Sugong Chen June 22 2015 When does it start As soon as you meet the patient Remember we are surgeons so every patient is a potential surgical candidate Why is it important Identifies patients who might require a more extensive preoperative evaluation ID: 710282
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Slide1
Preparing Patients for the Operating Room
Sugong Chen
June 22, 2015Slide2
When does it start?
As soon as you meet the patient!
Remember we are surgeons so every patient is a potential surgical candidate Slide3
Why is it important?
Identifies patients who might require a more extensive preoperative evaluation
Predicts post operative complications and morbidity/mortalitySlide4
Top patient risk factors most predictive of post operative mortality
VARIABLE
ODDS RATIO
95% CI
14 Private Sector Hospitals (
N
= 54,450; C-index = 0.934)
ASA 4/58.16.0-11.0ASA 33.52.7-4.7Albumin g/dL0.620.56-0.69Emergency operation2.62.2-3.1Age/yr1.041.03-1.04Platelet count <150,0001.91.6-2.2Disseminated cancer2.92.3-3.7Dyspnea at rest1.61.3-2.0Dyspnea with minimal exertion1.31.0-1.5DNR3.92.6-5.8BUN >40mg/dL1.31.0-1.6Work RVU/unit1.021.01-1.03
128 VA Hospitals (
N
= 129,546; C-index = 0.900)
ASA 4/5
5.3
4.3-6.6
ASA 3
2.6
2.2-3.2
Albumin g/dL
0.6
0.57-0.63
Emergency operation
2.0
1.9-2.2
Disseminated cancer
3.3
2.9-3.8
Age/yr
1.04
1.03-1.04
Work RVU/unit
1.05
1.04-1.05
Dyspnea at rest
1.4
1.2-1.6
Dyspnea with minimal exertion
1.3
1.2-1.5
DNR
2.8
2.4-3.3
Ascites
2.3
1.9-2.7
BUN >40mg/dL
1.4
1.2-1.6Slide5
ASA Classification
I -- Normal healthy patient
II -- Patient with mild systemic disease
III -- Patient with severe systemic disease that limits activity but is not incapacitating
IV -- Patient who has incapacitating disease that is a constant threat to life
V –
Moribound
patient is not expected to survive 24 hours with or without an operationSlide6
Key components
Chief Complaint and History
Past medical and surgical history
Allergies
Medications
Review of Systems
Physical Exam
Appropriate Labs and Studies Slide7
Is patient stable
ABC
Vitals
Monitors
Imaging
Resuscitate as neededSlide8
Key Component: History
Get the details and summarize pertinent details
LOCATES
Don’t forget pertinent negatives
PMHx
PSHx
SocHxSlide9
Key Component: Allergies
Drugs
Contrast
LatexSlide10
Key Component: Medications
Important to know for
peri
-op care
Cardiac
Glucose control
Antihypertensives
AnticoagulationAnti-platelet therapiesSlide11
Key Component: Review of Systems
Constitutional/ General
Eyes
Ear, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary Musculoskeletal IntegumentaryNeurological PsychiatricEndocrineHematologic/ lymphaticAllergic/ immunology Slide12
Exam
Heart
Lungs
Pulses
Abdomen
Scars, bowel sounds, distension, tenderness, location, peritoneal signs (guarding, rebound)
Etc.
ImagingLabsSlide13
Informed consent
Blood
Pre printed forms that detail the risks of blood transfusion
Operative/ Invasive
Generic forms
Procedure specific forms
Must list the risks associated with the procedure and generalized risks as well as benefitsSlide14
Pre-op Note
PRE-OP
DIAGNOSIS:
PROCEDURE: planned surgery.
LABS: CBC, chemistries,
PT/INR,
urinalysis, etc.
CHEST X-RAY: note findings.EKG: note findings.ADDITIONAL STUDIES: echo, imaging, etc.BLOOD: not needed, type/screen or type/cross 2 units packed RBCs, etc.ORDERS: NPO, preoperative antibiotics, skin or colon preps, etc.CONSENT: signed and on chart / CSOC.Slide15
Pre-op Orders/ Considerations
CXR
EKG
Labs
Type and screen/cross
Anticoagulation reversal
Diet- NPO after midnight versus Hold tube feeds on call to OR.
Maintenance IVF while NPO Special orders- bowel preps, ostomy site marking etc. Slide16
Prior to going to the OR, all patients need…
Full H&P within 30 days of the operation
Unless they are an inpatient
Interval H&P morning of surgery
Consent for the operation/blood
Type and screen
Pre-op orders
NPOMIVFAntibiotics on call to OR (if needed)Appropriate labs