Preoperative Management

Moderator : Dr.Aseffa (ENT-surgeon )

Presenter : Dr. Yibeltal Teshome ( PGY-1)
Seminar Outline
• Introduction
• Reassurance ,advice
• Informed consent
• Preoperative evaluation
• Treating medical conditions
• Measures To Prevent SSI
• VTE prophylaxis
• References
Introduction
• To obtain satisfactory results in general surgery requires a careful approach to preoperative
preparation of patients.
• High risk patients should be identified early and appropriate measures are taken to reduce
complications.
• Preoperative management encompasses preoperative evaluation and preoperative
preparation.
• Preoperative evaluation:
• History and physical examination
• Preoperative investigations
• Preoperative management of medications
• Preoperative preparation:
• General preoperative preparation
• Special preoperative preparation
Reassurance & Advice
• Make the patient share his worry and offer reassurance.
• Facilitate a meeting directly with the anesthesiologist if the patient expresses
concerns.
• Patients should not eat or drink prior to anaesthesia to reduce the risk of
aspiration of gastric contents.
• The Association of Anaesthetists of Great Britain and Ireland recommends the
following fasting periods which are now generally accepted:
• 6 hrs for solid food, infant formula or other milk
• 4 hrs for breast milk.
• 2 hrs for clear non particulate and noncarbonated fluids.
• There is no evidence that safety is improved by extending these fasting times.
Informed Consent
• Physicians have a legal and ethical responsibility to provide adequate
information to the patient so that the patient will make an informed
decision.
• The benefits of informed consent include:
• Engaging the patient in his or her health care
• Enhancing the physician-patient relationship
• Encouraging physicians to thoroughly review the patient’s therapeutic options
• Reducing discontent and litigation when there are complications
• In order for consent to be valid, the patient must be competent.
• If not competent it extends to the proxy.
Cont’d…
• Material facts are those that are relevant to decision making and usually
include:
• Diagnosis
• Proposed treatment.
• Risks and benefits of treatment.
• Alternative treatment options (surgical or medical) along with their risks and benefits.
• The risks of refusing treatment.
• Physician must answer truthfully if a patient asks questions about the
number of similar procedures performed and their success rates.
• Failure to answer honestly leads to claims of fraud & misinterpretation as well as
negligent nondisclosure.
Cont’d…
• The physician must inform patients of all personnel and their respective
roles.
• The physician has to inform patients of any additional procedures that
may be necessary for a successful outcome.
• The physician can maximize the effectiveness of an informed consent
session by communicating in terms patients and their families can
understand.
• Focus the patient
• Comprehensible language
• Educational material
• Interpreters
Cont’d…
• Patients may not accurately remember all the facts disclosed in a
discussion.
• A physician must document the content of informed consent sessions.
• The informed consent discussion and its documentation should be
done by the physician who will be performing the procedure.
• The physician should date and time the written summary of what was
said and to whom, making note of relatives, friends, or support staff
such as nurses or interpreters who are present.
Informed Consent In Ethiopia
• Article 26: It is the duty of the doctor to inform the patient about the
treatment (Including surgical procedures), she/he intends to carry out.
The doctor is always obliged to obtain a written consent of the patient
before carrying out procedures. In the case of minors or persons who
are unconscious or of unsound mind, the necessary consent should be
obtained from parents or legal guardians, if there is no other legal
provision.
• Article 27: On legitimate grounds, left to the discretion of the doctor,
information about serious diagnoses and/or prognosis may be withheld
unless the patient demands it. However, it is, desirable to inform the
nearest relative when the outcome is likely to be unfavorable.
Cont’d…
• Article 28: The doctor has an ethical obligation to help the patient
make choices from among the therapeutic alternatives consistent
with good medical practice.

Adopted from:
Medical Ethics for doctors in Ethiopia, page 9
Produced and publicized by: EMA
Addis Ababa : April, 2016
Preoperative Evaluation

• History and physical examination remain the cornerstones of the

preoperative evaluation, with particular attention to specific
conditions such as diabetes, bleeding disorders, insufficiency of
cardiac , pulmonary systems and renal systems.
• laboratory tests, radiographic examination, and specialty consultation
are performed on an outpatient basis.
• The aim of preoperative evaluation is not to screen broadly
undiagnosed diseases but it is to identify and quantify any
comorbidity that may affect the operative outcomes.
Cont’d…
• On all anesthetic charts , the patient will be given an ASA grade after
the preoperative assessment which is objective & directly correlates
with the risk of post-op complications and absolute mortality.
ASA Grade Criteria Absolute mortality
(%)
I Normal healthy patient .1

II Mild systemic disease .2

III Severe systemic illness, a functional limitation of their 1.8

activity
IV Severe systemic illness that is constant threat to life. 7.8

V Moribund 9.4

E Suffix added if an emergency operation

Preoperative Tests
• Recommendations come ASA Task Force & Association of Anesthetists of Great
Britain and Ireland.
• Audiometry is undertaken for patients undergoing middle ear surgery.
• Vocal cord visualization if the surgery is suspected to damage RLN.
• Hemoglobin in all female ,males > 40 yrs & in patients blood grouping undertake
• Clotting studies when indicated by history.
• Blood grouping and rh if anticipated blood loss is > 15 %.
• Pregnancy testing when pregnancy is possible.
• Electrocardiography in any patient with cardiovascular disease or in asymptomatic patients
aged over 60-70 years.
• Chest x-ray in patients with signs or symptoms of cardiac, respiratory or multisystem
disease referable to the chest.
Scott-Brawn's Otorhinolaryngology, HNS,7th edition.
Medical Conditions In
Preoperative Patients
CARDIOVASCULAR COMPLICATIONS
• Are the most common cause of perioperative mortality.
• History like PND, previous MI, HTN, angina, previous MI, dyspnea and ...
Should be asked.
• Meticulous review of the cardiovascular system is of utmost
importance and risk factors should be identified.
• In the head and neck oncology patient population, the high incidence
of tobacco and alcohol abuse leads to a relatively high incidence of
CAD, cardiomyopathy, and peripheral vascular disease.
• Investigations like ECG, echocardiography and cardiac catheterization
are included.
Cont’d…
• In general, patients are maintained on their antihypertensive,
antianginal, and antiarrhythmic regimens up to the time of surgery.
• Preoperatively, serum electrolytes and antiarrhythmic levels should be
checked and adjusted as necessary.
• Patients with prosthetic valves, endocarditis, unrepaired CHD and HCM
should receive antibiotics at the time of surgery.
• Agents such as lidocaine, epinephrine, and cocaine, which are frequently
used in sinonasal surgery, can trigger undesirable cardiovascular events.
• The mortality and morbidity could be patient related factors such as
HTN,CHF,MI or aortic stenosis or procedure related factors.
Hypertension
• In perioperative period, poorly controlled HTN is associated with
increased incidence of ischemia, left ventricular dysfunction,
arrhythmia and stroke.
• Patients should continue taking preoperative medications throughout
the entire preoperative period.
• The goal is systolic BP < 140 mmHg and systolic BP <90 mmHg with
elective surgery.
• IV esmolol, labetalol, nitroprusside or nitroglycerin may be used for
acute episodes of HTN and calcium channel blockers and ACEI may be
used in less acute situations.
Congestive Heart Failure
• The mortality rate increases following the noncardiac surgery increases with
advancing stages of NEW YORK HEART STAGE.
• The perioperative mortality rate depends on the patient’s condition at the time
of surgery.
• Therapy is aimed at reducing ventricular filling pressure in addition to
improving cardiac output.
• The morbidity and mortality is reduced using :
• ACE inhibitors
• Beta blockers
• Spironolactone
• Digoxin and diuretics improve morbidity rates without reducing mortality.
Ischemic Heart Disease
• Major detrimental of preoperative morbidity and mortality.
• Studies in 1970s show that:
• 30 % of reinfarction or cardiac death for patients undergoing surgery within 3
months of an MI.
• 15% when surgery is performed within 3-6 months.
• 5 % when surgery is performed 6 months later.
• True life saving surgery should be performed regardless of cardiac risk,
but consideration should be given to performing elective surgery 4-6
wks following MI.
Aortic Stenosis
• AS is associated with a 13 % risk of perioperative death.
• Risk varies on the severity of AS.
• The clinician should enquire history of syncope, angina and dyspnea.
• Crescendo-decrescendo murmur, a soft S2, late peaking murmur ,
brachoradial delay should raise the suggestion of AS.
• Echocardiography :
• Aortic valve area less than .7 cm2
• The clinician should delay surgery ,except for emergencies, and
should consider preoperative valve replacement.
Procedure-related Factors
• The clinician must consider 2 factors when assessing the patients
cardiovascular risk:
1) The type of surgery
2)The hemodynamic stress associated with the stress.
• Surgical procedures may be classified as follows:
• High risk ( > 5 % rate of perioperative death) –peripheral artery or aortic surgery,
prolonged procedures with large amount of blood loss involving the abdomen,
thorax, head and neck.
• Intermediate risk ( 1-5 % rate of perioperative death or MI) –urologic, orthopedic ,
uncomplicated abdominal, head , neck & thoracic surgery.
• Low risk ( 1% ) – cataract removal, endoscopy, superficial procedures and breast
surgery.
RESPIRATORY COMPLICATIONS
• Postoperative pulmonary complications are the second most common cause of
perioperative mortality.
• A positive history of the ff diseases requires heightened attention before surgery.
• Asthma
• Chronic obstructive pulmonary disease
• Tobacco use
• Pneumonia
• Pulmonary edema
• Pulmonary fibrosis
• Adult respiratory distress syndrome
• Treatment for the above problems include medications such as steroids,
antibiotics, bronchodilators and intubation or oxygen therapy.
Cont’d…
• The otolaryngologist should obtain an estimate of the patient’s
dyspnea, exercise limitation, cough, hemoptysis, and sputum
production.
• Coexisting cardiac and renal disease, such as CHF and chronic renal
failure, also heavily impact pulmonary function.
• Pulmonary hypertension and cor pulmonale secondary to OSA , cystic
fibrosis, muscular dystrophy, emphysema, or kyphoscoliosis further
complicate anesthetic management.
Cont’d…
• On physical examination, the clinician should be attuned to the patient’s body
habitus and general appearance.
• Obesity, kyphoscoliosis, and pregnancy can all predispose to poor ventilation, atelectasis,
and hypoxemia.
• Cachectic patients are more likely to develop postoperative pneumonia.
• Clubbing and cyanosis could be indicative of underlying COPD.
• RR, use of accessory muscle, diaphoresis, stridor should be documented.
• Auscultation should be done to rule out lung pathologies as well.
• In patients with pulmonary disease chest X-ray is mandatory.
• Arterial blood gas (ABG) testing on room air is also indicated.
• Preoperative pulmonary function tests, such as spirometry and flow-volume loops,
are quite helpful.
Cont’d…
• The preoperative management of otolaryngology patients with
significant pulmonary disease is vital and should follow the
recommendations of a pulmonologist.
• Smokers are advised to cease smoking for at least a week before surgery.
• Chest physiotherapy aimed at increasing lung volumes and clearing
secretions is instituted.
• Acute infections should be cleared with antibiotics and chest
physiotherapy before elective surgery.
• Finally, the medical regimen must be optimized, including the use of
inhaled β-adrenergic agonists, cromolyn, and steroids.
Chronic Obstructive Lung Disease
• Should be aggressively treated in order to achieve their best possible
baseline level of function.
• Treated by bronchodilators, antibiotics and systemic steroid, smoking cessation and
chest physiotherapy.
• All patients with symptomatic COPD should receive daily inhaled ipratropium
or tiotropium.
• Inhaled beta-agonists should be used as needed for symptoms and wheezing
in patients with COPD in the perioperative period.
• Administered by nebulizer in the immediate perioperative period.
• Patients with COPD and persistent wheezes or functional limitations despite
bronchodilator therapy should be treated with perioperative glucocorticoids.
Asthma
• Poorly controlled asthma is a risk factor for the development of postoperative
pulmonary complications.
• Patients whose asthma is not well-controlled should receive a step-up in asthma
therapy.
• In patients with asthma who require endotracheal intubation, we suggest inhaled
rapid-acting beta agonist two to four puffs or a nebulizer treatment within 30 minutes
of intubation( UpToDate 21.2).
• Inhaled beta agonists may be continued by nebulizer in the perioperative period; they also can be
used in the circuit of anesthesia tubing for prolonged procedures, and for patients still intubated
immediately after surgery.
• Preoperative systemic glucocorticoid be reserved for patients with a history of poorly-
controlled, brittle, severe, or glucocorticoid dependent asthma.( UpToDate 21.2)
Upper Respiratory Infection
• The risk of anesthesia and surgery in the setting of a viral upper
respiratory tract infection (URI) is unknown.
• One study of 489 children undergoing myringotomy showed no difference in
the incidence of pulmonary complications between those with URIs at the
time of surgery and those free of upper respiratory symptoms. (UpToDate
21.2).
• No studies have addressed the issue of risk in adults undergoing high
risk upper abdominal or thoracic surgery.
• Nevertheless, pending pertinent data, it is reasonable to delay
elective surgery in the presence of a viral URI.
Smoking
• Current cigarette smokers have increased risk, even in the absence of
chronic lung diseases.
• A prospective cohort study of 410 patients undergoing elective , non
cardiac surgery found that smoking was associated with >5x increase in
the post operative complications.
• Smoking hx of 40 pack years or more is associated with increased
pulmonary complications.
• Stopped smoking < 2 months : stopped smoking for > 2 months
=4:1( 57%:14.5).
• Quit smoking > 6 months: never smoked =1:1
DIABETES MELLITUS
• Ideally, all patients with diabetes mellitus should have their surgery as early as
possible in the morning.
• Diabetes mellitus is associated with increased risk of perioperative infection and
postoperative cardiovascular morbidity and mortality.
• The key aspect of preoperative DM management is glycemic control.
• Surgical patients can have labile blood glucose level due to :
• Sepsis
• Disrupted meal schedule & altered nutritional intake
• Hyperalimentation
• Emesis
• The assessment of cardiovascular, renal, cerebrovascular and autonomic neuropathy
is essential in preoperative diabetic patients.
Cont’d…
• The goal of perioperative diabetic management include:
• Maintenance of fluid and electrolyte balance
• Prevention of ketoacidosis
• Avoidance of marked hyperglycemia
• Avoidance of hypoglycemia
• There is no evidence ‘how tight’ the blood glucose level should be in surgical
patients.
• Reports the achieving normogylcemia ( 80-110 mg/dl) in cardiac and ICU requiring patients
may decrease mortality.
• Different guidelines recommend the ‘reasonable’ blood glucose level in perioperative patient
below 200 mg/dl.
• The American Diabetes Association has endorsed fasting glucose goals of 140 mg/dL for
general hospitalized patients, with random glucose readings <180 mg/dL .
Cont’d…
• Generally, patients with type 2 diabetes managed by diet alone do not require any
therapy perioperatively.
• Subcutaneous sliding scale in may be established patients whose glucose levels rise over the
desired target.
• Type 2 diabetes patients on oral hypoglycemic are advised to continue the
medication till the morning of the surgery.
• For patients who develop hyperglycemia, supplemental short-acting insulin may be
administered subcutaneously as a sliding scale, based on frequently measured glucose levels.
• Most antidiabetic medications can be restarted after surgery when patients resume
eating, with the exception of metformin.
• Patients who use insulin can continue with subcutaneous insulin perioperatively for
procedures that are not long and complex.
Cont’d…
• Some clinicians switch their patients taking long-acting insulin to an
intermediate-acting insulin one to two days prior to surgery because
of a potential increased risk for hypoglycemia with the former.
• It may be prudent to reduce the night time intermediate-acting
insulin on the night prior to surgery to prevent hypoglycemia if the
patient has borderline hypoglycemia or "tight" control of the fasting
blood glucose.
• Basal metabolic needs utilize approximately one-half of an individual's
insulin even in the absence of oral intake.
Cont’d…
• Some clinicians switch their patients taking long-acting insulin to an intermediate-acting insulin
1-2 days prior to surgery.
• Intravenous insulin is usually required for long and complex procedures for type 1 or insulin
dependent type 2 DM patients.
• Insulin infusions should be started early in the morning prior to surgery to allow time to achieve
glycemic control.
• Several insulin infusion algorithms published in literatures with glucose and insulin infused
separately or combined.
• Glucose insulin potassium infusion(GIK)-500 ml 0f 10% dextrose, 10 mmol of K+,15 units of short acting
insulin, infused at a rate of 100ml/hr.
• Separate insulin and glucose intravenous solutions-dextrose is administered at 5-10 g/hr and short acting
insulin infusion( 1-2 units/hr) for type1 but type 2 may require higher.
•  Generally the preoperative DM treatment regimen (oral agents, oral agents plus insulin, or
basal-bolus insulin) may be reinstated once the patient is eating well.
MYTHS ABOUT PERIOPERATIVE DM
MANAGEMENT
• DEXTROSE SHOULD NOT BE GIVEN

• SHIFT THE PATIENT TO INSULIN

• MANAGE PATIENT ON SLIDING SCALE

• FOUR HOURLY BLOOD GLUCOSE

• LOW SUGAR DIET

Thyroid Disorders
• Treatment of hyperthyroidism attempts to establish a euthyroid state and to
ameliorate systemic symptoms.
• Propylthiouracil inhibits both thyroid hormone synthesis and the peripheral
conversion of T4 to T3.
• In patients with sympathetic hyperactivity, β-blockers have been used effectively.
• Glucocorticoids are used to decrease the peripheral conversion of T4 to T3.
• No evidence suggests that patients with mild to moderate hypothyroidism are at
increased risk for anesthetic complications.
• Severe hypothyroidism resulting in myxedema coma is a medical emergency and
associated with high mortality rate ,IV infusion of T3 or T4 with glucocorticoids
should be combined with ventilatory support.
HEMATOLOGIC DISORDERS
• A history of easy bruising or excessive bleeding with in prior surgery
should raise suspicion of a possible hematologic diathesis.
• History, P/E and laboratory studies (CBC, PT,PPT) should be obtained by
the clinician.
• A standard CBC includes a platelet count, which should be greater than
50,000/μL to 70,000/μL before surgery.
• Patients might have congenital deficiencies involving the clotting factors.
• Patients with factor VIII:C are transfused ever 8 hrs with cryoprecipitate.
• Patients with von willebrand disease are transfused with cryoprecipitate every
24-48 hrs.
Cont’d…
• Walfarin,heparin and aspirin are medications currently prescribed commonly.
• The benefit of surgery relative to the risk of normalizing coagulation should be clearly
established.
• Warfarin should be stopped at least 3 days before surgery, depending on liver function.
• Discontinuation of heparin approximately 6 hours before surgery should provide
adequate time for reversal of anticoagulation.
• Anticoagulative therapy can be reinstituted soon after surgery if necessary or several
days after the surgery if unless this is contraindicated.
• Aspirin, an irreversible inhibitor of platelet function, leads to prolonged bleeding time.
• No strong evidence that aspirin leads to excessive intra operative bleeding.
Cont’d…
• Patients with liver failure can come to medical attention with several
hematologic abnormalities:
• Bleeding from esophageal varices can lea to anemia.
• Hypersplenism can lead to severe thrombocytopenia.
• Elevated PT indicates deficient vit. K dependent factors and factors produced in
the liver.
• Excessive fibrinolysis can occur in advanced disease.
• These hematologic sequelae of hepatic failure increase the risk of
operative morbidity and mortality.
• Preoperatively, the anemia, thrombocytopenia & clotting factor
deficiencies should be corrected.
Cont’d…
• A decrease in platelet number can occur due to:
• Massive transfusion
• DIC
• Aplastic anemia
• Blood cancers
• ITP
• Preoperatively, the platelet count should be greater than 50,000/μL.
• At levels below 20,000/μL, spontaneous bleeding may occur.
• Correction of thrombocytopenia with platelet transfusion should preferably
come from human leukocyte antigen–matched donors, particularly in patients
who have received prior platelet transfusions and may be sensitized.
NEUROLOGIC DISORDERS
• Neurologic consultation is required for possible nonotolaryngologic etiology for
certain complaints such as headache and disequilibrium.
• The potential for nerve injury or sacrifice with the possible sequelae of these
actions must be communicated to the patient.
• In seizure patients, the type, pattern, frequency of epilepsy as well as the
medication the patient is taking must be identified.
• Preoperative CBC, liver function tests, and coagulation studies are thus advised.
• Anesthetic agents such as enflurane, propofol, and lidocaine have the potential to
precipitate convulsant activity.
• Symptomatic autonomic dysfunction can contribute to intraoperative hypotension.
• Patients with motor neuron diseases have increased risk of aspiration.
Cont’d…
• Parkinsonism presents the challenge of :
• Excessive salivation and bronchial secretion.
• Gastroesophageal reflux
• Obstructive and central sleep apnea
• Autonomic insufficiency
• These factors predispose to difficult intubation and blood pressure mx.
• Dopaminergic medications should be administered up to the time of surgery
to avoid the potentially fatal neuroleptic malignant syndrome.
• Patients with multiple sclerosis should also undergo full pulmonary
evaluation preoperatively, if indicated.
• Poor respiratory and bulbar function
RENAL PROBLEMS
• The preoperative identification and evaluation of renal problems are imperative.
• Preexisting renal disease is a major risk factor for the development of acute
tubular necrosis both during and after surgery.
• Electrolyte abnormalities should be treated and the surgery is delayed if
necessary.
• Renal failure affects the types, dosage, interval of perioperative drugs and
anesthesia.
• An oliguric or anuric condition requires judicious fluid management, especially in
patients with cardiorespiratory compromise.
• CKD is associated with anemia, platelet dysfunction and coagulopathy.
Cont’d…
• Hyperkalemia can lead to arrhythmia.
• The otolaryngologist must also be wary of the potential for injury to
demineralized bones during patient positioning.
• Preoperative testing on patients with significant renal disease routinely
includes
• ECG
• Chest radiography
• Electrolytes
• Chemistry panel
• CBC, PT/PTT
• Platelet counts
HEPATIC DISORDERS
• Suspected or known hepatic disorder patients should be evaluated for history of hepatotoxic
drug therapy, jaundice, blood transfusion, UGIB and previous surgery and anesthesia.
• The physical should include examination for hepatomegaly, splenomegaly, ascites, jaundice,
asterixis, and encephalopathy.
• Blood tests like CBC, LFT, BUN, creatinine and PT/PTT are important.
• Diuretics given to decrease ascites can often lead to intravascular hypovolemia, azotemia,
hyponatremia, and encephalopathy.
• Fluid management in the perioperative period should be followed closely with dialysis
instituted as needed for acute renal failure.
• Appropriate blood products are used to correct anemia and thrombocytopenia.
• Encephalopathy is treated with hemostasis, antibiotics, meticulous fluid mx and low protein
diet.
PREOPERATIVE FLUID MANAGMENT
• Perioperative fluid therapy decisions influence postoperative outcome.
• The aim of perioperative fluid management is to maintain an adequate circulating
volume to ensure end-organ perfusion and oxygen delivery to the tissues.
• The daily adult fluid and electrolytes are:
• Sodium 70-120 mmol/day
• Potassium 40-80 mmol/day
• Chloride 110-150 mmol/day
• Water 2.5-3 liters.
• Careful monitoring should be undertaken using clinical examination, fluid charts and
regular weighing when possible.
• Oral fluids should not be withheld for more than 2 hrs prior to the induction of
anesthesia.
Cont’d…
• Preoperative administration of carbohydrate rich beverages 2-3 hrs
before induction of anesthesia improves patient well being.
• Excess losses from gastric aspiration/ vomiting should be treated
preoperatively with crystalloids and potassium.
• In high risk patients , IV fluid & inotropes should be aimed at
achieving predetermined goals CO & oxygen delivery.
• Hypovolemia is treated with crystalloids, colloids and if necessary
blood components.
Cont’d…
• In children:
• Maintenance fluid is calculated using the formula:-
• < 10 kg  4 ml/kg/hr
• 10-20 kg 40 ml/hr+ 2ml/kg/hr
• > 20 kg60 ml/hr +1 ml/kg/hr
• A fluid management plan for any child should address 3 key issues:
1) any fluid deficit which is present
2)maintenance fluid requirements
3)Any losses due to surgery.
Measures To Prevent SSI
• SSI are infections related to surgical procedure that occur at or near the surgical
incision with in 3o days of operative procedure or with in one year of an implant
is left in place. ( CDC definition)
• The most important factors in the prevention of surgical site infection (SSIs) are
meticulous operative techniques and timely administration of effective
preoperative antibiotics.
• Preoperative showering with antimicrobial soaps
• Preoperative application of antiseptics to the skin of the patient
• Washing and gloving of the surgeon's hands
• Use of sterile drapes
• Use of gowns and masks by operating room personnel
• Most of these interventions were developed to reduce contact with normal flora.
Antimicrobial Prophylaxis
• The goal of antimicrobial prophylaxis is to prevent surgical site infection (SSI)
by reducing the burden of microorganisms at the surgical site during the
operative procedure.
• Preoperative antibiotics are warranted if there is a high risk of infection or if
there high risk of deleterious outcomes should infection develop at the
surgical site.
• The antibiotics should ideally be given 1-2 hrs before the first incision.
• Cefazolin 1-2 gm is 1st generation cephalosporin generally active against
streptococci and Methicillin susceptible staphylococci bacteria.
• Cefuroxime (1.5 g IV) is a second generation cephalosporin with broader
coverage against gram-negative organisms.
Cont’d…
• Patients with hx of allergy to penicillin manifesting as an uncomplicated
or minor skin rash may be treated with cephalosporins.
• If an IgE-mediated reaction against penicillin has occurred in the past,
cephalosporins should be avoided.
• Vancomycin or clindamycin plus agents with activity against gram
negative like gentamycin, ciprofloxacillin and levofloxacin are
alternative to cephalosporins.
• Local resistance patterns should be considered.
• Vancomycin is preferable to cephalosporins in locations where methicillin-
resistant Staphylococcus aureus or methicillin-resistant coagulase-negative
staphylococci frequent cause of SSI.
Cont’d…
• Antimicrobial therapy should be administered within 60 minutes prior to the surgery
to ensure adequate drug tissue levels at the time of initial incision.
• Ensures adequate drug tissue level.
• Reduces the likelihood of antibiotic-associated reactions at the time of induction of anesthesia.
• With in 2 hrs if vancomycin or fluoroquinolone is given.
• For procedures lasting less than four hours, a single repeat dose of intravenous
antimicrobials is appropriate.
• In general, repeat antimicrobial dosing following wound closure is not necessary and
may increase antimicrobial resistance.
• Clindamycin or cefazolin combine with metronidazole or ampicillin-sulbactam is the
choice of antibiotics if there is an incision through the oral/pharyngeal mucosa to
cover anaerobes, enteric gram-negative bacilli & staph aureus.
VTE prophylaxis

• VTE is one complication among hospital inpatients and contributes to

longer hospital stays, morbidity and mortality.
• Risk factors associated with VTE are:
• History of previous VTE
• Prolonged immobility
• lower limb, pelvic or abdominal operations
• Trauma particularly of pelvis or acute spinal injury
• Medical illnesses like DM, stroke, CF and acute respiratory failure
• Estrogen use like OCP,HCT
• Cancer , especially metastatic adenocarcinoma
• Age > 40 years , lupus
Cont’d…
• All pre-op patients are placed in risk stratification for VTE.
• Expert hematological assessment is required when acquired or inherited
hypercoaguable states are suspected.
• Low risk Uncomplicated surgery in patients aged < 40 years with minimal
immobility postoperatively and no risk factors.
• Moderate risk Any surgery in patients aged 40-60 years, major surgery in
patients < 40 years and no other risk factors, minor surgery with one or more risk
factors.
• High risk Major surgery in patients > 60 years, major surgery in patients aged
40-60 years with one or more risk factors.
• Very high risk Major surgery in patients > 40 years with previous VTE, cancer or
known hypercoaguable state.
Cont’d…
• The preventive measures which are shown to reduce VTE include early
mobilization, pneumatic intermittent calf compression, low-dose
unfractionated heparin (LDUH) and low molecular weight heparin
(LMWH).
• LMWH has the advantages over LDUH of once daily dosage and lower
incidence of heparin-induced thrombocytopenia, but is more expensive.
• LDUH is given 5000 units 8-12 hourly and LMWH is given high dose/low dose
( <3400 anti-Xa />3400 anti-Xa IU ) daily.
• High-dose LMWH appears to be associated with more surgical bleeding problems.
• Unfortunately, little data exist on preventative measures in head and neck
patients exclusively.
Cont’d…
• A reasonable strategy for VTE prophylaxis in head and neck patients
might be:
• Low risk patients No specific prophylaxis other than early ambulation.
• Moderate risk patients Either LMWH < 3400 U daily, LDUH 12 hourly,
compression elastic stockings or intermittent pneumatic compression. Each
alone is better than no prophylaxis.
• High risk patients LDUH eight hourly, or LMWH > 3400 U daily plus
compression stockings, or compression stockings and intermittent calf
compression if anticoagulation considered inadvisable.
• Very high risk LDUH eight hourly or LMWH > 3400 U daily plus
compression stockings and intermittent pneumatic compression.
Key points
• Consider day surgery where possible.
• Assess the risk of operation/anaesthesia.
• Moderate or severe cardiorespiratory disease requires
medical/anaesthetic review.
• Routine preoperative tests are expensive and unnecessary.
• Valid, written consent required for most surgery.
• Consider venous thromboembolism prevention.
• Book ICU bed (if required) as soon as date of surgery known.
References
• Scott-Brawn's Otorhinolaryngology, HNS,7th edition.
• Cummings
• Uptodate 21.2
• Medscape
• Online sources