ARBAMICH UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH

SCIENCE
DEPARTMENT OF MIDWIFERY.

11/27/2023 preoperative care 1

Preoperative Care
• Prepared by:- Dessalew and Eyob

• Modulator- Dr. Mastewal (MD, General Surgeon)

11/27/2023 preoperative care 2

Objective
 At the end of this presentation participant can

 Evaluate & prepare pt preoperatively

 Assess & optimize the patient before surgery

 Can give appropriate care for pt who are candidate

for surgery

 Can take valid consent

11/27/2023 preoperative care 3

Introduction

Peri-operative Care:- care that patients receive

before, during, and after surgery.

- Preoperative Period

- Intraoperative Period

- Postoperative Period

11/27/2023 preoperative care 4

Preoperative care

• Preoperative care is the preparation and

management of a patient prior to surgery (Elective
or Emergency).

• It includes both physical and psychological

preparation

11/27/2023 preoperative care 5

Preoperative evaluation should include
- Medical and surgical history
- complete history and physical examination
- Routine lab. Tests:-
• Complete blood count
• Blood typing and Rh-factor determination
• Urinalysis
- Decision making and Preparation for surgery

• Further laboratory tests should be performed only when

indicated by the patients’ medical condition or by the
type of surgery to be performed.

11/27/2023 preoperative care 6

1. Medical and surgical history

• Key elements of the history should include:

 Preexisting medical conditions
 Prior operations, operative complications, and
 The patient's use of tobacco, alcohol, and/or drugs

11/27/2023 preoperative care 7

1. Cardiovascular history focusing on
 high blood pressure,
 chest pains,
 palpitations,
 syncope,
 dyspnea and
 Poor exercise tolerance.
 Patients with heart disease should be considered high-
risk and must be fully evaluated.

11/27/2023 preoperative care 8

• Patients with symptoms of previously undiagnosed heart
disease (E.g. Chest pain, dyspnea, pretibial edema or
orthopnea)
• Recent history of congestive heart failure
• Recent myocardial infarction
• Severe hypertension
• Varicose vein and deep venous thrombosis
Such patients should be evaluated with the assistance
of medical or cardiology consultation.

11/27/2023 preoperative care 9

2. respiratory problems
should be explored further if there is
 history of smoking,
 Productive cough,
 wheeze,
 dyspnea,
 hoarseness of voice or stridor present.
 Increasing severity of symptoms generally indicates
worsening of the condition.

11/27/2023 preoperative care 10

• Respiratory tract problems make patients high risk for
surgery;
E.g. • Upper airway infections
• Pulmonary infections
• Chronic obstructive pulmonary diseases:
chronic bronchitis, asthma
• Elective surgery should be postponed if acute upper or
lower respiratory tract infection is present.
• Acute asthma attack should be treated
• If emergency surgery is necessary in the presence of
respiratory tract infection, regional anesthesia should be
used if possible.
• Chest x-ray investigation, sputum exam
11/27/2023 preoperative care 11
3. Renal system
• Renal function should be appraised
• If there is a hx of kidney disease, DM and HTN
• If the patient is over 60 years of age
• urinalysis reveals:- proteinuria or RBC

• Further evaluate Renal function by

- creatinine clearance,
- Blood urea nitrogen and
- plasma electrolyte determination.

11/27/2023 preoperative care 12

4. Hematologic system

4.1 Anemia
- Anemia affects the oxygen carrying capacity of the
blood, which can complicate the stress of surgery.

4.2 Thrombocytopenia
- platelet count < 150,000/µl
- Thrombocytopenia begins to manifest itself clinically
as the count falls below 100,000/ml
- treat the underlying cause and support with platelet
transfusions and clotting factors as necessary before
surgery.
11/27/2023 preoperative care 13
11/27/2023 preoperative care 14
5. Endocrine system
5.1 Diabetes mellitus
• Diabetics with poor control are especially susceptible to
post operative sepsis.
• Important to ensure control of diabetes before, during
and after surgery.

• In type - II patients, avoid hypoglycemia by closely

monitoring blood sugar on the day of surgery, and
possibly by not using the longer acting oral
hypoglycemic agents -2 days before operation.

11/27/2023 preoperative care 15

• Type I diabetics with good control should be given half
of their total morning dose as regular insulin on the
morning of surgery.

• This is preceded or immediately followed by 5%

dextrose solution intravenously to prevent
hypoglycemia.

• Regular insulin should then be given every 6hrs based

on plasma glucose level.

• control before surgery (e.g. levels 120 to 250 mg/dl. )

11/27/2023 preoperative care 16

5.2 Thyroid disease
• postponed Elective surgery when thyroid function is
suspected of being either excessive or inadequate. (T3, T4,
and TSH levels.)

 Hyperthyroidism:-patient should be rendered euthyroid

before surgery.
• Tx with anti-thyroid medications(≈2 – 3 mths)
 Hypothyroidism:-
• Tx with thyroxin before surgery. ( Begin with slow Dose –
Synthetic levothyroxine (T4) 0.1 to 0.2mg/day

11/27/2023 preoperative care 17

6. The history of past surgery and anesthesia can reveal
problems that may present during current hospitalization
(E.g. intraabdominal adhesions and suxamethonium apnea).

• The use of recreational drugs and alcohol consumption

should be noted as they are known to be associated with
adverse outcomes.

• Check for allergies and risk factors for deep vein thrombosis
(DVT).

• Social history, ability to communicate and mobility are

important in planning rehabilitation after surgery
11/27/2023 preoperative care 18
 Examination specific to surgery

• Clinical findings,
• Site, side
• Specific imaging or investigation findings related to
the pathology for which the surgery is proposed
• Suitability of the patient for the proposed surgical
option

11/27/2023 preoperative care 19

 Investigations

• Minor and intermediate surgery generally requires

no routine investigations unless the patient has
comorbidities
• Routine investigations are
Full blood count.
• For major operations,
• in the elderly and in those with anemia or
• pathology with ongoing blood loss.

11/27/2023 preoperative care 20

Urea and electrolytes.
• Before all major operations,
• in most patients over 60 years of age especially
with cardiovascular, renal and endocrine disease or
if significant blood loss is anticipated.
• It is also needed in those on medications which
affect electrolyte levels, e.g. steroids, diuretics,
digoxin, NSAIDs intravenous fluid or nutrition
therapy.

11/27/2023 preoperative care 21

Electrocardiography.
• patients aged over 60 years,
• cardiovascular, renal and cerebrovascular
involvement,
• diabetes and
• those with severe respiratory problems.

11/27/2023 preoperative care 22

Arterial blood gases.
• For detailed assessment of severe respiratory
conditions and acid–base disturbances.
Liver function tests. These are indicated in
• patients with jaundice,
• known or suspected hepatitis, cirrhosis, malignancy
• patients with poor nutritional reserves.

11/27/2023 preoperative care 23

Other investigations
• to assess capacity of specific organ system and risks
associated.
• Specialist radiological views and recent imaging are
sometimes required.

11/27/2023 preoperative care 24

Routine diagnostic testing

11/27/2023 preoperative care 25

 Preoperative care and pregnancy

The diagnosis of early pregnancy must be

considered in the decision to do elective major
surgery in reproductive age female.
Things to consider during pregnancy are
1. urgency of the surgery
• Emergency surgery should not be delayed because of
the pregnancy.
• the usual guidelines for treating trauma, an open
fracture, or appendicitis should be followed.
• A pregnant woman should never be denied indicated
surgery.
11/27/2023 preoperative care 26
2. Preoperative evaluation
• If the fetus is pre-viable (<24 weeks gestation),
continuous fetal monitoring is rarely indicated.
• Fetal heart tones can be checked pre- and
postoperatively.
• All pregnant patients are treated as though they have a
full stomach and are at risk for aspiration.
• Premedication with some combination of an H2
receptor blocking agent, metoclopramide, and clear
antacid should be considered.

11/27/2023 preoperative care 27

• Evaluations related to trauma or to the surgical condition
should not be denied or avoided simply because the
patient is pregnant.
• Shielding can be provided for x-rays or CT scans.
• If appropriate, MRI and ultrasound are imaging
techniques without risk of radiation exposure to mother or
fetus.

11/27/2023 preoperative care 28

3.implications of co-existing disease on perioperative
care?
• Preoperative evaluation – Obstetric evaluation should
include gestational age, viability and growth of the
fetus, and recommendations for intermittent or
continuous fetal monitoring.
• Evaluation will include ultrasound evaluation in
addition to history and physical examination.
• Perioperative risk reduction strategies-
anesthesiologists should be aware of the physiologic
changes of pregnancy and how they may impact
anesthetic management.

11/27/2023 preoperative care 29

• Fetal concerns include teratogenesis, preterm delivery,
spontaneous abortion, as well as behavioral effects
due to exposure to anesthetic agents.
• equipment and personnel from the labor and delivery
suite should be made available in the preoperative
area, operating room, and PACU as needed.
• If delivery is a potential option during the surgical
case, cesarean section instruments and a warmer for
the newborn should be brought to the main operating
room.

11/27/2023 preoperative care 30

4.patient's medications and how should they be
managed in the perioperative period?
• Pregnant women rarely take medications other than
prenatal vitamins and iron.
• They can be discontinued while the patient is NPO.

11/27/2023 preoperative care 31

 5. What laboratory tests

• Hemoglobin levels: Obtain a baseline level to assess

the dilutional effects of plasma volume expansion.
• Electrolytes: A baseline creatinine level may be
obtained to assess the effect of increased glomerular
filtration rate.
• Coagulation panel: A baseline platelet count will rule
out gestational thrombocytopenia.

11/27/2023 preoperative care 32

For all pts
History of serious reactions or sickness after injections,
oral administration or other uses of substances like
narcotics, anesthetics, analgesics, sedatives, antitoxins
patients’ general hydration status should be assessed and
made optimal.
Nutritional status of the patient also needs evaluation
and correction.

11/27/2023 preoperative care 33

Preoperative medications

• In general, patients should continue their medications

in the immediate preoperative period.
• Exceptions to this rule include:
• Diabetic (oral hypoglycemic agents) medications
• Anticoagulants and
• Antiplatelet agents.

11/27/2023 preoperative care 34

Specific assessment in preoperative
management.
1. Cerebrovascular disease
o uncommon surgical complication, occurs in < 1% of
general patients
o majority (>80%) of these events occur postoperatively
o Risk factors include :
previous CVA, age, hypertension, coronary artery
disease, diabetes, and tobacco use.
o Elective surgery for patients with recent
cerebrovascular accident should be delayed for a
minimum of 2 weeks.
11/27/2023 preoperative care 35
2. Cardiovascular disease
• Leading causes of death after non cardiac surgery.
• MI after non cardiac surgery has hospital mortality rate
of 15% - 25%
• Risk factors:
• Age >70 years
• Unstable angina is C/I for elective operation
• Recent myocardial infarction (MI)
• well-defined risk factor for cardiac morbidity.
• risk of reinfarction is significant if an operation
is performed within 6 months of an MI.

11/27/2023 preoperative care 36

 Cont…
3. Untreated CHF
• predictor of perioperative cardiac morbidity.
• Consequently, these patients should be optimized
before any operative procedures are performed.

11/27/2023 preoperative care 37

4. Pulmonary disease
• COPD is by far the most important risk factor, increasing
pulmonary complications 3-4x
• Symptoms that indicate underlying lung disease are
• Cough, shortness of breath and hemoptysis, purulent
sputum and the presence of wheeze.

11/27/2023 preoperative care 38

• Productive cough is associated with an increase in
postoperative chest complications.
Recent onset  postpone surgery and commence
appropriate treatment with antibiotics and chest
physiotherapy.
Chronic productive cough, elective surgery
should be postponed only if the patient has
additional signs suggesting an infection.

11/27/2023 preoperative care 39

 • Smoking is also a significant risk factor
• Advanced age, older than 60 years
• Obesity.
• Type of surgery :
• Thoracic and
• Upper abdominal procedures.
• Acute respiratory infections -- postpone elective
surgery for 2–4 weeks.
11/27/2023 preoperative care 40
Cont..
5. Preoperative prophylaxis and management
• Pulmonary toilet
• Increasing lung volume by the use of
preoperative incentive spirometry is potentially
effective in reducing pulmonary complications
• Antibiotics
• Cessation of smoking
• Bronchodilators

11/27/2023 preoperative care 41

6. Renal disease
• Metabolic and physiologic derangements of renal
insufficiency
• Electrolyte abnormality e.g. hyperkalemia,
• Acid-base disturbance,
• Platelet dysfunction (qualitative)
• Intravascular volume overload

11/27/2023 preoperative care 42

• Risk factors for perioperative renal dysfunction
• Elevated preoperative BUN or creatinine,
• CHF,
• Advanced age,
• Intraoperative hypotension,
• Sepsis,
• Intravascular volume contraction.
• Nephrotoxic agents, e.g. aminoglycosides
• Underlying medical disease
• Diabetes or hypertension

11/27/2023 preoperative care 43

7. Gastrointestinal disease
• Malnutrition
• nutritional support for a minimum of 2 weeks
before surgery
• Obesity
• Regurgitation risk
• Chemical pneumonitis, severe bronchospasm,
pneumonia and death.
• Patients with a hiatus hernia, bowel obstruction
or paralytic ileus, as well as emergency
patients.
• Jaundice
11/27/2023 preoperative care 44
Current ASA fasting guidelines

Ingested matter Minimum fasting hours

Clear liquids 2hr

Breast milk 4hr

Non -human 6hr

milk
A light meal 6hr

After 8hrs
fatty/fried meal
11/27/2023 preoperative care 45
 8. Hepatic risk

• Mortality predictors are

• Bilirubin above 2,
• Albumin below 3,
• Prothrombin time above 16,or
• Encephlopathy.

11/27/2023 preoperative care 46

9. Infectious complications (prediction)
• Surgical risk factors • Patient-specific risk
• Type of procedure factors
• Degree of • Age,
contamination • Diabetes,
• Duration and • Obesity,
urgency of the • Immunosuppression,
operation • malnutrition,
• preexisting infection,
and
• chronic illness.
11/27/2023 preoperative care 47
Infectious …
o Prophylaxis
o Non-antimicrobial strategies
o Antibiotic prophylaxis has contributed to a
reduction in superficial wound infection rates.

11/27/2023 preoperative care 48

10. Diabetes mellitus
• Diabetic patients experience
• Increased infectious complications
• Impaired wound healing
• Vascular disease is common in diabetics,
• MI, often with an atypical presentation, is the
leading cause of perioperative death among
diabetic patients

11/27/2023 preoperative care 49

• Diet-controlled DM can be maintained safely
without food or glucose infusion before surgery.

• Patients who are taking oral hypoglycemic

agents should discontinue these medications the
evening before scheduled surgery.

• Patients who normally take insulin require insulin

and glucose preoperatively to prevent ketosis and
catabolism.

11/27/2023 preoperative care 50

11. Adrenal insufficiency and steroid dependence
• Patients receiving steroids regularly (including up to 2
months before surgery) will have adrenocortical
suppression.
• Effect will depend on the dose
• Perioperative stress dose not required if
• Oral steroids were discontinued for more than three
months or
• Dose <10mg/day.

11/27/2023 preoperative care 51

Preop dose Type of Perioperative Stress dose
surgery (hydrocortisone)
<10mg/day Any None

Minor 25mg IV @ induction.

Resume preop oral dose
postoperatively.
>10mg/day Moderate 25mg IV @ induction.
PLUS 25mg IV TID for 24hrs.
THEN Resume preop oral dose
postoperatively.
Major 50mg IV @ induction.
PLUS 50mg IV TID 48-72 hrs.
THEN Resume preop oral dose
postoperatively.
11/27/2023 preoperative care 52
12. Coagulation disorders
• Patients taking drugs that interfere with the clotting
cascades
• Warfarin is the commonest drug in this category.
• For simple AF, warfarin stopped 3–4 days before
surgery and then restarted at the normal dosage
level on the evening after surgery.
• Alternative perioperative anticoagulation is not
required

11/27/2023 preoperative care 53

• IF thrombosis is significant, for instance with a
mechanical heart valve, the warfarin should be
replaced with an infusion of heparin, which is stopped
6 hours before surgery and restarted immediately
afterwards

11/27/2023 preoperative care 54

Preoperative assessment in emergency
surgery
• the principles of preoperative assessment should be the
same as in elective surgery, except that the opportunity
to optimize the condition is limited by time constraints.
• Medical assessment and treatments should be started
(e.g. according to the Advanced Trauma Life Support
(ATLS) guidelines) even if there is no time to complete
those before the surgical procedure is started.
• Some risks may be reduced, but some may persist and
whenever possible these need to be explained to the
patient

11/27/2023 preoperative care 55

Preoperative antibiotic prophylaxis
Defined as the use of antibiotics to prevent infections at
surgical site.

 Principles of surgical antibiotics prophylaxis

 Decide if the prophylaxis is appropriate

Determine the bacterial flora most likely to cause the post

ops infection

Choose the narrowest antibacterial spectrum required

Choose less expensive & less toxicity if 2 drugs are required

11/27/2023 56
Indications for antibiotics prophylaxis
 Widely accepted indications are:

 Clean contaminated & contaminated wound

Surgery involving the insertion of artificial devices/prosthetic

material

Clean wound with impaired host immune

 Major surgery involving vascular system:

o Neurosurgery

o Open heart surgery

11/27/2023 57
o
Classification of surgical wound

11/27/2023 58
Skin preparation
 Skin prep. is the process to remove transient flora & reduce
the number of resident microbes to the least possible number
on the intended operative site.

 Two types ( mechanical & chemical means)

 Antiseptic solution: is a substance which inhibits the growth

& dev’t of MO.

 Types of antiseptic solution

a. Alcohol 70% - have rapid reduction of microbial count

 11/27/2023
May used after iodine to provide better adhesion of bio-drape
59
Skin prep…
b. Iodine: fastest acting /reduction of MO

 May cause skin irritation( so dry or blot with sterile

towel after 2-3 minute)

c. Iodophors: less irritating to skin/ no need to remove

d. Chlorohexidine: less rapid reduction of microbial

count but long lasting(4-6hrs)

e. Hexachlorophene: can be used several days before

surgery
11/27/2023
as it builds up a lasting or cumulative effect 60
Risk assessment and consent
• All life- or limb-threatening complications and all
complications with an incidence of 1 per cent or more
should be discussed with the patient.
• The risk of death doubles with every seven years of
adult life lived.

11/27/2023 preoperative care 61

Consent
• Consent should be voluntary or informed

• Supported decision making is considered as a good

practice.

• Explain all the treatment options and risks

• Capacity is needed for a patient to give their consent

• For child guardian should take full responsibility

11/27/2023 preoperative care 62
• Valid consent implies that it is given voluntarily by a
competent and informed person who is not under
duress
• In emergency situations or in an unconscious patient,
consent may not be obtained and the procedure carried out
‘in the best interests of the patient’.
• Adults are presumed to have capacity to consent unless
there is contrary evidence.
• For adults who are not deemed competent to give consent,
treatment can still proceed in their best interests by filling
in an inability to consent form.

11/27/2023 preoperative care 63

LED TO REASON
• Lead - in Introduce yourself and identify the patient
• Explore- How much does the patient know
• Diagnosis- Why the operation is being proposed
• Treatment- Explain whether the treatment proposed is
in
accordance with protocols and if not why not
• Options- Discuss all the options including that of
doing nothing, use lay language

11/27/2023 preoperative care 64

• Results- Explain likely outcome in terms of pain,
mobility,
work, diet and return to normal activities
• Eventualities- For example, the possibility of needing to
remove the testicle in a hernia operation
• Adverse events- Myocardial infarction, stroke and
embolus,
bleeding and specific damage
• Sound mind- Ask if they have understood
• Open question- Check if further clarification is needed
• Notes- Document everything discussed and agreed

11/27/2023 preoperative care 65

Arranging the theatre list
• The date, place and time of operation should be
matched with
availability of personnel.
• Appropriate equipment and instruments should be
made available.
• The operating list should be distributed as early as
possible to all staff who are involved in making the list
run smoothly

11/27/2023 preoperative care 66

• Prioritize patients,
• children and diabetic patients -at the beginning of
the list
• life- and limb-threatening surgery should take
priority;
• cancer patients need to be treated early.

11/27/2023 preoperative care 67

Summary
Preoperative preparation includes:
 preoperative assessment/evaluation
 Hx & P/E
 Nutritional assessment
 Investigations
 Risk assessment
 Preparation
 Consent
 prevention of CVS & RS complication
 Aspiration prevention
11/27/2023
preparation of bowel & others 68
 REFERENCES

1. Bailey & Love’s short practice of surgery 26th

Edn.
2.Manual manipal of surgery.
3.Antibiotic Prophylaxis For Surgery Guideline 2019

11/27/2023 preoperative care 69

 Thank you !
Thank you !
70