Perioperative Care

1
Perioperative Care

• Dr Robin Correa FRCA FFPMRCA
• Consultant Pain Management
• and Anaesthetics
• 03 May 2012

2
Perioperative Care

• Preoperative Care
• Fluid management and nutrition
• Assessment
• Intraoperative Care
• Antibiotic and thromboprophylaxis
• Sterilisation, disinfection and antisepsis
• - Transport, positioning, scrubbing up,
  instruments, incisions, closures, drains, stomas
  and sutures
• Postoperative Care
• Drain, fluid and acid base management, pain,
  surgical complications and critical care

3
Fluid Management

• Introduction
• Fluid compartments
• Stress response and fluid
• GIFTASUP recommendations

4
Introduction

• Fluid and electrolyte balance consists of
• - external balance between the body and its
  environment
• - internal balance intravascular, interstitial
  and intracellular
• compartments
• Twenty four hour requirements in normal adult are
  25 35 mL/kg or 1.5 2.5 L of water with 70
  mmol of sodium and 40 - 80 mmol of potassium
• Fluid requirements sometimes classified as that
  for replacement, maintenance and resuscitation

5
Introduction

• Fluid and electrolyte balance consists of
• - external balance between the body and its
  environment
• - internal balance intravascular, interstitial
  and intracellular
• compartments
• Twenty four hour requirements in normal adult are
  25 35 mL/kg or 1.5 2.5 L of water with 70
  mmol of sodium and 40 - 80 mmol of potassium
• Fluid requirements sometimes classified as that
  for replacement, maintenance and resuscitation

6
Introduction

• Crystalloid solutions contain low molecular
  weight salts or sugars which dissolve completely
  in water and pass freely between intravascular
  and interstitial compartments
• Colloid solutions contain larger molecular weight
  substances that do not dissolve completely and
  remain for a longer period in the intravascular
  compartment

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Fluid compartments
8
Fluids
Fluid Sodium mmol/L Potassium mmol/L Chloride mmol/L Osmolarity mosm/L
Plasma 136-145 3.5-5.0 98-105 280-300
Hartmanns 131 5.0 111 275
Dextrose 4 saline 0.18 30 0 30 283
5 Dextrose 0 0 0 278
Gelatine 4 (Gelofusine) 145 0 145 290
0.9 Saline 154 0 154 308
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Fluids

Volume effect () Average MW (kDa) Circulatory half life
Gelatins 80 35 2 3 hrs
Dextran 70 120 41 2 12 hrs
6 HES Hydroxyethyl Starch 100 70 Up to 17 days
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Stress response and fluid

• Along with other hormones, stress response to
  surgery releases vasopressin and triggers the
  RAAS (renin angiotensin aldosterone system)
• Net effect is an increase in body water with the
  retention of sodium and excretion of potassium.
  Oliguria is common which is accompanied by a
  reduced capacity of kidney to dilute or
  concentrate urine
• A catabolic state from surgery results in an
  increased production of urea and other
  metabolites which compete with electrolytes
  (mainly Na and Cl-) for excretion by the kidney
• Recovery phase is characterised by a diuresis
  with loss of both sodium and water

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GIFTASUP

• GIFTASUP (October 2008) - British Consensus
  Guidelines on Intravenous Fluid Therapy for Adult
  Surgical Patients
• A 1997 UK study showed that postoperative
  patients were frequently in positive fluid
  balances of 7 litres or more with a sodium load
• of 700 mmol
• In the US, excessive fluid administration causing
  pulmonary oedema has been blamed for 8315
  patient deaths a year

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GIFTASUP

• A 2002 postal survey of 710 consultant surgeons
  revealed that PRHOs were most commonly
  responsible for fluid prescription.
• Only 16 of respondents felt that their
  preregistration house officers (PRHOs) were
  adequately trained in the subject before
• joining their firm
• A survey of 33 foundation year 1 doctors in
  their first post shows that knowledge about
  intravenous fluid administration continues to be
  poor (BMJ May 2011)

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GIFTASUP

• Clinical experience is
• Making the same mistakes with increasing
  confidence
• over an impressive number of years
• A Sceptics Medical Dictionary. BMJ Publication
  1997

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GIFTASUP

• GIFTASUP has made 28 recommendations in total
  to include assessment of
• fluid requirements, perioperative fluid and
  nutrition management
• Levels of evidence (Oxford Centre for Evidence
  based Medicine )
• 1A Systematic Review of Randomized Controlled
  Trials (RCTs)
• 1B RCTs with Narrow Confidence Interval
• 1C All or None Case Series
• 2A Systematic Review Cohort Studies
• 2B Cohort Study/Low Quality RCT
• 2C Outcomes Research
• 3A Systematic Review of Case-Controlled Studies
• 3B Case-controlled Study
• 4 Case Series, Poor Cohort Case Controlled
• 5 Expert Opinion

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GIFTASUP

• Recommendation 1 Normal Saline is Abnormal
• Recommendation 2 Dextrose can be dangerous
• Recommendation 3 Equal electrolytes by
  any route
• NB words in red are an aide memoire and do not
  form part of the GIFTASUP document

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GIFTASUP

• Recommendation 1 (Normal Saline is Abnormal)
• Evidence level 1b
• Because of the risk of inducing hyperchloraemic
  acidosis ? in routine practice, when crystalloid
  resuscitation or replacement is indicated,
  balanced salt solutions e.g. Ringers
  lactate/acetate or Hartmanns solution should
  replace 0.9 saline, except in cases of
  hypochloraemia e.g. from vomiting or gastric
  drain
• ? http//www.frca.co.uk/article.aspx?articleid10
  0924

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GIFTASUP

• Normal Saline is Abnormal
• 0.9 saline contains supranormal amounts of Na
  and Cl-
• (154 mmol/L each ) compared to physiological
  concentrations
• (140 and 95 mmol/L respectively)
• A sodium load can be difficult to excrete
  especially in the oliguric phase of the stress
  response
• Hyperchloraemia causes renal vasoconstriction and
  a reduced glomerular filtration rate
• Excess serum sodium can aggravate interstitial
  oedema caused by capillary endothelial leaks

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GIFTASUP

• Recommendation 2 (Dextrose can be
  dangerous)
• Evidence level 1b
• Solutions such as 4 /0.18 dextrose/saline and
  5 dextrose are important sources of free water
  for maintenance, but should be used with caution
  as excessive amounts may cause dangerous
  hyponatraemia, especially in children and the
  elderly
• These solutions are not appropriate for
  resuscitation or replacement therapy except in
  conditions of significant free water deficit e.g
  diabetes insipidus

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GIFTASUP

• Recommendation 3 (Equal electrolytes by any
  route)
• Evidence level 5
• To meet maintenance requirements, adult patients
  should receive sodium 50-100 mmol/day, potassium
  40-80 mmol/day in 1.5 - 2.5 litres of water by
  the oral, enteral or parenteral route (or a
  combination of routes)
• Additional amounts should only be given to
  correct deficit or continuing losses. Careful
  monitoring should be undertaken using clinical
  examination, fluid balance charts, and regular
  weighing when possible

20
Curve A represents the hypothesized line of risk.
Broken line B represents a division between
patient groups in a wet vs dry study. Broken
line C represents a division between patient and
groups in an optimized vs non-optimized"
study M. C. Bellamy Wet, dry or something else?
Br. J. Anaesthesia 2006 97 755-757
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GIFTASUP

• Fluid optimisation
• 250 ml fluid challenge
• ?
• Stroke volume increase gt10 Yes
• ? No
• Observe ? Yes DO2 gt600ml/min/m2 ? No
  Fluid losses gt input ? Yes ?
  No
• Dopexamine 1mcg/kg/min
• No Yes
• DO2 gt600ml/min/m2
• Using monitors such as oesophageal doppler, PA
  catheter or pulse contour analysis
• (e.g. LiDCO)

22
Fluid Monitors

• Principle
• Heart is normally sensitive to cyclical changes
  in preload during mechanical ventilation
• It should therefore be sensitive to changes in
  preload induced by a fluid load (fluid
  responsiveness)
• Arterial pulse pressure variation(PPV) and stroke
  volume variation (SVV) can be used accurately to
  predict fluid responsiveness

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Fluid Monitors

• Principle

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LiDCO Rapid
25
Oesophageal Doppler
26
NICE guidelines

• Cardio Q - ODM (Oesophageal Doppler monitor)
• Medical Technology Guidance (MTG3) March 2011
• http//guidance.nice.org.uk/MTG3
• Evidence of reduction in post-op complications,
  use of central venous catheters and in-hospital
  stay compared with conventional clinical
  assessment with or without invasive
  cardiovascular monitoring
• Consider use in patients undergoing major or
  high-risk surgery or other surgical patients in
  whom a clinician would consider using invasive
  cardiovascular monitoring

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GIFTASUP

• Postoperative fluid management
• Details of fluids administered must be clearly
  recorded and easily accessible
• When patients leave theatre for the ward, HDU or
  ICU their volume status should be assessed
• In patients who are euvolaemic and
  haemodynamically stable a return to oral fluid
  administration should be achieved as soon as
  possible
• In patients requiring IV maintenance fluids,
  these should be sodium poor and of low enough
  volume until the patient has returned their
  sodium and fluid balance over the peri operative
  period to zero

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Scenario 1

• 80 yr old female for elective total hip
  arthroplasty
• Scheduled last on PM list but starved from 1800
  hrs
• previous day
• Start Hartmanns 1 litre to run over 6 hours

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Scenario 2

• yr old male on ward after elective hemi
  colectomy
• 6 hrs prior
• Urine output 50 mls in the last 3 hours
• Check vitals
• Look for overt signs of bleeding
• Fluid challenge 250 mls crystalloid or colloid

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Scenario 3

• 27 yr old postoperative lap appendicectomy. No
  overt
• losses and patient looking well
• Oral intake planned as sips of water next day
• Maintenance fluid aim for 1.5 2.5 L of water
  with
• 70 mmol of sodium and 40 - 80 mmol of potassium.
• Hartmanns / Dextrose saline with potassium
  chloride

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Scenario 4

• 60 yr old male AP resection 4 days ago.
• Hypotensive but feels warm to touch, anuric for
  last
• 5 hours
• Check vitals and temperature
• Judicious fluid challenge
• Seek senior help early

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Resources

• Association of Surgeons of Great Britain and
  Ireland
• http//www.asgbi.org.uk
• Intensive Care Society
• http//www.ics.ac.uk
• NICE guideline (nutritional support)
• http//www.nice.org.uk/Guidance/CG32
• Surgical Tutor
• http//www.surgical-tutor.org.uk/default-home.htm
  ?principles/postoperative/fluid_balance.htmright

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Summary

• Fluids are distributed into various body
• compartments according to their solute molecular
  weight and content
• Normal saline is abnormal
• Fluid type and volume must always be tailored to
  clinical condition

34

• Every time I learn something new, it pushes some
  old stuff out of my brain

35
Perioperative Care

• Preoperative Care
• Assessment
• Fluid management and nutrition
• Intraoperative Care
• Antibiotic and thromboprophylaxis
• Sterilisation, disinfection and antisepsis
• - Transport, positioning, scrubbing up,
  instruments, incisions, closures, drains, stomas
  and sutures
• Postoperative Care
• Drain, fluid and acid base management, pain,
  surgical complications and critical care

36
Assessment

• Objectives of preoperative assessment
• Preoperative assessment clinics
• Infrastructure
• Personnel
• Process
• Pathways and basic investigations
• Special investigations
• CPX testing

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CPX
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CPX
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CPX

• Cardio- Pulmonary Exercise Testing (CPET or CPX)
• The anaerobic threshold (AT) is the uptake of
  oxygen (ml/kg/min) at the point when there is a
  surge in CO2 production during increasing
  workload
• This reflects maximum ability of patient to
  increase oxygen delivery / consumption and
  cardiopulmonary fitness
• AT gt 11 ml/kg/min can be used to categorise
  patients fit for major abdominal surgery
• Postoperative mortality can be predicted from AT
  values and
• presence of test ECG ischaemia

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CPX

• Older, P et al Chest 1999116355-362

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Perioperative Care

• Preoperative Care
• Assessment
• Fluid management and nutrition
• Intraoperative Care
• Antibiotic and thromboprophylaxis
• Sterilisation, disinfection and antisepsis
• - Transport, positioning, scrubbing up,
  instruments, incisions, closures, drains, stomas
  and sutures
• Postoperative Care
• Drain, fluid and acid base management, pain,
  surgical complications and critical care

42
Antibiotic prophylaxis

• Principles
• NICE guidelines
• Department of Health (DH) guidelines

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Antibiotic prophylaxis

• Classification
• Bacterial spectrum (broad vs.narrow)
• Type of activity (bacteriocidal vs.
  bacteriostatic)
• Route of administration (injectable vs. oral vs.
  topical)
• Based on chemical structure (beta lactam e.g.
  Penicillin)

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Antibiotic prophylaxis

• Principles
• High circulating serum levels of antibiotics at
  the time of tissue contamination
• Usually of limited duration e.g. 24 hours post op
• Extended duration (3 days or more)
• Immunosuppressed patients
• Malnourished patients
• Patients with prosthetic implants e.g. heart
  valves
• Established postoperative surgical infections

45
NICE guidelines

• Surgical Site Infection
• http//www.nice.org.uk/Guidance/CG74 October 2008
• Antibiotic prophylaxis
• Give antibiotic prophylaxis to patients before
• clean surgery involving placing a prosthesis
  or implant
• clean-contaminated surgery
• contaminated surgery
• Do not give antibiotic prophylaxis routinely for
  clean non-prosthetic uncomplicated surgery
• Antibiotic prophylaxis against infective
  endocarditis is not recommended
• Use the local antibiotic formulary and consider
  potential adverse effects when choosing
  antibiotics

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Antibiotic prophylaxis

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NICE guidelines

• Antibiotic prophylaxis (contd.)
• Consider the timing and pharmacokinetics of the
  antibiotic
• Consider giving a single dose of antibiotic
  prophylaxis intravenously on starting anaesthesia
  or earlier if a tourniquet is used
• Give a repeat dose when the operation is longer
  than the half-life of the antibiotic
• Give additional antibiotic treatment to patients
  having surgery on a dirty or infected wound
• Whenever possible, inform patients before their
  operation if they will need antibiotic
  prophylaxis, and afterwards if they have been
  given antibiotics

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DH guidelines

• Clostridium Difficile Infection (CDI) How to
  deal with the problem
• http//www.dh.gov.uk/en/Publicationsandstatistics/
  Publications/
• PublicationsPolicyAndGuidance/DH_093220
  January 2009
• Restrictive antibiotic guidelines should be
  developed by trusts
• stressing the following recommendations
• Use narrow-spectrum agents for empirical
  treatment where appropriate
• Avoid use of clindamycin and second- and
  third-generation cephalosporins, especially in
  the elderly
• Minimise use of fluoroquinolones, carbapenems and
  prolonged courses of aminopenicillins

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Thromboprophylaxis

• Definitions
• Aetiology
• Methods
• NICE / DH guidelines

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Thromboprophylaxis

• Definitions
• Venous thromboembolism (VTE) is the formation of
  a blood clot
• (thrombus) in a vein which may dislodge from its
  site of origin to
• cause an embolism
• Most thrombi occur in the deep veins of the
  legs this is called deep vein thrombosis (DVT)
• Dislodged thrombi may travel to the lungs this
  is called a pulmonary embolism (PE)
• Aetiology
• Series of contributing factors called Virchow's
  triad
• - alterations in blood flow (stasis)
• - injury to the vascular endothelium
• - alterations in the constitution of blood
  (hypercoagulability)

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Venous Thromboembolism
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Thromboprophylaxis

• Methods
• Mechanical devices
• Graduated compression stockings, pneumatic
  compression devices
• Drugs acting on the clotting cascade
• Heparin unfractionated or low molecular weight
  (LMWH) - activates antithrombin III
• Apixaban direct inhibitor of Factor Xa
• Antiplatelet drugs
• Aspirin, Dipyridamole, Clopidogrel
• Drugs indirectly affecting clot formation
• Dextran 70
• General measures
• Early mobilisation, foot elevation, hydration

53
Mechanical devices
54
NICE guidelines

• Venous thromboembolism reducing the risk
• http//www.nice.org.uk/Guidance/CG92
• January 2010

55
NICE guidelines

• Care pathway Patient admitted to hospital
• Assess VTE risk
• Assess bleeding risk
• Balance risks of VTE and bleeding. Offer VTE
  prophylaxis if appropriate.
• Do not offer pharmacological VTE prophylaxis
  if patient has any risk factor
• for bleeding and risk of bleeding
  outweighs risk of VTE
• Reassess risks of VTE and bleeding within 24
  hours of admission and whenever clinical
  situation changes.

56
NICE guidelines

• Apixaban
• http//www.nice.org.uk/ta245 January 2012
• Direct inhibitor of activated Factor X
• Recommended dosage is 2.5 mg orally twice daily
• Initial dose should be taken 1224 hours after
  surgery
• Treatment durations are 3238 days for patients
  having hip replacement surgery and 1014 days for
  patients having knee replacement surgery
• Apixaban more clinically effective and cheaper
  than Enoxaparin and is recommended as an option
  for VTE prevention after elective hip or knee
  replacement

57
Assessing risks of VTE

• Patients at risk of VTE
• Surgical patients and patients with trauma
• If total anaesthetic surgical time gt 90 minutes
• If surgery involves pelvis or lower limb and
  total anaesthetic surgical time gt 60 minutes
• If acute surgical admission with inflammatory or
  intra-abdominal condition
• If expected to have significant reduction in
  mobility
• If any VTE risk factor present

58
Assessing risks of VTE

• VTE risk factors
• Active cancer or cancer treatment
• Age gt 60 years
• Critical care admission
• Dehydration
• Known thrombophilias
• Obesity (BMI gt 30 kg/m2)
• One or more significant medical co-morbidities
  (for example heart disease metabolic, endocrine
  or respiratory pathologies acute infectious
  diseases inflammatory conditions)
• Personal history or first-degree relative with a
  history of VTE
• Use of HRT
• Use of oestrogen-containing contraceptive
  therapy
• Varicose veins with phlebitis

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Assessing risk of bleeding

• Patients at risk of bleeding
• Active bleeding
• Acquired bleeding disorders (such as acute liver
  failure)
• Concurrent use of anticoagulants known to
  increase the risk of bleeding (such as warfarin
  with INR gt 2)
• Lumbar puncture/epidural/spinal anaesthesia
  within the previous 4 hours or expected within
  the next 12 hours
• Acute stroke
• Thrombocytopenia (platelets lt 75 x 109/l)
• Uncontrolled systolic hypertension ( 230/120
  mmHg)
• Untreated inherited bleeding disorders (such as
  haemophilia or Von Willebrands disease)

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DH guidelines

• Venous thromboembolism (VTE) risk assessment
• http//www.dh.gov.uk/en/Publicationsandstatistics/
  
• Publications/PublicationsPolicyAndGuidance/DH_0882
  15 March 2010
• All patients should be risk assessed on
  admission to hospital
• Any tick for thrombosis risk should prompt
  thromboprophylaxis according to NICE guidance.
• Patients should be reassessed within 24 hours of
  admission and whenever the clinical situation
  changes
• From 1st June 2010 all NHS Trusts are required to
  be able to demonstrate that more than 90 of
  their inpatients receive a Venous Thromboembolism
  Risk Assessment (VTE RA) on admission to hospital
  

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Questions ?