Presentation on Pre operative assessment and operation theatre protocols Presentation by Dr.G.Kathirvel M.D.S (OMFS).,

1. PREOPERATIVE ASSESSMENT AND
THEATRE PROTOCOL
Dr. Kathirvel G
PG OMFS

2. CONTENTS:
• Introduction
• Primary goals in preoperative assessment
• Steps in preoperative assessment
• History taking
• Physical Examination
• Laboratory Investigation
• Preoperative treatment
• Informed Consent
• Operation theatre protocols

3. Introduction:
• Proper planning is the key to success
• Proper preoperative assessment of a patient is considered as half success to
surgery
• It helps to assess pre-existing medical conditions and expected
complications, thus to reduce morbidity and mortality.

4. PRIMARY GOALS OF PREOPERATIVE EVALUATION
• Documentation of the condition for which surgery is needed.
• Assessment of the patient’s overall health status.
• Uncovering of hidden conditions that could cause problems both during and
after surgery.
• Preoperative risk determination.

5. • Optimization of the patient’s medical condition in order to reduce the patient’s surgical
and anesthetic perioperative morbidity or mortality.
• Education of the patient about surgery, anesthesia, intraoperative care and
postoperative pain treatments in the hope of reducing anxiety and facilitating recovery.
• Reduction of costs, shortening of hospital stay, reduction of cancellations and increase
of patient satisfaction.

6. PREOP ASSESSMENT
EMERGENCY CONDITION ELECTIVE CONDITION

7. PREOP ASSESSMENT IN EMERGENCY SITUATION:
GLASGOW COMA SCALE

8. PRIMARY SURVEY IN EMERGENCY CONDITION
A B C
Airway maintenance with cervical spine protection
Breathing and ventilation
Circulation with hemorrhage control
During the primary survey, the life-threatening conditions are identified and treated
and vital signs are stabilized.

9. AIRWAY MAINTANENCE WITH CERVICAL SPINE CONTROL
• Initial evaluation of airway patency is most important.
• The causes of upper airway compromise in the trauma patient may be tongue position,
aspiration of foreign bodies or facial, mandibular, tracheal and/or laryngeal fractures,
bleeding, a retropharyngeal hematoma resulting from cervical spine fractures or
traumatic brain injury.
Reference: Perry M, Morris C: Advanced trauma life support (ATLS) and facial trauma: Can one size fit all? Part 2: ATLS
maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg 37:309, 2008

12. PREOPERATIVE ASSESSMENT STEPS IN ELECTIVE CONDITIONS:
• History taking
• Physical Examination
• Laboratory Investigation
• Preoperative treatment
• Informed Consent

13. HISTORY TAKING

14. HISTORY TAKING:
• Chief complaint
• History of present illness
• Past medical history
a. Medical history
b. Hospitalizations
c. Past surgical history (operations: major and minor)
d. Anesthesia experience (adverse reactions or complications)
e. Past dental history
f. Medications and dosages (past and present, including herbal medicines and
nonprescription drugs)
g. Allergies and reactions (including latex allergy)

15. I. Cardiovascular System
 Rheumatic heart disease, valvular heart disease, heart murmurs, congenital heart
disease
• Consider cardiology consultation, if indicated
• Consider ultrasonography or echocardiography for documentation of cardiac valvular
function
• Follow AHA subacute bacterial endocarditis prophylaxis regimens for the at-risk
patients undergoing at risk procedures

16. Wilson W, Taubert KA, Gerwitz M, et al: Prevention of infective endocarditis: guidelines from the American Heart
Association. Circulation 116:1736, 2007.

17. Wilson W, Taubert KA, Gerwitz M, et al: Prevention of infective endocarditis: guidelines from the American Heart
Association. Circulation 116:1736, 2007.

18.  Ischemic Heart Disease, Hypertension, Angina Pectoris, Myocardial Infarction (MI)
• Determine current level of control (eg: exercise-tolerance, METs)
• Consider consultation with physician
• Consider Cardiac Risk Stratification for Noncardiac Surgical Procedures

19. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and
care for noncardiac surgery. J Am Coll Cardiol 50:e159, 2007

20. • Use stress reduction techniques
• Consider discontinuation of antiplatelet therapy only with cardiology consultation.
• Consider limitation of epinephrine dosage contained in local anesthetic solution
• Be prepared for Basic Life Support (BLS) / Advanced Cardiac Life Support (ACLS)
in emergency situations

21. RESPIRATORY SYSTEM
 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, EMPHYSEMA
• Consider consultation with physician
• Consider pulmonary function testing to determine the extent of the disease and
degree of respiratory reserve
• Use supplementary steroids when indicated
• Use supplemental oxygen cautiously
 ASTHMA
• Consider consultation with physician
• Determine severity based on history and careful physical examination including
respiratory rate and lung auscultation
• Consider pulmonary function testing
• Consider prophylactic use of inhaler
• Use stress reduction techniques

22. ENDOCRINE SYSTEM
 Diabetes mellitus (DM)
• Determine level of diabetic control (based upon history, fasting and post prandial
blood glucose analysis, hemoglobin A1c)
• Consider hypoglycemic agent scheduling
• Consider discontinuation or reduction of oral hypoglycemic agents before surgery.
• Metformin should be discontinued 48 hours before surgery only in patients with
compromised renal function

23. • Consider rescheduling surgery if blood glucose level is significantly elevated, but
this decision should be based on other factors as well
• Avoid hypoglycemia
• Consider prophylactic antibiotics
• Consider an extended period of NPO status
• Consider cardiac evaluation since DM patients have “silent” heart disease

24. HEMATOLOGIC DISORDERS
 Coagulopathy, Bleeding Disorders , Therapeutic Anticoagulation
• Determine laboratory values (eg, CBC, PT, PTT, INR)
• Consider temporary discontinuation of anticoagulation or antiplatelet therapy
(with physician consultation) to achieve a reasonable INR for surgical hemostasis
based on specific procedures performed
• Consider adjustment of medication(s) for the patient on multiple anticoagulants or
anti-platelet medications (eg, clopidogrel)

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27.  ANEMIA
• Consider a CBC with platelet count
• Consider auto-donation of blood or blood products if a large percentage of blood
volume loss during surgery is anticipated
GASTROINTESTINAL DISORDERS
 HEPATITIS
• Consider liver function tests, PT/PTT, INR, platelet count, bleeding time
• Consider hepatitis B surface antigen screening
• Avoid medications with hepatic metabolism, such as acetaminophen
• Monitor the use of NSAIDs medications

28. RENAL DISEASE
 RENAL FAILURE
• Consider hemodialysis and schedule surgery accordingly
• Consider the impact of medications removed by hemodialysis
• Consider avoidance of drugs with renal metabolism
• Monitor the use of NSAIDs medications

29. NEUROLOGIC DISORDERS
• Some neurologic disorders, such as intellectual disability, attention-
deficit/hyperactivity disorder, autism, and their associated medical treatments may
affect the ability of an Oral and maxillofacial surgeon to perform an adequate
patient assessment and subsequent management.
• Consideration should be given to comprehensive dental and oral surgical
management in an operating facility under sedation or general anesthesia.

30. MISCELLANEOUS
 OBESITY
• Consider Body Mass Index (BMI) calculation
• Consider altered airway anatomy
• Consider medication dosage adjustment
• Consider an extended period of NPO status
 Pregnancy
• Consider elective surgery in second trimester
• Consider drug safety pregnancy profiles

31. HISTORY TAKING:
• Family history
• Social history
a. Occupation
b. Substance use (eg, tobacco [pack-years], alcohol [daily amount], recreational drugs
[specific drugs and frequency of use])

33. HISTORY TAKING:
• Drug History
Generally, administration of most drugs should be continued up to surgery
But, Some drugs should be discontinued preoperatively.
o The oral contraceptive pill should be discontinued at least 6 weeks before elective
surgery because of the increased risk of venous thrombosis.
o Aspirin should be discontinued 7-10 days before surgery to avoid excessive bleeding
and clopidogrel for 2 weeks before surgery.

34. o Selective cyclooxygenase-2 (COX-2) inhibitors do not potentiate bleeding and may be
continued until surgery.
o Oral anticoagulants should be stopped 4-5 days prior to invasive procedures, allowing
INR to reach a level of 1.5 prior to surgery
o Recently, the American Society of Anesthesiologists (ASA) examined the use of herbal
supplements and all patients are requested to discontinue their herbal supplements at
least 2 weeks prior to surgery.

35. PHYSICAL EXAMINATION

36. Physical examination:
• General Examination (Alert and Oriented)
• Vital signs (heart rate, blood pressure , temperature, respiratory rate)
• HEENT (head, ears, eyes, nose, and throat, including oral cavity)
• Neck, including lymph nodes, trachea, and thyroid
• Chest and lungs (inspection, palpation, percussion, auscultation)
• Abdomen
• Musculoskeletal
• Neurologic
• Extremities

38. LABORATORY INVESTIGATION

39. LABORATORY INVESTIGATIONS:
• Complete blood count (CBC), white blood cell count (WBC), haemoglobin,
haematocrit
• Prothrombin time (PT), partial thromboplastin time (PTT) and international
normalized ratio (INR)
• Bleeding time, Clotting time
• Arterial blood gas
• Fasting blood glucose, random blood glucose, glucose tolerance test,
haemoglobin A1c

40. LABORATORY INVESTIGATIONS:
• Sodium, potassium, chloride, serum bicarbonate
• Blood urea nitrogen, creatinine
• Pregnancy testing, serum or urine
• Pulmonary function tests
• Liver function tests
• Urinalysis
• Chest X-ray
• ECG

43. HEMATOLOGY
Test Normal value Increased Decreased
RBCs 4.5 - 6 million cells /cmm • Polycythemia • Anemia
• Bone marrow
disorder
WBCs 4,500 - 11,000 cells /cmm • Leukemia
• Infections
• Malnutrition
• Depressed bone
marrow
Platelets 1,50,000 – 4,00,000 /cmm • Cancer
• Infection
• Bone marrow
disorder
• Accelerated
destruction
Hb Male – 13-16 mg/dl
Females – 12-15 mg/dl
• Chronic lung disease
• Heart failure
• Anemia
• Kidney and liver
disease

44. RBS 80 – 140 mg/dl • Diabetic • Hypoglycemia
Blood sugar – Fasting 70 – 100 mg/dl
Blood sugar -
Postprandial
70 -140 mg/dl
HbA1C 5.7 – 6.5
Bleeding time
(Duke method)
3 – 5 min • Decreased
thrombocytes
• Von willebrand disease
Clotting time
(Capillary glass tube
method)
4 – 9 min • Deficiency of Clotting
factors
• Vitamin K deficiency
HEMATOLOGY
Test Normal value Increased Decreased

45. LFT
Test Normal value Increased Decreased
Total Bilirubin 1.5 – 15 mg/dl • Hepatitis
• Hemolytic anemia
• Internal hemorrhage
Alkaline phosphatase 30 – 130 U/L • Bile duct
obstruction
• Hypophosphatasia
Albumin 3.5 – 5 gm/dl • Diabetic kidney
damage
• Hepatitis
• Liver cirrhosis
INR 0.9 – 1.1 • Increased risk of
Hemorrhage
• Increased risk of clot

46. RFT
Test Normal value Increased Decreased
Sodium 135 – 145 mEq/L • Increased intake of
salt
• Diabetes insipidus
• Decreased renal
function
Potassium 3.5 – 5.0 mEq/L • Decreased renal
function
• Intake of diuretics,
Insulin
Serum urea 6 – 24 mM/L • Acute renal failure
• Heart failure
• Protein malnutrition
Serum Creatinine 0.7 – 1.2 mg/dl • Muscular disorders
• Diabetes mellitus
• Renal failure
• Malnutrition
• Liver disease
• Pregnancy

47. A: Airway—large airways, lung, and pleura
• Trachea in midline or deviated
B: Bones—clavicles, ribs, and spine
• Any fracture is evident
C: Circulation—heart, mediastinum and vascular markings
• Cardiac outline is essential to detect abnormality.
• Left and right brachiocephalic vein, the pulmonary artery of corresponding sides
D: Diaphragm
• The right diaphragm should be 1– 3 cm higher than the left.
• Look through the diaphragmatic shadow for pathology in the lung bases and the
pleural reflections for evidence of pleural fluid.

48. Indication for ECG

50. PATIENT PHYSICAL EXAMINATION BY ANESTHETIC TEAM
• Focused airway examination
a. Mallampati score
b. Range of mouth opening
• Auscultation of lungs
• Observation of extremities for venipuncture sites

51. Mallampati classifiction:

52. Modified Mallampati classification:
Class I: Visualization of the soft palate, fauces, uvula, anterior and the posterior pillars.
Class II: Visualization of the soft palate, fauces and uvula.
Class III: Visualization of soft palate and base of uvula.
Class IV: Only hard palate is visible. Soft palate is not visible at all.

53. Patil’s test
Thyromental distance
Thyromental distance

55. PATIENT PREPARATION
PREPARATION OF ORAL CAVITY
• The oral cavity should be thoroughly inspected for any septic foci, calculus, tarter,
infected carious teeth, infected periodontal pockets etc. and they should be
removed.
• Antiseptic mouth washes should be prescribed for periodic mouth rinsing to
reduce the count of microorganism.
• Loose teeth should be extracted as they may come in the way of intubations of
patient and may get knocked out and aspirated during the intubation.

56. DAY BEFORE SURGERY
• Patient and close relatives should be informed about the exact surgical procedure and
expected complications
• Informed consent to be obtained
• Preparations should be done. This eliminates the contamination of the surgical site.
• NPO should be started as per the anesthetic instruction
• Preanesthetic medications should be taken strictly according to anesthetic opinion

58. CONSENT FORM
To obtain informed consent from a patient for medical or dental treatment, the
following 3 conditions must be fulfilled:
1) The patient’s ability to make a sensible decision: is the patient able to give consent?
2) Has the informed consent been given voluntarily?
3) Has the patient been adequately informed before the operation?

61. A regular informed consent is a critical part of the preanesthetic review and should
include the nature of anesthetic plan, the material risks and benefits and the alternatives to
the plan
High-risk informed consent for high risk patients
Who are at high risk?
• A particular subgroup of patients with multiple comorbidities in a decompensated stage
are at risk of specific complications such as intra- and postoperative myocardial
ischemia, respiratory failure, perioperative renal failure and even cardiac arrest.
• These are the patients in whom specific risk has to be explained in addition to the
routine informed consent in terms of risk to life, morbidity, organ failure, and
postoperative Intensive Care Unit stay and consent has to be obtained.

62. PATIENT PREPARATION
PREPARATION OF PATIENT IN THE WARD
• Preparations should be done. This eliminates the contamination of the surgical site.
• A good bath to clean all the dirt from the body.
• Outside clothing should be discarded and the patient should be provided clean
hospital clothing.
• Lipstick, nail varnish & other cosmetics should be removed.
• Patient should not be shifted in operating room with full bladder.

63. OPERATION THEATRE PROTOCOLS

65. DESIGN OF OPERATION THEATRE
• The OT complex should have only one entry.
• Marble or polished stone flooring is the preferred type with glazed tile walls
• The ideal operating room walls should be of stainless steel without sharp line angles and
corner should be molded round.
• The floors and walls should be absolutely smooth and easily cleanable
• The ceilings should be painted with oil paints which give smooth finish.
• Flooring should be non porous, scratch proof, anti skid and antistatic.
• Drainage pipe lines should be concealed.

66. STAFF RELATED PROTOCOLS
SURGICAL TEAM
• Chief surgeon - who directs the surgery.
• One or more assistant surgeons, who help the chief surgeon
• Anesthesiologist - who controls the supply of anesthetic and monitors the patient closely.
• Scrub nurse - who passes instruments to the surgeon.
• Circulating nurse - who provides extra equipment to the operating team.

67. ASSISTANCE
Scrub Nurse
• Before surgery:
1. Scrub nurse arrange the instruments in a designated fashion in the trolley and count
them.
2. Pass the gown, gloves to the surgeon.
3. Handover the paint and drapes to the surgeon, co-ordinate with the floor nurse for
passing consumables and connect various tubes and wires as required.
• During surgery:
1. Pass the instruments to the surgeon as required.
• End of surgery:
1. Scrub nurse should count the instrument at the end of the procedure.
2. After surgery she should assist in surgical site dressing and re-gowning the patient.

68. ASSISTANCE
Floor nurse - The duty is to receive the patient from the ward
Instructions
• Unsterile team member should provide wide margin away from sterile area.
• Face the sterile area while passing.
• Stand at a safe distance while adjusting the light.
• Everything under hip level and behind are considered unsterile

69. Hand wash technique

75. Gloving technique:
1. Closed gloving technique
• Contact with gloves by sterile scrub
• The left glove is slided over the hand
with the right hand covered by sterile
gown.
• The right cuff is then adjusted with
gloved left hand
• The right glove is slided using left
gloved hand without touching the
outside of the gloves with bare hands.

76. 2. Open gloving technique:
• Left glove is picked up with bare right
hand, touching its inside and slided
over left hand without uncuffing it.
• The right glove is picked up with
gloved left hand touching only its
outside.
• It is uncuffed over the cuff of the gown.
• Then with the gloved right hand the left
glove is uncuffed.

77. PREPARATION OF SURGICAL SITE
• The most commonly used antiseptic agents for surgical scrubbing include
chlorhexidine gluconate, alcohol-based solutions and iodophors such as
povidone-iodine.
• The scrubbing is started from the center and goes to periphery and the swab is
discarded.
• In no case the swab from periphery should touch the central area.
• This is first done with swab soaked in antiseptic soap solution like savlon,
cetrimide or povidon iodine (Beta scrub) for about 2 minutes.

78. • Finally the area is painted with 5% povidon iodine solution and this should not be
wiped off because microbial activity is sustained by release of free iodine as the
agent dries and color fades from skin. It should remain on skin for at least 2
minutes.
• The area is isolated by draping the other parts with the help of sterile surgical
towels exposing only the surgical field.
• A double layer drape is effective.

79. THE CLOSE OF OPERATION
• Check for satisfactory wound closure & cessation of hemorrhage.
• Mouth should be checked for – Clot, Debris, Swabs, Extracted teeth.
• Confirm the completion of the entire surgical plan.
• Report the anesthetist regarding completion of procedure.
• Throat pack should be removed.
• Write the operative notes.
• Shift the patient on a trolley equipped with oxygen cylinder & mask.
• Keep the patient in recovery room & in recovery position.
• Emergency situations can be managed by surgeon/anesthetist/both.

81. CLEANING AND FUMIGATION
• Daily cleaning should be carried out after the operating sessions are over.
• All the surfaces should be cleaned with detergent and water and may be wiped over with
a phenol if any spills with blood / body fluid are present.
• All the walls must be wiped down to hand height everyday.
• The floors should be scrubbed with warm water and detergent and dried.
• The O.T. table and other non clinical equipment must be wiped to remove all visible dirt
and left to dry.
• The storage shelves must be emptied and wiped over, allowed to dry and restacked

85. THANK YOU