Perioperative Care

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Perioperative Care

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Introduction

• Are there absolute contraindications to surgery
  related to cardiac, pulmonary, or renal disease?
• What is the optimal method of perioperative deep
  venous thrombosis prophylaxis?
• What constitutes optimal perioperative management
  of the gastrointestinal tract?
• What constitutes the optimal incision or approach
  for a gynecologic cancer procedure?

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Cardiac Risk

• High-risk surgical procedure ( intraperitoneal)
• Hisotry of ischemic heart disease (excluding
  coronary revascularization)
• History of heart failure,
• History of stroke or transient ischemic attack
• Preoperative insulin therapy
• Creatinine levels gt 2 mg/dl

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Cardiac Risk
James W, et al.Gynecologic cancer controversies
in management, 2004.
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Benefit of perioperative B-blocker
therapy

• Randomized in high-risk surgical patients
  (abdominal aortic aneurysm repair)
• Bisoprolol versus placebo
• Cardiac mortality ( 17 versus 3.4, p0.002)
• Myocardial infarction (17.4 versus 0, plt0.001)

Poldermans D et al.Eur Heart J 2001221353-1358.
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Pulmonary risk

• Postoperative pulmonary complications (POPC)
  after abdomnal surgery more frequently (10-30)
  than cardiac complications.
• Postanesthetic changes in vital capacity,
  functional residual capacity, ventilation-perfusio
  n abnormality, diaphragmatic dysfuction,
  decreased number, activity of alveolar
  macrophages inhibiting mucocilicary clearance,
  increased alveolar-capillary permeability.

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Pulmonary risk

• Postoperative respiratory failure, perioperative
  pneumonia, COPD, asthma, atelectasis and pleural
  effusion.
• Formal spirometry may predict risks lacks
  sensitivity and specificity.
• Lack of preoperative predictability in creating
  an effective plan for prevention of pulmonary
  morbidity.

Smetana GW.N Engl J Med.1999340937-944.
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Pulmonary risk
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Smoking

• Effect of short-term smoking cessation has not
  been effective in preventing perioperative
  morbidity.
• Perioperative morbidity stop
  smoking lt 8 versus gt 8weeks (33 versus 14)

Smetana GW. Clin Geriatr Med 20031935-55.
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Pulmonary risk

• Absence of risk assessment stragegy and inability
  to modify pulmonary risk factors for morbidity.
• Early involvement of a pulmonary consultant may
  be the best strategy.
• In most situations, patient benefits from an
  intensive postoperative pulmonary program.

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Renal disease risk

• Renal failurerise in serum creatinine over
  baseline by 0.5 mg/dL, a reduction of calculated
  creatininte clearance of 50, or the need for
  dialysis.
• Postoperative renal failure is associated with a
  dramatic increase in mortality (45),
  particularly in presence of hypotension, sepsis
  and exposure to nephrotoxic drugs.

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Gynecology cancer Renal disease risk

• Radical surgery risk for prerenal, intrinsic
  renal or postrenal dysfunction.
• Dehydration, sepsis, blood loss, 3rd-space of
  fluid, and exposure to nephrotoxic agents
  (intravenous radiocontrast media, specific
  antibiotic, cisplatin, NSAID, ACE inhibitors.

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Current popular strategies for renal protection

• Aggressive hydration by pulmonary artery
  catheters.
• Renal-dose dopamine
• Induction of mannitol or furosemide diuressis
• Unfortunately, none of these strageies has prove
  effective.

Sadovnikoff N. Int Anesthesiol Clin
20013995-109.
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No renal protective strategy exists

• Careful preoperative analysis of patients
  medication
• Perioperateive supportive care
• Minimizing exposure to nephrotoxic agent
• Postoperative surveillance to detect and treat
  postoperative renal insufficiency.
• Anxiously await new renal protective drugs and
  new strategies.

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What is the optimal method of perioperative deep
venous thrombosis prophylaxis?

• DVT1.5-38 after routine gynecologic surgery.
• Prophylaxis reduce risk by 75 .
• Cancer patients high risk for DVT.
• Developing clinical DVT may extend for weeks.
• Delayed DVT a poor cancer prognosis.

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IPC intermittent pneumatic compression.(Efficacy,
ease, low side effect) LDUH low-dose
unfractionated heparin. ESelastic stockings.
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Deep venous thrombosis prophylaxis

• Elastic stock not represent sufficient
  prophylaxis for the higher risk patients.
  (history of DVT, older than 60 years, gynecologic
  cancer).
• 332 patients, 6-10 in hospital days of LMWH.
• Randomized to placebo or LMWH for an additional
  21 days.
• DVT rate placebo versus study group( 12 versus
  4.8, p0.02)

Bergqvist D et al. N Engl J Med 2002346975-980.
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Treatment of venous thromboembolic disease

• Low molecular weight heparin (LMWH, clexaneSC,
  30mg q12h).
• Heparine (initial IV bolus 5000-10000 units, then
  IV infusion 20000-40000 or initial SC 10000-20000
  units then 10000units q8h)
• Placement of an inferior vena cava filter.

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Heparin

• Heparin temporary discontinuation of therpay 6
  hours before surgery and resumption 6-12 hours
  after surgery.
• LMWH lower reported incidence of bleeding
  complications.

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Highest risk for intraoperative bleeding

• IVC filter placement
• Delay surgery for up to 1 month after the
  diagnosis of VTE.
• If delay is not feasible, LMWH for several days
  after the diagnosis of VTE

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Prevent recurrence of VTE

• Warfarin ( coumadin) International normalized
  ration of 2-3, planned more than 6 months
  treatment.
• 50 risk reduction for recurrent VTE in cancer
  paitents.

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What constitutes optimal perioperative management
of the gastrointestinal tract?
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Preoperative sigmodioscopy

• Correct prediction to avoid resection (21/25,
  84)
• Correct prediction to resection (5/9)
• Although no strict guidelines, pelvic surgeon
  should offer preoperative colon or intestinal
  evaluation in clinical situations in which
  abnormalities are likely to be present.

Gornall R. Eur J Cynaecol Oncol 19992013-15.
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(Evac enema)
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Preoperative preparation

• NO single drug or regimen has documented
  superiority, a short course of a broad-spectrum
  antibiotic ( single dose if the surgery is not
  twice as long as the drug half-life) is
  appropriate.
• 99 colorectal surgeons use mechanical bowel
  preparation before intestinal resection.

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Preoperative mechanical preparation

• Failed to demonstrate a lessened risk of wound or
  abdominal infection.
• The incidence of anastomotic breakdown was not
  lowered.
• Colonic anastomoses can be safely performed in
  women even in the absence of a mechanical
  preparation.

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Postoperative GI care

• Normal function returns in the stomach and
  intestine at 8 hours, right colon at 48 hours,
  sigmoid colon at 72 hours after an abdominal
  procedure.
• Little adverse effect on return of bowel function
  related to duration of surgery, intestinal
  manipulation, narcotics, retroperitoneal
  dissection.

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Nasogastric suction

• Surgical dogma to use NG suction.
• A 1999 survery suggested gynecologic oncologist
  commonly incorporate NG suction after
  cytoreduction (57), LN dissection (34), radical
  hysterectomy (29) and routine hyestereocmty
  (15).
• Always used NG suction after colon resection(
  90) and small bowel resection (97).
• Rationale for use was to decrease distension
  (67), avoid an ananstomic leak (39) and lessen
  nausea (36).

Brewer M. Gynecol Oncol 199868126.
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No difference in deaths, aspiration, nausea,
vomiting, abdominal distention, wound dehiscence,
wound infection, anastomotic leak or length of
stay.
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• In extreme risk of a prolonged postoperative
  ileus ( extensive dissection after irradiation).
  Intraoperative gastrostomy tube placement should
  be considered as a comfortable alternative.

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Early oral feeding

• Well tolearted
• Shorter hospital stays
• No increase the risk of ileus or other
  complication.

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• Routine NG drainage does not lessen risks.
• Infectious complications are controlled by
  broad-spectrum antibiotics.
• Intra-abdominal abscesses are usually (85)
  manage successfully with percutaneous drainage.

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Postoperative obstruction

• After excluding the possibility of strangulation,
  adhesive postoperative obstruction is typically
  successfully managed conservatively, with
  resolution frequently occurring with 48 hours.
• Early use of contrast enhanced radiology should
  be considered to those without resolution in 48
  hours .

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Summary

• Are there absolute contraindications to surgery
  related to cardiac, pulmonary, or renal disease?
• What is the optimal method of perioperative deep
  venous thrombosis prophylaxis?
• What constitutes optimal perioperative management
  of the gastrointestinal tract?

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Thank you for your attention
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