18 terms

Pre-operative Care

Preparing the patient for surgery
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What is the goal of Preoperative Care?
'The goal of the evaluation of the healthy patient is to detect unrecognized disease and risk factors that may increase the risk of surgery above baseline and to propose strategies to reduce this risk.'
~uptodate
What are the components of Preoperative care?
Diagnostic Workup
Preoperative Evaluation
Preoperative Preparation
Components of the initial diagnostic work up?
-Should be focused on cause(s) of presenting complaints
-Supplemented with assessment of pt.s general health, looking for abnormals/operative risks
-Complete H&P
Diagnostic Work-up:
What does 'building the Hx with inductive reasoning' mean?
Inductive reasoning in this instance means to take all the pertinent findings and draw a conclusion specific to this instance that is the most "PROBABLE", but not the definite answer. A fancy way to say you gather the info that leads you to a most probable cause for your top DDX. *The conclusions you draw must be supported by your findings.
Diagnostic Work-up: Assess Pain.
Pain - one of the most important features of a surgical history
Pt.s rxn to pain is telling, truuly severe pain will result in a pt. who is hard to communicate with. Though, mild to moderate pain can be amplified by anxiety and fear.
**Pain can also be most responsive to reassurance
Diagnostic Work-up: Bowel work up.
- Any changes in bowel movements, recurrent changes from diarrhea to constipation... think colon cancer
-Hematemesis or Hematochezia: critical to consider, significant bleeding is critical. Blood character, clotting? bright red/dark? coffee ground emesis? dark tarry stool?
Diagnostic Work-up: Consider Trauma
A clear hx is crucial: weapon size, shape, trajectory.
Diagnostic Work-up: The Histories
-PMHx: be thorough and don't miss details
-Nutritional Hx: malnourished? electrolyte imbalance due to emesis and diarrhea?
-PsychHx: issues typically under-reported. Stress of surgery can illicit underlying psych problems
Diagnostic Work-up: Complete Physical Exam
-Use all your senses, use the 4 cardinal techniques of PE: inspection, palpation, percussion, auscultation
-Compare body parts symmetrically, left hand to right hand for example.
-Carefully inspect the patients hands as they can offer many clues.
-Touch the patient
-Examine every orifice as needed: opthalmoscope and sigmoidoscope
Preoperative Evaluation: Occurs in conjunction with the diagnostic work up:
-Complete assessment of Pt.s general health, again search for abnormalities and risk factors.
- Initially focus on risk factors identified in patients history, this will guide remainder of eval.
Preop Eval: Is age a factor?
Age is a risk factor for overall mortality, but the relationship between risk and age is linear, not exponential.
Age is also more physiological than chronological. Some 60 yo are physically more preserved than a 40 yo who has abused there body thoroughly.
Preop Eval: Have they taken care of their body? 6 risk factors to consider:
1-Exercise capacity: capable of 1-10 mets?
2-Obesity: increase risk of PE, CV surgery has higher risks.
3-Obstructive Sleep Apnea (OSA): the body becomes accustomed to less O2 and gradually deteriorates, hypoxemia, respiratory failure, unplanned intubation, ICU transfer. Commonly associated with obesity.
4- Alcohol abuse: Use AUDIT-C questionaire, increased risk of infection with high score.
5- Illicit drug use: duh! resistance to opioids, withdrawal.
6- SMOKING: increased risk of cancer and everything else bad that can happen.
Obesity Paradox:
Obesity is a major risk factor for cardiovascular disease (like hypertension, congestive heart failure, coronary artery disease) and chronic renal disease. However, in patients with these chronic diseases, it appears that obesity is associated with better survival.
Preop Eval: Any FamHx of anesthesia complications?
Malignant Hyperthermia: anesthesia causes an adverse reaction of the body heating up until patient dies.
-inherited
Preop Eval: Include CV, Pulm, and Neuro specific examination in your complete physical exam:
-Heart and Lungs: get a baseline for comparison and document
-examine peripheral perfusion and neuro
- Suspect PVD in pt. with Hx of TIAs, clauditcation, and/or diabetes.
Preop Evals: LABS
All indicated based on pt med hx:
-CBC for all pt over 65, and for younger pt if significant blood loss expected.
-CXR, EKG for pt >50yo
-Serum creatinine in pt >50yo, for renal function. serum creat >2.0 = CV risk
-Serum electrolytes:only indicated if HX
-Glucose: slightly hyper is better than hypo.
-LFTs are not rec'd unless HX calls for it
-Hemostais: not routinely done
-HCG: pregnancy test done in all women of reproductive age.
-ECG: good to have pre and post opp if CVD present, not needed if asymptomatic
Preop Eval: CXR
Indications: Not routinely indicated; CXRs recommended for patients with cardiopulmonary disease, >50 yrs, who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery
Preop Eval: Pulmonary Function
Generally reserved for patients who have dyspnea that remains unexplained after careful clinic examination
Clinical findings are more predictive
Indications: not indicated for healthy patients prior to surgery
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