Perioperative Management

Perioperative period Definition not well established Importance directly related to the outcome of surgery itself Composition preoperative preparation & postoperative management

Preoperative Preparation The principle Different preparation for different operation The classification of operations according to the characteristics of operations 1. Elective surgery 2. Restrictive surgery 3. Emergent surgery

Preoperative Assessment To confirm the diagnosis To assess the risk of operation To assess the general condition and function of important organs To evaluate the patients endurance to the operation and risk of operation

Essential steps in preoperative assessment and preparation History taking Physical examination Collating pre-admission information about diagnosis Arranging any further diagnostic investigation Making special preparations for the particular operation Investigating any intercurrent or occult illness suggested by medical clerking

Essential steps in preoperative assessment and preparation Discussing the operation with the patient and his family and obtaining signed consent Marking the operation site Making arrangements for the operation with the operating theatre staff Arranging and informing the anaesthetist Prescribing medication prophylactic antibiotics etc. Planning rehabilitation and convalescence

General Preparation Psychological preparation talk frankly and appropriately to patients Physiological preparation Adaptive exercise Transfusion Prevention of infection Gastro-intestinal tract preparation Maintenance of fluid, electrolyte and nutrition

Specific Preparation Malnutrition and dysfunction of immune system Malnutrition dramatically increases the morbidity and mortality Preoperative nutritional support is more valuable

Hypertension Mild-to-moderate essential hypertension systolic pressure ＜ 180mmHg diastolic pressure ＜ 110mmHg At minimal risk of cardiac complication Antihypertensive drugs should be used all time Sudden withdrawal of drugs is dangerous

Severe or poorly controlled hypertension At high risk of perioperative cardiac failure or stroke. This type of patients should not undergo general anaesthesia and surgery until adequately treated. The blood pressure should be reasonably controlled under 160/100 mmHg.

Cardiovascular disease Ischaemic heart disease Cardiac failure Arrhythmias Valvular heart disease Cerebrovascular disease

Angina Previous infarction Stable angina poses little increased risk during operation but unstable angina is as dangerous as recent myocardial infarction Previous infarction The risk of reinfarction is about 30% if an operation is performed during the first 3 months At 6 months the risk is about 10 ~ 15% which may be acceptable for important elective surgery

Adequate preparation for heart disease To correct the fluid and electrolyte imbalance. To correct anaemia through several blood transfusion with small amount. To control the cardiac arrhythmias. (Atrial fibrillation, Tachycardia, Bradycardia)

Respiratory dysfunction Respiratory complications occur in up to 15% of surgical patients and are the leading cause of postoperative mortality in the elderly.

respiratory complication Risk factors for respiratory complication Chronic obstructive pulmonary or airways disease (Chronic bronchitis, emphysema, bronchiectasis, pneumoconiosis, pulmonary tuberculoses) Cigarette smoking Current respiratory infections Asthma

Preoperative investigation of respiratory disease A chest X-ray, CT scan if necessary EKG Spirometer Blood gas measurement

Perioperative management of respiratory disease and high risk patients 1. Preoperative physiotherapy teaching the patient breathing exercises and correct posture 2. Drug therapy Theophyllines Prophylactic antibiotics Preoperative bronchodilator Adequate hydration

3. Encourage to stop smoking from the time of book for elective surgery 4. Alternation methods of anaesthesia Local, regional or spiral anaesthesia should be considered 5. Early postoperative physiotherapy to enhance deep breathing, coughing and general mobility

Liver disorder The tolerance to operation depends upon the severity of liver function impairment. The liver function could be estimated by Child staging. Malnutrition, ascites and jaundice are contraindications except for emergency surgery.

Preoperative assessment and management Serological test for HBV and HCV, full blood count, clotting screen and platelet count, plasma urea and electrolytes, bilirubin, transaminases, calcium, phosphate, gamma glutaryl transferase and albumin. When prothrombin time is prolonged, vitamin K should be given for several days before operation.

Renal disorders Preoperative assessment plasma urea, electrolytes, creatinine and Bicarbonate should be checked Mild chronic renal failure Drugs should be given in smaller doses Fluid and electrolyte homeostasis Moderate-to-severe chronic renal failure Operations should be performed under haemodialysis

Disorders of Adrenal Function Adrenal Insufficiency The most common cause of adrenal insufficiency is hypothalamo-pituitary-adrenal suppression by long-term corticosteroid therapy. The lack of adrenal response in these patients may cause acute post-operative cardiovascular collapse with hypotension and shock. For any steroid-dependent patient, a doctor should write clearly in the note “Treat any unexplained collapse with hydrocortisone”.

Diabetes Mellitus At special risk from general anaesthesia and surgery Patients with diabetes fall into three groups 1. Insulin dependent 2. Taking oral hypoglycaemic medication 3. Diet-controlled

Perioperative management Attempt to maintain blood glucose level between 4 and 10 mmol/L, avoid hypoglycemia in particular. Blood glucose level ＞13 mmol/L, an unreceptible risk of ketoacidosis or a hyperosmolar non-ketotic state.

The general principle of perioperative management Establish good diabetic control before operation Given insulin as a continuous intravenous infusion during the operative period Given an infusion of dextrose throughout the operative period to balance the insulin given and to make up for lack of dietary intake

The general principle of perioperative management Add potassium to the dextrose infusion Monitor blood glucose and electrolytes frequently throughout the operative and early postoperative period

Post-operative Management Recovery room is necessary ICU is optimal if possible Monitoring Closely monitor the life signs as a routine CVP monitoring is necessary if hemodynamic unstable during operation Other items monitored accordingly Fluid balance

Position and getting up Supine position for spiral anaesthesia Semireclining position for neck and chest operation. Lateral position for obesity patients. Get up as early as possible and make movements as much as possible

Diet and transfusion Period of fast depends upon the type of operation. Enteral and parenteral nutrition should be taken into consideration. Fluid and electrolytes homeostasis should be maintained.

Management of Drainage Different drainage for different purpose (infection focus, leakage prevention and massive exudation) Nasal-gastric tube Urinary catheter

Wound healing and suture removing Classification of incision clean incision contaminated incision infected incision Type of healing Type A perfect healing B some inflammation C infected

Management of postoperative complaint 1. Postoperative pain any motions increasing tensions will increase pain Analgesia is obligatory 2. Pyrexia common postoperative observation a search be made for a focus of infection non-infective causes of pyrexia

Nausea and Vomiting Drugs (opiates, erythromycin, metronidazole) Bowel obstruction mechanical obstruction Adynamic bowel Hypokalaemia faecal impaction Systemic disorders electrolyte disturbances Uraemia raised intracranial pressure

Abdominal distension Hiccup More common after abdominal surgery Diaphragm irritation or central nervous system stimulated Subphrenic infection should be suspected for continuous hiccup

Retention of urine There is a palpable suprapubic mass with dull to percussion. Urinary catheter is indicated when diagnosed.

The main postoperative complications: Atelectasis Chest infection Aspiration pneumonitis Pneumonia

Management of postoperative complications Postoperative Haemorrhage Causes inadequate operative haemostasis a technical mishap as slipped ligature Management re-operation to stop bleeding some preparation is necessary

Wound Dehiscence (Burst Abdomen) Causes blood supply is poor excess suture tension long-term steroid therapy immunosuppressive therapy malnutrition infection coughing or abdominal distension Management re-suturing with tension sutures the whole thickness of the abdominal wall

Wound Infection Minor wound infections localized pain, redness and a slight discharge Wound Cellulitis and Abscess cellulitis treated by antibiotics abscess treated by surgical drainage

Atelectasis Prevention and treatment Airway become obstructed and air is absorbed from the air spaces distal to the obstruction Bronchial secretions are the main cause of this obstruction Prevention and treatment perioperative physiotherapy is the best way for prevention deep breathing exercises regular adjustments of posture vigorous coughing flexible bronchoscopy to aspirate occluding mucus plugs

Urinary Tract Infections Causes reduced urinary output reducing “flushing” of bladder incomplete bladder emptying inadequate perineal hygiene Treatment ensuring adequate fluid input appropriate antibiotics

Deep vein thrombosis Causes bed bound after operation venous stasis plasma concentrated due dehydration viscosity increased Manifestations swelling of the leg tenderness of the calf muscle increased warmth of the leg calf pain on passive dorsiflexion of the foot

Treatment Anticoagulation: Systemic thrombolytic therapy: streptokinase Local thrombolytic drugs is more promising intravenous heparin subcutaneous heparin oral warfarin therapy

Prevention postoperative mobilization adequate hydration avoiding calf pressure for high risk cases low dose subcutaneous heparin calf compression devices graded-compression ‘anti-embolism’ stockings Intravenous dextran Warfarin anticoagulation

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