Lecture 20: Pre-Operative Patient Assessment & Preparation - SA

What is included in a SA preoperative assessment?

• Patient history

• Physical exam

• Laboratory data

• Associated underlying disease

• Patient stabilization

What is the first thing that should be obtained when gathering a patient history?

signalment

What is one of the best determinants of the likelihood of cardiopulmonary emergencies during or after surgery?

evaluation of the preanesthetic physical status

What is the “big 4” or “Quats” of laboratory data that young, healthy animals undergoing elective procedures should receive?

• PCV (Hematocrit)

• Total Protein (TP)

• Blood Glucose

• BUN

What is included in the “minimum data base” that animals older than 5-7 years or having systemic signs (ex. dyspnea, heart murmur, anemia, shock, etc) should have?

• CBC & Differential

• Serum Biochemical Profile

• Urinalysis

What additional pre-operative laboratory data should be collected if neoplasia is suspected?

evaluate for metastasis:

• Thoracic Imaging [radiographs, computed tomography (CT), or positron emission tomography (PET/CT)

• Abdominal ultrasound

• Lymph Node Aspiration

What additional pre-operative laboratory data should be collected if cardiac disease is suspected?

• Thoracic Radiographs

• Cardiac Ultrasound Scan

• Electrocardiogram

Why should trauma patients have thoracic radiographs before undergoing a procedure?

• Diaphragm – Diaphragmatic Hernia

• Pleural Space –Pneumothorax, Pleural Effusion

• Lungs – Pulmonary Contusion

Where would a patient coming in for an elective procedure, such as an OVH, fall on the physical status scale?

I: healthy with no discernable disease

Where would a patient with patellar luxation, a skin tumor, or a cleft palate without aspiration pneumonia fall on the physical status scale?

II: healthy with localized disease or mild systemic disease

Where would a patient with pneumonia, fever, dehydration, heart murmur, or anemia fall on the physical status scale?

III: severe systemic disease

Where would a patient with heart failure, renal failure, hepatic failure, severe hypovolemia, or severe hemorrhage fall on the physical status scale?

IV: severe systemic disease that is life threatening

Where would a patient with endotoxic shock, multiorgan failure, or severe trauma fall on the physical status scale?

V: moribund - patient not expected to live more than 24 hours with or without surgery

What should owners be informed of before surgery?

• Diagnosis

• Surgical and Nonsurgical Options

• Potential Complications

• Postoperative Care

• Prognosis

• Cost (estimate and kept updated as price changes)

What is indicated for all animals undergoing general anesthesia and surgery, including healthy animals having elective procedures?

IV fluids

How long is food intake generally restricted before induction of anesthesia to avoid intraoperative or postoperative emesis and aspiration pneumonia in adult animals?

6-12 hours

Food should not be withheld from young animals for longer than 4 to 6 hours because ______ may occur.

hypoglycemia

What is the most common source of SSIs?

endogenous microbial flora (s. aureus and streptococcus spp.)

To be considered an SSI, infection must:

• Occur within 30 days of the surgical procedure

• Occur within 1 year if it is associated with a surgical implant and the infection appears to be related to the operation

What is the difference between a superficial and deep incisional SSI?

• Incisional - infection of the actual site of the surgical incision

  • Superficial - involving the skin and subcutaneous tissue

  • Deep - involving deep soft tissue layers such as incisional fascia and muscle

What is the difference between an incisional and organ/space SSI?

Incisional - infection of the actual site of the surgical incision

Organ/Space - infection of an anatomic part that was manipulated during the operation

Normal or resident organisms living in the skin's superficial cornified layers and the outer hair follicles of dogs include:

• Staphylococcus epidermidis

• Corynebacterium spp

• Pityrosporum spp

What are some transient pathogens that cause SSIs?

• Staphylococcus aureus

• Staphylococcus intermedius

• Escherichia coli

• Streptococcus spp

• Enterobacter spp

• Clostridium spp

Why is preoperative preparation of a patient important for reducing the risk of SSIs?

Preoperative preparation reduces the number of bacteria and the likelihood of infection

What is antisepsis?

The prevention of sepsis by preventing or inhibiting the growth of resident and transient microbes

What is an antiseptic?

• Product with antimicrobial activity that formerly may have been referred to as an antimicrobial agent

• An agent capable of producing antisepsis

True or false: The current literature strongly suggests that CHG (Chlorohexidine Gluconate) is superior to PVI (Povidone Iodine) for preoperative antisepsis for patients.

true

What are the characteristics of an ideal preoperative antiseptic?

• Kill all bacteria, fungi, viruses, protozoa, tubercle bacilli, and spores

• Be hypoallergenic

• Be nontoxic

• Have residual activity

• Not be absorbed

• Be nontoxic and be able to be used repeatedly safely

• Be safe to use on all parts of the body and in all body systems

Preventive preoperative measures that can reduce the risk of SSI include:

• Administration of antimicrobial prophylaxis

• Proper utilization of skin antiseptic agents for the surgical team and the patient

What prep step is associated with a significant increase in superficial skin infection rates if done the night before and should NEVER be done in the operating room?

shaving

Where is the hair generally clipped for an OHE?

clip just above the xyphoid to the pubis and laterally beyond the nipple line

What patient prep is done before sterile application of the epidermal gemicide?

• Patient is moved to the operating room

• Positioned so the operative site is accessible to the surgeon

• Secured with ropes, sandbags, troughs, tape, or vacuum-activated positioning devices

What are the purposes of the preoperative skin preparation?

1. Remove soil and transient microorganisms from the skin

2. Reduce the resident microbial count to subpathogenic levels in a short time and with the least amount of tissue irritation

3. Inhibit rapid rebound growth of microorganisms

How should the patient’s skin be scrubbed to maintain sterility?

• have a clean and dirty hand while wearing gloves

• use dominant hand to scrub and non dominant hand to retrieve sponges

• scrub in circular motion, starting at incision site and moving towards periphery

• drape after solution is fully dried

What should be done if an abdominal incision extend to the pubis in male dogs?

clamp the prepuce to one side with a sterile towel clamp. Placing a sterile 4x4 gauze sponge may decrease tissue trauma

True or false: The tips of the towel clamps are considered nonsterile once they have been placed through the skin and should be handled appropriately

true