6-Pre-operative care assessment and preparations-1 - Copy - Copy.pptx
- 1. Pre-operative care assessment and preparations by Aburi Godfrey James and Rahima Abdulaziz 5th/09/16
- 2. 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
- 3. 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
- 4. 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.
- 5. 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.
- 6. 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
- 7. 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
- 8. Preoperative investigations • These are undertaken to assess; – fitness for anesthesia – Identify problems amenable to correction prior to surgery. • They are based on: – A good history and thorough examination – Factors apparent from the clinical assessment – The likelihood of asymptomatic disease – The type of surgery and anesthesia planned – Surgical unit protocols guiding the use of preoperative investigations
- 9. Preoperative Investigations Haematocrit, blood sugar, blood urea, serum creatinine, electrolytes, chest-Xray, ECG, blood grouping, blood-gas analysis, cardiac assessment.
- 10. Cont’d • Investigations commonly done include; – hematological; • Full blood count: • Coagulation screen • Cross matching – Biochemical: • Liver function tests • Urea and electrolytes • urinalysis – Cardiac investigations • Electrocardiography • Echocardiography • Exercise testing
- 11. Cont’d • Respiratory investigations – Chest x-ray – Sputum culture and drug sensitivity – Pulmonary function tests – Arterial blood gases • Other investigations; – b-Human chorionic gonadotropin – Hepatitis /HIV virus serology – MRSA screening
- 12. Indications for routine preoperative investigations investigations indications CBC most patients, young women with menorrhagia, patient whose surgery may involve significant blood loss, old patients with undiagnosed anemia Coagulation screen suspected abnormal clotting, on anti-coagulation treatment, consideration of epidural anesthesia Urea and electrolytes Patients over 65yrs, history of cvs, pulmonary, or renal problems LFTs Jaundice, known/suspected hepatitis, cirrhosis, malignancy, portal hypertension, malnutrition ECG Patients over 65yrs, history of cvs, pulmonary and anesthetic problems, expectation of significant blood loss Chest x-ray In case of significant cardiac history or respiratory problems
- 13. Management • Management plan – Drawn up in discussing with the patient using language the patient understands. The discussion involves; – The specific surgical diagnosis or diagnoses . – Confounding issues e.g. medical comorbidities that will complicate the management plan
- 14. Key points in management plan discussion • Provide all of the information necessary for the patient to make an informed decision • Use language that the patient will understand • Discuss the options rather than telling the patient what will be done • Give the patient time to think things over • Encourage the patient to discuss things with a trusted friend/partner • Suggest that the patient write down a list of points that he or she wishes to discuss
- 15. Psychological preparation • Patients are often fearful or anxious about having surgery • Variety of fears cause operational anxiety. They include fear of: • The unknown • Surgical failure • Anesthesia • Pain • Unsuccessful recovery • Incisions with needles or knives • Death, Unsuccessful recovery
- 16. Cont’d • Effects of preoperative anxiety:- – Physiological responses such as tachycardia, hypertension, elevated temperature, s weating, nausea, heightened senses such as smell, touch and Peripheral vasoconstriction. – Psychological effects: behavioral and cognitive changes resulting in increased tension, apprehension, nervousness and aggression.
- 17. Cont’d • Ways of psychological preparation; – Preoperative patient teaching or tours – Providing accurate and thorough information about the operation – Permitting family members to be present before the operation and involving them in psychological preparation – Creating a good patient-doctor relationship. Patient concerns should be expressed and the surgeon notified. Children; should be allowed to have parents around as much as possible. Use of puppets in a play activity to demonstrate medical procedures and should be encouraged to bring favorite toys on the day of surgery
- 18. Cont’d • Benefits of psychological preparation: – Patients and families tend to cope better with the patient’s postoperative course – Goals of recovery are known ahead of time which leads to superior outcomes, and the patient is able to manage postoperative pain more effectively.
- 19. The preoperative ward round • Purpose; to ensure that the patient has been adequately assessed and prepared for surgery Surgical staff • Re-examine the patient to ensure the operation proposed is still appropriate • Records are checked to make sure that all essential investigations have been completed. • Address patient questions and fully explain surgical procedure, anesthesia, postoperative analgesia, use of catheters, drains and postoperative monitoring. • Should also take the responsibility that the patient has understood the nature of the operation and its implications.
- 20. Cont.’ Nursing staff • Responsible for removing and safeguarding the dentures, rings and other jewellery, giving premedication, testing urine and fixing a band around a patients wrist which indicates name, religion and dose and time of administration of premedication. 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.
- 21. 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
- 22. 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
- 23. 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.
- 24. 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.
- 25. The WHO surgical safety checklist
- 26. 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.
- 27. • 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.
- 28. • Renal risk • CKD is the most common renal risk that is encountered preoperatively in this group. • Blood Urea & S. Creatinine should be done. • Moderate elevation of urea & Creatinine can be considered in elderly patient. • Patient on dialysis should be dialyzed preoperatively to ensure good fluid balance & to correct any hyperkalemia.
- 29. Cont.’ • Patient on renal transplants require to have their immunosuppressant preoperatively. • Ensure adequate hydration to avoid precipitating renal failure in frail & critically ill patient. • Always consult with a nephrologist.
- 30. Rational use of antibiotics • Antibiotic use depends on whether it is going to be clean or contaminated operation and type of flora likely to cause infection. • Patient with clinical infection should be treated with broad spectrum antibiotics prior to surgery. • Clean procedure (e.g. varicose vein surgery) do not need antibiotic prophylaxis. • Abdominal surgery, which is not associated with significant contamination (e.g. elective cholecystectomy) requires only a single dose of prophylaxis given on the induction of anaesthesia.
- 31. Cont.’ • Procedures with a contaminated field (e.g. Appendicitis, Peritonitis, Perforation etc.) should be treated with a preoperative dose and two post operative doses. • The most common antibiotics used preoperatively are: – Cephalosporins; – Floroquinolones; – Metronidazole; – Anti staphylococcal penicillin; – Co amoxyclav etc.
- 32. Prophylaxis against DVT & pulmonary emboli • Pulmonary emboli and DVT are two major causes of death of surgical patients. Prophylaxis should be taken for all patients preoperatively to minimize post operative morbidity & mortality. • Risk factors: recent surgery, trauma, diabetes, immobilization, old age, cancer, obesity, heart failure
- 33. Cont.’ • The risk factors can be minimized preoperatively by: 1. Pre and post operative subcutaneous heparin administration. 2. Graduated compression stockings. 3. Intraoperative intermittent pneumatic calf compression.
- 34. Preoperative anxiolytic medication • Aim: patient to arrive in the anaesthetic room in a relaxed, pain-free state. • For very anxious patients • Oral benzodiazepines are commonly used as they have a relatively long duration of action.
- 35. Preoperative fasting • Purpose: to try to ensure an empty stomach and minimize the risk of regurgitation and aspiration during induction of anaesthesia. • patients should be starved of food for 6 hours and of clear fluids for 2 hours. • NGT indicated in situations where an empty stomach cannot be guaranteed despite fasting e.g.. Pregnancy, gastric outlet or bowel obstruction.
- 36. Preparation for surgery in special groups • Bowel surgery: - Bowel preparation is considered prior to bowel surgery. - For elective surgery, bowel preparation is most commonly achieved by placing the pt on liquid diet 3-5 days prior to surgery & administering oral purgatives or enema on the day prior to surgery. - Specially for small bowel surgery, proper hydration & nutrition should be maintained. - If there is evidence of obstruction, an NG tube should be inserted to prevent aspiration
- 37. • Preparation for jaundiced patient: The risk of surgery in a patient with obstructive jaundice can be reduced significantly by careful preoperative management. Preoperative drainage by a Biliary endoprosthesis should be considered in elderly patients who are deeply jaundiced or all patients with biliary tract sepsis.
- 38. Cont.’ Vitamin K should be given to all patients with obstructive jaundice prior to surgery. A coagulation profile should be checked. Adequate hydration should be done to prevent hepato-renal syndrome. Antibiotic prophylaxis should be given to combat high infective complications in a jaundiced patient.
- 39. • Thoracic surgery: - Assessment of respiratory function is the most important aspect of preoperative preparation. - Active preoperative physiotherapy, treatment of any respiratory infections with antibiotics and good post operative analgesia minimize the risk of postoperative respiratory failure. - Subcutaneous heparin is routine to prevent pulmonary embolus.
- 40. • Endocrine surgery: -For thyrotoxicosis patients, a period of antithyroid drug & beta blockers is given to prevent thyrotoxic crisis. - Patients with pheocromocytoma may require admission a week before surgery to evaluate & block the alpha & beta adrenergic effects of catecholamines.
- 41. References • Bailey & Love Short practice of Surgery (25th edition) • Principles and practice of surgery (6th edition) • General Surgical Operations – R. M. Kirk (5th edition) • Clinical Surgery in general – R M Kirk (3rd edition)