PRE-OPERATIVE

CARE INCLUDING BY

THE HIGH-RISK ANAESTHESIA DEPARTMENT

SURGICAL AVICENNA MEDICAL COLLEGE

PATIENT
  To be able to organize the preoperative care and the operating
list
 To understand preoperative preparation for surgery
Learning  • Anaesthetic aspects of assessment

Objectives:  • How to optimize the patient’s condition

 • How to identify and optimize the patient at higher risk
 • Importance of critical care in management
 • How to take consent
 • How to organize an operating list
 Major surgery can lead to:
 Increased oxygen demand by about 40%
 cytokine release-related inflammatory changes
PHYSIOLOGICAL
 endocrine responses
SURGICAL
 Hypercoagulability
STRESS  redistribution of fluid between compartments
RESPONSE
The purpose of careful preoperative planning is to minimise the
unwanted effects of these physiological changes.
 ●Gather and record all relevant information

AIMS OF PRE- ● Optimize patient condition

OPERATIVEASSESSMEN ● Choose surgery that offers minimal risk and maximum benefit
T ● Anticipate and plan for adverse events
● Adequate hydration, nutrition and exercise are advised
Principle of History
Taking
● Listen: What is the problem? (Open questions)
● Clarify: What does the patient expect? (Closed
questions)
● Narrow: Differential diagnosis (Focused
questions)
● Fitness: Comorbidities (Fixed questions)
 Examination(Contd.)

 General: Anemia, jaundice, cyanosis, nutritional status, sources of infection (teeth, feet, leg
ulcers)
 Cardiovascular: Pulse, blood pressure, heart sounds, bruits, peripheral oedema
 Respiratory: Respiratory rate and effort, chest expansion and percussion note, breath
sounds, oxygen saturation
 Gastrointestinal: Abdominal masses, ascites, bowel sounds, hernia, genitalia
 Neurological: Consciousness level, cognitive function, sensation, muscle power, tone and
reflexes
 Airway assessment
 Specific Pre-operative Problems &
Management

 Cardiovascular Disease
 Hypertension, IHD, stents
 Dysrhythmias
 Implanted pacemakers and cardiac defibrillators
 Valvular heart disease
 Regional anaesthetic techniques/less invasive surgical options
Respiratory should be considered in respiratory compromised cases.

Disease  Elective surgery should be postponed until acute

exacerbations are treated.
 The patient should be referred to a respiratory physician if:
● There is a severe disease or significant deterioration.
● Major surgery is planned in a patient with significant
respiratory comorbidities.
● Right heart failure is present – dyspnea, fatigue, tricuspid
regurgitation, hepatomegaly and edematous feet.
● The patient is young and has severe respiratory problems
(indicates a rare condition).
  Nil by mouth (6 hours for solids, 2 hours for clear fluids)

Gastrointestinal  Assessment for aspiration risk (obesity, diabetes, hiatus hernia,

pregnancy are high risk for aspiration)
Disease
 Liver disease (ascites, hypoalbuminemia, esophageal varices,
sodium and water retention, altered metabolism of anaesthetic
drugs)
Genitourinary Disease
Renal Disease (Acute kidney injury,
chronic kidney disease, UTI)

Endocrine & Metabolic Disorder

Malnutrition (Ideal BMI 18-25)
Diabetes Mellitus
Obesity
Adrenocortical suppression
 Risk factors for thrombosis:
● Age >60 years
● Obesity BMI >30 kg/m2
● Trauma or surgery (especially of the abdomen, pelvis and lower
limbs), anaesthesia >90 minutes

Coagulation ● Reduced mobility for more than 3 days

● Pregnancy/puerperium
Disorders ● Varicose veins with phlebitis
● Drugs, e.g. estrogen contraceptive, HRT, smoking
● Known active cancer or on treatment, significant medical
comorbidities, critical care admission
● Family/personal history of thrombosis, e.g. deficiencies in
antithrombin III, protein S and C
  Medicines for epilepsy and Parkinsonism to be continued
Neurological &
Psychiatric  Lithium to be stopped 24hrs pre-operatively

Disease  History to be taken regarding use of TCAs and MAOis =>

interaction with anaesthetic drugs (tramadol, pethidine)
Musculoskeletal  Rheumatoid disease (unstable cervical spine)

Disease  Ankylosing spondylitis

 SLE
 Patient factors that predispose to high risk of morbidity and mortality:
 Previous severe cardiorespiratory illness, e.g. acute myocardial infarction
 COPD or stroke Late stage vascular disease involving aorta

Assessment of  Age >70 years with limited physiological reserve in one or more vital organs
 Extensive surgery for carcinoma
High Risk  Acute abdominal catastrophe with haemodynamic instability (e.g. peritonitis)

Patient 

Acute massive blood loss >8 units
Septicaemia- Positive blood culture or septic focus
 Respiratory failure: PaO2 0.4 or mechanical ventilation >48 h
 Acute renal failure: urea >20 mmol or creatinine >260 mmol/L
A practical approach to the care for the high-risk patient

● Identify the high-risk patient

● Assess the level of risk

● Detailed preoperative assessment

● Adequate resusciatation

● Optimise medical management

● Investigation to define the underlying surgical problem

● Immediate and definitive treatment of underlying problems

● Consider admission to a critical care facility postoperatively

Questions?