Pre and Post Operative Care

Fayemi Johnson CSA MD MRCOG

Approach to the Surgical
Patient
 General
– Sympathy, love and understanding
– Judgment and courage
– Patient’s trust and confidence
– Old-fashioned doctor: engineer, plumber
– Technical skills and training:
diagnosis and treatment
Approach to the Surgical
Patient
 History
– Two components: chief compliant, medical
history
– First interaction: establish rapport
– Allow patient to give history: listen and learn
– Avoid leading questions, preconceived ideas and
hasty conclusions
– Determine facts, search for clues and concealed
information
– Inductive reasoning to establish diagnosis
Approach to the Surgical
Patient
 Important symptoms and history
 Pain
– nature, character, onset, location, intensity,
duration, relief and aggravating factors
– Patient’s reaction: over versus under reactors
 Vomiting
– Content, quantity, frequency, appearance and
projectile
Approach to the Surgical
Patient
 Change in bowel habits
– Common compliant but mostly not
significant
– Size or shape of stool usually not
important
– Regular bowel movement change to
alternating diarrhea and constipation may
be significant ? colon ca
Approach to the Surgical
Patient
 Hematemesis or hematochezia
– Always significant
– Quantity, onset, duration, and character
– Color: bright red or dark altered blood
Approach to the Surgical
Patient
 Trauma
– Common in children: self or inflicted
– Establish details: where, when, how
– Loss of consciousness, retrograde
amnesia ? Cerebral damage
– No external head injury, loss of
consciousness or retrograde amnesia R/O
brain damage
Approach to the Surgical
Patient
– Gunshot wound and stab wound
• Entry, trajectory, exit
• Nature, size, shape of weapon
• Position of patient at time of injury
– Preexisting conditions leading to accident:
epilepsy, hypoglycemia, MI
Differential Diagnosis

 At end of history of present illness,

formulate a list of differentials
Past History
 Illuminate obscure areas of history of
present illness (HPI)
 Remember: people who are well are almost
never sick; people who are sick are almost
never well
 Check medical, surgical history
 Formulate a system review to cover all
areas of past history and HPI
 Establish a defined pattern of review:
HEENT, CVS, respiratory, etc.
Past History
 Family history
– Hereditary conditions: polyposis of the colon,
diabetes, chronic pancreatitis, cancer
 Drug history: medication, illicit drug, alcohol
 Allergy: drug, food, reaction type
 Social history: married, sexual orientation,
hobbies
Past History

 Emotional status: mentally challenged

? Psychiatric consultation
 Surgical patient with emotional issues:
malignancy, mutilating procedures,
require empathy, understanding,
reassurance
Physical Examination (P/E)

 Elective
– Orderly, detailed, same sequence
– Put patient at ease: comfortable
environment, drapes
– All patients are embarrassed and sensitive
– Continue medical history taking during
exam, relaxation
Physical Examination
(P/E)
– General physique and habitus
– Vital signs and patient’s hands: heart,
hematologic and pulmonary disease
– HEENT-nodes, breasts, CVS, lungs, abdomen,
extremities, genitalia, rectal, neurologic
– Inspection, palpation and auscultation
– Ancillary exam: ophthalmoscope, sigmoidoscope
and cystoscope
– Radiology exam: cardiac catheterization, x-ray,
ultrasound
Physical Examination
(P/E)
 Emergency
 Limited history or no history if patient is
unconscious
 Focused P/E or institute treatment if life
threatening situation e.g. cardiac arrest
 Primary consideration: ABC, opened airway,
breathing, pulse, heart beating? CPR
Physical Examination
(P/E)
 Assess for vertebral injury: stabilize
spine
 Assess for external and internal
bleeding: resuscitation, pressure and
elevate extremity, fluids, colloid, blood
Physical Examination
(P/E)
 After stabilizing patient, do rapid survey
exam (2-3 mins): head, chest, abdomen,
extremity, genitalia
 If cervical cord damage has been R/O turn
patient to examine back, buttocks and
perineum
 After complete P/E give emergency
treatment: control pain, suture laceration,
splint fractured limbs
Diagnosis
 Labs
 Screen for asymptomatic disease
 Identify diseases that may contraindicate
surgery or require treatment for surgery:
diabetes, CHF
 Diagnose disorders that may require surgery
 Evaluate extent of metabolic or septic
complications
Preoperative Evaluation
 Assess patient’s general health
 Must be done before every major
surgical procedure
 Includes history and P/E
 Note comorbid conditions
 Identify factors that may influence
patient’s risk of surgery or future well-
being
Preoperative Evaluation
 Note especially bleeding tendencies,
medications, allergies, reaction to antibiotics
 Display adverse reactions or significant
abnormalities prominently on patient’s chart
 Thorough P/E
 Diagnostic tests: based on physical findings
 In general, patients over 40: CBC, electrolytes
Patients over 50: EKG, CXR in addition
Preoperative Evaluation

 Note liver and kidney function ?LFTs,

BUN, creatinine – important in
clearance of various anesthetic agents
 Seek appropriate consultation if
required
Specific Risk Factors and
Evaluation
 Identify the compromised host whose
normal response to operative trauma may
be altered
 Assess nutritional and immunologic status ?
supportive measures to reduce post op
morbidity
 Note drugs that reduce patients resistance
to infection or response to trauma e.g.
steroids or immunosuppressive drugs
 Prolonged antibiotic usage: increased risk of
opportunistic infections e.g. fungi
Preoperative Notes
 Summary of diagnostic workup and
preop evaluation
 Documentation of pertinent findings,
decisions, indications and type of
surgery
 Discussions between patients and
surgeon regarding procedure
 Display prominently in patient’s chart
Surgical Consent
 Permit should state patient’s understanding
of nature, type and possible outcomes or
complications of procedure
 Avoid medical jargon, use understandable
terms
 Must be signed by patient or legal guardian
before any major or minor procedure
 Permit may be waived in life
threatening/emergency procedure although
every effort should be made to obtain
permit
Postoperative Care
 Recovery from major surgery involves three
phases
 immediate or post anesthetic
 Intermediate or hospitalization
 Convalescent: transition phase between
hospitalization and full recovery
 The first two phases involve maintenance of
hemostasis, pain control, prevention and/or
detection of complication
Immediate Postop Care
(OR to PACU)
 Skilled personnel involved in patient
transport: anesthesia, surgical and
nursing personnel
 Major cause of early complication:
pulmonary, cardiovascular and fluid
derangement
Immediate Postop Care
(OR to PACU)
 Postop team
 Anesthesiology service: cardiovascular,
pulmonary, fluid and electrolyte
dysfunction
 Surgical service: operative field/wound
care
Immediate Postop Care
(OR to PACU)
 Nursing service: trained nurse in PACU
 Monitor patients vital signs, respiratory
function: adequate air exchange
 Monitor input and output
 Ensure wound remains dry and clean
 Report any abnormalities to anesthetic
or surgical service
PACU to Floor/Ward or ICU

 PACU stay usually one to three hours

depending on surgery, postop
response and organ function recovery
 If above normal: floor/ward
 Ventilatory/CVS support or
comorbidities: ICU
PACU to Floor/Ward or
ICU
 ICU nursing staff/patient ratio – higher
than floor
 Skilled personnel: more individualized
care and frequent monitoring
 Monitoring equipment to detect early
derangement in cardio respiratory
function
Postop Orders

 Stated clearly in patient’s chart

 Necessary to direct postop care
 Very important orders: nature of
surgery, presence of comorbidities,
should be reported verbally to nursing
team
Postop Orders
 Postop orders should include
– monitoring
– respiratory care
– Position in bed and mobilization
– Diet
– Fluid and electrolytes
– Drainage tubes
– Medication
– Lab and imaging
Postop Orders
 Monitoring
 V/S
– Frequently till stable, then regularly till
discharged from PACU
– If arterial line in place, continuous BP, pulse,
ECG in PACU
 CVP
– Record frequently if large blood losses or fluid
shifts have occurred
Postop Orders
 Fluid balance
– Anesthetic record shows fluid
administered, blood loss, urine output
and losses from drains and stoma
 Respiratory care
– Mechanical ventilation or oxygen by face
mask
– Intubated patients may require frequent
suctioning to keep airway clear
Postop Orders

 Position in bed and mobilization

– Specify
– If condition permits change position every
30 mins till conscious
– Pneumatic stockings and intermittent
compression of calf muscles, early
ambulation: DVT prophylaxis
Postop Orders
 Diet
– NPO till GIT function returns
– ? po liquids when alert
 Fluids and electrolytes
– Maintenance needs should be met
– Replace losses from GIT: drains, fistula and
stoma
 Meds
– Specific orders for drug, dose, frequency
– Timing of preop meds
Intermediate Postop
Period
 Hospitalization period: complete
recovery from anesthesia till discharge
to continue convalescence at home
 Gradual return to normal/basal body
functions
 Ensure stabilization of various organ
functions
 Wound healing/healed
Wound Care
 Within hours after wound closure,
inflammatory exudate fills wound space
 Epidermal cells at wound margin proliferate
and bridge gap across wound surface
 Within 48 hrs wound surface is sealed
protecting deeper layers
 Sterile dressings applied postop provide
additional protection against infection
Wound Care
 Contaminated/infected wound
– Leave open to heal by delayed primary closure
or secondary intention
– Pack with moist saline sterile gauze
– Remove pack 4-5 days later
 If wound contains only small exudate or
serous fluid, approximate margins
 If infection is present, change moist
dressing daily and allow to close by
secondary intention
Wound Care

 Factors that affect wound healing

– Nutritional deficiencies/hypovitaminosis
– Vit A: epithelialization
– Vit C: collagen synthesis
– Cu, Mg: scar formation
– Corticosteroids: inhibit inflammatory
response, fibroblast proliferation and
protein synthesis
Postop Pain

 Usually follows all operative

procedures: major or minor
 Factors that influence severity of pain
– Duration of surgery
– Type of incision
– Degree of operative trauma
– Magnitude of intraop retraction
Postop Pain

 Factors that decrease postop pain

– Gentle tissue handling
– Short procedures
– Good muscle relaxation
– Individual physical, emotional (anxiety)
and cultural characteristics
Postop Pain

 Physiology of pain
– Transmission of pain impulses via
splanchnic afferent fibers from op site to
CNS
– At CNS, spinal, brainstem or cortical
reflexes are stimulated
Postop Pain
 Spinal responses from stimulation of
anterior horn cells  skeletal muscle spasm,
vasospasm and GIT ileus
 Brainstem responses: alteration in
ventilation, BP and endocrine function
 Cortical responses: voluntary movements
and physiologic changes; fear and
apprehension
 These emotional responses perpetuate the
perception of pain
Pain Control

 Physician/patient communication
– Know your patient
– Aware of needs
– Show concern, empathy
– Inquire about daily progress and pain
control
– Reassurance
Pain Control
 Parenteral opioids
– Mainstay of therapy for postop pain following
major procedures
– Analgesic effect is via two mechanisms
• Direct effect on opioid receptors
• Stimulation of descending brain stem fibers that
contribute to pain sensation
– Substantial relief of pain
– Do not modify reflex phenomenon associated
with pain e.g. muscle spasm
Pain Control
 IM administration
– Convenient, but result in wide variation in
plasma concentration
– Wide variations in analgesic dosage among
patients
– These two factors reduce analgesic efficacy of
IM administration
– Addiction fears may lead to inadequate dosage
and frequency
– Note: opioid usage for temporary pain relief
rarely leads to addiction
Pain Control

 Prototype: morphine
 IV administration
– Intermittent or continuous
– Close supervision in PACU or ICU
 Side effects
– Respiratory depression, nausea, vomiting,
clouded sensorium
Pain Control

 Meperidine (demerol)
– Good opioid 1/8th potency of morphine
– Similar quality of pain control and side
effects as morphine
– Shorter duration of pain relief than
morphine
– Can be given IV with close supervision
Pain Control

 Other opioids
– Hydromorphone
– Methadone
 Advantages of methadone
– Longer half-life (6 – 10 hrs)
– Prevents withdrawal symptoms with
morphine dependence
Pain Control
 Non-opioids Parenteral analgesics
– NSAIDs: prototype-ketorolac
– Potent analgesic
– Moderate anti-inflammatory activity
– Available in injectable form suitable for postop
pain control
– No respiratory depression
 Side effects of NSAIDs (GIT ulceration,
impaired coagulation, reduced renal
function) usually not seen with short term
use of ketorolac
Pain Control

 Oral analgesics
– Used several days after major op when
pain severity decreases
– Avoid aspirin postoperatively: inhibits
platelet function, prolongs bleeding time,
decreases effects of anticoagulation
Pain Control
 Available meds
– Acetaminophen + codeine: Tylenol 3
– Acetaminophen + Hydrocodone: vicodin
– Acetaminophen + oxycodone: percocet
– Aspirin + oxycodone: percodan
 Oxycodone is an opioid with slightly less
potency than morphine
 Like all opioids, tolerance may develop with
long term use
Pain Control
 Patient controlled analgesia (PCA)
– Patient controls frequency of administration of a fixed
dose of analgesic within safe limits
– Analgesic is usually morphine delivered via an IV line that
goes through a device that contains a pump and timing
unit
– Patient presses a button and a fixed dose (~ 1-3 mg) of
morphine delivered
– Overdosing prevented by inactivation period of about 6-8
mins and the need for patient to be awake to operate unit
 PCA improves pain control and decrease total daily
opioid dose
Pain Control

 Continuous epidural analgesic

– Epidural opioid (morphine)
– Produce intense prolonged segmented
analgesic
– Less respiratory depression, sympathetic
motor or sensory disturbances
Pain Control
 Epidural versus parenteral opioids
– Similar dosage for pain control
– Slightly delayed onset of action
– Provides longer pain relief
– Better preservation of pulmonary function
– Side effects: pruritus, nausea, urinary retention,
hypotension
– Insert foley catheter, hydrate and monitor vital
signs
Pain Control
 Intercostal block
– Used for pain relief for thoracic or abdominal
operations
– Illuminates muscle spasm induced by cutaneous pain
– Helps restore respiratory function
– Does not include visceral afferents so pain relief is
not complete
– Produce analgesic for 3 – 12 hrs
– No risk of hypotension as seen in epidural analgesia
– Main disadvantage: pneumothorax, repeated
injections
DVT Prophylaxis

 Without prophylaxis 1/4th of postop

patients will develop DVT
 Increased risk because of Virchow’s
triad: stasis, hypercoagulability and
endothelial damage
DVT Prophylaxis
 Mainstay of DVT prophylaxis
– Heparin: unfractionated or LMWH
– Low dose unfractionated heparin is as effective
but less than LMWH
– Heparin compounds can lead to HIT
 Adjunctive therapy
– Intermittent pneumatic compression: poor
patient tolerance
– Adequate hydration, support/TED stockings
– Early ambulation
Post Op Complications
 Malignant hyperthermia
 Potentially fatal hypermetabolic
condition of skeletal muscles
accompanied by marked increase in
core body temperature following
exposure to trigger agents
 Incidence: 1:14,000 children, 1:50,000
adults
Post Op Complications

 Trigger agents
– Anesthetic drugs: succinylcholine
– Extreme stress (heat)
– Vigorous exercise
Post Op Complications
 Clinical manifestation
– First sign: abrupt rise in end tidal CO2
– Abrupt rise in body temperature
– Tachycardia, cyanosis and muscle rigidity
– Muscle necrosis, rhabdomyolysis, compartment
syndrome
– Hyperkalemia or hypercalcemia from muscle
necrosis  cardiac arrythmia
– Mixed respiratory and metabolic acidosis
– DIC
Post Op Complications
 Treatment
 Early recognition
 D/C trigger agent
 Dantrolene: muscle relaxant blocks calcium release
from sarcoplasmic reticulum. Only drug known
 Cooling blankets: hyperthermia
 IVF, manitol: myoglobinuria from rhabdomyolysis
 Mechanical ventilation: acidosis
 Dextrose + insulin, sodium polysterene sulfate or
IV calcium gluconate: hyperkalemia
Post Op Complications

 Atelectasis
– Collapse of an alveolus or lung segment
following mucous plugging of airways in a
postop patient
– Seen in up to 90% of patients following
general anesthesia irrespective of agent
used
Post Op Complications
 Factors contributing to Atelectasis
– Supine position: elevates diaphragm and
compresses lung
– General anesthesia decreases functional
residual capacity of lung
– Under GA patient does not sigh or cough
 decrease mucociliary clearing of
tracheobronchial tree
– Post op pain
Post Op Complications

 Management
– Begin preop: smoking cessation for 8
weeks preop, deep breathing exercises
especially in COPD patients
– Adequate pain control
– Early mobilization
Post Op Complications

 Surgical wound failure

– Wound healing is a complex process
involving cellular, hormonal and molecular
actions initiated at time of injury
– Alteration of the above process by
mechanical factors or infections leads to
acute wound failure or dehiscence
Post Op Complications
 Factors contributing to dehiscence
– Tissue ischemai from poor surgical technique: suture
placed too tight
– Local infection leading to destruction of fascia
 Spontaneous serous drainage from wound usually
precedes dehiscence
 Partial dehiscence: fascia intact
 Complete dehiscence: disrupted fascia +/-
evisceration
 Cover with sterile saline towel and return to OR
immediately for closure
Surgical Site Infection
 Surgical site infection
 Frequency varies according to hospital,
surgeon, type of surgery and patient
 Antibiotic resistant organisms becoming a
problem
 Increase length and cost of hospital stay
 Increase morbidity and mortality from
wound dehiscence: incision of hernia, soft
tissue infection and fistula formation
 Surgical Site Infection

Classification of surgical wounds

Wound Bacterial Source of Infection Examples
Contaminants Contamination Frequency
Clean Gram positive OR surgical team 3% Inguinal hernia,
Patient’s skin thyroidectomy
mastectomy, aortic grafts

Clean- Polymicrobial Endogenous 5 – 15% CBD exploration, elective

contaminated colonization of patient colon resection

Contaminated Polymicrobial Gross contamination 15 – 40% Spill during elective GIT

surgery

Dirty Polymicrobial Established infection 40% Drainage of intra

abdominal abscess,
retention of infarcted
intestine
Surgical Site Infection

 Surgical site infection is a measure of

quality of care and surveillance tool to
judge overall sterile technique
especially when infection develops in a
clean wound
Surgical Site Infection
 Prevention: preop
– Limit preop admission period to decrease risk of
hospital acquired infection
– Preop showers especially op site
– Hair removal to be done immediately before
procedure
– Shorter surgical times
– Look for areas of co-existing infection in preop
evaluation and treat before procedure
Surgical Site Infection
 Prevention: intraop
– Sterile technique, universal precaution, PPE, limit traffic in OR
– Minimize bacterial contamination
– Maintain hemostasis
– Avoid excessive suturing and cauterization: devitalized tissue
– Irrigate to remove bacterial laden clot and fibrin
– Remove foreign body and debris
– Preserve tissue oxygenation and perfusion
– Closed suction drain through separate stab wound
 Periop antibiotics
Types of surgical wounds
 Clean wounds
– Prophylactic antibiotic not generally indicated
except when a foreign body is permanently
implanted and infection of this will markedly
increase morbidity or mortality e.g. hip
replacement, aortic graft
– Antibiotic should be given within 1 hr of incision
and repeated 4-6 hrs later
Types of surgical wounds
 Clean contaminated wound
– Elective GIT surgery e.g. colon resection: orally
administered, poorly absorbed antibiotics e.g.
neomycin-erythromycin based antibiotics are
used along with mechanical bowel prep
 Grossly contaminated/dirty wounds
– Only fascial layers are usually closed.
– Skin and subcutaneous layers: left opened
– Saline/antiseptic soaked dressing BID
– Delayed primary closure or healing by secondary
intention
Common Soft Tissue Infections
Etiology Organism Physical Treatment
Findings

Cellulitis Break in skin Group A strep Blanching Systemic

barrier Erythema penicillins,
cephalosporins,
Tenderness
wound
cleansing
Furuncle Bacterial Staph aureus Localized I+D of abscess,
Carbuncle growth within induration systemic
skin glands & Erythema, antibiotics
crypts creamy pus against staph
formation
Hidradenitis Bacterial Staph aureus Multiple I+D of small
Suppurativa growth within abscesses, thick lesions, wide
apocrine pus from axilla debridement,
sweat glands or groin excision and
grafting of
large areas
 Common Soft Tissue Infections
Etiology Organism Physical Treatment
Findings

Lymphangitis Infection within Staph aureus Swelling and Local wound

lymphatics erythema of cleansing,
distal extremity removal of
Inflamed foreign body,
streaks along systemic
the lymphatics penicillins
cephalosporins
Grangrene or Destruction of Staph & strep Necrotic skin Radical
necrotizing healthy tissue mixed aerobic, fascia, extremity debridement of
fascitis by virulent anaerobic, swelling, grayish necrotic tissue,
microbial clostridium discharge, parenteral broad
enzymes organisms crepitation, gas spectrum
formation antibiotics
Diabetic fetid Ischemia, Mixed aerobic Foot erythema, Radical
foot neuropathic anaerobic swelling, debridement
injury, pressure organisms malodorous including soft
ulceration discharge and bony
tissues, broad
spectrum
antibiotics
Basic Anesthetic Technique

 Three categories
– General
– Regional
– Local
Basic Anesthetic
Technique
 General anesthesia
– Involves use of gas, volatile anesthetic, IV drugs
(narcotic, sedative), muscle relaxant
– Provides analgesia, unconsciousness, muscle
relaxation and autonomic control
– Used when complete insensitivity is desired
– When surgery involves the part of the body not
assessable to regional or local anesthetic
– When mechanical ventilation is necessary
– When position required for procedure does not
allow patient to be comfortable when awake.
Basic Anesthetic
Technique
 Regional
– Achieved by central or peripheral techniques
– Central: spinal, epidural and caudal anesthesia
– Peripheral: nerve plexus and IV bier blocks
– Provide loss of pain perception in areas of
surgical intervention
– Patient usually awake and breathing adequately
– Monitoring and observation in OR and PACU
similar to GA
– Most common: low spinal nerve roots (spinal,
epidural and caudal blocks) and brachial plexus
Basic Anesthetic
Technique
 Local
– Involves infiltration of anesthetic agents
into skin and subcutaneous tissue around
op site
– Choice of anesthetic: responsibility of
anesthesiologist, surgeon and patient
– Explain alternatives, risks, benefits and
allow patients to choose technique
Basic Anesthetic
Technique
 Factors that influence anesthetic technique
– Site of surgery
– Whether local or regional technique will provide
adequate analgesia
– Duration of procedure
– Position of patient during procedure
– Patient factors: presence of comorbidities,
bleeding tendencies, infection, age, full stomach,
personality and skill of surgeon and
anesthesiologist
Patient monitoring
 Patient intraop monitoring
– Oxygenation: inspired oxygen
concentration, pulse ox, skin color
– Ventilation: observation and auscultation
end tidal CO2, confirm ET tube placement
– Circulation: ECG, BP, heart rate,
peripheral perfusion pulse ox.
– Temperature: hypothermia,
hyperthermia.
Complications
 Pulmonary
– Respiratory depression: inhaled or IV agents, residual
neuromuscular blockade
– Upper airway obstruction: tongue, other soft tissue
– Laryngeal obstruction: injury, irritation, secretion lead to
laryngospasm
– Signs: nasal flaring, suprasternal and intercostal retraction
– Mgt
• neck extension and anterior displacement of mandible
• Insert nasopharyngeal or oropharyngeal airway
• ET tube
Complications
 Circulatory: most common,
hypotension, hypertension and cardiac
arrythmia
 Hypotension: hypovolemia - most
common cause of hypotension - fluids
– Hemorrhage – fluids or blood, elevate
legs
– Acute MI, preexisting ventricular
dysfunction
Complications
 Hypertension: pain, excitement,
delirium, volume overload
 Cardiac arrythmia: hypoxia,
hypercarbia, electrolyte abnormalities,
MI
 Monitor ECG, check BP, pulse-ox, CVP,
correct circulatory changes,
hypovolemia and hypoxia
Complications

 Renal
– oliguria from hemodynamic and
mechanical compromise, renal
insufficiency secondary to preexisting
renal disease, sepsis, elderly patient
 Mgt: foley to monitor u.o.
– Hydrate to correct hypovolemia
– Diuretics to improve renal function