PREOPERATIVE AND POSTOPERATIVE CARE
I. NEED FOR OPERATIONA. RELATIVE RISKS AND BENEFITS OF
SURGERY
II. ASSESSMENT OF OPERATIVE RISK risk with age, urgency of
operation and relation of physical status to anesthetic
morality
A) CARDIOVASCULARPre-op Assessment1. Coronary artery disease,
CHF, arrhythmias, PVD or severe BP
2. Goldman cardiac risk in noncardiac surgery (1) Class III and
IV patients warrant routine preoperative cardiology
consultation.(2) Class IV typically restricted to life-saving
procedures only.Poor HOPE1-2 RF: blockade preop3+ RF: periop
block
Interventions to operative riskCAD: Evaluated by RKG, exercise,
or dipyridamole thallium scan, multigated acquisition, or echo.
Coronary angiography may be indicated. Coronary artery
revascularization has been shown to decrease risk for postoperative
myocardial infarction.CHF: Risk factors for postoperative CHF are
CAD, age, major operation. optimally controlled (e.g., diuretics,
digoxin). Preoperative PA pressure monitoring and intraoperative
TEE can guide fluid management hemodynamic performance (i.e.,need
for fluids, inotropes, or vasodilators).Arrhythmias: medically
control before surgery, b. High-grade block and bradyarrhythmias
may require preoperative temporary or permanent pacing.HTN:
antihypertensives should be continued until time of surgery except
MAOIs (d/c 2w b4 surgery). Work up new-onset or severe
hypertension
B) RespiratoryPre-op AssessmentRisk factors: smoking (2F), COPD
(6F), age, pulmonary disease, thoracic or upper abdominal surgery,
pulmonary hypertension, sleep apnea,
ID pulm risk for nonthoracic operations: Inability to blow out a
match with unpursed lips from a distance of 20 to 25 cm, Shortness
of breath during one to two flights of steps, . PCO2 >45mmHg on
RA, maximumbreathing capacity < 50% predicted, FEV1< 2 L, PA
pressure> 30 mm Hg, FEV1/FVC < 65%
Interventions to operative risk8w smoking cessation is required
to have effect on postoperative morbidity.Teach and use chest
physical therapy, incentive spirometry, and deep-breathing
exercises before surgery.COPD: Initiate or continue use of
bronchodilators antibiotics, chest physical therapy, and steroids
4. Pneumonia or acute bronchitis: Delay elective surgery and treat
with pulmonary toilet and antibiotics.5. Bronchiectasis: Improve
operative risk via preoperative expectorants, pulmonary toilet,
incentive spirometry training, and antibiotics based on patients
cultures.
Post-op CareA. PULMONARY1. Postoperative pulmonary complications
cause significant perioperative morbidity and mortality increasing
hospital stay.2. Complications include atelectasis, pneumonia,
prolonged mechanical ventilation and respiratory failure, and
worsening of underlying lung disease.3. Operation-specific risk
factorsa. Incidence of complications increases with proximity of
incision to the diaphragm.b. Duration of operation greater than 3
to 4 hoursc. Type of anesthesia and half-life of neuromuscular
blockade4. Postoperative pulmonary carea. Early ambulationb.
Aggressive pulmonary toilet (incentive spirometry, deep
breathing,coughing)c. Adequate analgesia(1) Epidural analgesia in
upper abdominal operations decreases incidence of pulmonary
complications and length of hospital stay.(2) Advantages of
epidural narcotics (morphine, fentanyl, sufentanil,
hydroxymorphine)(a) Longer duration of action(b) Minimal sedation
and respiratory depression (c) Minimal sensorimotor loss(3) Local
anesthetic (bupivacaine, ropivacaine) may be added for shorter
onset of action without risk for hypotension and motor blockade.(4)
Pain can also be controlled via patient-controlled analgesia (PCA)
to minimize narcotic use.Preoperative and Postoperative
Care51B.1.a. b.c.d.C.1.2. 3.D.1.a.b.
F. RENALRISK1. Renal insufficiency (blood urea nitrogen [BUN] 50
mg/dl; creatinine concentration 3 mg/day). Remember, however, that
serum BUN and creatinine abnormalities are not seen until more than
75% to 90% of renal reserve is lost.2. Greatest risk in acute renal
failureG. HEPATICRISK1. Cirrhosis, hepatitis2. Surgical mortality
significantly increased in patients withbilirubin level greater
than 2 mg/dl, albumin level less than 3 g/dl, prothrombin time
greater than 16 seconds, presence of encephalopathy, and advanced
ChildPugh classification.3. Mortality associated with noncardiac
surgery is caused by high-output cardiovascular failure and low
peripheral resistance.a. Less than 5% of class A patientsb. Five
percent to 10% of class B patientsc. Twenty percent to 50% of class
C patientsd. Eighty percent mortality rate if blood ammonia greater
than 150 g/dlor albumin level less than 2.5 g/dlH. ENDOCRINERISK1.
Diabetes mellitusa. A growing body of literature suggests that
tight glycemic control (glucose between 80 and 110 mg/dl) is
beneficial (e.g., see Van den Berghe G, Wilmer A, Hermans G, et al:
Intensive insulin therapy in the medical ICU. N Engl J Med
354:449461, 2006).b. Sixteen percent to 23% of patients experience
development of diabetes mellitus in the perioperative period, most
commonly after operations for vascular disease.c. It is an
independent predictor of postoperative myocardial ischemia among
cardiac and noncardiac surgical patients.d. Stress of operation
causes secretion of epinephrine, growth hormone, glucocorticoids,
and glucagon.e. Anesthetic agents affect sympathetic tone, thereby
decreasing insulin secretion.2. Hyperthyroidism or
hypothyroidismPreoperative and Postoperative Care43I.
HEMATOLOGICRISK1.a. b. c.Thromboembolic disease (Table 4-4)True
prevalence is unknown and varies with the type of surgery, use and
type of prophylaxis, and mode of diagnosis.Without prophylaxis,
fatal pulmonary embolism occurs in 0.1% to 0.8% of patients
undergoing elective general surgery.Risk factors for developing
short-term (30-day) postoperative deep venous thrombosis:(1) Age
older than 50 years(2) History of varicose veins(3) History of
myocardial infarction(4) History of cancer(5) History of atrial
fibrillation(6) History of ischemic stroke(7) History of diabetes
mellitus(8) Other risk factorsprevious deep venous thrombosis,
heart failure,obesity, paralysis, and inherited conditions (factor
V Leiden, prothrombin gene mutation, protein S deficiency,
antithrombin deficiency)NUTRITIONAL-IMMUNOLOGICRISKRisk increased
if severe malnutrition presentweight loss greater than 15% over
previous 3 to 4 months, albumin level less than 3.0 g/dl, anergy to
injected skin-test antigens, transferrin level less than 200
mg/dl.J.1.III. INTERVENTION TO REDUCE OPERATIVE RISKA.1.
2.B.1.a.b.2.a.b. c.EMERGENTOPERATIONSProcedure should not be
delayed for most situations.Exception is volume-depleted patients
(e.g., those with intestinal obstruction, peritonitis, perforated
viscus), who should undergo fluid and electrolyte repletion before
induction of anesthesia.D. RENAL1. Identify and correct causes of
renal insufficiency including, but not limited to, infection,
uncontrolled hypertension, obstruction, dehydration, drugs (i.e.,
aminoglycosides).2. Reduce azotemia with peritoneal dialysis or
hemodialysis if needed.3. Correct electrolyte abnormalities.4.
Optimize volume statusconsider use of pulmonary artery
monitoring.E. HEPATIC (SEE CHAPTER 45)1. Abstain from alcohol,
spironolactone, and furosemide with fluid restriction to control
ascites; limit sodium to 0.5 to 2 g/day.4PREOPERATIVE AND
POSTOPERATIVE CARE46a.b.c.Indications(1) Preoperative for
adrenalectomy(2) Known history of adrenal insufficiency(3) History
of adrenal or pituitary surgery or surgery for renal
cellcarcinoma(4) Inflammatory bowel disease, steroid
dependentEndogenous cortisol output(1) Normal unstressed adult8 to
25 mg/day(2) Adult undergoing major surgery75 to 100 mg/dayGuide to
steroid coverage(1) Correct electrolytes, blood pressure, and
hydration ifnecessary.(2) Hydrocortisone phosphate or
hemisuccinate100 mg intravenouspiggyback on call to operating
roomPerioperative CareF. ENDOCRINE (SEE SECTION V AND CHAPTER 32)1.
Glucose controla. For patients with type I diabetes, minimize
effect of fasting and ketosis by scheduling operations early in the
day.b. Halve dose of long-acting insulin before surgery.c. Hold
oral diabetic agents on the day of surgery because
metformin,secretagogues, and sulfonylureas can be associated with
lactic acidosis, hypoglycemia, and increased risk for perioperative
myocardial infarction, respectively.2. SteroidsG.H.1. If
malnourished, recommend preoperative enteral or
parenteralHEMATOLOGIC (SEE CHAPTER 13) NUTRITION (SEE CHAPTER
6)nutrition for a minimum of 4 to 5 or 14 days, respectively, to
normalize short-turnover proteins (retinol-binding protein,
prealbumin, and transferrin).IV. GENERAL PREOPERATIVE PREPARATIONA.
OVERALL ASSESSMENT AND DOCUMENTATION1. For discussion of the
patient, history, physical examination, indications for the
procedure, informed consent, and preoperative note, see Chapter 2;
for operative risk, see section II.B. PREOPERATIVE LABORATORY AND
IMAGING EVALUATIONAlthough several studies have documented that
many preoperative laboratory studies are not cost-effective, these
preoperative studies are performed at many institutions.1.
Laboratory studiesa. Complete blood cell count, urinalysis,
electrolytes, BUN, creatinine, prothrombin time, partial
thromboplastin timePreoperative and Postoperative Care47b. Room-air
arterial blood gas if at risk for respiratory insufficiency (see
section II) or if prolonged postoperative ventilator support is
anticipated2. Radiographsposteroanterior and lateral chest
radiograph unless previously normal within the past 6 months or
patient younger than 35 years3. Electrocardiogram if patient older
than 35 years or if otherwise indicated by cardiac historyC. BLOOD
ORDERS1. Type and screen or type and cross-match for the number of
units appropriate for the procedureD. SKINPREPARATION1. Hair
removal is best performed the day of surgery with an electric
clipper. Shaving the night before surgery is associated with an
increased risk for infection.2. Provide preoperative (night-before)
scrub or shower of the operative site with a germicidal soap (e.g.,
Hibiclens, pHisoHex).E. PREOPERATIVEANTIBIOTICS1. When used, should
have an established blood level at the time of initial skin
incision. Administer preoperative antibiotics 30 minutes before
incision.2. Indications for prophylactic antibioticsa. Clean
proceduresmost cardiac, noncardiac thoracic, vascular,
neurosurgery, orthopedic, and ophthalmic procedures require
cefazolin 1 to 2 g intravenously (IV) or vancomycin 1 g IV.b.
Clean/contaminated proceduresgastrointestinal/genitourinary tract,
gynecologic, respiratory tract, head and neck procedures use
cefazolin 1 to 2 g IV; for colorectal procedures, use oral neomycin
and erythromycin, and cefoxitin or cefotetan 1 to 2 g IV.c. Dirty
procedure/ruptured viscuscefoxitin or cefotetan 1 to2 g IV with or
without gentamicin 1.5 mg/kg every 8 hours IV, or clindamycin 600
mg IV every 6 hours and gentamicin 1.5 mg/kg every 8 hours IV.d.
Special consideration must be given to patients with prosthetic
heart valves or history of valvular heart disease.e. Redose the
antibiotic if the operation lasts longer than 4 hours or twice the
half-life of the antimicrobial agent.f. Prophylactic antibiotics
should not be continued beyond the day of the operation.F.
BACTERIAL ENDOCARDITIS PROPHYLAXIS1. Indications: Patients with the
following conditions are particularly vulnerable to bacteriologic
seeding during transient bacteremia:4PREOPERATIVE AND POSTOPERATIVE
CARE
48Perioperative Carea. Prosthetic valveb. Congenital valve
diseasec. Rheumatic valve diseased. History of endocarditise.
Idiopathic hypertrophic subaortic stenosis.f. Mitral valve prolapse
with murmur (Barlow syndrome)2. Antibiotic recommendations: Table
4-5 shows the use of antibiotics for endocarditis prophylaxis in
dental, upper respiratory, genitourinary, and gastrointestinal
procedures.a. Antibiotic prophylaxis as described in Table 4-5 is
used for patients with valvular heart disease, prosthetic heart
valves, most forms of congenital heart disease (but not
uncomplicated secundum atrial septal defect), idiopathic
hypertrophic subaortic stenosis, and mitral valve prolapse with
regurgitation.b. Oral regimens are more convenient and safer.
Parenteral regimens are more likely to be effective; they are
recommended especially for patients with prosthetic valves, those
who have had endocarditis previously, or those taking continuous
oral penicillin for rheumatic fever prophylaxis.c. A single dose of
the parenteral drugs is adequate for most dental and diagnostic
procedures of short duration. However, one or two follow-up doses
may be given at 8to 12-hour intervals in selected high-risk
patients.G. RESPIRATORYCARE1. Preoperative incentive spirometry on
the evening before surgery when indicated (upper abdominal
operations, thoracic operations, predisposed to respiratory
insufficiency)2. Bronchodilators for moderate-to-severe chronic
obstructive pulmonary disordersH. BOWEL PREPARATIONThe purpose of a
bowel preparation is as follows: (1) to remove all solid and most
liquid from the bowel, and (2) to reduce the bacterial population
in anticipation of procedures or complications of procedures that
may contaminate the wound and the peritoneal cavity. All patients
are NPO (nothingby1.2.a.b.c.mouth) after midnight before the day of
surgery.Nonbowel operation: Stomach decompression before induction
of anesthesia by patient remaining NPO after midnight before
surgery or by nasogastric suctionBowel operationBowel prep may be
helpful if any of the upper or lower gastrointestinal tract is to
be opened or if there is a risk for enterotomy (e.g., complicated
ventral hernia repair).Achlorhydria, gastric carcinoma, prolonged
H2 blocker usage, and obstructive peptic ulcer disease allow
bacterial growth in the stomach. Consider using an oral antibiotic
prep (e.g., neomycin) for gastric surgery in these patients.Many
variations exist, but all have the same goal of achieving a bowel
movement before surgery that is liquid, clear, and free of any
stool. For largeand small-bowel resection, the following is a
standard bowel prep:(1) Clear liquid diet 48 hours before the
procedure (2) Day before surgery:8 oz water PO8 oz water PO and
neomycin 500 mg and metronidazole5:00 PM7:00 PM10:00 PM(3) If stool
contains solid material, the patient can be given 1 bottle of4
bisacodyl 5-mg tablets PO1 bisacodyl 10-mg suppository by
rectumneomycin 500 mg and metronidazole 750 mg PO magnesium citrate
orally.4910:00 AM8 oz water45 ml Fleet Phospho-soda orally (PO)
followed by4PREOPERATIVE AND POSTOPERATIVE CARE50Perioperative
CareJ. OTHERCONSIDERATIONS1. Administer a maintenance rate of
intravenous fluids beginning at midnight before the surgery.2.
Thromboembolic prophylaxis with sequential compression devices or
heparin if greater risk3. Maintenance medications (e.g.,
antihypertensives, cardiac medications, anticonvulsants) may be
given the morning of surgery with a sip of water before routine
operations.4. Preoperative diabetic management; hold oral
antihyperglycemic drugs.5. Subacute bacterial endocarditis
prophylaxis (see section V)6. Perioperative steroid coverage (see
section V)7. The site for a stoma, if applicable, may be marked by
the stomaltherapist in elective situations, ideally at least 2
inches away from the skin fold at the level of the umbilicus.V.
POSTOPERATIVE CAREHEMATOLOGYPrevention of thromboembolism (Table
4-6)Especially important in patients with cancer, elderly adults,
and patients undergoing orthopedic proceduresAbsolute
contraindications to pharmacologic treatmentactivebleeding, severe
bleeding diathesis, platelet counts less than 20,000/l,
neurosurgery, ocular surgery within the past 10 days or
intracerebral or subarachnoid hemorrhage within the past 48
hoursRelative contraindications to pharmacologic
treatmentmild-to-moderate bleeding diathesis, platelet count 20,000
to 100,000/l, brain metastases or recent major trauma, major
abdominal surgery withinthe past 2 days, gastrointestinal or
genitourinary bleeding within the past 14 days, infective
endocarditis, malignant hypertension Nonpharmacologic measuresearly
ambulation, graduated compression stockings that can be used on
upper extremities, intermittent pneumatic compression (be cautious
if patient has been immobilized or on bedrest for 72 hours because
of the possibility of disrupting newly formed clots; do not use
with lower extremity operations or injuries)RENALHyperkalemia (7.5
mEq/L) with electrocardiographic changesIV calcium, one-half ampule
of D50 followed by 10 units of insulin IV, one-half ampule of
bicarbonate, 5 g sodium polystyrene sulfonate (Kayexalate) PO or
enemaAs BUN reaches 100 mg/dl, dysfunctional platelets may cause
gastrointestinal bleeding, which further increases BUN.
Postoperative low urine output can have several causative factors
hypovolemia, depressed cardiac function, diuretic dependence,
urinary retention, obstruction of Foley catheter.ENDOCRINEIntensive
glycemic control has become the standard of care because of its
proven benefits, including reduced morbidity and mortality American
Diabetes Association Recommendations for Target Inpatient Blood
Glucose Concentrations:(1) General surgical patientrandom less than
180 mg/dl, fasting less than 90 to 126 mg/dl; better outcomes
provide for lower infection rates(2) Cardiac surgeryless than 150
mg/dl; allowing for reduced mortality and risk for sternal wound
infections(3) Critically ill80 to 110 mg/dlMethods for achieving
strict glycemic control (80110 mg/dl):(1) Piggyback infusion of
regular insulin (50100 units per 50100 ml normal saline) with
infusion rate (units per hour) calculated as serum glucose
(mg/dl)/150 with sampling via an arterial line.2.a. b.c. d.
e.E.1.a. b. 2.a. b.c.3.F.1.a.(2) Length, type of surgery, and
severity of glucose dysregulation determines need for intravenous
insulin therapy.Steroidsguide to steroid coverage:Hydrocortisone
phosphate or hemisuccinate100 mg IV before surgery in
postanesthesia care unit and every 6 hours for the first 24 hoursIf
progress is satisfactory, reduce dosage to 50 mg every 6 hours
for24 hours, then taper to maintenance dosage over 3 to 5 days.
Resume previous fluorocortisol or oral steroid dose when patient is
taking oral medications.Maintain or increase hydrocortisone dosage
to 200 to 400 mg/24 hours if fever, hypotension, or other
complications occur.If patient has potassium wasting, may switch to
methylprednisolone (Solu-Medrol).High-dose (300600 mg/day)
methylprednisolone regimens are potentially deleterious secondary
to impaired wound healing, increased catabolism, electrolyte
abnormalities, and increased infectious
complications.IMMUNOLOGIC/FEVERAll pyrogens evoke a common mediator
(interleukin-1), which alternates the activity of
temperature-sensitive neurons in anterior hypothalamus.Internal
thermostat is increased with blood temperature remaining relatively
low, causing chills and shivering to increase blood temperature. If
set-point drops, a flush phase or crisis with vasodilation and
sweating develops to rid body of heat.Common causes of fever are
referred to as the five Wswind (atelectasis), water (urinary tract
infection), wound (wound infection), walking (thrombophlebitis),
and wonder drugs (drug-induced fever). Within 24 hoursatelectasis
or failure to clear pulmonary secretionsAt 24 to 48
hoursrespiratory complications, less likely catheterrelated
problemsAfter 48 to 72 hoursif previously afebrile, likely because
of significant complication: bloodstream infection,
thrombophlebitis, wound infection, urinary tract infection
pneumonitis, acute cholecystitis (acalculous if immobile or
received large volumes of blood), idiopathic postoperative
pancreatitis, drug allergy; Candida if receiving total parenteral
nutrition (if blood cultures are negative but have Candida in
another site, discontinue total parenteral nutrition line and start
antifungal agent)If no systemic symptoms or supportive physical
findings, no need to obtain routine chest radiographs,
pan-cultures, or white blood cell
counts.INTEGUMENTARY/WOUNDCOMPLICATIONSWound infectionUsually
Staphylococcus aureus hemolytic streptococci (3%), Enterococci,
Pseudomonas, Proteus, or Klebsiella4PREOPERATIVE AND POSTOPERATIVE
CARE54Perioperative Careb. Incidence(1) Clean, atraumatic,
uninfected wound3.3% to 4%(2) Clean wounds without emergent
operation, drained wounds, stabwounds7.4%(3) Bronchus,
gastrointestinal tract or oropharyngeal cavity entered10.8%(4)
Perforated viscera28.3%c. Risk factorsadvanced age, steroids,
obesity, duration of operation, malnutritiond. Preventionskin
preparation (clip immediately before surgery), bowel preparation
(most effective being mechanical preparation with clear liquids and
cathartics), prophylactic antibiotics (given 1530 minutes before
the incision, keeping serum levels greater than the minimally
inhibitory concentration throughout the operation), meticulous
technique with minimal tissue destruction, temperature maintenance,
appropriate drainagee. Usually present between the fifth and eighth
postoperative day; however, necrotizing fascitis (dishwater pus
with Gram stain of mixed flora of gram-negative rods and
gram-positive cocci) or clostridia myositis (crepitus, vesicles on
the skin) can manifest within 24 hoursf. Management of wound
infectionsdepends on extent of destruction and type of infection,
ranging from opening the incision to radical debridement; if
surrounding cellulites and edema, antibiotics (Ancef IV or Keflex
PO) are typically indicated.2. Wound hematomasa. Caused by
inadequate hemostasisb. Risk factorsanticoagulation, fibrinolysis,
polycythemia vera,myeloproliferative disorders, decreased or
inadequate clotting factorsc. Cause pain and swelling with
serosanguineous drainaged. If discovered early, return to operating
room to evacuate hematoma andcontrol bleedinge. If discovered late,
apply heat, manage expectantly3. Wound dehiscencea. Separation of
the fascial layerb. Incidence rate0.5% to 3.0%c. Usually caused by
a technical errord. Heralded by serosanguineous, salmon-colored
drainage from the wounde. Contributory factorsmalnutrition,
hypoproteinemia, morbid obesity,malignancy, uremia, diabetes,
increased abdominal pressure, remoteinfection, and excessive suture
materialf. Treatmentfluid resuscitation, application of sterile
dressing, earlyreturn to the operating room for repair
