Preoperative preparation

Preoperative preparation covers the period from the decision of surgical treatment to the transfer of the patient to the operating room. The period before the operation is mainly intended to examine the overall condition of the patient in order to complete and tolerate the operation in the best possible condition. Prior to urgent procedures, examination and preparation will be limited, the basic safeguards include stabilization of blood circulation to values ​​that will ensure perfusion of vital organs - brain and myocardium.

The goal of preoperative training is to create suitable conditions for uncomplicated healing with subsequent convalescence. Preoperative preparation includes general elements that must be met during each surgical procedure and special elements that depend on the diagnosis and type of operation.

In the preoperative period, the anesthesiologist meets the patient at the anesthesiology consul. The main tasks of an anesthesiologist are to evaluate the preoperative internal and complementary examination, get acquainted with the performance indication and surgical plan, check the ordered blood reserve, evaluate the risk on a scale according to the American Society of Anesthesiologists (ASA), prescribe prepremedication and premedication. , issue a plan anesthesia, create a record in medical records.

Preparation for the operation includes general universal training, general special training and local training.

General training
The role of the surgeon is to provide a sensitive description of the surgical treatment with possible risks and possible consequences. It is necessary to explain to the patient the procedures associated with special preoperative preparation, the type of anesthesia (general/local anesthesia), where the patient wakes up after the operation, or the postoperative course (drains, probes, coils, catheters, etc.). The average length of hospital stay and the possible impact of treatment should be approximated. In amputations, psychological preparation before the operation itself is important. The task of the medical staff is to create a suitable, calm and comfortable environment. Essential questions must be answered by the attending physician or surgeon and a record of the information must be made. With the operation, its risks and outcome, the patient or his legal representative must sign the so-called informed consent. In addition to providing information, the overall general training is based on the creation of homeostasis by modifying body fluids, minerals, nutrients and initiating rehabilitation. It is important to train physical activity, which affects the circulation, venous return (prevention thromboembolism), healing of surgical wounds, return of intestinal peristalsis.

Total special training
Its aim is to influence the consequences and specific risk factors.

Influence of consequences
GIT disease causes changes in water and mineral metabolism and nutritional disorders, and their adjustment is important because, with further damage to the body, they determine the course of the body's inflammatory response. Nutritional disorders are associated with a higher incidence of infections, impaired wound healing and the development of immune defects. Mineral support is especially important in patients with significant weight loss and when we expect a longer period of time when the patient is unable to take food through the enteral route (tumors, Crohn's disease).

Hepatobiliopancreatic disease with fat-soluble vitamins leads to lower production of  prothrombin with a blood clotting disorder. This disease causes digestive disorders, insufficient nitrogen resorption and  hepatocyte] disorders]. Bile accumulation can be affected by percutaneous transhepatic drainage, an established stent with transpapillary bile drainage, administration of [[glucose, lactulose, vitamin K and application  enemas.

Specific risk factors
Ancillary diseases pose risks to the safe conduct of anesthesia, surgery and wound healing.

Patients with pulmonary diseases are at risk in the postoperative period hypoxic condition to  pulmonary insufficiency, so the examination and assessment of the respiratory system is always part of the preoperative examination. Serious surgery requires blood gas tests and functional lung tests. In patients with acute lung disease, it is necessary to consider the indication for surgery, or to postpone the operation after the cure of lung disease. Preoperative preparation, which includes a smoking ban, is required for patients with chronic lung disease. In bronchiectasis, postdural drainage with bronchodilators and  expectorants with a combination of  antibiotics is important. A risk factor for respiratory complications is obesity.

In patients with heart disease, the need for surgery and the possibility of postponing it should be considered. The most serious problem is the indication of patient surgery after myocardial infarction. In the first 3 months after MI, the risk of new ischemia is up to 30%, after half a year 5%. Myocardial infarction, valve defects and angina pectoris are contraindications to surgery. To assess operational risk, the so-called Goldman's Index or NYHA Classification.

GOLDMAN'S INDEX contains factors and ratings:

S3, increased BP points: 11

IM for the last 6 months points: 10

More than 5 extrasystol / min points: 7

Non - sinus rhythm points: 7

Age over 70 points: 5

Urgent operation points: 4

Intraperitoneal, thoracic, aortic surgery points: 3

Aortic stenosis points: 3

Poor internal condition of the patient points: 3

RATING

0-5 points risk of heart complications and death less than 1%

13-25 points risk of complications 13% and death 2%

26 or more points risk of complications 78% and mortality 56%

Diabetes patients usually have high blood sugar levels in the preoperative period. The cause is trauma, mental stress, underlying disease, hypokalemia and lack of movement of lying patients. In the preoperative period, it is necessary to ensure that during the day glycemia up to 10 mmol/l and without acidosis, complete kidney examination, ECG, ensure treatment of the infection site, ensure glucose administration to prevent  hypoglycemic condition. Depending on the blood glucose level, we give an infusion of 5% glucose (25 g of glucose with 6 j insulin before the surgery to patients with [[Diabetes mellitus type 2 | DM type 2], with a blood glucose higher than 10 mmol/l the glucose dose is increased by 1 unit for each blood glucose increase of 2 mmol/l above 10). Preoperative blood glucose values ​​should not be higher than 10 mmol/l and lower than 4 mmol/l!

Surgery for patients suffering from adrenal disease can cause an Addisonian crisis with hypovolemia, mineral loss, hypotension, which can be fatal. These patients should be given corticoids and fluid volume and mineral balance monitored.

Oncological patients there is a high probability of thromboembolic complications, this risk also arises in orthopedic operations in the area of ​​large joints, long bones, pelvis, obese, women using hormonal contraception, long-term patients, patients with Varix varices, the elderly. Before the operation, we can prevent these complications by certain measures, which include elevation of the lower limbs to 15 degrees, which will reduce venous volume in the calf, training of active exercises and elastic compression (stockings). From anticoagulants, low molecular weight  heparin is used, which has a lower risk of bleeding than heparin. By default, the miniheparinization method is used, 5000 j before surgery and still once every 12 hours. Other substances use vitamin K antagonists ( Warfarin). Dextran and substances that affect blood viscosity (Ancord) are used to prevent venous thrombosis. Patients taking coumarin-type anticoagulants can only undergo surgery if their prothrombin time is above 25% and INR is below 1.5. If the values ​​are lower, it is advisable to administer vitamin K in a dose of 5 mg before surgery, which adjusts the prothrombin time within 2 days. In patients taking heparin, the effect of heparin must be neutralized with protamine sulphate before the emergency operation (amount mg ​​= number of heparin units divided by 100). If the operation is not urgent, it is enough to postpone the operation by 6-8 hours.

The central venous access allows the measurement of central venous pressure and the infusion of larger volumes. It is part of the preoperative preparation before surgery, which is expected to cause greater blood loss.

Bladder catheterization allows you to measure hourly diuresis.

Local training
The introduction of a nasogastric tube has several meanings: aspiration of gastric and duodenal contents, gastric toning occurs after removal of the contents, this has a beneficial effect on healing of anastomoses, reduces the risk of aspiration at the beginning of anesthesia, aspiration reduces pancreatic juice secretion. A 2 mm diameter najejunal probe is most often used for enteral nutrition.

Emptying the contents of the colon prevents its volume from increasing and prevents contamination of the peritoneal cavity and surgical wound. Enema cleansing of the intestine is used to clean the distal part of the intestine under an obstacle that obscures the intestine.

Orthograde preparation involves lavage with a hypertonic solution taken orally or gavaged. There are products (Golytely solution, Fortrans) that are used to clean the intestine without the possibility of electrolyte and fluid imbalance, these products are not used in patients with cardiac failure, dehydration, intestinal obstruction. Bowel emptying is also used before diagnostic procedures (X-rays, colonoscopy, rectoscopy).

Pre-operation skin preparation refers to the overall hygiene of the patient, the operating field and the washing of the hands of the surgical staff. The operating field gets rid of hair just before the operation, shaving a few hours before the operation increases the presence of bacterial flora. Various skin antiseptics are applied to the skin, and their selection is governed by hospital habits, patient tolerance, and the nature of the disease.

Before transporting the patient to the operating room, the nurse's task is to check the patient's consent to the procedure and anesthesia, hygienic measures, bandages, probes, coils, DK bandages, absence of dental prosthesis, removal of jewelry and nail polish removal.