Preoperative Period

PREOPERATIVE PERIOD, the time required for the examination and preparation of a patient for an operation. During the period of the flourishing of surgery, with its enthusiasm for the technical details of operating and the development of techniques for new operations, surgery paid little attention to the pre- and postoperative period. However, a number of unsuccessful outcomes of operations that were technically brilliantly performed led surgeons to the conviction that to achieve the desired results, it is necessary not only to have a technically good performance of the operation, but also appropriate preparation and a postoperative regimen. Subsequently, a great deal of attention was paid to the postoperative period, and only in the last decades has surgery been on the right path of preventing postoperative complications through the appropriate preparation of the patient for the operation. This preparation is especially necessary in the event that any of the organs is already pathologically changed and the operation may affect it particularly harmfully. The duration of the preoperative period can vary depending on the nature of the disease and the necessary preoperative measures; in urgent operations (ectopic pregnancy, perforated gastric ulcer, acute appendicitis, hemorrhage), its duration must be very limited; after a careful but as quick as possible examination of the patient, one or another measure is applied if necessary (temporary cessation of bleeding, combating shock in major injuries, etc.), after which the patient is transported to the operating room, and sometimes the operation is performed under any conditions (stopping bleeding, tracheotomy). In other cases, the preoperative period can be long. During this time, the patient is carefully examined and prepared for the operation by various measures. On average, for ordinary operations (appendectomy, hernia repair), the preoperative period is equal to a few (2-3) days. During this time, the patient not only prepares for the operation but also gets used to the surrounding environment. In many cases, the concept of the preoperative period will be vague, but since for the majority of patients admitted to a surgical department, surgical intervention is required, for them the preoperative period begins from the moment of admission to the institution. In some cases, if the operation is not an emergency, it has to be postponed due to intercurrent acute diseases (tonsillitis, influenza, etc.). In particular, after having suffered from influenza and tonsillitis, it is recommended to perform the operation no earlier than 25-30 days after the establishment of a normal temperature. Patients who have rashes on the body (scabies, furunculosis) or are febrile upon admission, regardless of the underlying disease, cannot be subjected to surgical intervention until the cause of the febrile state is clarified or the painful phenomena are eliminated. Before admission to a surgical institution, the patient must take a bath, if there are no contraindications to this (weak, severe, emergency patients), and undergo a thorough examination to avoid the introduction of infection or parasites into the department. It should be particularly emphasized that patients transferred from other departments (therapeutic, neurological) must be examined just as carefully as newly admitted ones, to avoid unpleasant surprises for the surgeon, since ultimately only he bears the responsibility for the indications for the operation. The patient should spend the preoperative period in the calmest possible environment in order to exclude unnecessary psychological trauma as much as possible. This especially concerns so-called "nervous patients." The cleanliness of the room, discipline, well-organized work of the staff, and a caring attitude on the part of the latter have a calming effect on the patient's psyche. The question of the room for preoperative patients is also important. The sight of patients suffering from pain or vomiting after an operation, especially if the postoperative period is proceeding with severe complications, can have a depressing effect on a patient who is still to undergo an operation. Furthermore, the conditions of care for operated patients and those who have yet to undergo an operation are different, and for the purpose of rationalizing this care, it is desirable that patients spend the preoperative period in separate wards. If the department is small, then it is possible to place preoperative patients and convalescents in the same room. In large hospital institutions, patients pass through a so-called sorting department. In the preoperative period, among patients, just as among convalescents, cultural services should be organized: chess, a library, radio, film screenings, sanitary education work; however, the latter should not touch upon topics that cause the patient unnecessary anxiety (the question of malignant neoplasms, etc.). If, due to the nature of the disease, emergency surgical intervention is required, then only the most necessary methods are used when examining the patient (examination of the heart, lungs, urine). In all other cases, a thorough and comprehensive examination of the patient is performed using clinical, laboratory, and radiological methods: this clarifies the indications for surgical intervention, its nature, the method of anesthesia, and also reveals the necessity for preoperative preparation of organs that are known to be diseased or whose function suffers most from the operation (heart, lungs, liver, kidneys). It is necessary to give due attention to the anamnesis. Indications in the anamnesis of existing diseases of the heart, lungs (tuberculosis), kidneys (nephritis), or diabetes will force one to examine the patient even more carefully in this direction and, in some cases, to refuse surgical intervention when complications from the indicated organs would be more dangerous than the underlying disease for which the operation was intended for the patient. Everyone knows, for example, cases of exacerbation of a pulmonary process after operations, especially under general anesthesia. The importance of the anamnesis and the clarification of the presence of foci of dormant infection [past erysipelatous processes, suppuration, osteomyelitis, sometimes scars after gunshot wounds, etc. (Solovov)] is significant. If the presence of such foci is established clinically (examination of the oral cavity, teeth, old scars; provocation of dormant infection), then before the operation, to avoid sometimes severe complications (streptococcal sepsis, tetanus), a fight against this latent infection will be necessary. One must also pay attention to the possibility of alcoholism, syphilis, or malaria, because with some of them, poor healing of surgical wounds is noted (alcoholism, syphilis), and with others, an exacerbation of a subsided process (malaria) or newly arising severe complications (delirium tremens of alcoholics). To avoid these complications, it is not recommended to operate on syphilitics in the presence of traces of fresh lues (Wassermann reaction in the first place); in the case of alcoholism, the patient should not be completely deprived of alcoholic beverages; in the case of malaria, prophylactic quinine treatment is required. For emaciated, dehydrated patients, it is necessary to administer fluids subcutaneously, intravenously, or per rectum, or to perform a blood transfusion. For obese subjects, on the contrary, a cautious course of treatment against obesity is sometimes recommended before the operation. Constitutional features are also of great importance. It is also important to clarify whether the patient has status thymicolymphaticus. Often a surgeon has to deal with bronchitis and pulmonary emphysema. In the case of acute bronchitis, if the operation is not urgent, it is postponed until the moment of recovery from bronchitis. In chronic bronchitis, as well as in emphysema accompanied by bronchitis, its preliminary treatment is necessary. In elderly patients suffering from emphysema and bronchitis, special preventive measures are required in the preoperative period. This is especially important in cases of operations in which complications from the lungs and bronchi are generally not uncommon. Such operations generally include laparotomies, especially in the upper abdomen, and operations requiring prolonged bed rest in the postoperative period. Preventive measures in all such cases include respiratory gymnastics, inhalation of carbon dioxide, cupping, camphor, etc. Prophylactic injection of antipneumococcal serum, recommended by a number of authors to avoid postoperative pneumonia, has not become widespread. The effect of prophylactic injections of various kinds of polyvalent sera (pneumo-strepto-staphylococcal, etc.), the use of which some authors recommend against local suppuration in the wound, peritonitis, etc., is also not great. When examining the heart and circulatory organs, in addition to percussion, auscultation, and pulse examination, blood pressure measurement must be considered mandatory. Based on blood pressure figures, one can, for example, to a certain extent establish indications for one or another method of anesthesia; thus, with low blood pressure, splanchnic anesthesia is contraindicated. Some surgeons attach great importance to the so-called Stange's breath-holding test; it is performed as follows: the patient is asked to take a deep breath while sitting and hold their breath as long as possible. Most authors consider general anesthesia contraindicated if the patient cannot hold their breath for more than 20 seconds. Of course, this test is not absolutely indicative, especially if one keeps in mind that with appropriate training in certain professions, one can significantly lengthen the breath-holding time even with a poor state of circulation.

Some surgeons recommend the Katzenstein test (the effect of femoral artery compression on pulse and blood pressure) and the Mosler test (the effect of breath-holding on blood pressure, etc.). If, by one means or another, disturbances of the cardiovascular apparatus are established, some of them may serve as a contraindication for performing operations (decompensated defects); in other cases, the operation should be postponed until cardiovascular activity is regulated. Furthermore, a number of heart diseases (mild myocarditis) make it necessary, without delaying the operation for a long period, to take a number of measures in the preoperative period to improve the function of the cardiovascular system; these include bed rest, diet, and a number of medicinal measures (strychnine, adrenaline, camphor, digitalis, subcutaneous administration of physiological solution, etc.). Indications for such a thorough examination are, first and foremost, diseases of the blood, then of the liver, kidneys, diabetes, etc. A general blood examination, besides its diagnostic significance for the underlying disease (anemia in malignant neoplasms, leukocytosis in inflammatory conditions), indicates in a number of cases the necessity for appropriate preparation; this includes blood transfusion, preparation for diabetes, and cholemia. The presence of leukocytosis with a neutrophilic shift, if it is not caused by the underlying disease, prompts a search in the body for the source of this condition (existing or recently suffered purulent diseases). The indications for surgery depend on the results of such an examination. The presence of dental caries, stomatitis, or tonsillitis dictates a number of measures to eliminate them. Some surgeons, not without reason, attach such great importance to the sanitation of the oral cavity that they recommend sending every patient for whom an operation is planned to a dentist beforehand. Even if one should not be so demanding in all cases, every surgical patient should still be taught by the staff to keep the oral cavity clean—rinsing the mouth after eating and brushing teeth should be widely promoted among patients both in the preoperative period and in the postoperative period; this is one of the measures that prevents the development of postoperative parotitis, pneumonia, etc. In the preoperative period, it is also important to pay attention to the gastrointestinal tract. Until recently, preparation with laxatives was considered mandatory. The justification for giving laxatives before an operation was: 1) reducing the danger of vomiting in the postoperative period, 2) reducing the danger of intoxication from the intestine, 3) combating meteorism, 4) eliminating contamination of the abdominal cavity when opening the intestine. As subsequent observations, especially those of the last decade, have shown, preparing the body with laxatives (together with the previously mandatory fasting before an operation) is not only aimless but also harmful. It has been noted that the postoperative period in individuals who were not prepared with laxatives and fasting much less frequently proceeded with the complications common in the past—vomiting, meteorism, urinary retention, and similar symptoms, which are associated with postoperative acidosis (see Acidosis, postoperative acidosis). In Russian literature, Korganova-Müller was the first to present such observations. Working in two different institutions, in one of which patients were prepared for surgery with laxatives and fasting, while in the other they were operated on without such preparation, the author was able to notice a significant difference in the postoperative period. Thus, in appendectomies, she observed a smooth postoperative course in 41% of patients with standard preparation and in 76% without such preparation. The study of the problem of postoperative acidosis shows that not only preoperative preparation but also the operative trauma itself, anesthesia, and the patient's nervous excitement before the operation are causes that induce acidosis after the operation. Even if we take into account that not all authors associate these phenomena with acidosis and that far from everyone considers postoperative acidosis to be true, the observations nevertheless undoubtedly indicate that the less we prepare a patient for surgery with laxatives and fasting, the less frequent are postoperative complications of the order mentioned above. It has long been noted that emergency operations, which were usually performed without such cleansing of the intestine, proceeded no worse than operations before which the intestine was thoroughly cleansed. Over the last decades, a number of surgeons have expressed doubt about the necessity of cleansing the intestine with laxatives before operations. Interest in this issue has especially increased over the last ten years, mainly in connection with questions about postoperative acidosis. At present, it has been established that none of the pursued goals is achieved by giving laxatives and that the results are often exactly the opposite. Vomiting in the postoperative period cannot be associated with the filling of the intestine, since food usually leaves the stomach already a few hours after ingestion, and a full stomach is cleansed not by laxatives but by a stomach tube (emergency operations, especially ileus). Furthermore, in the postoperative period, vomiting is usually not associated with food intake (see below). As for the danger of intoxication and infection from the intestine, it is now known that it is greater with the administration of laxatives than without them. The intestinal mucosa is damaged as a result of increased peristalsis, which also disrupts the natural barrier and increases the absorption of intestinal contents into the blood. Meyer's experiments showed that after giving laxatives to rabbits, blood cultures for bacteria usually yielded a positive result, whereas in control rabbits, the cultures were usually sterile. Postoperative meteorism, which is based mainly on a disturbance of mesenteric circulation occurring either as a result of a disturbance in the tone of the autonomic nervous system after the operation, or as a result of trauma to the intestine, or as a result of infection, is also not eliminated by giving laxatives; rather the opposite. The paresis of the intestine that occurs following increased peristalsis after the administration of laxatives further increases meteorism. Flerov confirmed this experimentally by operating on dogs after the preliminary administration of laxatives and without them. In the first case, the intestine was always somewhat distended, in the second—collapsed in the form of flat ribbons. Laxatives, by thinning the intestinal contents, also increase the danger of infecting the abdominal cavity when opening the intestine; this especially applies to the large intestine, the solid fecal masses of which contain bacteria, most of which are already dead, while liquid contents are rich in living flora. Contamination of the abdominal cavity is easier to avoid with solid feces than with liquid, since the former can be more easily pushed aside, and can be scooped out more easily and neatly, etc. The danger of surgery on the large intestine, according to Mayo, increases with the administration of laxatives. The harm of laxatives also lies in the dehydration of the body. Based on these and a whole series of other observations, the majority of surgeons at the present time refuse to prescribe laxatives before operations unless this is dictated by special circumstances. However, the indications for prescribing laxatives are still different among different surgeons to this day. While some still consider it necessary to prescribe laxatives before all gastrointestinal operations, others prescribe them only for operations on the rectum and in the small pelvis. As for cleansing the intestine before an operation with enemas, for the majority of patients they will also prove unnecessary. It is necessary to prescribe them for constipation, although even here it is better to regulate bowel movements with diet. For surgery on the rectum or for hemorrhoids, a single dose of laxatives (castor oil 30.0) is required 2 days before the operation. On the eve of the operation, in the morning and evening, enemas are administered until the so-called "clear water" (usually 2-3). Disinfection of the intestine before an operation with salol, benzonaphthol, etc., also does not achieve its goal, although some surgeons do use these agents. Fasting before operations is also now recognized as unnecessary and harmful. This position naturally follows from everything that was said above regarding laxatives. The body, which is subjected to increased and unusual demands during an operation, is weakened, and sometimes very strongly, without due cause by preoperative fasting. The liver, which is an organ that suffers particularly during an operation (mainly from general anesthesia), is deprived of glycogen stores as a result of fasting, whereas at the present time we strive to increase these glycogen stores in some cases even by the subcutaneous introduction of glucose with insulin. In view of this, the preoperative diet should be as rich in carbohydrates as possible. For the majority of operations, if not dictated by special indications (operations on the rectum, metabolic diseases), the preoperative diet should be considered superfluous.

Until the very evening preceding the day of the operation, the patient should consume normal food, and even early in the morning on the day of the operation, he is given a glass of hot, sweet tea, and in the case of operations under local anesthesia, even a piece of white bread (for stomach operations, only hot, sweet tea is given). However, many surgeons, without sufficient grounds, recommend prescribing liquid and semi-liquid food as early as the day preceding the operation. A special preoperative diet is required for operations on the large intestine, rectum, and for hemorrhoids, with liquid and semi-liquid food (semolina porridge, fruit jelly, broth) being prescribed the day before the operation. The pancreas usually does not require special preoperative preparation. However, in cases of diabetes mellitus caused by damage to the internal secretory apparatus of the pancreas (see Diabetes mellitus), special measures are required in the preoperative period. Every surgeon is aware of the danger of surgical intervention in diabetics; poor wound healing and reduced resistance to infection were formerly common complications in the postoperative period. The overall postoperative mortality rate among diabetics reached 37%, and in operations for diabetic gangrene, up to 80%. True, for a long time now, thanks to appropriate dietary preparation (which Noorden especially insisted upon), the mortality rate in the hands of some surgeons (e.g., at the Mayo Clinic) has equaled 5-7%. However, only with the discovery of insulin has the danger of the operation been, if not eliminated, then significantly reduced. The average percentage of postoperative mortality, according to Reed, is currently 12.7%. The successes of recent years have allowed a number of surgeons (Christie) to assert that the danger of surgical intervention with appropriate preparation in diabetics is no greater than in individuals with normal metabolism. Other authors (Grote and Flesch-Thebesius) present observations showing that the operation still causes, to one degree or another, a worsening of the course of diabetes. Preparation is carried out according to the standard plan for treating diabetes, on average over 5-7 days. On the morning of the operation, carbohydrates are given in liquid form (150 g of orange juice) with an appropriate dose of insulin. In the case of an emergency operation, the same measures are necessary as for a coma (see), i.e., the subcutaneous or intravenous administration of glucose and large doses of insulin. Examination of urine in the preoperative period for at least sugar and protein should be considered just as mandatory as checking temperature. With such a simple and quick measure, in a number of cases, dangerous, sometimes fatal, postoperative complications can be avoided. In case of necessity, if kidney disease is suspected, a number of additional examinations are required (see Kidneys, functional diagnostics). Establishing a disturbance of kidney function will, in some cases, dictate appropriate preparation of patients with kidney damage for the operation, and in others, will lead to the refusal of general anesthesia, which has a harmful effect on the renal parenchyma, and sometimes even to the refusal of the operation. A fairly frequent complication in the postoperative period—urinary retention—is advised by some surgeons to be prevented by accustoming patients to urinate while lying in bed during the preoperative period. Along with the heart, lungs, and kidneys, the liver is also an organ on which surgery and especially general anesthesia have an unfavorable effect. Therefore, in appropriate cases, a particularly thorough examination of its functions is necessary (see Liver, functional diagnostics). In the case of established liver function insufficiency, Lepehne recommends its preoperative preparation by prescribing insulin simultaneously with glucose, which promotes the accumulation of glycogen in the liver. A liver rich in glycogen better resists infection and intoxication than a liver deprived of glycogen due to disease, starvation, or an insufficient amount of carbohydrates in the food. Blood transfusion in the preoperative period is also one of the greatest achievements of recent years. At the present time, preparing the patient's body for surgery with blood transfusion, just like blood transfusion in the postoperative period, makes it possible in a number of cases to perform operations that would otherwise be dangerous or even unfeasible. Blood transfusion in weak, emaciated, anemic patients, in many cancer patients, in Basedow's disease, in blood diseases (hemophilia, hemorrhagic diatheses), in cholemia, in acute blood loss (trauma, hematemesis)—transfusion to avoid postoperative shock during major operations (gastric resection), etc., has significantly lowered the percentage of postoperative mortality and expanded the indications for performing surgical intervention. Crile, who systematically uses blood transfusion in the preoperative period for individuals whose hemoglobin percentage is below 75, has reduced postoperative mortality from 12.4% to 1.2%. The question of whether it is possible to operate during the menstrual period is decided by surgeons in different ways. The majority avoid operating at this time. One of the serious reasons is the difficulty of caring for the genital organs of a menstruating woman who is weakened by the operation and sometimes forced to lie in bed for a long time. Reduced blood clotting during the menstrual period and the rush of blood to the pelvic organs also make it necessary to consider this time inconvenient for operating. However, in cases of vital and urgent indications, the presence of menstruation should not deter the surgeon from the necessary intervention. In addition to the general preoperative measures cited, in some cases, special preparation of the patient is required in connection with the nature of his underlying disease. For patients with Basedow's disease, bed rest (on average about 15 days) and preparation with iodine according to Plummer are recommended. In appropriate cases, it is necessary to prescribe cardiacs and nervines. The surgeon must be extremely careful with a patient with Basedow's disease; the psyche of these patients is sometimes so unstable that death can occur on the operating table even before the operation begins. To spare the psyche of these patients, some surgeons advise not informing them of the date of the operation in advance to avoid prolonged nervous excitement. Gastric patients as a rule do not require special preparation, but in the case of a large decaying tumor, or in cases of stenosis (benign and malignant), systematic gastric lavage is recommended by the majority of surgeons. In many cases, one can limit oneself to a single or double gastric lavage on the evening before the operation; it is not recommended to perform lavage on the morning of the day of the operation, as the patient arrives on the operating table severely weakened. In connection with the theory of postoperative acidosis, a number of surgeons have proposed preparation for the operation of patients with stomach cancer by subcutaneous administration of insulin and glucose (Berezov). A disturbance of carbohydrate metabolism, similar to that which occurs in diabetics, a disturbance of oxidative processes in the body of cancer patients, as well as, as Berezov points out, trauma to the pancreas during the operation with subsequent disturbance of its function, theoretically justify this preparation to some extent. Although much in this matter remains unclear, the beneficial results of glucose-insulin preparation of cancer patients are nonetheless certain. According to Berezov, the preparation is carried out as follows: 2 days before and on the morning before the operation, the patient is injected with 10 units of insulin; a glucose solution is administered intravenously at an average rate of 3 g of glucose per 1 unit of insulin. After the operation, it is necessary to continue the administration of glucose and insulin for 3-4 days, with up to 1.5 g of glucose being administered per 1 unit of insulin (for 10 units of insulin, 300 g of 5% glucose). In cases of cholemia, to avoid postoperative bleeding, Calcium chloratum and Calcium lacticum are prescribed. (However, some surgeons warn against the use of calcium in cholemia.) The most effective measure against postoperative bleeding is the transfusion of small amounts of blood (200-300 cm³) both before and after the operation. It is advised (Chasovnikov) to operate when blood clotting has been brought to normal, of course, if the operation can wait. For individuals suffering from very large hernias, a position in bed with the foot end of the bed raised is recommended. To avoid postoperative peritonitis, a whole series of measures is proposed, but they are not widely used. In emergency operations, one should not forget, in case of necessity, to "pump out" the stomach contents to avoid vomiting and the subsequent aspiration pneumonia that may occur. On the eve of the operation, the patient takes a bath, if there are no contraindications; the operative field is widely shaved, and the patient puts on clean linen. In emergency operations, it is recommended to shave dry. In some institutions, sterile linen is put on. Protecting the operative field with sterile, sublimate, etc., dressings should be considered superfluous. When shaving, attention is once again paid to the condition of the skin, mainly in the area of the operation, as even an insignificant abscess or boil will be a contraindication to performing the operation until it is cured. Patients should spend the night before the operation as calmly as possible.

For this purpose, it is recommended to prescribe nervina, somnifera—bromine, luminal, veronal, etc., at night for nervous, excitable patients.