Perioperative

Management
{Pantja Wibowo
Karawaci, 24 November 2011
 History

Examination

Investigations

Diagnosis

Treatment
Taking history
Physical examination
Laboratory examination
Radiology
Consultation
PERIOPERATIVE
{In details
 ❧ The care of the patient preparing for,
having, and recuperating from surgery
❧ Concert of surgeon, anesthesiologist,
and other consultants

Definition
 ❧ High risk patients
❧ Patient’s satisfaction

Points of Interest
 ❧ Emergency
❧ Urgency

❧ Elective

Types of surgery
 ❧ A surgical procedure that cannot be delayed, for
which there is no alternative therapy, and which a
delay could result in death or permanent
impairments of health.
❧ Examples: open fracture skull, some gunshot and
stab wounds, urinary obstruction, intestinal
obstruction, ruptured appendix, twisted ovarian
cyst, ruptured fallopian tube.

Emergency surgery
 ❧ Surgery that required within 48
hours
❧ Example: kidney stone, stomach
obstruction or ulcer, bleeding
hemorrhoids, ectopic pregnancy

Urgent surgery
 ❧ Surgery of any operation that
can be performed with
advanced planning.
❧ Examples: cholecystectomy,
hernia repair, colonic resection,
coronary artery bypass.

Elective surgery
High Risk
{Point of Interest
❧ The definition is a complex and
controversial.
❧ Poorly understood and depends on
past individual and professional
perception, and societal norms.

High Risk Surgical Patient

❧ Complicated by practical considerations of the
ease with which risk can be measured with a
focus on objective measurements of cardiac
function.
❧ The usefulness is in doubt because there are very
few studies that have materially altered patient
outcome based on information gained by risk
assessment.

High Risk Surgical Patient

 Critical Care August 2005 Vol 9 No 4 Boyd and Jackson

Subject Definition
Patient ✓ Ability to return to work
✓ Possibility of disability
✓ Success of operation

Family ✓ Will patient be able to resume

role as career?
✓ Will patient survive?

High Risk (perception)

 Critical Care August 2005 Vol 9 No 4 Boyd and Jackson

Subject Definition
Nurse ✓ Infection transmission
✓ Violence towards self
Surgeon ✓ Likelihood of operative success
✓ Possibility of operative
misadventure

High Risk (perception)

 Critical Care August 2005 Vol 9 No 4 Boyd and Jackson

Subject Definition
Anesthesiologist ✓ Likelihood of surviving
30 days
✓ Likelihood of surviving
the anesthetic
Intensivist ✓ Likelihood of leaving
the intensive care unit
✓ Prolonged stay on the
intensive care unit

High Risk (perception)

 Critical Care August 2005 Vol 9 No 4 Boyd and Jackson

Subject Definition
Administrator ✓ Outcome poorer than comparative
unit
✓ Care costing more than allocated

High Risk (perception)

Class Description Mortality (%)
I Healthy 0.1
II Mild systemic disease – no functional limitation 0.7
III Severe systemic disease – definite functional limitation 3.5
IV Severe systemic disease – constant threat to life 18.3
V Moribund patient unlikely to survive 24 hours with or 93.3
without operation
E Emergency operation

American Society of Anesthesiologist’s

status classification
 STEP 1

Need for emergency

non cardiac surgery

Ye
No s Operating room

Perioperative
surveillance and post
operative risk
STEP 2 stratification and risk
management

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
 STEP 2

Active cardiac
conditions

Ye
No s Evaluate and treat as
per guidelines

Consider operating room

STEP 3

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
 STEP 3

Low risk surgery

Ye
s

No
Proceed with
planned surgery

STEP 4

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
 STEP 4

Functional capacity greater

than or equal to 4 METs
without symptoms

Ye
s
No or
unknown

Proceed with planned

surgery

STEP 5

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
 STEP 5a
3 or more clinical
risk factors

Intermediate risk
surgery
Vascular surgery

Proceed with planned surgery

Consider testing if it
with HR control or considering
will change
noninvasive testing
management

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
 STEP 5b
1 or 2 clinical risk
factors

Intermediate risk
surgery
Vascular surgery

Proceed with planned surgery

with HR control or considering
noninvasive testing

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
 STEP 5c

No clinical risk
factors

Proceed with
planned surgery

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Patient’s
Satisfaction
{
Point of Interest
 ❧ Patient and the family need
assurance
❧ Is the Informed consent
help?

Assuring
Informed consent
 ❧ Pain screening
❧ Pain assessment
❧ Pain management

5th Vital Signs

Pain
 ❧ Fasting
❧ Fasting before surgery
❧ Fasting after surgery
❧ Drug consuming

Preparation
❧ Perioperative management
involving multidiscipline that
should be orchestrated beautifully
❧ Orchestra is not a solo player!
❧ High risk surgery must be
anticipated by all of the orchestra
team members
❧ Patient’s satisfaction is one of the
important aim

Conclusions