Introduction:
The presurgical consultation and evaluation are important aspects between the surgeon and the patient. However, the most important reason for the preoperative evaluation is to minimize complications and enhance quick patient recovery. The presurgical preparation depends upon the patient's condition, the type of anesthesia, and the nature of the surgery.
What Is the Rationale Behind Surgical Patient Preparation?
Inadequate patient preparation can contribute to detrimental effects during surgery. Hence, a safe and effective surgical practice mandates optimal patient preparation. The following are the reasons for the same:
1. Patient health assessment is paramount. An unknown underlying medical condition can be difficult to deal with during and after surgery. A thorough evaluation can mitigate the patient’s medical condition. It helps reduce the associated morbidity (disease state) and mortality (death).
2. Patient education about the surgery, anesthesia, and post-operative management reduces any anxiety related to the procedures. It enhances patient safety and minimizes any chances of errors.
3. Patient preparation facilitates the condition documentation for which the surgery is required.
It helps in risk determination during surgery. Also, advanced preparation of equipment and facilities can be made.
4. Developing a surgical plan facilitates cost reduction, shorter hospital stays, and increased patient satisfaction.
Enhanced recovery after surgery (ERAS) has been a novel perspective in surgical patient care for the last two decades. It involves an interprofessional team of surgeons, anesthesiologists, nurses, and other staff. ERAS programs are now a part of the standard surgical preparation to enhance postoperative outcomes. It is also called ‘fast-track surgery.’
What Are the Steps Involved in Surgical Patient Preparation?
The routine steps involved in surgical patient preparation are:
1. History: History is the most necessary part of the evaluation. It must include the current and past medical history, family history, habit history, and allergies (including those to anesthesia). In addition, a complete review of systems is pertinent to diagnose any new condition. Also, the cardiac and respiratory system evaluation for fitness and anesthesia is advocated. Drug history is also of utmost importance in elderly patients. Many drug interactions and complications arise in this age group. Some drugs require dose modification. On the other hand, certain drugs, such as Aspirin, oral anticoagulants, and oral contraceptives, should be withdrawn within a time limit before surgery.
2. Physical Examination: After the history, physical examination forms an important part. Airway, heart, and lungs assessment is done. Vital signs are recorded. Abnormal findings must be documented. It is especially important in the case of elective surgery.
3. Laboratory Investigations: All patients do not require a preoperative laboratory workup. Surgeons should conduct lab tests based on the history and physical examination findings. The patient’s age and the type of surgical procedure are the other key factors. Lab tests are also done to confirm the disease and its extent, exclusion of other diseases, and for medico-legal considerations.
4. Informed Consent: Patients have an unknown outcome in most emergency surgeries. It is important to set realistic expectations. Hence, informed consent is essential.
5. Perioperative Risk Assessment: Perioperative risk is the risk encountered during surgery. It is the function of the preoperative patient’s medical condition, the type of anesthesia, and the depth of surgery. Risk quantification is important in some patients. As a result, a discussion with the patient can be done regarding the risks. The American Society of Anesthesiologists (ASA) devised a physical status grading system for the patients. It is widely accepted. 50 percent of the elective surgery patients comprise ASA grade I. However, grades IV and V increase emergency surgery patients' risk. Cardiac, respiratory, and infectious complications occur mostly during or after surgery.
- Cardiac Risk Assessment: Some cardiac complications during surgery are myocardial infarction (heart attack), cardiac arrest, and complete heart block. Some basic tests include an electrocardiogram (ECG), complete blood count, renal function, electrolytes, and urine analysis. Presurgical cardiac testing is not required for elective surgery.
- Respiratory Risk Assessment: Spirometry (air inhalation-exhalation test) is done to assess lung impairment. Post-surgical lung complications occur in about 20 to 30 percent of the patients undergoing major surgery. Some examples are pneumonia, low blood oxygen, bronchitis (inflammation of the tubes carrying air to the lungs), and respiratory failure.
- Infectious Risk Assessment: Surgical site infection is the most common postsurgical infection. It leads to increased hospital stays and higher costs. Antibiotic prophylaxis is very important in some surgeries. Short-term antibiotics, such as Penicillin, are administered at least one hour before the procedure.
What Are the Preoperative Considerations in Patient Preparation?
Successful patient recovery is a team effort. The surgeon and the anesthesiologist are the main contributors to the outcome. Various preoperative considerations to be kept in mind are:
1. Patient Selection: Patient selection is the most important consideration. Surgeons must assess their physical fitness and nutritional status. In addition, an evaluation of organ function must be done.
2. Preoperative Fasting: A six-hour solid and two-hour liquid fasting before surgery is optimum. Mechanical bowel preparation (cleaning of the large intestine) is not necessary for all patients.
3. Preoperative Exercise: Preoperative exercise can reduce hospital stays. Also, there can be a reduction in cardiac and respiratory complications. Exercise improves lung muscles' function, mobility, and overall quality of life. Moreover, patient anxiety and fear are greatly reduced. Preoperative exercise therapy improves physical fitness before major surgery. In addition, chest physiotherapy helps to reduce postoperative respiratory complications.
4. Recreational Drugs Cessation: Smoking, alcohol, and recreational drugs require cessation before surgery.
- Cigarette smokers are at an increased risk of bleeding, wound infections, and severe cardiac and respiratory complications. Smoking cessation about six to eight weeks before surgery can reduce postoperative complications by 50 percent.
- Heavy alcohol consumers are at increased susceptibility to postoperative complications. Like cigarette smoking, alcohol withdrawal also must be made six weeks before surgery. Alcohol abstinence significantly reduces the chances of surgical site infection and wound separation.
- Cocaine is a nervous system stimulant with anesthetic properties. Therefore, immediate cocaine use before surgery can predispose the patient to cardiac complications. Also, a long-time cocaine user may need additional analgesia (pain-killer) doses.
- Methamphetamine is another recreational drug. It stimulates the nervous system for up to 12 hours. It can cause long-term nerve damage. Methamphetamine use should be avoided several days before surgery.
Further, psychological preparation is pertinent. It includes relaxation, stress management, and education.
Conclusion
Proper presurgical patient preparation ensures a favorable outcome for the surgeon and the patient. Therefore, patient preparation is vital to patient safety. It requires good patient cooperation to warrant the procedure’s success. Furthermore, the surgeon’s familiarity with preoperative care practices is elementary.
