Preoperative Medical Fitness of the Operative cases


 Preoperative Medical Fitness 
of the Operative cases

Prof Altaf Hussain Rathore,
MBBS, FRCS, DA (London)
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It is estimated that 234 million of non-cardiac operation are performed every year in the whole world; out of them one million die and 3 to 17 percent get some sort of complication. To reduce this mortality and morbidity, we have to scan patient thoroughly before the operation for fitness.

Prof. Altaf Hussain Rathore

All this should be within the means of the patient. Ideally there should be a pre-operative clinic in every hospital comprising of a surgeon, physician and anaesthetist where proper assessment of the patient for fitness is done but such clinic perhaps does not exist in any hospital of Pakistan. For medically fitness for the patients, American Society of Anaesthetist (A.S.A) has given a guideline (Table).

SA (American Society of Anaesthesiologist)

Grade I and II patients can be operated in any moderately equipped hospital. Even some Grade III can also be managed provided hospital has somewhat better facilities to manage the others coexisting medical problems.

Problematic III and Grade IV and V should definitely be dealt in a highly specialised healthcare N.I.C.E (National Institute for Clinical Excellence) centre has given us a guideline how to deal with the different mild  to moderate  medical problems before and after operations. The main medical problem which increase the mortality and morality of the patient during and after to the operation are usually due to:

  1. Heart Diseases
  2. Hypertension  
  3. Diabetes Mellitus
  4. Liver Diseases
  5. Kidney Diseases
  6. Neurological  Diseases
  7. Respiratory Disease
  8. Disturbed thyroid  function
  9. Allergies and drugs already taking.

A- Heart Disease

  1. Asymptotic murmurs with poor exercise tolerance, history of angina, syncope, breathlessness, abnormal impulse and LHV. LV strain on Echo should be referred to the cardiologist, the murmurs without any symptom or signs can be operated without any special treatment.
  2. Myocardial infarction and acute coronary syndrome within 8 weeks should be postponed; after that period it can be operated  provided patient has no heart failure or arrhythmia or severe Valvular disease with normal E.C.G or Echo.

Following drugs should be continued if he is already taking

  1. Beta Blocker (Alpha Agonist is a better option)
  2. Nitrate
  3. Calcium Channel Blockers
  4. Aspirin
  5. Diuretic

Hb should be above 9g, Avoid tachycardia, hypotension or hypertension and give them good analgesia. Discontinue all the anti-platelet drugs/except aspirin, warfarin (for 5 days till INR is below 1.5 and start again 12-24 hours after operation), Un-fractionated heparin (4-6 hours before and start 12 hours after the operation).

 B- Hypertension: Uncontrolled and stage 3 hypertension (systolic B.P above 180 and diastolic above 110mm mercury) should be referred to the physician. Ideal B.P is 140/90 mm,Hg. Some patients get their B.P raised due to tension; such patients should be given I.V midazolam 2-3 Mg or diazepam 5-10 mg or diuretic or Inj hydralzin or sublingual captopril 25mg or Adalat.

C. Diabetes mellitus: Uncontrolled blood sugar when it is above 250mg and patients has Ketosis specially when associated with cardiac, Renal Disease and Hypertension should be deferred. Blood sugar from 150 to 180 is accepted. Long acting hypoglycaemic drugs should be stopped 24 hours before surgery. It is better to put the patient on insulin especially for Type I and keep the blood sugar at 4-10 mol.

D. Respiratory System: Uncontrolled asthma and cases with C.O.P.D above 50 years should not be operated. Mild coryza is no problem. Smoking is stopped 12 hours   before surgery. Continue aminophylline, mast cell stabilizer and steroid given to control asthma; give the patient additional 250 mg of hydro cortisone before induction of anaesthesia. For mild C.O.P.D, nebulize with bronchodilator or steroid or salbutamide before and after surgery.

E). Liver diseases: When patient has an advance liver disease operation should be avoided specially when platelet level is below 50x109 and bleeding varicies are controlled with or without treatment within 6 weeks. INR L.F.T, P.T  A.P.T.T and platelet count should be within normal range. If liver functions are mildly disturbed give them Vit.K.  varicies bleeding should be controlled first

F). Kidney Diseases:  Do not operate if creatinine and potassium is high (more than 5.5) and chloride is lower than 120 mg. The depressed kidney functions should be corrected by diuretic or dialysis 4-6 hours before. Hb of 9g per DL should be accepted and do not give too much blood quickly which may raise the B.P, hyperkalaemia and C.C.F

G). Thyroid disease: Hyper or hypothyroid function is dangerous. T3, T4, and TSH should be normal, continue beta blockers.

H). Central nervous system: The patient should not be operated within 5-6 months of the brain stroke. For epileptics continue anti-epileptic drugs; Diazepam and lorazepam are useful drugs for sedation; avoid prolonged fasting.

In conclusion for small or not very big hospitals take only category A, B and some very selected C A.S.A cases for operations. Examine them fully well in the OPD including Pulse B.P and All systems. Get essential investigations like HB, Sugar, Grouping, and Hepatitis B.C done; in doubt get ECG, X-ray chest done. For fitness try to avoid unnecessary tests in fit cases where they are not required. It is seen that some young enthusiastic anaesthetist ask for the entire test written in the text even for young fit patients being operated for ordinary cases. This practice should be stopped as it burdens the patents pocket at least Rs: 25000. Admit the case one day before operation; always get informed consent.

Tailpiece: Young and not very young surgeon should not try their hands on the very major operation where they have little experience or very advance and terminal cases when big institutions and surgeons have already refused to operate. Never fight a definitely losing battle.

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