The preoperative management of any patient is part of a continuum of care that extends from the surgeon’s initial consultation through the patient’s full recovery. While this ideally involves a multidisciplinary collaboration, surgeons lead the effort to assure that correct care is provided to all patients. This involves the establishment of a culture of quality care and patient safety with high, uniform standards. In addition, the surgeon is responsible for balancing the hazards of the natural history of the condition if left untreated versus the risks of an operation. A successful operation depends upon the surgeon’s comprehension of the biology of the patient’s disease and keen patient selection.
This chapter will consider preoperative preparation from the perspectives of the patient, the operating room facility and equipment, the operating room staff, and the surgeon.
PREPARATION OF THE PATIENT
History & Physical Examination
The surgeon and team should obtain a proper history from each patient. The history of present illness includes details about the presenting condition, including establishing the acuity, urgency, or chronic nature of the problem. Inquiries will certainly focus on the specific disease and related organ system. Questions regarding pain can be guided by the acronym OPQRST, relating to Onset (sudden or gradual), Precipitant (eg, fatty foods, movement, etc), Quality (eg, sharp, dull, or cramps), Radiation (eg, to the back or shoulder), Stop (what offers relief?), and Temporal (eg, duration, frequency, crescendo-decrescendo, etc). The presence of fevers, sweats, or chills suggests the possibility of an acute infection, whereas significant weight loss may imply a chronic condition such as a tumor. The history of present illness is not necessarily confined to the patient interview. Family members or guardians provide useful information, and outside records can be indispensable. Documents might include recent laboratory or imaging results that preclude the need for repetitive, costly testing. The surgeon should request CD-ROM disks of outside imaging, if appropriate. In the case of reoperative surgery, prior operative reports and pathology reports are essential (eg, when searching for a missing adenoma in recurrent primary hyperparathyroidism).
The past medical history should include prior operations, especially when germane to the current situation, medical conditions, prior venous thromboembolism (VTE) events such as deep vein thromboses (DVT) or pulmonary emboli (PE), bleeding diatheses, prolonged bleeding with prior operations or modest injuries (eg, epistaxis, gingival bleeding, or ecchymoses), and untoward events during surgery or anesthesia, including airway problems. One must secure a list of active medications, with dosages and schedule. Moreover, it is beneficial to inquire about corticosteroid usage within the past 6 months, even if not current, to avoid perioperative adrenal insufficiency. Medication allergies and adverse reactions should be elicited, although knowledge about environmental and food allergies is also valuable and should be recorded so that these exposures are avoided during the hospital stay. Some anesthesiologists are reluctant to use propofol in patients ...