Surgery Today - Preoperative procedures

Preparation of a patient for surgery involves a variety of procedures determined by the urgency of the operation, the anatomical area involved, the nature of the disease or injury requiring surgery, the general condition of the patient, and other factors. Emergency surgery of an accident victim in critical condition obviously requires a greatly accelerated pace of preparing the patient for the operating room; medical personnel may cut away the clothing of the victim in order to save precious minutes. An operation on the intestine, on the other hand, may require a full week of preparation, including the five or so days needed to evaluate laboratory tests and sterilize the bowel with drugs. However, most preop procedures, as they are commonly called, generally follow a similar pattern designed to insure a safe and sound operation. Even in a case of emergency surgery, certain information must be compiled to help guide the surgeon and other hospital staff personnel in making the right decisions affecting proper care of the patient during and after the operation.

Medical History

The medical history should reveal the general health of the patient and any factors that might increase the risk of surgery. Perhaps one of his parents or another close relative suffered from heart disease or diabetes; such facts might suggest a predisposition of the patient to problems associated with those disorders. The data should also show whether the patient has a tendency to bleed easily and whether he has been following a special diet, such as a sodium-restricted diet.

It is important that the patient reveal to his own physician, the surgeon, and the anesthetist, the names of any drugs or other medications used. It also is vital that the medical personnel have a complete record of any patient experiences, including allergic reactions to certain drugs, that might help predict drug sensitivities that could complicate the surgery. The simple fact that a patient suffers from asthma or hay fever might indicate that he may be more sensitive than other individuals to drugs that might be administered.

Allergic Reactions

Some patients are allergic to penicillin or other antibiotics. Others may be sensitive to aspirin or serums. Still others could be allergic to iodine, Merthiolate, or even adhesive tape. All of these factors, if they are known and if they apply to the patient about to undergo surgery, should be brought to the attention of the medical staff.

Medications Currently Being Used

Among medications routinely used by the patient that should be brought to the attention of the surgeon and anesthetist are insulin for diabetes, digitalis drugs for heart diseases, and cortisone for arthritis. Depending upon various factors relating to the individual case, the patient may be directed to continue using the medication as usual, change the size of the dose before or after surgery, or discontinue the drug entirely for a while.

A patient who has been taking certain sedatives or drinking alcohol beverages regularly for a prolonged period before surgery may begin to experience withdrawl symptoms or he may have developed a tolerance for the anesthetic used, which means that he would require a larger than usual dose to get the desired effect. A patient who has been using epinephrine-type eye drops for glaucoma may be asked to increase the dosage before surgery as an adjustment to one of the drugs used in conjunction.

Diuretics, tranquilizers, and anticoagulant drugs are among other medications commonly used by patients that could affect the manner in which a surgical procedure is carried out. Patients should take a sample of the medication or the pharmacist's label from a container of the medication to the hospital so the medical staff can verify the type of drug used.

Psychological Evaluation

Of increasing importance in recent years has been a psychological evaluation of the patient. Individuals with a past history of mental disease or patients whose complaints may be based on psychoneurotic factors may react differently to surgery than persons who could be described as psychologically well balanced. The preoperative interviews also may seek to obtain information about the patient's abuse of drugs or alcohol.

Physical Examination

In addition to the medical history evaluation, the surgeon will need vital information about the physical condition of the patient. This requires a complete physical examination, including a chest X ray, an electrocardiogram of the heart activity, a neurological examination, and a check of the condition of the blood vessels in various areas of the body. Other body areas may be checked as warranted by complaints of the patient or by the type of surgery to be performed. An examination of the rectum and colon may be suggested, for example, if the medical history includes problems related to the digestive tract. Adult women patients usually receive a Pap test and possibly a pelvic examination. Samples of blood and urine are taken for laboratory analysis, including blood typing in the event a transfusion is needed. The laboratory tests for older patients frequently are more detailed and may include an examination of a stool sample. Any or all of these tests can be conducted days or hours in advance of the surgery.

Additional blood and urine samples may be taken immediately after admission to recheck the body chemistry, and a brief physical examination may be made to make sure the patient does not have any open wounds or infections that might complicate the chances of recovery or introduce a dangerous strain of bacteria into the sterile environment of the operating room.

Legal Authorization

Before the preoperative preparations are complete, chances are good that a member of the hospital staff will make sure that the patient has signed a legal permit authorizing the operation. The permit describes the operation, special diagnostic or therapeutic procedure to be performed and it may be signed by a close relative or legal guardian if for some reason the patient is unable to take responsibility for this action. For example, a parent will be asked to sign a permit authorizing an operation on his child.

Exceptions may be made in cases of emergency surgery where the patient is unable to sign a permit and a relative or a guardian cannot be located in time. But there are in-house procedures of consultation among staff members who accept the responsibility. Laws regarding permission to perform surgery may vary locally.

Preop Meals

A light but adequate evening meal is served if the surgery is scheduled for the following morning, but no solid food is permitted for 12 hours before surgery. No fluids are allowed during the eight hours before surgery. Children and patients with certain diseases, such as diabetes, may be given special orders regarding nutrients.

Preparation of the Skin Area

The area of the skin around the surgery site is carefully prepared beginning the evening before the operation. A member of the hospital staff may assist or direct the cleaning of the area with soap and warm water. The cleaned skin area is usually scrubbed again in the operating room as further protection against possible infection.

Shaving

Whether or not the skin area is to be shaved depends upon the amount of hair present. If there is no hair, the tiny nicks or cuts made by a razor would constitute an unnecessary hazard of infection. Where hair is present, however, shaving is essential in order to make available a very clean skin surface. Also, it is important that no hair or hair fragments be close enough to the surgical incision to fall beneath the skin; the bit of hair beneath the skin could cause a serious infection after surgery.