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. Although this care generally involves multidisciplinary collaboration, surgeons lead the team to ensure that the best 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, operating room facility and equipment, operating room staff, and surgeon. The surgeon is the only professional present for each perioperative phase of care, including the preoperative evaluation, the immediate preoperative setting, the intraoperative phase, the early postoperative recovery, and the postdischarge convalescence. Therefore the surgeon bears the ultimate responsibility for meticulous planning and coordination throughout the phases to ensure the best outcome for the patient.
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), Quality (eg, sharp, dull, or cramps), Radiation (eg, to the back or shoulder), Stop (what offers relief?), and Temporal (eg, duration, frequency, crescendo-decrescendo). 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 ...