Surgery: Pre-Op Evaluation
Lori Meyers, MDAssistant Professor of Anesthesiology
LSI Part 2Understanding Patients with Reproductive and Surgical Needs
Learning Objectives Evaluate and treat patients with common surgical
problems in all phases of their care. Evaluate the impact of patient and surgical factors on
preoperative planning, healing and recovery for the following conditions:
Obesity
Chronic medical conditions
Diabetes
Anticoagulation
Stress
Infection
Surgical complications
Transfusion
Socioeconomic factors
Surgical trauma (including MIS)
Surgical technique and resources and anesthesia
Learning Objectives Evaluate and treat patients with common surgical
problems in all phases of their care.
Prevent and manage postoperative complications:
Exacerbation of comorbid conditions
Infection
DVT & DVT Prophylaxis
Bleeding
Learning Objectives Decide between medical and surgical intervention
for patients with common signs and symptoms.
Evaluate and discuss the management of various bleeding disorders: Hemophilia, Von Willebrand’s disease Qualitative and quantitative platelet deficiencies Disseminated intravascular coagulation Hypofibrinogenemia Immune thrombocytopenic purpura Hemolytic uremic syndrome
Learning Objectives
Differentiate hematologic disorders associated with the spleen and the role/indications for splenectomy and perioperative considerations (i.e. immunizations, Overwhelming Post-Splenectomy Sepsis OPSS)
Integrate causes of immunosuppression and the relationship of immune status to management of the perioperative patient.
Learning Objectives
Develop understanding of the pathophysiology of skin and wound healing.
Discriminate factors that positively or negatively impact wound healing.
Outline diseases (i.e. connective tissue disorders, etc.) that impact wound healing.
Relate how glucose control affects risk of perioperative infection and wound healing.
Relate the impact and assessment of nutritional status on perioperative patients and wound healing.
Learning Objectives
Develop understanding of the surgical and/or obstetric management of patients in order to critically evaluate and improve upon the care administered
Learning Resources
Jarrell, Bruce E & Carabasi, R Anthony (2008). NMS Surgery (5th ed). Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia: London
Hines, Roberta L. & Marschall, Katherine (2012). Stoelting's Anesthesia and Co-Existing Disease (6th ed.) Saunders, an imprint of Elsevier Inc: Philadelphia
Foundational Science
Even though this module deals with many clinical issues some of the basic science topics covered will include:
Pathophysiology of organ systems
Physiology and progression of possible complications that occur with surgery and anesthesia
Pharmacology for select medications
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Malnutrition Diabetes CAD COPD Liver Disease Renal Disease Infection Coagulopathies and hypercoagulable states Socioeconomic issues
Medical and surgical conditions associated with obesity
Organ System
Respiratory system
Cardiovascular system
Comorbid ConditionsObstructive sleep apneaObesity hypoventilation syndromeRestrictive lung disease
Systemic hypertensionCoronary artery diseaseCongestive heart failureStrokePeripheral vascular diseasePulmonary hypertensionHypercoagulable syndromesHypercholesterolemiaHypertriglyceridemiaSudden death
Obstructive Sleep Apnea: Risk Factors
S – Snoring History
T – daytime Tiredness
O – Observed Obstruction
P – high blood Pressure
B – BMI > 35 kg/m2
A – Age > 50
N – Neck circumference > 40 cm
G – male Gender
Medical and surgical conditions associated with obesity
Organ System Endocrine system
Gastrointestinal system
Musculoskeletal system
Comorbid ConditionsMetabolic syndromeDiabetes mellitusCushing’s syndromeHypothyroidism
Nonalcoholic steatohepatitisHiatal herniaGallstonesFatty liver infiltrationGERD, delayed gastric emptying
Osteoarthritis of weight-bearing jointsBack painInguinal herniaJoint pain
Medical and surgical conditions associated with obesity
Organ System
Malignancy
Other
Comorbid ConditionsPancreatic
Kidney
Breast
Prostate
Cervical, uterine, endometrial
Colorectal
Kidney failure
Depression
Overall shorter life expectancy
Modified from Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth. 2000;85:91-108.
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues
Pre-op Evaluation: Planning for Surgery
Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion The hospital’s/center’s resources
Pre-op Evaluation: Planning for Surgery
Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion The hospital’s/center’s resources
Pre-op Evaluation: Planning for Surgery
Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion The hospital’s/center’s resources
Pre-op Evaluation: Planning for Surgery
Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion The hospital’s/center’s resources
Pre-op Evaluation: Planning for Surgery
Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion
Febrile/allergic reactions ABO incompatibility Delayed hemolytic reaction Disease transmission Electrolyte disturbances and coagulopathy TRALI / TACO Increase in recurrence of cancer
The hospital’s/center’s resources
Pre-op Evaluation: Planning for Surgery
Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion The hospital’s/center’s resources
Pre-op Evaluation: Recovery Considerations
Common Post-op Complications Exacerbation of comorbid conditions Infection Bleeding
From surgery From patient co-morbidity From DVT prophylaxis or other patient medications Transfusion reaction DIC
DVT / PE
Pre-op Evaluation: Recovery Considerations
Common Post-op Complications Exacerbation of comorbid conditions Infection Bleeding
From surgery From patient co-morbidity From DVT prophylaxis or other patient medications Transfusion reaction DIC
DVT / PE
Pre-op Evaluation: Recovery Considerations
Common Post-op Complications Exacerbation of comorbid conditions Infection Bleeding
From surgery From patient co-morbidity From DVT prophylaxis or other patient medications Transfusion reaction DIC
DVT / PE
Pre-op Evaluation: Recovery Considerations
Common Post-op Complications Exacerbation of comorbid conditions Infection Bleeding
From surgery From patient co-morbidity From DVT prophylaxis or other patient medications Transfusion reaction DIC
DVT / PE
Pre-op Evaluation: Factors That Influence Healing
Diabetes Nutritional status
Malnutrition Obesity
Jaundice Renal dysfunction
Uremia
Pre-op Evaluation: Factors That Influence Healing
Diabetes Nutritional status
Malnutrition Obesity
Jaundice Renal dysfunction
Uremia
Pre-op Evaluation: Factors That Influence Healing
Diabetes Nutritional status
Malnutrition Obesity
Jaundice Renal dysfunction
Uremia
Pre-op Evaluation: Factors That Influence Healing
Immunosuppression Steroids Chemotherapy / radiation
Smoking, COPD Connective tissue disorders
Ehler-Danlos
Excessive bleeding/clotting
Pre-op Evaluation: Factors That Influence Healing
Immunosuppression Steroids Chemotherapy / radiation
Smoking, COPD Connective tissue disorders
Ehler-Danlos
Excessive bleeding/clotting
Pre-op Evaluation: Factors That Influence Healing
Immunosuppression Steroids Chemotherapy / radiation
Smoking, COPD Connective tissue disorders
Ehler-Danlos
Excessive bleeding/clotting
Pre-op Evaluation: Factors That Influence Healing
Immunosuppression Steroids Chemotherapy / radiation
Smoking, COPD Connective tissue disorders
Ehler-Danlos
Excessive bleeding/clotting
Pre-op Evaluation: Special Considerations
Patients with bleeding disorders Medical treatment vs. surgical treatment
Disorders of the spleen Splenectomy indications Splenectomy consequences
Immunosuppressed patients
Pre-op Evaluation: Special Considerations
Patients with bleeding disorders Medical treatment vs. surgical treatment
Disorders of the spleen Splenectomy indications Splenectomy consequences
Immunosuppressed patients
Pre-op Evaluation: Special Considerations
Splenectomy indications Massive splenic trauma or rupture Splenic abscess Primary splenic tumor Splenic cyst Disorders of splenic flow (esophageal varices) Hereditary spherocytosis Relative indications include but are not limited
to TTP, ITP, sickle cell anemia, and primary hypersplenism
Pre-op Evaluation: Special Considerations
Splenectomy consequences Atelectasis of left lower lung Injury to stomach or pancreas during surgery Post operative hemorrhage Sub phrenic abscess Thrombocytosis Overwhelming post splenectomy sepsis
Pre-op Evaluation: Special Considerations
Patients with bleeding disorders Medical treatment vs. surgical treatment
Disorders of the spleen Splenectomy indications Splenectomy consequences
Immunosuppressed patients Previous transplant Steroids Chemotherapy and radiation Diseases such as HIV and EBV
Summary
There are many comorbidities patients have that can affect their perioperative care and postoperative course.
Being aware of the risk these comorbid conditions cause and taking steps to mitigate them can improve patient outcomes.
Formative Quiz
Question 1 A 53 year old male has recently been diagnosed with an aggressive renal cancer. He had a DES stent placed in his right coronary artery 6 months ago and is currently on clopidogrel and aspirin. What is the correct preoperative management for this patient?
Correct Answer Schedule surgery urgently. Stop Plavix for 7 days preoperatively and continue aspirin as scheduled.
This is the current recommendation to minimize risk of perioperative bleeding and perioperative stent thrombosis.
Distractor 1 Schedule surgery in 6 months.
An aggressive cancer can become non-resectable in 6 months.
Distractor 2 Stop Plavix and Aspirin and proceed to surgery in 7-10 days.
This will greatly increase the risk of perioperative stent thrombosis.
Distractor 3 Proceed to surgery immediately and give FFP and platelets for bleeding problems perioperatively.
This will greatly increase the risk of perioperative bleeding.
Formative Quiz
Question 2 All of the following are risk factors for obstructive sleep apnea (OSA) EXCEPT:
Correct Answer Female gender Males are at greatest risk
Distractor 1 BMI > 35kg/m2 This is a risk factor
Distractor 2 Hypertension This is a risk factor
Distractor 3 Age > 50 This is a risk factor
Formative Quiz
Question 3 A 15 year old male presents for urgent appendectomy. He had a splenectomy 12 months ago s/p an ATV rollover accident. All of the following are true EXCEPT:
Correct Answer The patient should have been revaccinated for Hepatitis B post splenectomy.
These patients need protection from encapsulated bacteria, not viruses.
Distractor 1 The patient is at increased risk for sepsis.
True for many reasons: post splenectomy and appendicitis being 2 big reasons.
Distractor 2 The patient should receive preoperative prophylactic penicillin.
This is a specific post splenectomy recommendation.
Distractor 3 The patient should have received a polyvalent pneumococcal vaccine post splenectomy.
This is a specific post splenectomy recommendation.
Formative QuizQuestion 4 A patient in the preop holding area has a history of
Type 2 Diabetes. He is scheduled for a partial colectomy and his glucose level in preop is 240. How should you proceed?
Correct Answer Start an regular insulin drip and check glucose levels every hour during the surgery.
Of all the options, this one is the best for maintaining tight glucose control.
Distractor 1 Cancel the surgery. The patient’s glucose is not controlled.
The glucose level is high, but not high enough to cancel surgery.
Distractor 2 Proceed with surgery without intervention. The patient hasn’t eaten so the level will decrease on its own.
Glucose levels may actually climb from the stress of having surgery.
Distractor 3 Give a sliding scale dose of lispro insulin and check glucose level in recovery.
This option does not provide enough vigilance and glucose control.