Perioperative Care

1
Perioperative Care
2
DiagnosisHistory examination and investigation

• Nonsurgical Problem Appropriate
  medical referral
• Surgical Problem Does not need
  hospital admit Outpatient
  referred to workup
  
• Risk assessment for cardiopulmonary disease,
  nutrition, hematologic, etc.
• O.R.

3

• Needs hospital admit Needs emergent
  surgery Minimal diagnostic
  Tests and workup O.R
• Needs nonemergent surgery
• Risk assessment for cardiopulmonary disease,
  nutrition, hematologic, etc.
• 
  O.R.

4
Lab Studies

• The studies that are generally performed include
  a complete blood count, PT, and PTT.
• Liver and renal function studies.
• Blood sugar
• Serum electrolytes.
• Urine pregnancy test, when indicated
• A type and screen or type and cross match should
  be requested for operations where blood
  transfusions are likely.
• Selective laboratory evaluation, coupled with a
  thorough history and physical exam, will prove to
  be both safer and more cost-effective.

5
Selected surgical procedures and likelihood of
blood transfusion.

• Low (lt15) risk
• Childbirth
• Cesarean section
• Cholecystectomy
• Transurethral prostatectomy
• Vaginal hysterectomy
• High (gt50) risk
• Abdominal hysterectomy
• Cardiac surgery
• Colorectal surgery
• Craniotomy
• Mastectomy
• Radical prostatectomy
• Spinal surgery
• Total joint replacement
• Vascular graft surgery

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Imaging Studies

• The disease process being treated should dictate
  the imaging studies ordered.
• Healthy young patients with no evidence of
  pulmonary disease benefit little from a chest
  x-ray. It is rare in a patient who has a normal
  pulmonary exam that the chest x-ray significantly
  alters the operation for which it was ordered.
• It is more reasonable to obtain a chest x-ray in
  an elderly patient, and, at times, this results
  in interesting findings, such as a lesion
  requiring further workup.

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Risk Assessment

• Cardiac
• The mortality of a perioperative MI is high. The
  challenge is proper assessment of an individual
  for coronary artery disease and other cardiac
  problems.
• Elective surgery should be avoided or postponed
  in patients who have suffered a recent MI or who
  have unstable angina. This risk decreases over
  the ensuing weeks and drops to about 5 after 6
  months.
• For these patients, full hemodynamic monitoring
  may be beneficial.
• One cannot emphasize enough the need to optimize
  the patients underlying cardiac conditions prior
  to surgery. Congestive heart failure should be
  controlled, blood pressure optimized, cardiac
  rhythm stabilized, and medications fine-tuned.
  Frequently, the cardiologist or primary care
  physician can be extremely helpful in achieving
  these goals.

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Risk Assessment

• Pulmonary
• In patients with a history of pulmonary disease
  or for those who will require lung resection
  surgery, preoperative assessment of pulmonary
  function is of value. Postoperative respiratory
  complications are leading causes of postoperative
  morbidity and mortality.
• History and physical exam can be helpful in
  assessing a patients risk of pulmonary problems,
  and, frequently, these are all that are
  necessary.
• Certainly, a chest x-ray (posteroanterior and
  lateral) may be helpful in a patient with a
  history of chronic obstructive pulmonary disease
  (COPD), shortness of breath (SOB), and physical
  findings consistent with congestive heart failure
  (CHF) or upper respiratory infections or as
  screening for metastatic disease.
• A room air blood gas may provide useful baseline
  information .
• Spirometry before and after bronchodilators and
  analysis of forced expiratory volume in 1 second
  (FEV1) and forced vital capacity (FVC) usually
  provides enough information .
• Cease smoking prior to surgery.

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Risk Assessment

• Nutritional
• There is a strong inverse correlation between the
  bodys protein status and postoperative
  complications.
• Parameters such as weight loss, albumin have been
  used to classify patients into states of mild,
  moderate, and severe malnutrition.
• In general, a weight loss of 5 to 10 over a
  month or 10 to 20 over 6 months is associated
  with increased complications from an operation.
• It is important to take the patients nutritional
  state into consideration after surgery. In the
  majority of well-nourished patients, little needs
  to be done other than to ensure that they resume
  a normal diet as soon as possible after surgery,
  preferably within 5 to 10 days. In patients who
  are severely malnourished, aggressive nutritional
  support may be of some benefit, with most of the
  benefit occurring in the early postoperative
  period.

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Risk Assessment

• Hematologic
• The patients ability to form clots is always a
  double-edged concern.
• On the one hand, the surgeon depends on it so
  that the patient does not exsanguinate from the
  intervention (fortunately, an exceedingly rare
  event). Conversely, a patient in a hypercoaguable
  state may suffer from a thromboemblic event that
  could be life threatening.
• In addition, a growing number of patients
  requiring surgical intervention are chronically
  anticoagulated for a number of reasons, e.g., A.
  fib, previous valve replacement, history of
  hypercoaguablity, etc., and the surgeon needs to
  have a strategy to deal with these patients.
• Historical information of importance includes
  whether the patient or a family member has had a
  prior episode of bleeding or a thromboembolic
  event, and whether the patient has a history of
  prior transfusions, prior surgery, heavy
  menstrual bleeding, easy bruising, frequent
  nosebleeds, or gum bleeding after brushing teeth.
  Information on the coexistence of kidney or liver
  disease, poor dietary habits, excessive ingestion
  of alcohol, and use of aspirin, other
  nonsteroidal antiinflammatory drugs (NSAIDs),
  lipid lowering drugs, or anticoagulants must be
  ascertained. If the history is negative and the
  patient has not had a previous significant
  hemostatic challenge, then the likelihood of a
  bleeding or thrombotic event is exceedingly rare
  .
• The standard coags routinely ordered as
  screening testthe prothrombin time (PT),
  activated partial thromboplastin time (aPTT), and
  platelet count.
• Discontinue their warfarin for several days prior
  to surgery. The patient can be anticoagulated
  with unfractionated intravenous heparin. The
  heparin infusion is discontinued approximately 4
  hours prior to surgery (the half-life of heparin
  is about 90 minutes), and surgery proceeds with
  good hemostasis.
• There is growing interest in the use of low
  molecular weight heparin (LMWH) as a bridge for
  surgery, and it is an attractive option, yet data
  are currently insufficient to provide a
  definitive recommendation for its use.

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Risk Assessment

• Other disease
• Renal failure
• Liver disease
• DM
• Anemia
• Obesity
• Thyroid status
• Supra-renal gland and steroid therapy
• Fluid electrolyte and acid base balance
• Alcohol and Drug Abuse
• Allergy
• Psychiatric Illness

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American Society of Anesthesiologists Physical
Status Classification Nonemergency Surgery

• Class I Normal, healthy patient
• Class II Patient with mild systemic
  diseasea mild to moderate systemic disorder
  related to the condition to be treated
  or to some other, unrelated process
• Class III Patient with severe systemic
  disease that limits activity but is not
  incapacitating
• Class IV Patient with incapacitating
  systemic disease that is life threatening
• Class V Moribund patient not expected to
  survive 24 hr without an operation
• Examples
• An inguinal hernia in a fit patient or a fibroid
  uterus in a healthy woman
• Moderate obesity, extremes of age,
  diet-controlled diabetes, mild hypertension,
  chronic obstructive pulmonary disease
• Morbid obesity, severely limiting heart disease,
  angina pectoris, healed myocardial infarction,
  insulin-dependent diabetes, moderate to severe
  pulmonary insufficiency
• Organic heart disease with signs of cardiac
  insufficiency unstable angina refractory
  arrhythmia advanced pulmonary, renal, hepatic, or
  endocrine disease
• Ruptured aortic aneurysm with profound shock,
  massive pulmonary embolus, major cerebral trauma
  with increasing intracranial pressure

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Selection of Appropriate Site for Procedure

• The following are the four main types of
  facilities used in the performance of outpatient
  surgical procedures
• 1. Office surgical facilities (OSFs). These
  include individual surgeons offices and larger
  group-practice units.
• 2. Freestanding day surgical units. These are
  often used by managed health care systems and
  independent contractors.
• 3. In-hospital day surgical units. These are
  often associated with inpatient units.
• 4. In-hospital inpatient units.

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Antibiotic Prophylaxis

• Surgery is an insult to the bodys immune system
  and infection is frequently an unwanted side
  affect.
• Antibiotic therapy may help decrease the
  incidence of postoperative infection.
• Antibiotic therapy must be used judiciously so as
  to avoid overuse and selection of resistant
  strains of bacteria

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Evidence-based guidelines for the prevention of
surgical site infection (wound infection)

• 1-Preparation of the patient
• Level I
• Identify and treat all infections remote to the
  surgical site before elective operations.
• Postpone elective operations until the infection
  has resolved.
• Do not remove hair preoperatively unless hair at
  or near the incision site will interfere with
  surgery. If hair is removed, it should be removed
  immediately beforehand, preferably with electric
  clippers.
• Level II
• Control the blood glucose concentration in all
  diabetic patients.
• Encourage abstinence from tobacco for a minimum
  of 30 days before surgery.
• Indicated blood transfusions should not be
  withheld as a means to prevent surgical site
  infection.
• Patients should shower or bathe with an
  antiseptic agent at least the night before
  surgery.
• Wash and clean the incision site before
  antiseptic skin preparation.

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Evidence-based guidelines for the prevention of
surgical site infection (wound infection)

• 2-Antimicrobial prophylaxis
• Level I
• Administer antibiotic prophylaxis only when
  indicated.
• Administer the initial dose intravenously, timed
  such that a bactericidal concentration of the
  drug is established in serum and tissues when the
  incision is made.
• Maintain therapeutic levels of the agent in serum
  and tissues for the duration of the operation.
• Levels should be maintained only until, at most,
  a few hours after the incision is closed.
• Before elective colon operations, additionally
  prepare the colon mechanically with enemas or
  cathartic agents. Administer nonabsorbable oral
  antimicrobial agents in divided doses on the day
  before surgery.
• Level II Do not use vancomycin routinely for
  surgical prophylaxis.

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Evidence-based guidelines for the prevention of
surgical site infection (wound infection)

• 3-Hand/forearm antisepsis
• Keep nails short.
• Scrub the hands and forearms up to the elbows for
  at least 25 min with an appropriate antiseptic.
• 4-Surgical attire and drapes
• A surgical mask should be worn to cover fully the
  mouth and nose for the duration of the operation,
  or while sterile instruments are exposed.
• A cap or hood should be worn to cover fully hair
  on the head and face.
• Wear sterile gloves after donning a sterile gown.
• Do not wear shoe covers for the prevention of
  surgical site infection.
• Use surgical gowns and drapes that are effective
  barriers when wet.
• Change scrub suits that are visibly soiled or
  contaminated by blood or other potentially
  infectious materials.

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Evidence-based guidelines for the prevention of
surgical site infection (wound infection)

• 5-Asepsis and surgical technique
• Level I
• Adhere to principles of asepsis when placing
  intravascular devices or when dispensing or
  administering intravenous drugs.
• Level II
• Handle tissue gently, maintain hemostasis,
  minimize devitalized or charred tissue and
  foreign bodies, and eradicate dead space at the
  surgical site.
• Use delayed primary skin closure or allow
  incisions to heal by secondary intention if the
  surgical site is contaminated or dirty.
• Use closed suction drains when drainage is
  necessary, placing the drain through a separate
  incision distant from the operative incision.
  Remove drains as soon as possible.
• 6-Postoperative incision care
• A sterile dressing should be kept for 2448 h
  postoperatively on an incision closed primarily.
  No recommendation is made regarding keeping a
  dressing on the wound beyond 48h.
• Wash hands before and after dressing changes and
  any contact with the surgical site.
• Use sterile technique to change dressings.
• Educate the patient about surgical site
  infections, relevant symptoms and signs, and the
  need to report them if noted.

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PREOPERATIVE PATIENT EDUCATION

• ORAL-INTAKE GUIDELINES
• PREMEDICATION
• Narcotics

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Informed Consent

• Informed consent should be viewed as an
  opportunity for the surgeon to take some time to
  explain to the patient why an operation is
  necessary, what the operation entails, what sort
  of recovery to expect, and what complications
  might be incurred.
• The discussion should be frank and honest while
  sensitive to obvious anxieties of the
  preoperative patient. It is also helpful, when
  possible, to have this discussion in the presence
  of a concerned spouse or family member.
• Time should be given for all involved to ask
  questions. With this in mind, the discussion may
  best be done sometime well in advance of the
  operation. This understandably is not always
  possible. The discussion, when possible, also
  should include nonoperative therapies for the
  given disease process.