Preoperative Assessment

Preoperative Assessment Importance of preoperative assessment    Structured approach of questioning, a targeted clinical examination and the careful consideration of the which investigations are needed to plan for the best patient outcomes. Helps with avoiding possible risks. Informs the need for further investigations and optimisation of patients with medical comorbidity to reduce the risk of perioperative problems. Basics Steps of Preoperative Assessment 1. Diagnosis.  Provisional diagnosis – how confident one is with it.  Any further investigations needed to confirm the primary diagnosis.  Important aspects of the history.  Findings of the examination.  Results of already performed investigations.  Is it appropriate and possible to obtain biopsies before the surgery. 2. Operation.  What operation or procedure is planned.  Have any circumstances relating to the surgery or procedure changed.  Has the patient gotten better or worse.  Has any new information from history, examinations or investigations been revealed?  Is the planned operation still appropriate?  Any special risks during and after the surgery? E.g. DVT following.  Any standard precautions that need to be done during the operation> 3. Anaesthesia  What type of anaesthesia should be used?  Can the anaesthesia risks be anticipated? E.g. vomiting during induction. 4. Fitness for the operation  Any recurrent diseases and are they being appropriately treated or any that might posses a special risk?  Are any preoperative investigations or treatments needed for intercurrent diseases.  Dose the surgical condition has special problems?  Is the patient taking any drugs which might cause problems with anaesthesia or the operation?  Is the patient fit for the planned anaesthesia or operation? 5. High risk  Is the patient predisposed to anaesthetic or surgical complications? 6. After the operation  Can any special problems be anticipated during the post-operative period and after discharge? E.g. elderly patients living alone.  Any problems specific to this anaesthetic or operation regarding recovery and rehabilitation, and is any special planning required? Methods of evaluating patient risks    Clinical judgement Risk scores or models. Evaluation of functional capacity. Basic Patient Preparation 1. Marking the operation site:  When obtaining the final consent, the surgeon should mark the surgery site on the patient’s skin with an indelible pen. - Especially important when the surgery is to be done on right or left or when the patient will be turned into prone position. 2. Preoperative fasting and fluid restriction:  General anaesthesia depresses the protective airway reflexes of gag and cough.  To minimise the risk of gastric content aspirations into the lung during anaesthesia induction or in early recovery, the patient should be fasting.  Guidelines on fasting: - Stop solids before 6 hours. - Stop liquids before 2 hours.  For patients at higher risk of aspiration e.g. GERD, intestinal obstruction and pregnancy, the anaesthetist may prescribe an antiacid medication.  Should CHECK IF THIS HAS BEEN FOLLOWED. 3. Liaison with Anaesthetist  Evaluation of patient.  The anaesthetist is responsible for ensuring that the patient is fit for surgery and assists in resus if needed. 4. Operating theatre arrangement  The intern is responsible for informing the operating department about the operation any special arrangements needed.  A formal operating theatre list should include: - Name - Age - Sex - Ward - Proposed operation  The side of the body to be operated on should be clearly noted.  The presence of transmissible infections e.g. MRSA or HCV should document.  The amount of bank bloods ordered for the patient should be noted.  If changes are made, a completely new list must replace the old list. 5. Planning the order of the operating list:  Latex allergy -> remove all latex containing products.  Paediatric patients -> minimise the period of fasting and reduce anxiety.  Diabetic patients -> make perioperative management as smooth as possible to minimise fasting period and return to normal diet and management. Preparation for a major surgery 1. History  Presenting complaint  Results of outpatient investigations. E.g. colonoscopy.  Systems review  Past medical history  Family history  Social history  Drug history. 2. Examination.