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Preoperative preparation is part of the continuum of care that begins with the surgeon’s initial assessment and optimization of the patient. This ideally involves a multidisciplinary collaboration in a culture of excellence and high standards. The surgeon determines the risks and benefits of proceeding with an operation versus the natural history of the condition if left untreated. The surgeon may collaborate with the patient’s primary care physician, other specialists, and a preoperative clinic to ensure the best care. A successful operation depends on the surgeon’s comprehension of the biology of the disease and keen patient selection.
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This chapter will consider preoperative preparation from the perspectives of the patient, operating room facility and equipment, operating room and perioperative staff, and surgeon. The surgeon is usually the only professional involved in each phase of care, including preoperative evaluation, immediate preoperative setting, intraoperative phase, early postoperative recovery, and 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.
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History & Physical Examination
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The initial assessment involves eliciting a thorough history and conducting a good physical examination. The history of present illness includes details about the presenting symptoms, including acuity, chronicity, quality and duration, precipitating or alleviating factors, concurrent symptoms, and features of pain (eg, radiation). Secondary symptoms should also be assessed. Fevers, sweats, or chills may suggest a concurrent infection, and unplanned weight loss may increase the suspicion of malignancy. Family members, friends, or guardians accompanying the patient may provide useful information and should be engaged when appropriate. Outside records can be indispensable and avoid costly redundant tests, especially when electronic copies of outside imaging studies are available. The primary care physician may also be consulted when necessary. In the case of a reoperation, prior operative reports and pathology reports are essential (eg, when planning a neck reexploration for primary hyperparathyroidism).
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The past medical history should consider previous operations and comorbidities, particularly a history of venous thromboembolism (VTE), such as deep vein thromboses (DVT) or pulmonary emboli (PE), bleeding disorders, prolonged bleeding associated with prior operations or modest injuries (eg, epistaxis, gingival bleeding, or unprovoked ecchymoses), and complications during or after other operations or procedures. 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 to avoid perioperative adrenal insufficiency. Medication allergies and adverse reactions should be elicited; knowledge about environmental and food allergies is also valuable and should be recorded so that these exposures are avoided during the hospital stay. Some anesthesiologists are reluctant to use propofol in patients with egg allergies, and reactions to shellfish suggest the possibility of intolerance of iodinated contrast agents.
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The social history classically involves inquiries about tobacco, alcohol, and unprescribed or illicit ...