aishah awatif haziq
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Pre-operative evaluation and preparation (prior to procedure under general anesthesia)

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Aishah Awatif Haziq. Pre-operative evaluation and preparation (prior to procedure under general anesthesia). Introduction . Anaesthesia = absence of all sensation Analgesia = absence of pain

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  • Anaesthesia = absence of all sensation
  • Analgesia = absence of pain
  • General anaesthesia = a state where all sensation is lost and the patient is rendered unconscious by drugs.
  • GA should be performed by qualified anasthetists in a hospital setting with access to appropriate medical support.
assessment of risk
Assessment of risk
  • Patient should be made as fit as possible for the operation.
  • The anticipated benefit should outweigh the anesthetic and surgical risks involved.

Overall mortality rate ≈ 1 in 100 000

  • Surgical mortality ≈ 1 in 1000
  • Factors contribute to this mortality:
    • Poor preoperative assessment
    • Inadequate supervision and monitoring in the intraoperative period
    • Inadequate postoperative care
aims of pre operative evaluation and preparation
Aims of Pre-operative evaluation and preparation
  • To provide diagnostic & prognostic information.
  • To ensure the patient understands the nature, aim, and expected outcome of surgery.
  • To relieve anxiety and pain.
  • Ensure that the right patient gets the right surgery.
  • Get informed consent.
  • Assess/balance risks of anaesthesiaans maximize fitness.
  • Check anaesthesia/analgesia type with anesthesia.
  • Past medical history:
    • Asthma
    • Diabetes
    • Tuberculosis
    • Seizures
    • Chronic organ dysfunction
    • HIV infection
    • Drug allergy
    • DVT
    • Post-operative nausea and vomiting
drug history
Drug history
  • Drug interactions
    • Anticoagulant might be contraindicated to spinal, epidural or other regional techniques
    • Anticonvulsants might increase the requirements for anasthetic agents, enflurane should be avoided as it might precipitate seizures
    • Beta-blockers – negative ionotropic effect – hypotension

Corticosteroids – extra cover might be needed

  • Diuretics – might have hypokalaemia
  • Insulin – careful monitoring of plasma glucose
  • Antibiotics: tetracycline and neomycin may ↑ neuromuscular blockade.
social history
Social history
  • Ceasing smoking 12h before surgery can improve the oxygen carrying capacity of the blood.
  • Excessive alcohol – hepatic and cardiac damage
family history
Family history
  • Hereditary traits:
    • Haemophilia
    • Porphyria
    • Cholinesterase abnormalities – prolongation of muscle relaxants such as suxamethonium
physical examination
Physical examination
  • Assess cardiorespiratory system, exercise tolerance, existing illness, drugs, and allergies.
  • Is the neck unstable (eg; arthritis complicating intubation?)
  • Assess past history of; MI, diabetes, asthma, hypertension, rheumatic fever, epilepsy, jaundice.
  • Assess any specific risk, eg is the patient pregnant? Is the neck/jaw immobile and teeth stable (intubation risk)?

Has there been previous anaesthesia?

  • Were there any complications (eg nausea, DVT)?
  • Is DVT/PE prophylaxis needed?

Indications of preoperative investigations

  • Full blood count
    • anaemia
    • females post menarche
    • cardiopulmonary disease
    • possible haematological pathology, e.g.
    • haemoglobinopathies
    • likelihood of significant intraoperative blood loss
    • history of anticoagulants
    • chronic diseases such as rheumatoid disease

Clotting screen

    • liver disease
    • anticoagulant drugs or a history of bleeding or
    • bruising
    • kidney disease
    • major surgery
  • Urea and electrolyte concentrations
    • major surgery >40 years
    • kidney disease
    • diabetes mellitis
    • digoxin, diuretics, corticosteroids, lithium
    • history of diarrhoea and vomiting

Liver function tests: these will be carried out when there

    • is any suspicion of liver disease
  • ECG
    • >40 years asymptomatic male or >50 years asymptomatic female
    • history of myocardial infarction or other heart or vascular disease
    • <40 years with risk factors e.g. hyperlipidaemia, diabetes mellitus, smoking, obesity, hypertension and cardiac medication
  • Chest radiography
    • breathlessness on mild exertion
    • suspected malignancy, tuberculosis or chest infection
    • thoracic surgery
pre op therapy
Pre-op therapy
  • Pt with respiratory disease – physiotherapy or bronchodilator therapy
  • Infective endocarditis – prophylactic antibiotic
  • Hypertension – adjustment of drug therapy to obtain optimal control (diastolic pressure below 110 mmHg)
postponement of surgery
Postponement of surgery
  • Pt with acute upper resp tract infection
  • Cardiac/endocrine diseases that are not yet under optimal control
  • Elective surgery should not be undertaken unless:
    • Pt has fasted for 6h for solid food, Infant formula or other milk
    • 4h for breast milk
    • 2h for clear non-particulate and non-carbonated fluids
pre medication
  • benzodiazepines – anxiolysis, anterograde amnesia
  • Anticholinergic drug – reduce excessive secretions in the airway
  • Antiemetic
  • Antihistamine
  • Metoclopramide - enhance gastric emptying
  • Sodium citrate, H2 blockers, proton pump inhibitor – reduce gastric acidity
preparation for anesthesia
Preparation for anesthesia
  • Fast patient.
    • Nil by mouth ≥ 2h pre-op for clear fluid and ≥ 6h for solids
  • Is there any bowel or skin preparation needed, or prophylactic antibiotic?
  • Start DVT prophylaxis as indicated, eg: graduated compression stockings + heparin 5000U sc 2h pre-op, then every 8-12h sc for 7d or until ambulant.

Write up the pre-meds; book any pre-, intra-, or post-operative x-rays or frozen sections. Book post-op physiotherapy.

  • If needed, catheterize and insert Ryle’s tube before induction. These can reduce organ bulk, making it easier to operate in the abdomen.