Perioperative management

• Care given to a patient before & after surgery

• Include:
– Appropriate History and physical examination
– Full investigation
– Decision making
– Preparation for surgery
 Preoperative care cont…
• History and physical examination
– key parts of surgical decision making
– Examine the whole system of patient
– Assess his/her
• General health
• Nutrition
• Volume status
– Look for anemia
– Remember to ask about chronic or intercurrent
illnesses

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 Preoperative care cont…
• Investigations: general principles
– Laboratory and diagnostic imaging investigations
to confirm a clinical hypothesis
– Hct and blood group with Rh mandiatory
– Investigation to assess functional status of the
patient

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• Decision making
– Surgery is required or not
– If surgery is required:
• Type of the procedure
• Place of surgery
• Do we have nursing facilities for good postoperative
care?
 Preoperative care cont…
• Preparation for surgery
– Patient must be seen by the surgeon and anesthetist
– X-matched blood should be prepared based on the
disease condition of the patient
– Correct gross malnutrition
– Treat serious bacterial infection
– Correct gross anemia
– Control diabetes: sliding scale for 24-48hrs before
surgery
– Control hypertension : should be < 160/110 but best if
<140/90

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• Tell the patient to fast( 2hrs clear fluid & 8 hrs
for solid diet)
• Body preparation
• Prophylactic antibiotic administration
• Provide safe and effective anaesthesia
 Postoperative care
• Prevention of complications
• Encourage early mobilization:
– Deep breathing and coughing
– Active daily exercise
– Joint range of motion
– Muscular strengthening
– Make walking aids such as canes, crutches and
walkers available and provide instructions for
their use

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• Ensure adequate nutrition
• Prevent skin breakdown and pressure sores
– Turn the patient frequently
– Keep urine and faces off skin
• Provide adequate pain control
• Wound care
 Postoperative complications
• Represent one of the most frustrating
occurrences experienced by surgeons
• Cost is enormous
• May result from primary disease the
operation or unrelated factors
• Clinical signs often blurred
• Early detection mandatory

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 Post op fever
• Low grade post operative fever – 50%

• Less concerning in the first 48 to 72 hrs.

• High sustained fever with large fluctuations is worrisome

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 Causes
Infectious Noninfectious
• UTI • Atlectasis
• Pneumonia • MI
• PTE
• Abscess • A.cholecytitis
• Wound infection • Transfusion rxn
• Empyema • Hepatitis
• Peritonitis • DVT
• Thrombophlebitis • Allergic rxn
• Drug rxn
• Pancreatitis
• Parotitis

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• Fever after day 2 post op
– Catheter related phlebitis
– Pneumonia
– UTI
• Fever after day 5 post op
– Wound infection
– Anastomotic break down
– Intra abdominal abscess
• After first week
– Allergy to drugs
– Transfusion related fever
– DVT
– Intra abdominal abscess

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 Wound complications
• Seroma
• Most benign but bother some cxn
• A collection of fat, serum& lymphatic fluid
• Clear, yellow & viscous liquid
• Delay healing
• Present as localized, well circumscribed swelling &
exudation of clear liquid.
» Evacuation and compression dressings
» Placement of suction drains under flaps

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 Hematoma
• Abnormal collection of blood & clot
• Causes
• Inadequate heostasis and rough handling of tissues
• Coagulopathy
•Arterial HTN after surgery
• History
•Pain + swelling
• Physical findings
•Purplish blue discoloration
•Localized wound swelling
•Drainage of dark red fluid

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• Treatment
• Depends on the size & age of the wound
• Prevention
• Careful hemostasis of the subcutaneous layer during
closure
• Correction of all clotting abnormalities & discontinuing
drugs that can prolong BT
 Wound Dehiscence
• Separation of fascial layers
• Partial or total
• Is of greatest concern because of evisceration
• Factors associated with wound dehiscence
– Technical errors
– Intra abdominal infection
– Malnutrition
– Advanced age
– Chronic corticosteroid use
– Hematoma ,infection, tension
– Underlying illness
– Increased intra abdominal pressure

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 Wound Dehiscence cont…
• Presentation
– Most common b/n 5 & 8 post op days.
– Sudden dramatic drainage of clear salmon colored
fluid
• Management
– Depends on the condition of fascia
• Prevention
– Adequate bite with proper spacing of fascia

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• Surgical wound infection
 Hemorrhage and thrombosis
• Hemorrhage
– Primary
– Reactionary
– Secondary
• Deep Venous thrombosis
– Seen in up to 20% of cases
– Risk factors
– Contraceptives
– Major pelvic, orthopedic surgeries, genito urinary procedures.
– Features
– Unilateral leg swelling, warmth, erythema.
– Diagnosis
• Doppler ultrasound
– Treatment
• Aim- prevent PTE
• Anticoagulation

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 Respiratory complications
• Most common single cause of morbidity
• Elderly patients are at much higher risk
– Atelectasis
• Most common pulmonary complication
• Most frequent in the first 48 hours
• Pathogenesis involves- closure of bronchioles, low
FRC & obstruction
• May secondarily become infected
• Findings - tachypnea, tachycardia & reduced breath sounds
basally
• Is self limited

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Atelectatic right upper lobe produces a
triangular apical opacity (arrow)

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 Respiratory complications cont…
• Aspiration pneumonitis
– Normally prevented by sphincters
– Pathophysiology-pulmonary intake of gastric content at a low
PH with particulate matter.
– Depends on volume & nature of material aspirated
• Clinical features – vomiting, SOB, tachypnea, cyanosis
,wheezes & may progress to respiratory failure
– CXR---infiltrates
• Management
» Oxygen
» Antibiotics
» Intubation

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 Post op pneumonia
• Most common pulmonary cxn among patients who die after surgery
• Tends to occur with in the first 5 days
• Risk factors include
– Mechanical ventilation
– Anesthesia
– COPD, smoking, atelectasis, aspiration etc…
• Clinical features
• Fever ,SOB, tachypnea, cyanosis
• Creps, BBS
– Mortality 20-40%
• Etiologic agents
• Gram –ve and s. aureus
• Treatment
• Antibiotics

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 Pulmonary thromboembolism
• A very serious complication
• Risk factors
• Severity related to clot size
• Clinical features
– Dyspnea, pleuritic chest pain, cough, apprehension,
hemoptysis
• P/E - tachypnea, tachycardia
-1/3 demonstrate signs of DVT
• Inv—ECG, CXR, blood gas analysis
• Treatment- anticoagulation
- oxygen

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 Cardiac complications
• Arrhythmias
– Most are benign
– Causes
• Electrolyte disturbance
• Stress
• Pain, fever, hypoxia,etc…
• Ex. Sinus tachycardia, atrial flutter & fib

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 Post op myocardial infarction
• Mortality is high
• Prior MI -6 months should lapse
• Clinical features
– Chest pain ,SOB, tachycardia, hypotension
• Treatment same

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