Preparation of Patient for Surgery

Preparation of Patient for Surgery - The First Handshake

• Initial Contact: Build rapport; address patient concerns.
• Targeted History:
  • Key comorbidities: cardiac (IHD, HF), respiratory (COPD, asthma), renal, DM.
  • Medications: anticoagulants (stop/bridge?), antiplatelets, steroids (stress dose?), insulin.
  • Allergies & reactions.
  • Social history: smoking (cessation advice), alcohol, illicit drugs.
• Relevant Examination: General survey, vital signs, systemic exam pertinent to surgery.
• Informed Consent (Crucial):
  • Details: procedure, expected outcomes, common/serious risks, alternatives, anesthesia.
  • 📌 BRAIN: Benefits, Risks, Alternatives, Incision/Information, Nothing.
• Risk Stratification: ASA Physical Status (ASA I-VI) for perioperative risk.

⭐ Essential components of valid informed consent include disclosure, capacity, comprehension, and voluntariness.

Preparation of Patient for Surgery - Dodging Dangers

• Risk Stratification
  • ASA Classification:

    Class	Description
    ASA I	Healthy
    ASA II	Mild syst. disease
    ASA III	Severe syst. disease
    ASA IV	Severe dis., const. threat
    ASA V	Moribund, op last resort
    ASA VI	Brain-dead donor

  • Cardiac: RCRI >2 = ↑ risk. Components:

    Component
    HR surg
    IHD
    CHF
    CVA
    IDDM
    Cr >2 mg/dL

  • Pulmonary: Age >60, COPD, smoke, OSA.
  • VTE: Caprini score for prophylaxis.
• Preoperative Optimisation
  • Diabetes: Target HbA1c <7-8%.
  • Meds: Stop anticoag/antiplatelet (e.g. Warfarin 5d pre-op). Keep β-blockers.
  • NPO: Solids 6-8h, clears 2h. 📌 "2-4-6-8" (Clear-Breast-Formula-Solids).
  • Consent, Site Mark: Essential.

⭐ The ASA physical status classification is a crucial predictor of perioperative risk, independent of the surgical procedure.

Preparation of Patient for Surgery - The Pre-Op Checklist

• Consent: Verify signed informed consent.
• NPO Guidelines (📌 "2-4-6-8 rule"):

  Item	Duration Before Surgery
  Clear Liquids	2h
  Breast Milk	4h
  Infant Formula/Light Meal	6h
  Fried/Fatty/Meat	8h

• Investigations: Baseline: CBC, Blood group, Coagulation (PT/INR <1.5, aPTT), RFT, LFTs, Electrolytes. ECG (>40y/comorbid), CXR (if indicated).
• Medications:

  Medication	Action
  Anticoagulants	Hold (Warfarin 3-5d; DOACs 24-72h)
  Antiplatelets (Aspirin/Clopidogrel)	High cardiac risk: continue; else stop 5-7d
  Beta-blockers	Continue
  Oral Hypoglycemics	Hold AM dose
  Insulin	Adjust (e.g., 1/2 long-acting)
  ACEi/ARBs	Hold AM (per protocol)

• Site Marking: If applicable, by operating surgeon.
• Skin Prep: Antiseptic bath/shower; clip hair (no shave) pre-op.
• Prophylaxis: Prophylactic antibiotics (<60min pre-incision); VTE prophylaxis (mechanical/pharmacological).
• Anxiety: Anxiolysis/Premedication if required.

⭐ For elective surgery, patients can typically take clear liquids up to 2 hours before anesthesia induction.

Preparation of Patient for Surgery - Showtime Prep

• Final Verification: Patient ID, correct site/procedure, informed consent, NPO status confirmed.
• Surgical Site Marking:
  • Performed by a surgeon involved in the procedure.
  • Patient awake & aware, if possible.
  • Mark at/near incision site, unambiguous (e.g., "YES" or initials), visible after draping.
• Prophylactic Antibiotics:
  • Administer within 60 minutes before surgical incision; 120 minutes for vancomycin/fluoroquinolones. | Surgery Type | Common Prophylaxis | Notes | |-----------------------------------|--------------------------------------------------|------------------------------------------| | Clean (e.g., hernia repair, breast) | Cefazolin | | | Clean-contaminated (e.g., GI) | Cefazolin + Metronidazole (for anaerobes) | Or Cefoxitin/Ampicillin-Sulbactam | | Cardiac | Cefazolin / Vancomycin | Vancomycin if high MRSA risk/beta-lactam allergy |
• Skin Preparation: Antiseptic (e.g., povidone-iodine, chlorhexidine gluconate) applied, typically in expanding circles from incision site.
• Hair Removal: If necessary, use clippers immediately before surgery. Avoid razors (↑SSI risk).
• DVT Prophylaxis: Mechanical (e.g., SCDs) and/or pharmacological (e.g., LMWH) as per risk stratification.

⭐ Surgical site marking must be done by a practitioner involved in the procedure and while the patient is awake and aware, if possible, before non-emergent procedures.

High‑Yield Points - ⚡ Biggest Takeaways

• ASA classification is key for preoperative risk assessment.
• Advise smoking cessation at least 4-8 weeks before surgery to minimize pulmonary risks.
• Optimize glycemic control (HbA1c < 7%) in diabetic patients.
• Follow strict NPO guidelines (e.g., 2 hrs clear liquids, 6 hrs light meal) to prevent aspiration.
• Administer prophylactic antibiotics 30-60 minutes prior to surgical incision.
• Implement DVT prophylaxis based on individual risk assessment (e.g., Caprini score).
• Correct significant anemia and coagulopathy before elective procedures.