malnutrition, oedema, obesity : chest pain, dyspnoca, palpitations, syncope, oedema cough, sputum, snoring, dyspnoea, tachypnoea, wheeze : headache, convulsions, strokes, blackouts, sleep, gait jaundice, ascites, encephalopathy, hepatitis, cirrhosis : oliguria, polyuria, nocturia, haematuria
: dentures, caps, crowns, bridges, loose teeth, gums, sepsis : gastric stasis, heart burn, vomiting, bowel habits
Pre-operative Management
Endocrine : diabetes, thyroid, adrenocortical discase Musculoskeletal arthritis, myopathies, facial and spinal deformities EXAMINATION
Haematology anemia, coagulopathy
System based examination specially RS, CVS and those indicated by review Special: Airway, spine, venous access, varicose veins, skin, nerves, joints
INVESTIGATIONS
Investigations should be ordered on the basis of history and examination :
For diseases suspected / detected on clinical assessment or as base line For vital organ function which maybe compromised by surgery .
Consider its value: Will it reveal information not obtained by examination? Will the results alter management of the patient? Guidelines for investigations
Urine analysis Ward test for sugar, blood, protein, for all patients
Full blood count: All females, males > 40 years, major surgery, suspected anemia, If expected to exceed "allowable blood loss" (see page 23.12) Bleeding, pallor, coagulopathy, infection, vital organ dysfunction Blood grouping with antibody screen for surgery likely to require red cell transfusion Renal profile Diarrhoea, vomiting, metabolic disease, diabetes, anaemia
serum creatinine, Renal, CVS or hepatic disease, long term i.. therapy electrolytes and Drugs (diuretics, digoxin, antihypertensives, steroids) blood urea) Major surgery with expected large fluid shifts Chest X-ray and : CVS or RS disease, thoracic surgery Spo, Risk of tuberculosis or malignancy
ECG
Males 40 years, females post-menopausal Cardio-vascular disease, hypertension, diabetes
Echocardiogram : Cardiac symptoms, signs, BMI>35, hypertension, DM Blood sugar Age >40 years, obesity, chronic wounds Glycosuria, known diabetic or family history Cardio-vascular disease, steroid therapy
screen : Bleeding disorder, anticoagulant therapy, liver disease Liver function : Jaundice, alcoholic, hepatic disease, renal or cardiac failure Abnormal nutritional status or metabolic disease
Coagulation
Lung function Chronic respiratory disease, thoracotomy Arterial blood gas: Abnormal lung function Unexplained tachypnoca (possible metabolic acidosis)
Pregnancy test : Whenever there is a possibility of pregnancy
1.2
Pre-operative Management
1.1
RISK STRATIFICATION OF PROBLEMS IDENTIFIED
1. Patient risk factors What risk factors will lead to a poor outcome!
Is pre-operative optimisation needed and possible? Should surgery be delayed and for how long?
What specific goals may be achieved with optimisation? 2. Surgical requirements
Surgical access intubation, shared airway, positioning required Minimizing bleeding position, IPPV, hypotensive agents, adrenaline
Special problems increase of intraocular pressure, intra cranial pressure, co, (laparoscopy)
3. Anaesthetic problems "Full stomach", difficult
airway, high risk patient Optimal technique, drugs, monitoring, and post-operative care to be planned considering the surgery, patient problems, and possible complications leading to mortality and morbidity
/shared
RISK ASSESSMENT
Is the patient in optimum physical condition for anaesthesia? Are the benefits of surgery greater than the anaesthetic and surgical risks?
Procedure following risk assessment Medical disease institute or optimise appropriate therapy Discuss with surgeon timing of surgery, pre-operative treatment • Discuss with consultant: postponement of surgery, ICU care
CALISES OF PERI-OPERATIVE MORBIDITY AND MORTALITY
The overall post-operative mortality is about 1% Direct anaesthetic deaths are about 1:100,000 in ASA I and II patients.
The common causes of death and the high risk factors should be recognised pre operatively and prophylactic measures instituted.
• Haemorrhage Sepsis
Deep vein thrombosis and pulmonary embolism
Myocardial infarction • Pneumonia
• Emergency surgery outside normal working hours by inexperienced juniors