PERIOPERATIVE CARE

INTRODUCTION
A safe operative experience involves team from consultant surgeon until trainee (housemen) Gathering concisely relevant information hx, PE, Ix & Dx Planning to minimise risk & maximise benefit for the patient Prepared for adverse events & how to deal with them Communicating with the patient & all other

team members

PATIENT ASSESSMENT
History HOPI, past medical history, drug

history & social history Physical Examination general, CVS, Respiratory, GIT, neurological & local examination

 Investigations ordered only when clinically

indicated

Full blood count & GSH Renal profile Clotting screens CXR ECG Further cardiac evaluation ECHO<35% high risk of cardiac complications Further respiratory evaluations COPD

 Management
Discuss specific surgical diagnosis give patient

ample time to voice their own concerns Discuss confounding issues

Medical comorbidities that will complicate the management plan Allows truly informed consent to be given Patient is unsure best to defer a final decision

SPECIFIC PREOPERATIVE PROBLEMS

Cardiovascular Disease
Hypertension
Systolic > 160mmHg, Diastolic > 95mmHg elective

surgery deferred May need involvement of medical team

IHD - strong contraindication to elective anaesthesia

Significant mortality rate from anaesthesia within 3 months

of infarction Ideally delayed until at least 6 months

Dysrhythmias
Fast AF anti-arrhythmic agent 2nd or 3rd degree heart block pacemaker Necessary intervention depends on the physiological state

of the patient & the urgency of the surgery

 Cardiac failure
Require specialist medical input Oxygenation & fluid balance must be meticulously

monitored & documented

Anaemia & blood transfusion

Resulted from bleeding or chronic disease state
Hb < 8 preoperative transfusion Transfusion a day before surgery improve

oxygen-carrying capability of cells

Respiratory Disease
Infection
Antibiotics

Asthma
Continue usual inhalers Brittle asthmatics may need oral steroid cover

Gastrointestinal disease
Obesity
Increased risk: difficult intubation, regurgitation, DVT,

pressure sores, respiratory compromise, MI, CVA Requires extra prophylactic measures Risks incorporated into consent form

Regurgitation
Pulmonary aspiration acid pneumonitis severe

bronchospasm pneumonia death Increased risk: hiatus hernia, bowel obstruction & paralytic ileus KNBM 6 hours before op Others: preoperative use of H2 receptor blocker

Metabolic disorders
Diabetes
High risk of: sepsis (local & general), vascular

(cardiovascular, cerebrovascular, peripheral), renal complications, fluid & electrolyte disturbance Non-insulin-dependent diabetes omit morning dose list for early surgery restart OHA after eating postoperatively Insulin-dependent diabetes IVI insulin (started when patient first omit meal & continued until they have recovered from surgery)

Coagulation disorders
Drugs
Warfarin affect the INR Aim INR < 1.5 Risk of thrombosis significant replace with heparin infusion, stopped 2H before surgery & restarted immediately afterwards Needs close monitoring of sequential APTT Antiplatelets affect the bleeding times Effects cannot be acutely reverse until production of new platelets Takes a week

Risk group for thrombosis

Low risk
Minor surgery (<30min), no risk factors (RF), any age

Major surgery (>30min), no RF, age <40

Minor trauma or medical illness

Intermediate risk
Major surgery (not orthopaedic or abdominal cancer),

age 40+ or other risk factor Major medical illness, trauma or burns Minor surgery, trauma or illness in patient with a family/personal history

 High risk
Major surgery ( elective or trauma orthopaedic,

cancer) of pelvis, hip or lower limb Major surgery, trauma or illness in a patient with a family/personal history Lower limb paralysis/amputation

Prophylaxis against thrombosis

Mechanical

Early mobilisation Neuraxial anasthesia Leg compression stockings Calf & foot pumps Heparin & low molecular weight heparin Warfarin Aspirin Pentasaccharide (fondaparinux)

Pharmacological

OBTAINING CONSENT
Competence
Informed consent: patient must be competent Able to comprehend & retain information

discussed with them, believe it, weigh up & choose an array of treatment options Children < 16 years old: parents/social worker Not competent: obtain two consultants signature & reasons for actions taken must be fully documented

 Stages in the consent process

Patients demographic details Operation plan outlined & confirmed with the

patient Alternatives to the proposed plans & likely complications discussed Steps taken to minimise risks & what will happen if complications arise discussed

Adequate preoperative preparation happy

to consent

PERIOPERATIVE MANAGEMENT OF THE HIGH RISK SURGICAL PATIENTS

High Risk Patients

Every surgical procedure involves some risk

of significant post-operative complications & death In most cases, the risk is <1% Risk increased:
Elderly patients Comorbid conditions Needing emergency surgery (no time for

optimisation)

Patient factors
IHD COPD Diabetes Advance age Poor nutritional status

Surgical Factors
Emergency surgery Major or complex surgery Body cavity surgery Large anticipated blood loss Large insensible fluid loss Prolonged duration of surgery

Identification of High Risk Patients

Most commonly used is American Society of

Anaesthesiology (ASA)

ASA Class Class I Class II

Description A normal healthy person A patient with mild systemic disease that does not limit functional activity A patient with severe systemic disease that limits functional activity A patient with severe systemic disease that poses a constant threat to life A moribund patient who is not expected to survive longer than 24H, either with or without surgery

Risk of Cardiac Events & Death 1% 5%

Class III

16%

Class IV

56%

Class V

>56%

Perioperative Care for High Risk Patients

Full history & thorough physical examination Preoperative medical therapy
involves medical management review Eg: PCI, CABG, course of oral corticosteroid for

asthmatic patients etc

Investigation
Always include evaluation of respiratory & cardiac

function for determine cardiorespiratory reserve

Critical Care
High risk surgical patients may require

admission to critical care either before or after surgery Primary aim: ensure adequate tissue perfusion & oxygenation Basic clinical assessment pulse rate, resp rate, arterial pressure, urine output, GCS, CRT & presence of peripheral cyanosis

General Aspects of Critical Care

Tight glucose control with IVI insulin (aim 48mml/L) Maintain Hb >8 Withold enteral nutrition from patients for several days following surgery
Early enteral diet may jeopardise bowel anastomoses,

exacerbate postoperative ileus & delay recovery

DVT prophylaxis Acquired adrenocortical depression

Common in septic shock patients Low dose corticosteroids reduce vasopressor

requirements

ANAESTHESIA

General Anaesthesia
Triad unconsciousness, muscular blockade

& pain relief Induced by propofol Mantained by halothane, enflurane, desflurane or sevoflurane Neuromuscular blockade
Depolarizing: suxamethonium Non-depolarizing: atracurium, rocuronium,

mivacurium, vecuronium & pancuronium

 Pain relief eliminate pain, reduce autonomic

response & allow lower concentration of anaesthetic drugs to be given to maintain anaesthesia Opioid analgesics morphine, fentanyl, alfentanyl, ramifentanyl & pethidine Antagonist naloxone (overdose)

Management of Airway
Loss of muscle tone jeopardise airway

patency
Position head tilt & jaw thrust
LMA insertion Endotracheal tube passed into trachea by direct

laryngoscopy

Monitoring & Recovery

Monitoring

Inspired oxygen concentration Oxygen saturation by pulse oxymetry Expiratory carbon dioxide tension Blood pressure ECG

Recovery
Closely supervised by staff skilled in airway

management Equipped with tools for resuscitation & adequate monitoring devices

Local Anaesthesia
Depends on
Feasibility of the procedure Patients willingness & ability to cooperate Surgeons & anaesthetists preference

Complications
Local infection or haematoma Systemic overdosage, systemic hypotension &

vasodilation (epidural & spinal anaesthesia)

Types of Local Anaesthesia

Topical anaesthesia
Used on skin, urethral mucosa, nasal mucosa & cornea Amethocaine, lignocaine or prilocaine

Local Infiltration
Infiltration of LA drug into or around the operated

area Contraindicated near the infected site

Regional anaesthesia regional nerve block, spinal & epidural anaesthesia

Conducted in fully aseptic technique Requires preoperative preparation same as GA in case

of failed regional anaesthesia

 Regional nerve block

Brachial plexus block surgery on upper limb Field block inguinal hernial repair Regional block of ankle surgery on the foot/toes

Spinal anaesthesia
Useful in pelvic/lower limb surgery Bupivacaine injected single shot into CSF May cause hypotension & postoperative headache

Epidural anaesthesia
Advantage multiple dosing & prolonged use in post-

operative period Slower onset easier to control hypotension

THE OPERATION

Immediate Pre-operative Preparation Before Surgery

Patients identity & name checked &

confirmed Nature of operation confirmed with the patient Appropriate consent form checked All relevant results, investigations & imaging available Side to be operated marked with skin marker

The Operation
Transfer patient & set-up
Slow & smooth use sliding boards No contact between skin & metal if diathermy is

used

Asepsis
Scrubbing washing hands & arms prior to

donning a gown & gloves To minimize microbial loads that might come into contact with the patient

 Gowning
Folded gown lifted away from the wrapper &

trolley Grasp firmly at neckline & allow to unfold completely, the inside facing the wearer Arms inserted into armholes simultaneously Hand should stay inside the cuffs while gloving Circulating nurse helps to secure gown at the neck & waist Wrap around gown ties secured with help from scrub nurse

 Gloving
Prevent contamination from surgical wound &

protect scrub team from blood & body fluids Double gloving reduces chance of breach in this protection Hands must remain above waist level at all times once gowned & gloved Hands held together at chest height when not involved in sterile procedure

Skin Preparation Prepping & Draping

Aim
To reduce microbial count on the skin to the minimal level

possible Inhibit microbial regrowth & contamination of the wound during surgery

Prep
Includes surgical site & substantial area around it Start at the incision site, working outwards in expanding

circles Contaminated areas (eg axilla, groin or perineum) prepped last Common solutions used povidone iodine & alcohol based solution

 Drape
Covering area immediately surrounding the

operative site with sterile barrier material Purpose maintain protective zone of asepsis

Hypothermia
Heat loss

Conduction transfer of body heat to colder objects Convection through moving air currents Radiation transfer of heat to colder objects nearby Evaporation heat utilised during conversion of water to vapour Long pre-operative fasting (lowered patient metabolism) Prolonged immobility on the operating table Peripheral vasodilatation secondary to anaesthetic agents Evaporative heat loss from exposed viscera Children large surface area- to-weight lose heat quickly

Predisposing factors

 Sequelae
Poor clotting (DIVC) Cardiac arrhythmias Respiratory failure Sepsis

Death

Preventive measures warming blankets &

warmed IV fluids

POSTOPERATIVE CARE

Postoperative Care
Clear operative note written immediately

Patients details Date & time of operation Name of operation Surgeon, assisstants & anaesthetist Anaesthetic type Operative details (incision, approach & closure) & findings Postoperative instructions observation required, possible complications, treatment (IV fluids) & postoperative analgesia, instruction for sutures etc

Postoperative Period
Ensure airway, breathing & circulation are

satisfactory Monitor pain Watch for complications Monitor blood pressure, pulse & oxygen saturation

Specific Postoperative Complications

Respiratory
SOB lung atelectasis, pulmonary embolism,

chest infections, MI & heart failure Cyanosis asthmatic attack (acute bronchospasm)

Cardiovascular
Hypotension hypovolaemia, MI, overdose of

analgesics (opioids) Hypertension inadequate pain relief or anxiety DVT

 GIT
Postoperative nausea & vomiting Poorly controlled pain, use of opioids, GIT or ENT

surgery, acute gastric dilatation Tx: use of antiemetics & NG tube insertion

Urinary
Oliguria reduced renal perfusion from perioperative

hypotension Hourly urine output to ensure adequate fluid replacement Daily serum urea & creatinine until patient is fully recovered

Complications Related to Abdominal Surgery

Complications: anastomotic leakage, bleeding or abscess,

ileus Examine abdomen: excessive distension, tenderness, drainage from wounds or drain sites Localized infection: persistent abdominal pain, focal tenderness & spiking fever Wound dehiscence:

Partial or complete disruption of any or all of the layers in the

wound Occur up to 3% of abdominal wounds Commonly occurs from 5th to 8th postoperative day strength of wound at its weakest Tx: leave wound open with dressings or resuturing in the theatre

 Paralytic ileus: nausea, vomiting, bowel

distension, absence of flatus & bowel movements (supportive treatment adequate hydration & maintenance of electrolyte levels)

Discharge
Follow-up in the clinic
when key decision on management needs to be

made To decide further care plan

Reference
Williams N.S., Bulstrode C.JK. et al, 2008,

Bailey & Loves Short Practice of Surgery, 25th edition, Edward Arnold Ltd. (chapter 13,14,14,16 & 20) Gwinnutt C.L., 2004, Lecture Notes on Clinical Anaesthesia, 2nd Edition, Blackwell Publishing Ltd. (chapter 1 &2)

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