PERIOPERATIVE MANAGEMENT

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PERIOPERATIVE MANAGEMENT

• DR. CLEMENT R S D SOUZA,
• ASSOCIATE PROF.,
• DEPT. OF SURGERY,
• FR MULLER MEDICAL COLLEGE,
• MANGALORE
• clement62_at_rediff.com

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PERIOPERATIVE MANAGEMENT

• DEFINITION
• MANAGEMENT BEFORE, DURING AND AFTER A SURGICAL
  OPERATION

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PERIOPERATIVE MANAGEMENT

• PREOP ASSESMENT
• INTRAOP MANAGEMENT
• POSTOP MANAGENENT

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PREOP ASSESMENT

• AIMS
• OUTLINES RATIONALE FOR PREOP ASSESMENT
• ADVERSE EFFECTS OF PREOP MORBIDITIES SUCH
  ASDIABETES, HYPERTENTION ETC., ON POSTOP OUTCOME
• FAVOURABLE/ UNFAVOURABLE OUTCOMES
• RESOURSE IMPLICATIONS OF OVERINVESTIGATIONS
• COMMONLY PRESCRIBED DRUGS
• OPTIMISING HEMODYNAMIC PARAMETERS

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PREOP ASSESMENT

• OBJECTIVES
• IMPACT ON PATIENT MORBIDITY AND MORTALITY
• OPTIMISE PATIENT PHYSICALLY AND MENTALLY TO
  REDUCE RISK
• TO RETURN PATIENT TO A HEALTHY STATE AS EARLY AS
  POSSIBLE
• MANAGING EXISTING DRUG ADMINISTRATION
• TEAM APPROACH WITH THE PATIENT, RELATIVES, GP,
  SURGICAL TEAM, MEDICAL/DIAGNOSTIC/NURSING/PARAMEDI
  CALS

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Classification of Surgery

• Seriousness
• Major
• Minor
• Urgency
• Elective
• Urgent
• Emergency

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PREOP ASSESMENT

• IDENTIFICATION OF HIGH RISK PATIENT
• OPTIMISING HIGH RISK PATIENT

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PREOP ASSESMENT

• HIGH RISK PATIENT
• RISK OF DEATH AFTER OPERATION IS 0.7 TO 1.7
• 1/3 ON OR BEFORE 2 DAYS OF SURGERY
• EMERGENCY 15, URGENT 52, ELECTIVE 31
• 87 gt60 YRS . 71gt70YRS.
• 84 gt3 ASA SCORE.

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PREOP ASSESMENT

• HIGH RISK PATIENT
• 85 ONE OR MORE COMORBIDITIES.
• 23 HAD THEIR OPN. DELAYED TO IMPROVE HEALTH .
• 32 ICU, 8 IN HIGH DEPENDANCY WARD.
• CAUSE OF DEATH 37 RESP., 36 CARDIAC , 22
  RENAL.
• ELECTIVE SURGERY MORTALITY 5-10, EMERGENCY
  23-55

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PREOP ASSESMENT

• TO SUMMERIZE
• POST OP DEATHS ARE USUALLY IN ELDERLY, WITH
  COMORBIDITIES, IN EMERGENCY OPERATIONS, IN
  ABDOMINAL , COLORECTAL, ORTHO.SURGERIES.

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PREOP ASSESMENT

• HIGH RISK PATIENT IDENTIFICATION BY CLINICAL
  ASSESMENT
• USING 1) ASA SCORING SYSTEM
• 2)GOLDMAN INDEX SCORE

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PREOP ASSESMENTHIGH RISK FACTORS

• H/O SEVER CARDIORESP. ILLNESS.
• EXTENSIVE ABLATIVE SURGERY FOR MALIGNANCY
• SEVERE MULTIPLE TRAUMA(3 OR MORE ORGANS/2 OR MORE
  CAVITIES)
• MASSIVE ACUTE BLOOD LOSS gt8 UNITS.
• AGE gt 70YRS

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PREOP ASSESMENTHIGH RISK FACTORS

• CLINICAL SHOCK
• SEPTICAEMIA
• SIGNIFICANT RESP. FAILURE. PO2 lt60mmHg.
• ON MECHANICAL VENTILATOR FOR gt 48HRS
• ACUTE ABD. CATASTROFE WITH HEMODYNAMIC
  INSTABILITY.
• ACUTE RENAL FAILURE

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PREOP ASSESMENT

• IDENTIFICATION BY PHYSIOLOGICAL ASSESMENT
• BY IDENTIFYING LOW CARDIOVASCULAR RESERVE

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PREOP ASSESMENT PREOP VISIT

• TO ASSES IF PATIENT IS FIT FOR THE PROCEEDURE
• RISKS AND BENEFITS IN DELAYING THE PROCEEDURE
• ADEQUTE TIME SHOULD BE SPENT ON PREOP ASSESMENT

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PREOP ASSESMENT General Aspects

• CHECK NAME, PROPOSED OPERATION, HOSP. NO., PT.
  CHART FOR ANY PREVIOUS PROBLEMS AND PATHOLOGY

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PREOP ASSESMENT

• COMLICATIONS WITH PREVIOUS ANAESTHESIA
• NAUSEA, VOMITING TO ANAPHYLAXIS TO ANAESTHETIC
  DRUGS
• ANY SPECIFIC PROBLEM WITH ANY RELATIVES

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PREOP ASSESMENT SMOKING

• gt20/DAY
• INCREASED CARDIOVASCULAR AND RESP. PATHOLOGY
• 70 CHANCES OF RESP. INFECTION
• CARBONMONOXIDE LEVELS IN SERUM ARE RAISED 3 FOLD
  THEREBY DECREASING O2 CARRYING CAPACITY

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PREOP ASSESMENT SMOKING

• SHOULD PATIENT STOP SMOKING?
• 3 TO 6 MONTHS OF ABSTINANCE IS NEEDED TO REDUCE
  THE RISK OF RESP. INFECTION
• HOWEVER CO LEVELS DECREASE WITH ACUTE CESSATION
  OF SMOKING THEREBY O2 CARRYING CAPACITY INCREASES

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PREOP ASSESMENT..ALCOHOL AND DRUG ABUSE

• HIGH ALCOHOL INTAKE AND DRUG (ANALGESICS/SEDATIVES
  ) INCREASES AMOUNT OF DRUG ADMINISTRATION DURING
  ANAESTHESIA
• STOPPING INTAKE 1 MONTH BEFORE IS BENIFICIAL

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PREOP ASSESMENT.. OBESITY

• PRACTICAL PROCEEDURES LIKE VENOUS ACCESS/
  INTUBATION/LOCAL ANAESTHESIA/MOVING THE PT.
• INCREASED DEMAND ON HEART
• DECREASED FUNCTIONAL RESIDUAL CAPASITY DUE TO
  PRESSURE ON DIAPHRAGM FROM ABD. WALL
• SLEEP APNOEA

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PREOP ASSESMENTRESPIRATORY PROBLEMS

• ACUTE RESP. TRACT INFECTION
• BRONCHIAL ASTHMA
• CHRONIC OBSTRUCTIVE PULM. DISEASE

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PREOP ASSESMENTRESPIRATORY PROBLEMS
..MANAGEMENT

• APPROPRIATE ANTIBIOTIC
• BRONCHODILATORS
• CHEST PHYSIO
• REVERSAL OF BORDERLINE CORPULMONALE
• DEHYDRATION AND ELECTROLYTE IMBALANCE CORRECTION
• CESSATION OF SMOKING

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PREOP ASSESMENT DIABETES

• ON DIET ALONE
• ON ORAL DRUGS
• ON INSULINE

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PREOP ASSESMENT DIABETES

• QUALITY OF GLUCOSE CONTROL
• ASSTD. CARDIOVASCULAR, NEUROLOGIC, AND RENAL
  COMLICATIONS

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PREOP ASSESMENT DIABETES MANAGEMENT

• IN MINOR SURGERYOMIT DOSE PRIOR TO SURGERY
• IN MAJOR SURGERY.DAILY INSULIN REQUIREMENT IS TO
  BE MONITORED

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PREOP ASSESMENT RENAL DISEASE

• INVESTIGATIONS TO DETECT COMPLICATIONS OF SUCH
  AS HYPERTENSION, IHD.
• ANAESTHETIC PROBLEMS MAY ARISE IN PTS WITH RENAL
  IMPAIRMENT

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PREOP ASSESMENT RENAL DISEASE
MANAGEMENT

• DIALYSE PT. ON DIALYSIS 1 HR. BEFORE SURGERY
• ACTIVATED COAGULATION TIME PRIOR TO SURGERY

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PREOP ASSESMENTANATOMICAL DIFFICULTIES

• TO IDENTIFY DIFFICULTY IN AIRWAY
• INTUBATION DIFFICULTY?
• NECK MOVEMENTS

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PREOP ASSESMENT PREGNANCY

• AVOID ELECTIVE SURGERY
• SPONTAEOUS ABORTION
• ORGANODYSGENESISDRUGS
• SAFE ANAESTHETIC AGENTS

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PREOP ASSESMENT OVERALL ASSESMENT

• ASA SCORE
• ASA 1 NORMAL
• ASA 2MILD SYST. DISEASE
• ASA 3SEVER SYST. DISEASE
• ASA 4INCAPACITATING SYST. DISEASE
• ASA 5...MORIBUND
• E EMERGENCY SURGERY

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Intraoperative Care of Patient

• Nursing roles
• Holding area preparation
• Admission to OR

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Intraoperative Care of Patient(cont'd)

• Assessment
• Verification of patient, necessary assessments
  and documentation, and procedure
• patient comfort

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Intraoperative Care of Patient(cont'd)

• Physical preparation
• Patient positioning
• Application of support and monitoring equipment
• Introduction of anesthesia general, regional,
  local, conscious sedation
• Documentation

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Postoperative Care of Surgical Patient

• Immediate care PACU
• Surgical information
• Nursing assessments
• Interventions
• Discharge criteria ambulatory and acute care
  surgical settings

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Postoperative Care of Surgical Patient(cont'd)

• Overall assessment
• Vital signs
• Condition of dressings and drains
• Comfort level
• IV fluid status
• Urinary output

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Postoperative Care of Surgical Patient (cont'd)

• Assessment
• Respiration
• Circulation
• Temperature control
• Fluid and electrolyte balance
• Neurological function
• Skin integrity and wound condition

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Postoperative Care of Surgical Patient(cont'd)

• Assessment
• Genitourinary function
• Gastrointestinal function
• Comfort
• Client expectations

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Postoperative Care of Surgical Patient (cont'd)

• Respiratory complications
• Atelectasis
• Pneumonia
• Hypoxemia
• Pulmonary embolism

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Postoperative Care of Surgical Patient(cont'd)

• Circulatory complications
• Hemorrhage
• Hypovolemic shock
• Thrombophlebitis
• Thrombus formation
• Embolus

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Postoperative Care of Surgical Patient(cont'd)

• Gastrointestinal complications
• Abdominal distention
• Paralytic ileus
• Nausea and vomiting
• Urinary retention
• Urinary tract infection

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Postoperative Care of Surgical Patient(cont'd)

• Integumentary complications
• Wound infection
• Dehiscence
• Evisceration
• Skin breakdown
  
  
• Pain

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Postoperative Care of Surgical Patient (cont'd)

• Nursing diagnoses
• Impaired physical mobility
• Impaired skin integrity
• Disturbed body image

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Postoperative Care of Surgical Patient (cont'd)

• Planning
• Goals and outcomes
• Airway is patent and respirations are even
  and unlabored
• Vital signs return to preoperative baseline
• Setting priorities
• Continuity of care

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Implementation of Postoperative Care for Surgical
Patient

• Maintaining respiratory function
• Positioning and turning
• Suctioning
• Deep breathing (incentive spirometer), coughing
• Comfort
• Early ambulation
• Oral hygiene
• Oxygen

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Implementation of Postoperative Care for Surgical
Patient (cont'd)

• Preventing circulatory stasis
• Leg exercises
• TED stockings
• Early ambulation
• Positioning
• Anticoagulants
• Fluid intake

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Implementation of Postoperative Care for Surgical
Patient(cont'd)

• Achieving rest and comfort
• Analgesics
• PCA
• Pain assessment

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Implementation of Postoperative Care for Surgical
Patient(cont'd)

• Temperature regulation
• Warmed blankets
• Monitoring for hypothermia and malignant
  hyperthermia
• Assessment for signs of infection

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Implementation of Postoperative Care for Surgical
Patient (cont'd)

• Neurologic function
• Orientation to the environment
• Level of consciousness

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Implementation of Postoperative Care for Surgical
Patient (cont'd)

• Maintaining fluid and electrolyte balance
• IV therapy
• Oral intake when appropriate

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Implementation of Postoperative Care for Surgical
Patient (cont'd)

• Promoting normal elimination and adequate
  nutrition
• Gradual progression of dietary intake
• Ambulation and exercise
• Adequate fluid and food intake
• Elimination aids fiber, medications
• Control of nausea and pain

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Implementation of Postoperative Care for Surgical
Patient (cont'd)

• Promoting urinary elimination
• Normal positioning
• Frequent assessment
• Assessment of bladder distention

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Implementation of Postoperative Care for Surgical
Patient (cont'd)

• Maintaining/enhancing self-concept
• Provide privacy
• Maintain Patient s hygiene
• Prevent drainage devices from overflowing
• Maintain a pleasant environment
• Offer opportunities for Patient and family to
  express feelings and participate in care

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THANK YOU