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Pre-operative Assessment and Preparation By Dr.Rashad Al-Kashgari Associate Professor of Surgery 2001 Pre-operative Assessment and Preparation Why ? How ? When ? What ? Pre-operative Assessment and Preparation WHY ? Elective operation should be performed under optimal condition with full physical and psychological preparation of a fully informed patient. Emergency operation may have to be done in less than ideal circumstances . Pre-operative Assessment and Preparation HOW ? History Physical exam Investigation Pre-operative Assessment and Preparation WHEN ? Out patient visit Pre-operative ward round ER Pre-operative Assessment and Preparation WHAT TO DO ? . Six tasks To explain to the patient / relative the nature of the illness , implications of surgery and prognosis Identification of potential operative mortality and postoperative morbidity To assess the fitness for operation Identification of the risks of potential postoperative complications and prophylactic measures . Planning of operation and consent Task one To explain to the patient / relative Nature of surgery Implication of surgery Alleviate fear/anxiety of the patient Prognosis Task two Identification of potential operative mortality and morbidity Look for the risk factors? Risk factors of mortality and morbidity Myocardial infarction Pregnancy Thrombogenic drugs Smoking Previous anesthetics Allergies Avoid op.whenever possible for at least 6 months Elective op. is avoided.Risk of miscarriage & teratogenicity Steroids & pills Suxamthonium/halothane Penicillin/Iodine-containing drugs Task three To assess the fitness for operation Assessment of general condition Assessment of metabolic state Assessment of cardiovascular system Assessment of respiratory system Assessment of renal system Assessment of general condition Careful clinical exam. Pulse rate B.P. Full blood count Serum urea & electrolytes Blood group & save serum X-match blood if needed Assessment of metabolic state Height Weight Problems associated with obesity : Venepuncture Anatomical landmarks Respiratory problems Thromboembolism Wound infection Wound dehiscence Assessment of cardiovascular system Clinical exam of heart and vessels ECG Echocardiogram Cardiovascular conditions Increase risk of CVA/MI Hypertension Myocardial ischaemia Avoid techniques /drugs which increase heart rate/diastolic B.P/perfusion gradient Cardiac arrhythmias Discuss with cardiologist pre-op Valve disease/septal Cover with antibiotics defect Hypovolemia Restore blood volume pre-op Assessment of respiratory system Clinical exam of chest CXR Sputum for bacteriological exam Blood gases Pulmonary function tests: FEV1 FVC Respiratory conditions Chronic bronchitis Suffer HYPOXEMIA.DO blood gases High risk patients-consider only for urgent op . Asthma Brochiectasis Common cold At risk of post-op respiratory failure.Give bronchodilator. Best index: FEV1/FVC X100 Physiotherapy + Antibiotics (use local blocks instead of general anaesthesia) Cancel op. in acute phase Assessment of renal system Clinical examination Urinanalysis & microscopy Urine for microbiological examination Serum urea Serum creatinine Renal disorders Chronic retention Task four Identification of risks of potential post operative complications and prophylaxis Pulmonary collapse and Pre-op breathing exercises infection Cardiac complications Avoid excessive fluid post-op in all patients with cardiac ischemia or valvular disease Major causes are hypovolemia, Acute renal failure sepsis, jaundice and characterized by: (oliguria, dilute urine , & mismatched blood urea conc.<300 mmol/l) Task four (continue) Identification of risks of potential postoperative complications and prophylaxis (continue) Venous Thrombosis Wound infection Avoid compression of legs during and after op. If necessary,use graded compression stocking / low dose heparin 5000 I.u Q.12 hrs OR a single dose of LMW heparin Prophylactic antibiotics (Bactericidal best guess for offending organism,high doses,three doses..when? Task five Planning of the operation The operation should be properly named after full explanation to the patient and the side of operation is marked in case of bilateral parts. He/she should consent for it. The duration of hospital stay,convalescense and time off work should be indicated. CONSENT Explain to the patient in simple non medical language what is going to be done. Alleviate his/her fears. Do not deceive the patient. Reassure the patient Task six Pre-operative orders Keep NPO (Nil per Oral) from ??:00 hrs Medications Essential Prophylaxis Prepare area for surgery Cleaning Shave Enema Etc