NUR HAZIERAH

MUHAMMAD SYAZWAN

SUPERVISOR: MR. KUMAR

DR CHE AHMAD MUTTAQIN

OUR AIMS

(1) identify the patient's medical

problems

(2) determine if further information

is needed to characterize the patient's medical

status

(3) establish if the patient is medically

optimized

(4) confirm the appropriateness of

the planned procedure

Correct abnormalities

Informed consent

Details of Preparations

Lab Investigations

Cross-match blood

Physiotherapy

Breathing Exercise

DVT Prophylaxis

Anaesthetic Premedications

Principles of

Preoperative

Preparation

The Assessments

Full History

Examination

Lab Test

Radiographs

ECG

Appropriate Procedure

Risk factors associated with increased

perioperative mortality and morbidity

Age > 60 years

Arterial and pulmonary hypertension

Body mass index of <20 kg/m2 or >35 kg/m2

Congestive cardiac failure

Peripheral vascular disease

Diabetes mellitus

Renal insufficiency

Acute coronary syndromes

Chronic pulmonary disease

Neurological disease

Previous cardiac surgery

General Problems in Surgical Patients

• Extreme age

• Limits: cardiac, repiratory, renal reserve

• Smaller doses of narcotics, sedatives & analgesics

Age

• Affects wound healing

• High incidence of respiratory problems

• DVT & Pulmonary embolism are common

• Bedsores

Obesity

• Reduced response to trauma & infection

• Causes: Immunosuppressive drugs, uremia. Malnutrition or liver disease

Compromised Host

General Problems (cont.)

• Sensitivity to sedatives, anaesthetic, antibiotic drugs or dressing

• Unexpected reaction might occur

• Severe cases -> Anaphylactic shock

Allergies

• Diabetics might need to change to sliding scale

• Patient on steroids may need additional cover during major surgery

• Adjustment anticoagulant therapy

• Warfarin -> Heparin (perioperatively)

• Clopidogrel contraindicated in regional anaesthesia (causing epidural hematoma)

• Acetylcholine & ATH Inhibitor (Antithrombin + Heparin inhibitor) should stop 24hours before surgery to prevent severe & refractory hypotension

Drugs

CO

MO

RB

ID D

ISE

ASE

CARDIOVASCULAR DISEASE

RESPIRATORY DISEASE & SMOKING

MALNUTRITION, ADHESION AND JAUNDICE

RENAL DISEASE

HEMATOLOGICAL DISEASE

OBESITY

DIABETES MELLITUS

ASA Physical Status Classification System

1• A normal healthy patient

2• A patient with mild/moderate systemic disease

3

• A patient with severe systemic disease which limits activities

4

• A patient with severe systemic disease that is a constant threat to life

5

• A moribund patient who is not expected to survive without the operation

6

• A declared brain-dead patient whose organs are being removed for donor purposes

Routine testsBio

chem

istr

y

• Electrolytes

(Na+, K+), urea, creatinine

• Glucose (RBS/CBS)

• Liver function tests

Haem

ato

logy • FBC

• Coag. studies

(PT, APTT, INR)

Imagin

g/ O

thers • CXR

• Resting ECG

• Pulmonary function tests (spirometry)

PRE-OPERATIVE INVESTIGATIONSPatient status ECG CXR BUSE FBC RBS LFT COAG

<50years, ASA 1 No investigations needed

>50 years, ASA 1 X

>60 years, ASA 1 X X X X

Diabetes X X X X

HPT, IHD X X X

Anemia X

Renal disease X X X

Liver disease X X X X

Haematological disease X X

Respiratory disease X

Alcohol abuse X

On Chemotherapy X

On Anticoagulants X

Procedures with blood loss >15% X X

PROPHYLACTIC MEASURES AGAINST COMMON

POST OPERATIVE COMPLICATONS

• Antibiotics before op such as IV Rocephine and Flagyl

Surgical infections

• Chemical – Heparin

• Mechanical –compression stokings

DVT

• Adequate renal perfusion

• Adequate oxygenation

Renal failure

REASONS FOR ANESTHETIC REFERRAL

Allergy or intolerance to certain substances, drugs or classes of drugs

Documented allergy to anesthetic drugs, analgesics, localanesthetics or muscle relaxants

Instability or immobility of the cervical spine

Rheumatoid arthritis, Down’s syndrome, Ankylosing spondylitis

Previous instrumentation of the cervical spine

Known or potential difficult airway

Limited jaw opening (temperomandibular joint arthritis, trismusrelated to oral or submental sepsis, previously wired teeth, facialradiotherapy or burns, previous reconstructive surgery tomandible, tongue or mouth).

Small mandible

Large tongue (acromegaly, morbid obesity)

Difficult venous access

Previous chemotherapy

Abusers of intravenous drugs

Burns to upper limb

Severe and widespread skin disorders (psoriasis, epidermolysis

bullosa, pemphigus, pemphigoid)

Morbid obesity

Clotting disorders

Treatment with anticoagulant or anti-platelet drugs

Haemophilia and variants

Platelet disorders

ASSESSMENT OF THE LIKELY IMMEDIATE

POST-OP COURSE & THUS THE NEED FOR

HDU/ICU SUPPORT

Circumstance in which patients requiring ICU care

postoperatively:-

When an operation causes major physiological disturbances

requiring close monitoring and /or organ support (e.g. major

surgery)

When an unexpected major medical or surgical complication

occurs during surgery, threatening organ dysfunction (e.g.

intraoperative haemorrhage and myocardial infarction)

When previous intercurrent disease compromises physiological

reserve (e.g. patient with severe COPD undergoes major

abdominal surgery)

PART II: SURGICAL

CONSENT

Informed consent serves to identify and respect a

patient’s best interest by giving each patient the

opportunity to decide autonomously what his/her

best interest are in light of the planned

procedure.

SURGICAL CONSENT

CONSENT

Important because:

i) Rights of the patient

ii) Patient education

iii) Prevent misunderstanding

iv) Prevent medico-legal cases

INFORMED CONSENT

INFORMING THE PATIENT

IN GENERAL

Should presented clearly as possible

Include discussion of the diagnosis

Should include explanation of the procedure

Explanation of risks

Benefits

Potential consequences of the procedure

Treatment options

Alternatives to treatment (including nonsurgical management or non

intervention)

The consent process can technically be done

without satisfying any of the essential elements of

the “informed” component

Permissible for actual signature to be obtained by

resident, physician assistants after surgeon

properly informed the patients.

the actual informed consent documents need to

fullfill a number of criteria (table 2)

OBTAINING CONSENT FROM THE PATIENTS

Essential Components of

Documenting Consent

What is Legally Effective

Informed Consent

Under ordinary circumstances, legally effective

informed consent is obtained by reviewing the

approved informed consent with the subject,

answering any questions, and getting the subject’s

signature.

Subject Unable to Consent

• What if the subject

• Lacks capacity

• Has diminished decisional capacity

• Is a minor

• Is unconscious

Who is a Legally

Authorized Representative

• Legal Guardians

• Healthcare Surrogates

• Proxies

• Attorneys-in-fact

Other Considerations:

• Patient may refuse an operation because he/she unable to make decision

• Surgeon should explore with the patients the reason for refusing this gives some insight into patient’s thought process.

PATIENT REFUSAL

• Cognitive dysfunction, psychiatric illness

• Should consult with psychiatrists, lawyers, or other physicians goal is to improve the patient’s decision-making capacity. Not to simply obtain that the patient needs a proxy decision-maker.

DIMINISHED CAPACITY

• Korean americans, japanese americans, mexicanamericans

• Believe that terminal diagnosis relevant to treatment should be withheld from patient, and instead communicated only with the patient’s family.

CULTURAL AND FAMILIAL ISSUES