PERIOPERATIVE

EVALUATION
Dr. Deasiana Paksi Moeda Sp.B, FInaCs
24 Agustus 2021
Hippocrates (460-335 BC)
• Primum, non nocere
• First, do no harm
 Triage

Diagnosis

Kasus bedah / bukan ?

Masalah yang dapat timbul

Jenis / teknik Operasi

TOTAL CARE Timing Operasi

Masalah pra-bedah

Masalah intra-bedah

Masalah pasca-bedah

Follow up
Preoperative Evaluation
• The purpose of a preoperative evaluation is not to “clear” patients for
elective surgery, but rather to evaluate and, if necessary, implement
measures to prepare higher risk patients for surgery.
• Pre-operative outpatient medical evaluation can decrease the length
of hospital stay as well as minimize postponed or cancelled surgeries.
Preoperative History and Physical
Examination
• The history : the condition for which the surgery is planned, any past surgical procedures,
and the patient's experience with anesthesia.
• In children: birth history, prematurity at birth, perinatal complications and congenital
chromosomal or anatomic malformations, and history of recent infections
• Chronic medical conditions, particularly of the heart and lungs.
• Medications should be noted. Drug dosages may need to be adjusted in the perioperative
period. Aspirin and non-steroidal anti-inflammatory drugs should be discontinued one
week before surgery to avoid excessive bleeding.
• Immunization status can be documented, and vaccines can be updated if necessary.
• The patient should be asked about smoking history and alcohol and drug use.
• The physician should review the patient's social support and need for assistance after
hospital discharge.
• Patients with cardiopulmonary disease may warrant a second
examination just before hospitalization.
• Patients who have pulmonary disease or who will undergo abdominal
or thoracic surgery can be given instructions for performing incentive
spirometry. The patient should also be provided with information
about the expected postoperative course and possible complications.
• Informed consent
Laboratory Assesment
Preoperative laboratory studies : complete blood count, extensive blood chemistry profile, urinalysis,
prothrombin time, partial thromboplastin time, electrocardiogram (ECG) and chest radiographs.
• A hemoglobin measurement is useful in detecting unsuspected anemia and providing a baseline level,
which can be helpful information postoperatively, particularly for surgeries with potential hemorrhagic
complications.
• Renal and liver function studies are not routinely needed but may be indicated for patients who have a
medical condition
• Preoperative glucose determination should be obtained in patients 45 years or older,
• A urine pregnancy test should be considered for women of childbearing age.
• Coagulation times are not routinely indicated, as studies have shown that the yield is very low and that
abnormal results are expected or do not significantly affect
• An ECG is also not routinely indicated in patients 40 years or younger
• Chest radiographs should be obtained on the basis of findings from the medical history or physical
examination.
Cardiac Evaluation
• With the increasing size of the middle-aged and elderly population,
more surgical procedures will be performed in patients who have or
potentially have coronary artery disease.
• Cardiac complications are the most common type of complication
that can threaten the surgical patient's life or prolong the patient's
hospital stay.
Surgery-Related Predictors for Risk of Perioperative Cardiac Complications

High Risk Intermediate Risk Low Risk

• Emergency • Abdominal or • Breast surgery

surgery thoracic surgery • Cataract surgery
• Anticipated • Head and neck • Superficial
increased blood surgery surgery
loss • Carotid • Endoscopy
• Aortic or endarterectomy
peripheral • Orthopedic
vascular surgery surgery
• Prostate surgery
• Previous history of diagnosed coronary artery disease, any previous cardiovascular
procedural interventions or testing, current therapies and any current symptoms
suggestive of angina or congestive heart failure.
• Patients in whom cardiac stress testing was normal within the past two years or who
have had coronary bypass surgery within the past five years, and are without symptoms,
require no further assessment.
• Emergency surgery calls for expedited pre-operative cardiac assessment and
management. Patients undergoing elective or semi-elective procedures can proceed with
preoperative cardiac testing.
• Patients at high risk for complications usually warrant cardiology consultation and
possibly angiography. Cardiac stress testing should be performed in patients at
intermediate risk and with poor functional capacity or who are undergoing high-risk
procedures, such as vascular surgery.
Pulmonary assesment
• The major pulmonary complications in the perioperative period are
atelectasis, pneumonia and bronchitis.
• Predisposing risk factors include cough, dyspnea, smoking, a history of lung
disease, obesity and abdominal or thoracic surgery
• The most significant of these risk factors is the site of surgery, with abdominal
and thoracic surgery having pulmonary complication rates ranging from 30 to
40 percent. As a rule, the closer the surgery is to the diaphragm, the higher
the risk of pulmonary complications.
• Baseline chest radiographs may be helpful in at-risk patients.
• Pulmonary function testing may be helpful in diagnosing and assessing
disease severity
Nutritional Assesment
• Malnourished patients experience increased surgical morbidity and mortality. An assessment
of risk factors for malnutrition, especially in the elderly : Social isolation, limited financial
resources, poor dentition, weight loss and chronic disorders such as pulmonary disease,
congestive heart failure, depression, diarrhea and constipation are commonly associated
with malnutrition.
• In addition, patients often cannot eat for varying periods before and after surgery, further
compromising nutritional status.
• A weight loss of > 5 percent in one month or of 10 percent or more over six months, a serum
albumin of less than 3.2 g per dL (32 g per L), and a total lymphocyte count of less than
3,000 per μL3 (3.0 × 109 per L) can signify an increased risk of postoperative complications.
• Preoperative nutritional supplementation can be provided orally, with enteral tube feeding
or with parenteral nutrition. Enteral tube feeding is widely underused, much less expensive
than parenteral nutrition and may carry less risk for electrolyte abnormalities and infection. 
Intraoperative Evaluation
• Facility
• Type of surgery
• Duration of surgery
• Technique of surgery
• Anaesthesia monitoring
• Complication
Complication Incidence (%)
Infection 14.3
Wound 5.1
Pneumonia 3.6
Urinary tract 3.5
Systemic sepsis 2.1
Respiratory 9.5
Pneumonia 3.6
Failure to wean from respirator in 48 hours 3.2
Unplanned intubation 2.4
Pulmonary embolus 0.3
Cardiac 4.5
Pulmonary edema 2.3
Cardiac arrest 1.5
Myocardial infarction 0.7
Postoperative Evaluation
Arterial blood pressure
A cardinal parameter measured as part of the hemodynamic monitoring of
patients.
• Non-invasive measurement
--- use of inflatable cuff to increase pressure around an extremity, then
detect the presence or absence of artery pulsations (ex. Korotkoff sounds)
 systolic pressure
 diastolic pressure
--- photoplethysmography
• Invasive monitoring
• Invasive monitoring
--- using fluid-filled tubing to connect an intra-arterial catheter to an
external strain-gauge transducer  signal  continuous waveform by
an oscilloscope
Systolic and diastolic pressure
Mean pressure
--- radial artery (most common)
Electrocardiographic monitoring
• Records the electrical activity associated with cardiac contraction by
detecting voltages on the body surfaces
• Standard 3-lead ECG: placing electrodes that correspond to the left
arm (LA), right arm (RA), and left leg (LL).
• 12-lead ECG: potential myocardial ischemia, or to rule out cardiac
complications in other acutely ill patients
Cardiac output and related parameters
• Preload
-- the stretch of myocardial ventricular tissue just before the next contraction
• Afterload
-- the force resisting fiber shortening once systole begins (by calculating
systemic vascular resistance = MAP / CO)
• Contractility
-- the inotropic state of myocardium
-- contractility is increased when the force of ventricular contraction
increases at constant preload and afterload
Respiratory monitoring
• Arterial blood gases
• Important for respiratory failure
• The need for mechanical ventilation
• Detect alterations in acid-base balance (low QT, sepsis, renal failure, severe
trauma, medication overdose, or altered mental status)
• pH, PO2, PCO2, HCO3- concentration , Base deficit

• Determinants of oxygen delivery

• -- the primary goal : deliver oxygenated blood to the tissues
DO2 = QT x [( HgB x SaO2 x 1,36) + (PaO2 x 0,0031)]
• Pulse oximetry
-- non-invasive monitoring of the O2 saturation of arterial blood (SaO2)
• Capnometry
-- measurement of CO2 in the airway throughout the respiratory cycle
-- measured by infrared light absorption
Renal monitoring
• Urine output
• recorded hourly
• Gross indicator of renal perfusion
• Normal UO: 0,5ml/kgBB per hour for adults and 1 -2 ml/kgBB for neonates and infants
• Oliguria  inadequate renal artery perfusion due to hypotension, hypovolemia, or
low QT, or impending renal failure
• Bladder pressure
• Triad of abdominal compartment syndrome : oliguria, elevated peak airways pressure,
elevated intra-abdominal pressure (IAP)
• When IAP increases, perfusion of kidneys and other intraabdominal viscera is
impaired  oliguria
• ACS = > 20 – 25 mmHg
Neurologic monitoring
• Intracranial pressure
• Cerebral edema or mass lesions can increase ICP
• Severe traumatic brain injury, SAH, ICH
• The goal : to ensure cerebral perfusion pressure (CPP) adequate to support
perfusion of the brain
• Electroencephalogram and evoked potentials
• EEG : monitor global neurologic electrical capacity
• Evoked potential monitoring can asses pathways not detected by conventional EEG
(localizing brain stem lesions, proving the absence of structural lesions in metabolic
or toxic coma)
• Continuous EEG : monitoring status epilepticus, detect cerebral ischemia, adjust
level of sedation
• Transcranial Doppler Us
• Non-invasive
• Measure middle and anterior cerebral artery blood flow velocity – diagnose
cerebral vasospasme
• Jugular venous oxymetry
• A decrease in SjO2 – reflects cerebral hypoperfusion
• An increase in SjO2 – presence of hyperemia
• Associated with poor outcomes after TBI
Nutrition
• Enteral feeding
• Parenteral feeding
Conclusion
• With comprehensive pre, intra, and post-operative management, we
can reach the patient safety and succesfull of the surgery
References
• Brunicardi, F.C., et al. 2015. Schwartz’s PRINCIPLES of Surgery. USA :
McGraw-Hill Comp.
• Peri-operative Course and Acute Care Surgery. 2019. Kolegium Ilmu
Bedah Indonesia. Jakarta
• King M.S., 2000. Preoperative Evaluation. Northwestern Univ. Med.
School. Am Fam Physician. 2000 Jul 15;62(2):387-396.
Thank You