Preoperative preparation of the surgical patient

Preparation of the surgical patient begins with a consideration of all phases of surgical care when preparing a patient for surgery. Classic preoperative, intraoperative, and postoperative phases should be on the mind of the surgeon when developing their recommended surgical therapy. Initial presentation of the patient often reveals considerable information about the physical and mental state of the patient and should help guide the surgeon in recommending the most appropriate therapy to achieve the desired therapeutic goal. Shared decision-making models should take into account concerns about the intraoperative and postoperative phases of care when a surgeon and patient decide upon the surgical options and desired treatment goals during the preoperative phase.

The preoperative phase should be considered as two distinct phases, each with a different goal and thought process. The surgical planning phase begins with the diagnostic workup, followed by the identification of pathology and the exploration of treatment options. During this phase, the surgeon and patient are engaged in continual dialogue about the patient's goals, the various treatment options, and their respective risks, benefits, and likelihood of successful treatment. Options of expectant management, medical, alternative, and surgical treatments, to name a few, should be explored with the patient. The patient's pathology, state of health, and comorbidities must be carefully considered and weighed against the considered treatments and resulting recovery period. If surgical intervention is necessary, open, minimally invasive, endoscopic, or endovascular surgical options should be weighed against overall procedure length, anesthesia considerations, and immediate postoperative care requirements. This entire process is considered shared decision-making and results in the informed consent of a patient when a treatment option is agreed upon.

The second phase of preoperative preparation begins once a recommended surgery is deemed necessary and agreed to by the patient. This phase includes the medical optimization and anesthesia evaluation of the patient undergoing the intended procedure and the subsequent interpretation and evaluation of appropriate preoperative testing deemed necessary. In a relatively healthy patient undergoing a minor low-risk procedure, the preparation or testing can be kept to a minimum and will be discussed later in this chapter. A patient with a more complex medical history undergoing a difficult and lengthy procedure with a significant anticipated recovery period may require medical optimization in order to stabilize their medical condition and enhance their physical condition prior to surgery. Complex medical conditions out of the scope of the surgeon's practice may necessitate consultations with various medical specialties to manage their conditions preoperatively and postoperatively. An evaluation of the patient's social habits may indicate a need for referral to appropriate counseling to enhance the recuperation period and overall compliance with medical recommendations. The patient's family and support resources should be evaluated to ensure adherence with postoperative restrictions and not place the patient in jeopardy during their anticipated recovery period. The results of these evaluations and considerations must be continually balanced against the original surgical recommendation, and when necessary, the surgeon should recommend altering the surgical plan to accommodate these realities in order to most safely achieve the goal of treatment. After all, the dictum, primum non nocere, compels us to do no harm and compels us to improve and not worsen the overall condition of the patient with our surgical therapy.

Preoperative preparation can be very complex and often the care coordination required to safely prepare a patient overwhelms the surgeon and their staff. The number of consultations and referrals can multiply very quickly and the resulting number of follow-up recommendations and options can confuse even the most experienced surgeon. Each of these interactions presents an opportunity for error, and lack of coordination and preparation which may contribute to potential patient harm and poor outcomes. Many healthcare systems and surgical programs are employing multidisciplinary surgical care conferences to discuss upcoming complex surgical cases in order to streamline the process and enhance teamwork among the various disciplines of medicine. Effective conferences will include surgeons, anesthesiologists, internists, hospitalists, physiatrists, consultants, nurses, social workers, care coordinators, patient navigators, and home care specialists in the discussion of complex cases to ensure a tailored, comprehensive, and coordinated care plan is developed addressing the needs of the patient. Risk calculators and other algorithms may be employed to risk stratify appropriate candidates to be reviewed at the conference if an institution decides not to review every case. Alternative treatment options and experienced opinions are often discussed culminating in the sharing of best practices to be followed and the potential surgical pitfalls to be avoided. Necessary hospital resources can be anticipated and properly resourced when discussed prior to the surgery. Anesthesia concerns could be discussed with the appropriate consultants to better understand the patient's physiology and medical condition to guide intraoperative monitoring and postoperative critical care needs. Medical comanagement can be arranged for immediate postoperative hospitalization to aid the surgeon and critical care teams in the medical management of the patient. Discharge planning and home care coordination can be arranged with a better understanding of the anticipated recovery status and limitations of the patient. The multidisciplinary conference enhances the preparation and coordination for all five phases of the surgical continuum: surgical planning, medical optimization, intraoperative, postoperative hospitalization, and posthospital recovery phase. Care pathways and standardized treatment protocols can easily be constructed and followed to improve care and decrease variability and overall cost when a mature multidisciplinary conference is established in the culture of an organization.

From the moment the patient and surgeon decide to proceed with surgery, the preoperative time frame represents a golden opportunity to proactively manage and optimize the patient for the upcoming surgery. These interventions include identification and prophylaxis of patients at risk for deep venous thrombosis and pulmonary embolism; preoperative administration of beta-blockers; appropriate selection of antibiotics; and better glycemic control of diabetic patients. We believe that the future of perioperative medicine will usher in advances in proactively reaching out to surgical patients during this preoperative time period and delivering disease-specific management. There exists today technology that utilizes patient health records and online questionnaires that are tied to decision support systems to guide preoperative testing. By correctly identifying and risk stratifying surgical patients, we can tailor clinical pathways that optimize their medical conditions as well as better prepare them for surgery.

These authors are proponents of the preoperative clinic based on our experience at our institutions as well as a plethora of published studies demonstrating enhanced patient safety, patient satisfaction, reduction of testing and expenses, as well as a significant reduction in cancellations and delays on the day of surgery. We work together for our collective institutions in improving the Preoperative Processes, in an attempt to reduce malpractice claims and improve care. Our experience indicates that there are ample opportunities to reduce harm through better organization and preoperative preparation. Our patients who are “optimized” demonstrated fewer same-day cancellations, fewer day-of-surgery testing, and lower PSI-90 Complication rates. Time will indicate if this process also results in fewer malpractice claims.

However, not all patients should be required to make a separate trip to the hospital for an evaluation prior to surgery. At our institutions, we have created a Preoperative Roadmap that has been provided to our surgeons to give some guidance as to which patients should be selected to come to our clinic. Additionally, this roadmap provides some basic algorithms that indicate what testing should be done on patients deemed appropriate to bypass the clinic. This roadmap was developed based on principles defined by the American Society of Anesthesiologists (ASA) Task Force on Preoperative Testing convened in 2002 and updated based on new evidence regarding specific patient conditions. Fig. 9.1 is a diagram of the algorithm we utilize in our Roadmap to illustrate how to triage the surgical patient. Essentially, we ask our surgeons to determine if their patients are medically “sick”or “healthy.” Healthy patients only need to be seen in a preoperative clinic if they are having major surgery. We define major surgery as specified by the American Heart Association (AHA) as involving major blood vessels (vascular or cardiac) or extensive disruption of physiology such as an 8-hour Whipple procedure or major transplant procedure.

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Preoperative triage algorithm. Low-risk medical conditions: Healthy with no medical problems (ASA I) or well-controlled chronic conditions (ASA II). High-risk medical conditions: Multiple medical comorbidities not well controlled (ASA III) or extremely compromised function secondary to comorbidities (ASA IV). Low-risk surgical procedure: Poses minimal physiological stress (e.g., minor outpatient surgery). Intermediate-risk surgical procedure: Medium-risk procedure with moderate physiological stress and minimal blood loss, fluid shifts, or postoperative changes. High-risk surgical procedure: High-risk procedure with significant fluid shifts, possible blood loss, as well as perioperative stress anticipated.

PEC , preoperative evaluation clinic; PMD , primary medical doctor. A— May have preanesthesia assessment done day of surgery. B— Recommend preanesthesia assessment with PEC visit at least 24 h preoperatively. Should have an evaluation done prior to PEC visit by PMD. C— Recommend preanesthesia consult scheduled in PEC at least 48 h preoperatively. Should have an evaluation done prior to anesthesia consult by PMD.

From Johns Hopkins Preoperative Roadmap, available at http://www.hopkinsmedicine.org/anesthesiology/Patient_Care/Preoperative_Roadmap.pdf .

For a healthy patient scheduled for minor surgery, there really are no indications for much preoperative testing. Routine CxR and ECG are not warranted for most patients. It is common to find a requirement for an ECG for all patients over the age of 50; however, that is based on local custom and there is no real good evidence that this should be required. Additionally, laboratory testing should also be considered only for patient conditions or surgery that warrants the appropriate test. Minor outpatient surgery really only requires a hemoglobin level on menstruating females and possibly a urine pregnancy test, unless there is something in the history that stipulates further testing is indicated. A good example of a significantly oversubscribed preoperative test is coagulation studies. At most institutions, a Prothrombin time (PT/INR) and Partial Thromboplastin tests (PTTs) are ordered on the vast majority of patients. There are several problems with ordering this test preoperatively. First, most labs have now split out the PT/INR from the PTT, and ordering a PTT adds an additional cost to the test. There are practically no preoperative patients that warrant a PTT. Exceptions are hemophilias, and these should be identified from a basic history and physical. The PTT test represents the intrinsic coagulation pathway and is routinely used to monitor heparin dosing. Obviously, preoperative patients are rarely on heparin, so this test is worthless to obtain. As for the PT/INR, there are patients where this test is indicated. They would be patients with a history of liver disease or bruising and prolonged bleeding. Ironically, we typically order a PT/INR on patients on anticoagulants such as Coumadin. Again, there is little rationale for ordering this test preoperatively. These patients will all have abnormal values for their INR. There is rationale for ordering the tests the morning of surgery, but not a few days prior to surgery. Both of these examples illustrate how we can reduce the significant expense of unnecessary preoperative testing without affecting outcomes.