‫بسم اهلل الرحمن الرحيم‬

Preoperative Preparations
Dr \ Amir Siddig
Faculty of Medicine - Department of
Surgery
 Introduction
 Patients undergoing any surgical procedure
should be psychologically and physically
prepared .
 Psychological preparation includes explanation
of the procedure and alleviation of any
associated fear or anxiety .
 A written consent should be obtained from any
patient after being fully informed about the
operation .
 Preoperative Assessment

Aims :
 To confirm the diagnosis for which surgery is
performed .
 To detect and manage any risk factors that render
surgery hazardous.
 To ascertain the patient fitness for surgery.
 To control any systemic co-morbidities that may
increase operative risk e g diabetes and
hypertension .
 To plan any required preoperative
prophylactic treatment .
 Systemic Diseases Associated with
Increased Operative Risk
1. Cardiovascular disease :
 Uncontrolled hypertension is a
contraindication to elective surgery .
 Patients with a recent myocardial
infarction (3 months ) have a 30% risk of
a re-infarction .
 Patients with arrhythmias should be
referred to the cardiologist .
 Heart failure is a contraindication to
elective surgery.

The above conditions are detected in

the pre-operative visit by careful
history ,meticulous clinical
examination and routine
investigations for the CVS
2\ Respiratory diseases :
 Patients scheduled for elective surgery must
be assessed properly for the presence of
acute or chronic respiratory diseases .
 Special attention is paid to bronchial
asthma, pneumonia,TB and chronic
obstructive pulmonary diseases (COPD)
 Active asthma and acute respiratory tract
Infections (including common cold ) is a
contraindication to general anaesthesia
unless required by clinical emergency .
3\ Diabetes :
 In diabetics,hyperglycaemia is a possible risk due
to the stress of surgery and general anaesthia .
 On the other hand ,hypoglycaemia which is more
serious , can develop as a result of unnecessary
prolonged fasting or inappropriate medication .

 The blood sugar is normalized pre-operatively

 The dose of oral hypoglycaemic drugs is omitted
in the day before operation .
 Patients on long acting insulin are shifted to
soluble(short acting ) insulin. In the day of
operation the morning dose is omitted .
 The blood glucose level is monitored during and
after the operation .
 If postoperative fasting is required intravenous
glucose ,soluble insulin and potassium chloride
are administered .
4\ Renal Impairment :

 Two groups of patients must be identified:

1. Patients with established renal failure have a high
operative risk .Before embarking on elective surgery , the
benefits of surgery should be weighed against the
possible complications.
 Special anaesthetics and muscle relaxants are used . The
need for pre-operative dialysis should be carefully
assessed .

2.Patients who are at risk of developing renal failure .Factors

predisposing to peri-operative renal failure include :
Hypovolaemia,pre-existing renal
impairment,sepsis,diabetes,jaundice and elderly
patients .
 Prophylactic measures to minimize the risk of renal
failure centers around avoidance of
hypovlaemia ,hypotension ,nephrotoxic drugs and
hypoxia during the post-operative period .Urine
output should be monitored during and after the
operation .
 Consultation and involvement of a nephrologist may
be necessary .
5\ Liver Disease and Jaundice :
 In this group of patients certain
anaesthetics are avoided such as
halothane .
 Great care is paid to fluid and electrolyte
balance as these patients are prone to
develop acute renal failure and electrolyte
disturbance( hypokalaemia ) .
 Clotting disturbances must be anticipated
and managed .
6\ Thyroid Disease :
 It is advisable to delay elective
surgery in patients with uncontrolled
thyrotoxicosis because of the risk of
thyrotxic crisis .
 A large goitre may interfere with the

airway in the peri-operative period .

7\ Malnutrition :
 Malnourished patients have the following
problems :
1. Altered response to many drugs .

2. Increased risk of infection .

3. Poor temperature control(hypothermia).

4. Poor muscle function.

5. Poor wound healing .

 Other Risk Factors
1. Smoking :
 Ciliary function in the trachea and bronchi is
 affected .Laryngeal irritation and other
respiratory complications are likely to develop .
 Smokers are advised to stop smoking at least
two weeks before surgery .
2 .Alcohol :
Withdrawl of alcohol is associated with
irritability,nausea,anxiety, hallucinations and
convulsions .
3.Obesity :
 It may point to some diseases such

as cushing syndrome,hypothyrodism
and hypopiututarism.
 Obese patients are at

 risk of thromb-embolic phenomena

and respiratory complications .

4.Pregenancy
 Anaesthia (especially in the first trimester )
carries a minimal risk of abortion .
 The need for surgery has to be assessed
carefully .
5.Drugs :
 The drug history should reveal previous or
current use of the following drugs :
Steroides,antihypertensives,hypoglycaemic,an
tithyroid,anticoagulants,cytotxic,contracepti
ve,antiarrhythmics,NSAID and
antipsychotics .
 Allergies to any drug must be identified .

6.Contraceptive pills :
 Ladies in child bearing age should be

interrogated about the use of these pills .

 They carry the risk of thrombo-embolism
and must be stopped at least 3 weeks prior
to surgery .
7.Suxamethnium apnea :
 It is due to plasma cholinestrase deficiency .

 It may result in prolonged muscle relaxation

and paralysis of respiratory muscles .
8.Sickle cell disease :
 Conditions which provoke sickle cell crisis
must be avoided .These include
hypovlaemia,hypothermia and hypoxia .
 The opinion of the haematologist must be
sought .
 Prophylaxis in Surgery
1. Prophylaxis against DVT :
 Pharmacologic ( eg,heparin) or mechanical
(compression stockings) prophylaxis is
used for patients at risk .
 Examples of risk factors include old age,
obesity,malignancy,cotraceptive pills and
patients above 40 under going operations
taking longer than 30 minutes.
2.Prophylactic antibiotics :
 They are indicated in GIT, vascular,cardiac and
orthopaedic surgery .
 Patients with reduced immunity(eg
diabetics) and those with valvular heart
disease should receive prophylactic
antibiotics
3.Peptic Ulcer Prophylaxis :
 Patients known to have peptic ulcer and
those at risk (stressful surgery,NSAID)
should receive anti ulcer therapy in the
peri-operative period .
 Steps of Preparations
 Full history and clinical examination is
mandatory to detect any of the mentioned
systemic diseases or risk factors .
 Routine investigations :
- Full blood count,urine general,renal function and
RBS .
- Patients above 4o years need assessment of CVS
by CXR and ECG . Patients suspected to have
cardiac disease may need echocardiography .
- .

- In patients with history of jaundice or liver disease LFT is indicated .

 An informed consent should be obtained .
 If the operation is in one side or a paired organ the side of the
operation is clearly labeled with a mark .
 The patient fasts overnight for 6 hours . Diabetics need a longer
fasting.
 The patient must have a bath in the night before surgery .Hair in the
site of operation is shaved.

 The patient should fast for at least 6 hours. Diabetics need a longer fasting .
 Prophylactic antibiotics and heparin are
given with induction of anaesthia if
indicated .
 Premedications are administered 30
minutes before induction of anaesthia to
sedate the patient and reduce secretions
in the respiratory tract.