1. Preoperative evaluation of
surgical patients Part 1
Dr. Piyush Giri

2. Introduction
• Preoperative preparation is the preparation of
a patient requiring surgery to optimize
postoperative outcomes
• Begins from the time of contact of the patient
with the surgeon and ends on the day of
surgery
• The approach is multidisciplinary

3. Preoperative patient preparation
1. Gathering and recording: History,
examination, investigation, conclusion and
treatment plan
2. Planning to minimize risk and maximize
benefit for the patient
3. Being prepared for adverse events and plan
to how to deal with them
4. Communicating with patient and all other
members of the team

4. Patient assessment
• History
• Examination
• Investigations

5. History
• Presenting illness
• History of presenting illness
• Past medical history
• Drug history
• Social history

6. Examination
• General examination
• Cardiovascular system
• Respiratory system
• Gastrointestinal
• Neurological

7. • Explaining to the patient: discussing the
proposed management plan

8. Investigations
• Commonly needed investigations are
1. Full blood count : clinical diagnosis, anaemia,
blood loss
2. Urea and electrolyte:
>65 yrs, h/o of CVS, Pulmonary or renal
problems

9. 3. Liver function tests:
Jaundice, Infection, cirrhosis, clotting
problems, Portal Hypertension

10. • Hepatic risk:
• Predictors of mortality: Bilirubin (>2mg/dl),
Serum albumin (<3gm/dl), PT (>16secs),
Encephalopathy
• 40% mortality : if either of these present
• 80-85% mortality if 3 or more are present or if
bilirubin alone >4, albumin alone<2gm/dl, or
ammonia concentration > 150mg/dl

11. Investigations Contd.
4. Clotting screen: Anti coagulant therapy,
Abnormal LFT, bleeding disorder
5. Arterial blood gases: Acid- base abnormality
suspected or respiratory conditions
6. EKG: > 65 years, Past h/o of CVS, pulmonary
or anesthetic problems
7. Chest radiography: CVS and Pulmonary
problems

12. • Cardiac risk:
• Ejection fraction: <35% = incidence of MI 75-85%
and mortality 55-90%
• Goldman’s index: 11 points to raised JVP,
• 7 points to Premature ventricular contraction,
• 4 points to emergency surgery
• 3 points each to: Aortic valve stenosis, poor
medical condition, surgery within chest or
abdomen

13. • Interpretation of Goldman index and cardiac
complication
• <5 – 1%
• <12 – 5%
• <25 – 11%
• >25 – 22%

14. 8. Urinalysis: detects infections,
glycosuria, osmolarity, Haematuria
9. Beta- Human chorionic gonadotrophin:
in all female patients of childbearing age with
abdominal pain
or if she is unconscious

15. 10. Viral Serology: Hepatitis/ Human
immunodeficiency

16. NICE guidelines
• Guideline help guide appropriate routine
preoperative investigations
• Based on ASA grading and Surgery Grading

17. ASA Grading
• ASA Grade 1: Normal healthy patient
• ASA Grade 2 : A patient with mild systemic
disease
• ASA Grade 3 :A patient with severe systemic
disease
• ASA Grade 4 :A patient with severe systemic
disease that is a constant threat to life

18. • Grade 1 (minor): Excision of lesion of skin
• Grade 2 (Intermediate): Primary repair of
inguinal hernia
• Grade 3 (Major): Endoscopic resection of
prostate
• Grade 4 (Major +): Colonic resection;

19. SPECIFIC PREOPERATIVE PROBLEMS
1. Cardiovascular:
• Hypertension: BP: >160/95 mmHg: elective
surgery should be deferred
• Ischaemic heart diseases: recent MI is stong
contraindication,
significant mortality rate from anaesthesia if
within 3 months
elective surgery can be delayed upto 6
months

20. • Dysrhythmias: AF to be controlled, Heart
block: preoperative pacing, bipolar diathermy
should be used when possible
• Cardiac failure: Oxygenation and fluid balance
• Anaemia and blood transfusion: transfusion if
Hb < 8gm/dl

21. 2. Respiratory Problems:
• Infection: LRTI should be controlled before
surgery
• Asthma: Inhalers to be continued
• Chronic obstructive pulmonary disease:
regional anesthesia

22. 3. Gastrointestinal system.
BMI CLASSIFICATION
• <16 Severe malnutrition
• 16–16.99 Moderate malnutrition
• 17–18.49 Mild malnutrition
• 18.5–24.9 Normal
• 25–29.9 Overweight
• 30–34.9 Obese class 1
• 35–39.9 Obese class 2
• ≥40 Obese class 3

23. • Malnutrition:
Nutritional support for minimum 2 weeks,

24. MUST (Malnutrition Universal Screening) Tool:
BMI , Weight loss and Acute disease effect
Total: 6
0: low risk of undernutrition: routine clinical
care
1: Medium risk: Observe
2 or more : Treat: dietician or local policies, later
food fortification

25. • Obesity: BMI > 30
Advice to lose weight for elective procedure

26. • Regurgitation risk: in Hiatus hernia, bowel
obstruction, Paralytic ileus
decresed by Nil per oral: solid food 6 hours
and 2 hours for liquids
and also by: H2 receptor blockers and
Nasogastic tube insertion

27. • Jaundice: increased secondary complications:
Impaired clotting: Vitamin K
Renal failure: patient kept well hydration
Increased infection: prophylactic antibiotics

28. 3. Metabolic Disorder:
• Diabetes Mellitus: Are at high risk for
Complications,
• Improving Diabetic control
• Lipid lowering drugs
• Treating significant vascular stenosis
• For minor surgery: omiting morning dose, and
in insulin dependents: IV insulin given

29. • Adrenocortical Suppresion:
adrenocoritcal steroid> 2 months, need extra
doses at the time of surgery.

30. 4. Coagulation disorder:
INR to be < 1.5:
Warfarin: stopped 3-4 days earlier in Atrial
Fibrillation.
Is replaced with heparin where thrombosis is
significant, eg. Mechanical heart valve.
Asprin and Clopidogrel to be stopped before 1
week of surgery.

31. • Disseminated intravascular coagulation and
haemophilia to be treated accordingly.
• Prophylaxis against thrombosis:
• Mechnical: Early mobilisation, stockings, calf
and foot pumps.
• Pharmacological: Heparin and low molecular
weight heparin, Warfarin, Asprin

32. 5. Neurological and psychiatric disorder:
Anticonvulsant: to be continued
Psychiatrically disturbed: may require general
rather than regional
Tricyclic antidepressents and Monoamine
oxidase inhibitor to be discontinued: may have
unwanted interaction

33. 6. Locomotor disorder:
Most catastrophic being unstable cervical spine.
Disease modifying drugs may be continued in
Rheumatoid Arthritis

34. 7. Remote site infection:
from teeth or toe, to be treated preoperatively
or given appropriate antibiotic prophylaxis

35. Documentation
It should include:
• Clinical notes
• Investigations
• Management plan

36. Consent to be obtained, from person fully
conversent on planned surgery, alternative
and complication

37. Multiprofesional team Members
• For Theatre:
• Ward staff
• List organiser and circulator
• Theatre nursing staff
• Anaesthetic staff
• Radiology department
• Pathology department

38. • For Postoperative recovery:
• Rehabilitation staff
• Social care worker
• ITU/ High dependency unit staff
• Specialist nurse counsellor (stoma/
amputation)

39. • THANK YOU