OF SU [f&SlKcM (PMTENTS

BY DR. VIKAS KUMAR

M.S., IGMC SHIMLA
 INTRODUCTION
• In the last 10 years there has been a major shift from in-patient to out-patient surgery.

• Many patients requiring major in-patient elective surgery now arrive in hospital on the day

of surgery.
• Preoperative assessment and optimisation important part of modern surgical practice.

• The modern preparation of a patient for operation characterizes the convergence of the

art and science of the surgical discipline.

Important aspects of pre-op. preparation are :

1. GATHER AND RECORD

2. PLAN

3. BE PREPARED
4. COMMUNICATE
 PREOPERATIVE EVALUATION
• Aim : not to screen broadly for undiagnosed disease but rather to identify and quantify
comorbidity that may impact operative outcome.

• Driven by findings on history and physical examination suggestive of organ system

dysfunction.

• The goal is to uncover problems areas that may require further investigation or be amenable
to preoperative optimization.

• If significant comorbidity or evidence of poor control of an underlying disease process,

consultation with a specialist
 OUTINE PREOPERATIVE PREPARATION
FOR SURGERY
• History
• Physical examination
• Special investigation
• Informed consent
• Marking the site/side of
operation
• Antibiotic prophylaxis
SURGICAL HISTORY
• Hx taking is detective work.

• Preconceived ideas, snap judgment and hasty conclusions have no

place in this process.

• Do not be in any doubt that a good hx is not vital.

• If you embark on surgical treatment concentrating on a localized

lesion you will be unprepared if complications developed.

• If you take the wrong diagnostic path all the rest of your activities
misdirected.
PRINCIPLES OF HISTORY-TAKING

■ Listen: what does the patient see as the problem?

(Open questions)

■ Clarify: what does the patient expect? (Closed

questions)

■ Narrow the differential diagnosis. (Focused questions)

■ Fitness: what other comorbidities exist? (Fixed

Presenting complaint
questions) LAYOUT OF A STANDARD HISTORY
History of the presenting complaint
"SORE POPE"

■ Symptoms, including features not

present

■ Onset

■ Relieving factors

■ Exacerbating factors

■ Pain, nature of the pain, any radiation,

etc.

■ Other therapies

■ Planned surgery
PAST Hx

H/O DM, TB, HTN

Any previous op.or bleeding tendency Any

previous reaction to anaesthetic agent

DRUGS Hx

Interaction with anesthesia (MAOI)

Drugs for HTN ,IHD to be cont.over

preoperative period Anticoagulant drugs

Social history
Smoking
Alcohol
Occupation
Diet

Identify problems early to formulate a sensible postoperative plan

and prevent delays in discharge.
Family History
HTN, DM , TB, ALLERGIC DISORDER , CA , etc
PHYSICAL EXAMINATION
• This include a full physical exam

• Don’t rely on the examination of others

• Surgical signs may change and others may miss
important pathology

• One should acquire the habit of performing a

complete exam in exactly the same sequence;
• No step is omitted and added advantage of
: familiarizing what is normal so that
abnormalities can be more recognized
• PALLOR PULS
E
• ICTERUS B.P.
• CYANOSIS BMI
• JVP
• CLUBBING
• LAP
• P.EDEMA
SYSTEMIC EXAMINATION
Cardiovascular
■ Pulse, blood pressure, heart sounds, bruits, peripheral
pulses, peripheral oedema
Respiratory
■ Respiratory rate and effort, chest expansion and
percussion note, breath sounds, oxygen saturation
Gastrointestinal
■ Abdominal masses, ascites, bowel sounds, bruits,
herniae, genitalia
Neurological
■ Conscious level, any pre-existing cognitive
impairment or confusion, deafness, neurological status
of limbs
 —

INVESTIGATIONS
1) FULL BLOOD COUNT (WHEN TO PERFORM ?)
> All emergency Pre-operative cases
> All elective Pre-operative cases over 60 years
> All elective Pre-operative cases in adult females
> If surgery likely to result in significant blood loss
> Suspicion of blood loss, anemia,sepsis,CRD,coagulation problems

2.) UREA & ELECTROLYTES(WHEN TO PERFORM?)

> All Pre-operative cases over 65
> Positive result from U/A
> All pt with cardiopulmonary dis. or taking diuretics, steroids
> All pt with H/O renal/liver dis.or abn. nutritional state
> All pt with H/O diarrhea/vomiting or other metabolic/endocrine dis.
> All pt with IVF for more than 24hr’s
3) LIVER FUNCTION TESTS
Jaundice
Known Or Suspected Hepatitis
Cirrhosis
Malignancy
Portal Hypertension
Poor Nutritional Reserves Or
Clotting Problems
4) CLOTTING SCREEN
Patient On Anticoagulants
Compromised Liver Function Tests Or
Evidence Of A Bleeding Diathesis.
Surgery May Involve Heavy Blood
Loss.
5) ELECTROCARDIOGRAPHY All above age of 65
All patients in whom significant blood loss is possible
All those with a history of cardiovascular, pulmonary
or anaesthetic problems.

6) CHEST X-RAY
All elective pre-operative cases over 60 yrs
All cases of cervical,thoracic or abdominal trauma.
Acute respiratory symptoms or signs
Previous CRD and no recent CXR
Thoracic surgery
Malignant dis.
Viscus perforation Recent H/O TB Thyroid
enlargement
7) GROUP AND SAVE /CROSSMATCH
> Emergency pre-operative case
> Suspicion of blood loss,anemia,coagulatin defect
> Procedure on pregnant ladies

8) BLOOD SUGAR
- All diabetic pts
- All above 40 yrs of age
- Family hist
PREOPERATIVE EVALUATION
I) CARDIOVASCULAR

• Cardiovascular disease is the leading cause of death in the

industrialized world, and its contribution to perioperative mortality for
noncardiac surgery is significant.

• Nearly 30% have significant coronary artery disease or other cardiac

comorbidities.

As such, much of the preoperative risk assessment and patient

preparation centers on the cardiovascular system.
CARDIAC RISK INDICES
1) Goldman Cardiac Risk Index, 1977
2) Detsky Modified Multifactorial Index, 1986
3) Eagle's Criteria for Cardiac Risk Assessment,
1989Revised Cardiac Risk Index
1. Ischemic heart disease 1

Each increment in points increases the risk for

postoperative myocardial morbidity
2. Congestive heart failure 1

3. Cerebral vascular disease 1

4. High-risk surgery 1

5. Preoperative insulin treatment of diabetes 1

6. Preoperative creatinine >2 mg/dL 1

 DICTORS OF INCREASE TIVE CARDI CULAR RISK
LEADING TO MYOCARDIAL INFARCTION, HEART FAILURE, OR DEATH

Major Risk Factors

Unstable coronary syndromes
Acute or recent myocardial infarction with evidence of
considerable ischemic risk as noted by clinical symptoms or
noninvasive studies
Unstable or severe angina (Canadian class III or IV)
Decompensated heart failure Significant arrhythmias
High-grade atrioventricular block
Symptomatic ventricular arrhythmias in the presence of
underlying heart disease
Supraventricular arrhythmias with an uncontrolled ventricular
rate
Severe valve disease
Intermediate
Mild angina pectoris (Canadian class I or II)
Previous myocardial infarction identified by history or
pathologic evidence
Q waves
Compensated or previous heart failure Diabetes
mellitus (particularly insulin dependent) Renal
insufficiency

Minor Risk Factors

Advanced age
Abnormal electrocardiogram (e.g., left ventricular
hypertrophy, left bundle branch block, ST-T
abnormalities)
Rhythm other than sinus (e.g., atrial fibrillation) Low
functional capacity (e.g., inability to climb one flight of
stairs with a bag of groceries)
History of stroke
Uncontrolled systemic hypertension
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- Weigh the benefits of surgery versus the risk and determine whether
perioperative intervention will reduce the probability of a cardiac event.

- Coronary revascularization using coronary artery bypass or percutaneous

transluminal coronary angioplasty

- Sx delayed upto 4-6 wks after coronary intervention

 - Any patient can be evaluated as a surgical candidate after an acute MI
(within 7 days of evaluation), or a recent MI (between 7 and 30 days of evaluation).
-There is a significant mortality rate from anaesthesia within 3 months of
infarction and
elective_procedures_should_ideally_be_delayed_until_at_least_6_months
haveelapsed.

- Systolic pressures > 160 mmHg & diastolic pressures >95 mmHg -—
postpone
surgery

-Newly diagnosed hypertension may need further investigation

to look for an underlying cause; the medical team may need to be
involved.
*Perioperative risk for cardiovascular morbidity and mortality was decreased by

67% and 55%, respectively, in patients receiving R blockade in the perioperative

period versus those receiving placebo.

*Benefit noticeable in the 6 months following surgery,

better in the group that received R blockade up to 2 years after surgery.

II) PULMONARY

-Preoperative evaluation of pulmonary function may be necessary for either

thoracic or general surgical procedures.
-Extremity, neurosurgical, and lower abdominal surgical procedures do not
routinely require pulmonary function studies,
-Thoracic and upper abdominal procedures can decrease pulmonary
function and predispose to pulmonary complications.
As such, it is wise to consider assessing pulmonary function for
- all lung resection cases,
-thoracic procedures requiring single-lung ventilation, and -
major abdominal and thoracic cases in patients >60 years of age,
-have significant underlying medical disease
- smoke
-have overt pulmonary symptomatology.
Necessary tests include
1) the forced expiratory volume at 1 second (FEV1),
2) the forced vital capacity, and
3) the diffusing capacity of carbon monoxide.
Adults with an FEV1 of less than 0.8 L/second, or 30% of predicted, have
a high risk of complications and postoperative pulmonary insufficiency;
nonsurgical solutions should be sought.

General factors that increase risk for postoperative pulmonary complications

include : -Increasing Age,
-Lower Albumin Level,
-Dependent Functional Status,
- Weight Loss,
-Obesity
Concurrent comorbid conditions such as -
Impaired Sensorium,
-Previous Stroke,
-Congestive Heart Failure,
- Acute Renal Failure,
-Chronic Steroid Use,
- Blood Transfusion

Specific pulmonary risk factors include:

- Chronic Obstructive Pulmonary
Disease,
- Smoking,
- Preoperative Sputum Production,
- Pneumonia,
-Dyspnea, And -
Obstructive Sleep Apnea.
That may decrease postoperative pulmonary complications, include -
Smoking Cessation (2 mths)
-Bronchodilator Therapy,
-Antibiotic Therapy For Preexisting Infection, And -
Pretreatment Of Asthmatic Patients With Steroids.

Perioperative strategies include

-The Use Of Epidural Anesthesia,
-Vigorous Pulmonary Toilet And Rehabilitation, And -
Continued Bronchodilator Therapy.
III) RENAL

Approximately 5% of the adult population have some degree of renal

dysfunction .The identification of cardiovascular, circulatory, hematologic, and

metabolic derangements secondary to renal dysfunction should be the goal of

preoperative evaluation of these patients.

The patient should be questioned about prior MI and symptoms

consistent with ischemic heart disease. Cardiovascular examination should seek

to document signs of fluid overload.
Diagnostic testing for patients with renal dysfunction should include -

Electrocardiogram (ECG),
-Serum Chemistry Panel (Na,k,cl,urea,creatinine,ca,p Etc.)
- Complete Blood Count (CBC).
- Urinalysis And Urinary Electrolyte Studies
- Blood Gas Determination
- Prothrombin Time (PT) And Partial Thromboplastin Time
- Bleeding Time
-Pharmacologic manipulation of
* hyperkalemia,
Replacement of calcium for symptomatic hypocalcemia, and
*the use of phosphate-binding antacids for
hyperphosphatemia
-Sodium bicarbonate is used in the setting of metabolic acidosis
when serum bicarbonate levels are below 15 mEq/L. This can
be administered in intravenous (IV) fluid as 1 to 2 ampules in
5% dextrose solution.
-Hyponatremia is treated with volume restriction, although
dialysis is often required within the perioperative period for
control of volume and electrolyte abnormalities.
-Patients with chronic end-stage renal disease should undergo dialysis prior to
surgery, to optimize their volume status and control the potassium level.

-Intraoperative hyperkalemia can result from surgical manipulation of tissue or the

transfusion of blood. Such patients are often dialyzed on the day after surgery as
well.

- In the acute setting, patients who have a stable volume status can undergo
surgery without preoperative dialysis, provided that no other indication exists for
emergent dialysis.
 Indications for Hemodialysis

*Serum potassium >5.5 mEq/L *Blood urea

nitrogen >80-90 mg/dL *Persistent
metabolic acidosis *Acute fluid overload
*Uremic symptoms (pericarditis,
encephalopathy, anorexia)
*Removal of toxins
*Platelet dysfunction causing bleeding
^Hyperphosphatemia with hypercalcemia
*The prevention of secondary renal insult in the perioperative period must be the
focus of the anesthesia and surgical teams.

*This includes the avoidance of nephrotoxic agents and maintenance of adequate

intravascular volume throughout this period.

*In the postoperative period, the pharmacokinetics of many drugs may be

unpredictable, and adjustments of dosages should be made.

*Notably, narcotics used for postoperative pain control may have prolonged
effects, despite hepatic clearance.

*NSAIDs should be avoided.

IV) HEPATOBILIARY

-Hepatic dysfunction may reflect the common pathway of a number of

insults to the liver, including viral-, drug-, and toxin-mediated disease.

- careful assessment of the degree of functional impairment as well a

coordinated effort to avoid additional insult in the perioperative period.

Evidence of hepatic dysfunction include :

-Jaundice and scleral icterus
-Skin changes include spider angiomas, caput medusae, palmar erythema,
and clubbing of the fingertips.
- Abdominal examination may reveal distention, evidence of fluid
shift,and hepatomegaly.
- Encephalopathy or asterixis may be evident
- Muscle wasting or cachexia can be prominent
-LFT
-Albumin levels -Coagulation profile.
-Serologic testing for hepatitis A, B, and
C.
-Alcoholic hepatitis is suggested by lower transaminase levels and
an AST/ALT ratio greater than 2

-The patient with acute hepatitis with elevated transaminases

should be managed nonoperatively, when feasible, until several
weeks beyond normalization of laboratory
values.

-Urgent or emergent procedures in these patients are associated

with increased morbidity and mortality.

-The patient with evidence of chronic hepatitis may often safely

POINTS
1 2 3
Encephaopathy None Stage I or II Stage III or IV

Albumin(g/dl) >35 2.8-3.5 <2.8

Bilirubin(mg/dl) <2 3
2-
>3
<4 4-6 >6
PT
prolonged(sec)
INR <1.7 .7-2.3
1
>2.3
Ascites None Slight (controlled Moderate
with diuretics) despite
diuretic
treatment
Two common problems requiring surgical evaluation in the cirrhotic patient
are : *hernia (umbilical and groin) and
*cholecystitis.
-The presence of umbilical hernia is strongly associated with the presence of
ascites, and failure to operate can lead to spontaneous rupture, with an
associated mortality
of 50%.
-Elective repair with perioperative control of ascites is the preferred approach in
these cases, though still associated with mortality rates as high as 14%.
-Groin hernias are less strongly associated with the presence of ascites; their
repair is associated with far less risk of recurrence than umbilical hernias.
Laparoscopic cholecystectomy, performed in patients with Child's
classes A through C when compared to open cholecystectomy, less morbidity in
terms of blood loss and wound infection has been observed.
V) ENDOCRINE

The patient with an endocrine condition such as diabetes mellitus,

hyperthyroidism or hypothyroidism, or adrenal insufficiency is subject to
additional physiologic stress during surgery.

The preoperative evaluation should identify the type and degree of endocrine
dysfunction to allow for preoperative optimization.

The evaluation of a diabetic patient for operation should assess adequacy of

glycemic control and identify the presence of diabetic complications
Preoperative testing may include
* Fasting and postprandial glucose
* Hemoglobin A1c
* Serum electrolytes
* Urinalysis
* ECG
* Fundus exam

The existence of neuropathy in diabetics may be accompanied by a

cardiac autonomic neuropathy, which increases the risk of cardiorespiratory
instability in the perioperative period.
The diabetic patient may require early preoperative admission to optimize
glycemic control prior to operation.

Insulin is available in several types and is typically classified by its length of

action.

TYPE OF ONSET OF PEAK DURATION OF

INSULIN ACTION EFFECT ACTION
15-30 minutes 3-4 hours
Rapid acting 30-90
(Lispro) minutes
30-60 minutes 2-4 hours 6-10 hours
Short acting (Regular)
1-4 hours 4-12 hours 12-24 hours
Intermediate acting
(NPH Lente)
Long acting
Ultralente 1-2 hours 8-20 hours 24-30 hours
Glargine 1 hour 3-20 hours 24 hours
 -In insulin-dependent diabetics rapid-acting (Lispro) and short-acting
(Regular) insulin preparations are usually withheld when the patient stops oral
intake (NPO) and are used for acute management of hyperglycemia during the
NPO period

-Intermediate-acting (NPH Lente) and long-acting (Ultralente, Glargine)

insulin preparations are administered at two thirds the normal pm dose the night
before surgery and half the normal am dose the morning of surgery, with frequent
bedside glucose determinations and treatment with short-acting insulin as
needed.
An infusion of 5% dextrose is initiated the morning of surgery. If the planned
procedure is expected to take a long time, an insulin infusion can be
administered, again with frequent monitoring of blood glucose.

-Noninsulin-dependent diabetes should discontinue long-acting

sulfonylureas such as chlorpropamide and glyburide owing to the risk of
intraoperative hypoglycemia; a shorter-acting agent or sliding-scale insulin
coverage may be substituted in this period.

-The use of metformin should be stopped preoperatively because of its

association with lactic acidosis in the setting of renal insufficiency.
 -The patient with diabetes mellitus that is well controlled by diet or
oral medication may not require insulin perioperatively, but

- Those with poorer control or on insulin therapy may require

preoperative dosing and both glucose and insulin infusion during surgery.

-Frequent assessment of glucose levels should be continued through the

postoperative period.
-Adequate hydration must be maintained with avoidance of
hypovolemia.
 Thyroidectomy
opyright ©2006 by The McGraw-Hill Companies, Inc.
>o

II rights reserved.

Management of a solitary thyroid nodule. a (Except in patients with a history of external radiation exposure or a family history of thyroid
cancer). FNAB = fine-needle aspiration biopsy; RAI = radioactive iodine.
The patient with known or suspected thyroid disease should be evaluated with -
Thyroid function panel
-ECG
-CXR
-TG
-USG NECK
- Thyroid scan
-FNAC
-I/L
- Soft tissue neck x-ray
Operation deferred until a euthyroid state is achieved

In addition, if physical examination suggests signs of airway compromise, further

imaging may be warranted.

The patient with hyperthyroidism who takes antithyroid medication such as

propylthiouracil or methimazole should be instructed to continue this regimen on
the day of surgery. The patient's usual doses of R blockers or digoxin should also be
continued.
 In the event of urgent surgery in a thyrotoxic patient at risk for thyroid
storm, a combination of adrenergic blockers and glucocorticoids may be required
and should be administered in consultation with an endocrinologist.

The patient with newly diagnosed hypothyroidism generally does not

require preoperative treatment though may be subject to increased sensitivity to
medications, including anesthetic agents and narcotics.

Severe hypothyroidism can be associated with myocardial dysfunction,

coagulation abnormality, and electrolyte imbalance, notably hypoglycemia.

Pt should take the thyroxine on the day of surgery.

* The patient with a history of steroid use may require supplementation for a
presumed abnormal adrenal response to perioperative stress.

* Patients who have taken more than 5 mg of prednisone (or equivalent) per day
for more than 2 weeks within the past year should be considered at risk when
undergoing major surgery.

* Lower doses of steroid use or minor procedures are generally not associated
with adrenal suppression.
VW>'

PERIOPERATIVE SUPPLEMENTAL GLUCOCORTICC

No HPA Axis Suppression
Less than 5 mg of prednisone or equivalent per day for any duration
Alternate-day single morning dose of short-acting glucocorticoid of any dose or duration Any dose of glucocorticoid for less than 3 weeks
Rx: Give the usual daily glucocorticoid dose during the perioperative period HPA Axis Suppression Documented or Presumed
More than 20 mg of prednisone or equivalent per day for 3 weeks or longer Cushingoid appearance
Biochemical adrenal insufficiency on a low-dose ACTH stimulation test Minor procedures or local anesthesia
Rx: Give the usual glucocorticoid dose before surgery No supplementation

Moderate surgical stress

Rx: 50 mg hydrocortisone IV before induction of anesthesia, 25 mg hydrocortisone every 8 hours thereafter for 24-48 hours, then
resume usual dose
Major surgical stress
Rx: 100 mg hydrocortisone IV before induction of anesthesia, 50 mg hydrocortisone every 8 hours thereafter for 48-72 hours, then
resume usual dose
HPA Axis Suppression Uncertain
5-20 mg of prednisone or its equivalent for 3 weeks or longer
5 mg or greater of prednisone or its equivalent for 3 weeks or more in the year before surgery Minor procedures or local anesthesia
Rx: Give the usual glucocorticoid dose before surgery No supplementation
Moderate or major surgical stress
Check the low-dose ACTH stimulation test to determine HPA axis suppression or Give supplemental glucocorticoids as though
suppressed

ACTH, adrenocorticotropic hormone; HPA, hypothalamic-pituitary-adrenal axis.

Recent guidelines suggest titrating the dosage of glucocorticoid replacement to the
degree of surgical stress.
- Minor operations such as hernia repair require approximately 25 mg of
hydrocortisone equivalent.

-Moderate operations such as open cholecystectomy or lower extremity

revascularization require 50 to 75 mg of hydrocortisone equivalent for 1 or 2 days.

-Major operations such as colectomy or cardiac surgery should be covered

with 100 to 150 mg of hydrocortisone equivalent for 2 to 3 days.
Patients with pheochromocytoma require preoperative pharmacologic
management to prevent intraoperative hypertensive crises or hypotension leading
to cardiovascular collapse.

The state of catecholamine excess associated with pheochromocytoma should be

controlled by a combination of a-adrenergic and ^-adrenergic blockade prior
to surgery.
 -One to two weeks is usually required to achieve adequate therapeutic
effect by a blockade; this can be accomplished with either a nonselective agent
such as phenoxybenzamine, or selective a1 agents such as prazosin.

-R Blockade is initiated several days after the a agent is begun and serves
to inhibit the tachycardia that accompanies nonselective a blockade, as well as to
control arrhythmia.

- Patients with pheochromocytoma may undergo surgery when

pharmacologic blood pressure control is achieved.
The approach to a patient with suspected immunosuppression is the same,
results from
i) antineoplastic drugs in a cancer patient or
ii) immunosuppressive therapy in a transplant patient or
iii) acquired immunodeficiency syndrome.

Goal : to optimize immunologic function prior to operation and to

minimize the risks of infection and wound breakdown.

Preoperative assessment should include

- a thorough history of the patient's underlying disease and current
functional status
-history of immunosuppressive treatment,including names of
medications and duration of treatment; and -history of recent
changes in weight.
 *Physical examination should seek to document signs of organ
dysfunction, which may underlie the progression of disease or be related to its
treatment.

*Laboratory assessment should include -

CBC with differential
- electrolytes
-liver function tests, and an
-ECG
-chest radiograph
- T-cell,B-cell, polymorphonuclear,
or complement function

* Possible sites of infection

should be investigated, including
examination of any indwelling
catheters, and may warrant complete
Pt. may requie :
-Red blood cell transfusion -erythropoietin or -
colony-stimulating factors

*Careful attention is given to

nutritional deficiency in this patient
population, with supplementation indicated in
the perioperative period.
*Appropriate antibiotic prophylaxis is
critical.

*Risk of wound complications,

especially if on exogenous steroid therapy.
When taken within 3 days of surgery, steroids
reduce the degree of wound inflammation,
epithelialization, and collagen synthesis. This
can lead to wound breakdown and infection
VII) HEMATOLOGIC

Hematologic assessment may lead to the identification of disorders

such as anemia, inherited or acquired coagulopathy, or the hypercoagulable
state.
Substantial morbidity may derive from failure to identify these
abnormalities preoperatively.

Anemia is the most common laboratory abnormality encountered in

preoperative patients. It is often asymptomatic.
Physical examination for lymphadenopathy, hepatomegaly, or splenomegaly should be
made, and pelvic and rectal examinations should be performed.
CBC,reticulocyte count, and serum iron, total iron-binding capacity, ferritin, vitamin B12 ,
and folate levels should be obtained to investigate the cause of anemia.

Guidelines for Red Blood Cell Transfusion for Acute Blood Loss

i Evaluate risk of ischemia.

i Estimate/anticipate degree of blood loss. Less than 30% rapid volume loss
probably does not require transfusion in a previously healthy individual.
j Measure hemoglobin concentration: < 6 g/dL, transfusion usually required; 6-10
g/dL, transfusion dictated by clinical circumstance; >10 g/dL, transfusion rarely
required.

j Measure vital signs/tissue oxygenation when hemoglobin is 6 to 10 g/dL and

extent of blood loss is unknown. Tachycardia and hypotension refractory to
volume suggest the need for transfusion; O2 extraction ratio > 50%, VO2
decreased, suggest that transfusion usually is needed
All patients undergoing surgery should be questioned to assess bleeding risk.
Coagulopathy may result from inherited or acquired platelet or factor disorders or
may be associated with organ dysfunction or medications.

Assessment includes :
-personal or family history of abnormal bleeding.
- history of easy bruising or abnormal bleeding associated with
minor procedures or injury.
-nutritional status.
-Review of medications and the
-Use of anticoagulants, salicylates,NSAIDs, and antiplatelet drugs
should be noted -coagulation studies
Physical examination may reveal bruising, petechiae, or signs of liver
dysfunction.

Patients with thrombocytopenia may have qualitative or quantitative defects, due

to immune-related disease, infection, drugs, or liver or kidney dysfunction.

Qualitative defects --medical management of the underlying disease process,

whereas Quantitative defects -- platelet transfusion when counts are less than
50,000 in a patient at risk for bleeding.

Although should not be routinely ordered, patients with a history suggestive of

coagulopathy should undergo coagulation studies prior to operation
*Patients taking warfarin, the drug can be held for several
days preoperatively to allow the International Normalized Ratio (INR) to fall to
the range of 1.5 or less.

*Patients with a recent history of venous thromboembolism or acute arterial

embolism often require perioperative IV heparinization due to increased risk of
recurrent events in the perioperative period.
*Systemic heparinization can often be stopped within 6 hours of surgery and
restarted within 12 hours postoperatively.

*When possible, surgery should be postponed in the first month after an episode
of venous or arterial thromboembolism.

*Patients on anticoagulation for less than 2 weeks for pulmonary embolism or

proximal DVT should be considered for inferior vena cava filter placement prior to
operation
Level of Definition of Risk Level Fatal PE Prevention Strategy
Calf Proxim Clinica (%)
Risk
DVT al l
(%) DVT (%) PE (%)
Minor surgery in patients < 40 yr
Low 2 °.4 0.2 0.002 No specific measures
with no additional risk factors
Moderate 10-20 2-4 1-2 0.1-0.4 LDUH q 12 hr, LMWH,
Minor surgery in patients with
additional risk factors: nonmajor ES or IPC
surgery in patients aged 40-60 yr
with no additional risk factors; major
surgery in patients < 40 yr with no
additional risk factors
High 20-40 4-8 2-4 0.4-1.0 LDUH q 8 hr, LMWH or
Nonmajor surgery in patients > 60 yr IPC
or with additional risk factors; major
surgery in patients > 40 yr or with
additional risk factors
Highest 40-80 10-20 4-10 0.2-5 LMWH, oral
anticoagulants, IPC/ES +
Major surgery in patients > 40 yr plus
LDUH/LMWH or ADH
prior VTE, cancer, or molecular
hypercoagulable state; hip or knee
arthroplasty, hip fracture surgery;
major trauma; spinal cord injury
 ^ Appropriate arit^iotir^ for iDrophylaxio in ^irgory depends on the most likely

NATIONAL RESEARCH COUNCIL CLASSIFICATION OF

CLASS I (CLEAN)
OPERATIVE WOUNDS

Nontraumatic No inflammation No break in technique

CLASS II (CLEAN -CONTAMINATED)
CLASS III (CONTAMINATED)
CLASS IV ( DIRTY)
Respiratory, alimentary, or genitourinary tract not entered
Gastrointestinal or respiratory tract entered without significant
spillage
Major break in technique
Gross spillage from gastrointestinal tract
Traumatic wound, fresh
Entrance of genitourinary or biliary tracts in presence of infected urine or
bile
Acute bacterial inflammation encountered, without pus Transection of
“clean” tissue for the purpose of surgical access to a collection of pus
Traumatic wound with retained devitalized tissue, foreign bodies, fecal
contamination, or delayed treatment, or all of these; or from dirty

source
-The appropriate antibiotic should be chosen prior to surgery and administered before
the skin incision is made.
-Repeat dosing should occur at an appropriate interval,generally 3 hours for abdominal
cases or twice the half-life of the antibiotic.
-Perioperative antibiotic prophylaxis should generally not be continued beyond the day
of operation.
- With the advent of minimal access surgery, the use of antibiotics seems less justified
because the risk of wound infection is extremely low.
 ADULT
DOSAGE
NATURE OF COMMON RECOMMENDED BEFORE
OPERATION PATHOGENS ANTIMICROBIALS SURGERY
Gastrointestinal

Esophageal, gastro duo Enteric gram-negative bacilli, gram- High risk only: cefazolin 1-2 g IV
denal positive cocci

Biliary tract Enteric gram-negative bacilli, High risk only: cefazolin 1-2 g IV
enterococci, clostridia

Colorectal Enteric gram-negative bacilli,

anaerobes, enterococci Oral: neomycin + erythromycin base
OR metronidazole

Parenteral: cefoxitin] 1-2 g IV

OR cefazolin 1-2 g IV
+ metronidazole 0.5 g IV

OR ampicillin/sulbactam 3 g IV
Appendectomy, Enteric gram-negative bacilli, Cefoxitin 1-2 g IV
non-perforated anaerobes, enterococci
OR cefazolin 1-2 g IV
+ metronidazole 0.5 g IV
OR ampicillin/sulbactam 3 g IV
Genitourinary Enteric gram-negative bacilli, * 500 mg PO or 400 mg IV
enterococci High risk: only: ciprofloxacin

* Urine culture positive or unavailable, preoperative catheter, transrectal prostatic biopsy,

placement of prosthetic material
sabiston 18th edition
*
Parenteral prophylactic antimicrobials can be given as a single IV dose begun 60
minutes or less before the operation.
* For prolonged operations (>4 hours) or those with major blood loss, additional
intraoperative doses should be given at intervals 1-2 times the half-life of the drug for
the duration of the procedure in patients with normal renal function.

* If vancomycin or a fluoroquinolone is used, the infusion should be started 60-120

minutes before the initial incision in order to minimize the possibility of an infusion
reaction close to the time of induction of anesthesia and to have adequate tissue levels
at the time of incision.
-For patients allergic to penicillins and cephalosporins, clindamycin with
gentamicin, ciprofloxacin, levofloxacin, or aztreonam is a reasonable
alternative.

-For a ruptured viscus, therapy is often continued for about 5 days. Ruptured
viscus in postoperative setting (dehiscence) requires antibacterials to include
coverage of nosocomial pathogens.
A careful review of the patient's home medications should be a part of the preoperative
evaluation prior to any operation.
- In general, patients taking
*cardiac drugs, including R blockers and antiarrhythmics;
*pulmonary drugs such as inhaled or nebulized medications;
or *anticonvulsants,
*antihypertensives, or
*psychiatric drugs, should be advised to take their medications
with a sip of water on the morning of surgery.
- Medications such as lipid lowering agents or vitamins can be omitted on
the
day of surgery.
- Drugs that affect platelet function should be held for
variable periods:
* aspirin and clopidogrel should be held for 7 to 10 days,
*NSAIDs should be held between 1 day (ibuprofen and
indomethacin) and 3 days (naproxen and sulindac), depending on the
drug’s half-life.

- Estrogen use has been associated with an increased risk of

thromboembolism and should be withheld for a period of 4 weeks
preoperatively.
PREOPERATIVE CHECKLIST
• The preoperative evaluation concludes with a review of all pertinent studies and
information obtained from investigative tests.

• Documentation should be made in the chart of this review, which represents an

opportunity to ensure that all necessary and pertinent data have been obtained and
appropriately interpreted.

• Informed consent should be documented in the chart, which represents the result of
discussion(s) with the patient and family members regarding the indication for the
anticipated surgical procedure, as well as its risks and proposed benefits.

• Preoperative orders should be written and reviewed as well. The patient should receive
written instructions regarding time of surgery and management of special perioperative
issues such as bowel preparation or medication usage.
I ) COLORECTAL CARCINOMA A)

BOWEL PREPARATION
It is important to obtain physical clearance of the bowel. Many
surgeons have changed from traditional methods of bowel preparation to using
purgative (sodium citric acid 12g, magnesium oxide 3.5 g).

A suitable regime is :
Preoperative days 4 and 3: low residue diet Preoperative days 2 and 1:
liquid only diet
Day of admission: 1 sachet Picolax in morning, repeated in afternoon

These methods are contraindicated in complete intestinal obstruction

 -An appendicectomy is performed and a large calibre (30 F) Foley catheter is
brought through the anterior abdominal wall and inserted into the caecum and retained
in place by inflation of the balloon and insertion of a purse string suture on the bowel.

-After removal of the operative specimen, the divided colon is then intubated
by wide bore corrugated anaesthetic tubing which is draped over the patient's side into
a bucket.

-The Foley catheter is connected to a iv infusion set and normal saline is

infused until the bowel is clean. The anaesthetic tubing is removed and the operation is
completed.

-The Foley catheter is left as an intubated caecostomy for 10 days

postoperatively after which it is removed
*The postoperative wound infection rate is reduced by intravenous antibacterial agents;
giving them for 24h during and around the time of surgery is as effective as any other
regimen.
*Any combination of agents should include metronidazole which is active against
anaerobic bacteria. Metronidazole (500mg i.v.) is given on induction of anaesthesia and
repeated at 8 and 16 h postoperatively.
*Many surgeons add an antibiotic such as an aminoglycoside (e.g. tobramycin,
gentamicin) or a cephalosporin to metronidazole giving it at the same frequency and for
the same duration.
^Antibiotics are given for no more than 24h in the non-infected case. A full 5—7 day
course should be given where sepsis or toxicity is already present, e.g. diverticular
abscess, colonic abscess.
Preoperative education may include discussion of the proposed surgical option,
demonstration of appliances, and description of the type of stoma and how it will be
managed.

It is helpful to describe the stoma appearance, the usual consistency and quantity of
drainage, gas and odor control, diet, fluid and electrolytes, clothing, sexuality, recreation,
and return to
work.

The location of the site must be

(a) within the rectus muscle,
(b) outside of abdominal creases and scars, and
(c) within the patient's line of vision

The site should be marked preoperatively with waterproof ink and later
"scratched" with a sterile needle.
If a midline incision is used, it is best if the stoma
can be located at least two to three
fingerbreadths (about 2.5 in.) away from the
incision, as this will allow for an adequate barrier
to be placed around the stoma postoperatively.
It is best to stay at least two to three
fingerbreadths away from the iliac crest to avoid
interference with appliance adherence.

MAYO
OXOJ
II) OBSTRUCTIVE JAUNDICE

A) Correction of coagulation abnormalities

The shortage of vitamin K impairs the synthesis of prothrombin . If prothrombin time is
elevated, vitamin K should be given in the form of K1 intravenouslyhe.
A dose of 20mg is followed by a rapid return to a normal prothrombin time within 12—
24 ft if the liver is normal.
Vitamin K1 in a dose of 10—20mg should be given daily intravenously or intramuscularly
until operation takes place. It is usually unnecessary to continue the administration of
vitamin K postoperatively.
When there is severe hepatocellular damage fresh plasma frozen should be given.
Prothrombin activity is retained in these plasma fractions for several months.
Stored whole blood contains little or no prothrombin.

B) Prevention of renal failure

Jaundiced patients undergoing surgery have an increased tendency to develop renal

impairment due to renal tubular damage and hepatorenal syndrome. It is important
to keep the patient well hydrated before operation.

Use of nephrotoxic antibiotics should be avoided.

C) Antibiotics

Increased susceptibility to infection

Metronidazole combined with cephalosporins or aminoglycosides
D) Avoid constipation
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