1. SURGICAL MYTHS HOW TO IMPROVE THE MANAGEMENT OF OUR SURGICAL PATIENTS
Prof. Pankaj G.jani
Dept. of Surgery Uni. Of Nbi
Asso. Of surgs of Uganda
Annual Sc. Conf. April 2014, Jinja

2. FAST TRACK SURGERY Applicable to Elective operations Uncomplicated
< 2hrs Duration
Transfusion < 1 unit
Evidence based data ( All Referenced )

3. PLEASE NOTE These guidelines are NOT for Emergency Surgery
Long Elective operations
Complicated Surgeries
Pt. requiring > 2 units of transfusion

4. FAST TRACK SURGERY
Recent pathways reduce surgical stress, maintain postoperative physiological function, and enhance mobilization after surgery.
This has resulted in reduced rates of morbidity, faster recovery and shorter length of stay in hospital (LOSH)

5. Preadmission information, education and counseling
Detailed information given to patients before the procedure about surgical and anesthetic procedures diminishes fear and anxiety and enhance postoperative recovery and quickens hospital discharge

6. Alcohol
Alcohol abusers have a two-to-threefold increase in postoperative morbidity, the most frequent complications being bleeding, wound and cardiopulmonary complications. One month of preoperative abstinence reduces postoperative morbidity by improving organ function.
Smoking is another patient factor that has a negative influence on recovery. Current smokers have an increased risk for postoperative pulmonary and wound complications. One month of abstinence from smoking is required to reduce the incidence of complications.

7. Pre-Op fasting before Surgery
Norm -- Overnight fast Recommendation : Four-hundred milliliters of a 12.5 % drink of mainly maltodextrins (UPTO 2 HRS BEFORE INDUCTION OF ANAESTHESIA) has been shown to reduce preoperative thirst, hunger, and anxiety as well as postoperative insulin resistance. Carbohydrate treatment results in less postoperative losses of nitrogen and protein, as well as better-maintained lean body mass and muscle strength

8. Pre- Medication
Patients should not routinely receive long- or short-acting sedative medication (midazolam) before surgery because it delays immediate postoperative recovery.

9. NG Tube Postoperative nasogastric tubes should not be used routinely.
Nasogastric tubes inserted during surgery should be removed before reversal of anaesthesia.

10. Urethral Catheter
Intraoperative urine output was not a predictor of subsequent renal function or acute kidney injury
May not be necessary
With Major Abd Surgery -- Routine transurethral bladder drainage for 1–2 days is recommended.

11. Skin Prep.
Skin cleansing showed that the overall prevalence of surgical-site infection was 40 % lower in a concentration chlorhexidine-alcohol group than in a povidone-iodine group

12. Prevention of postoperative ileus (including use of postoperative laxatives)
Major cause of delayed Discharge after abdominal surgery is ileus
No prokinetic agent has been shown to be effective in attenuating or treating postoperative ileus

13. ILEUS
Mid-thoracic epidural analgesia as compared with intravenous opioid analgesia is highly effective at preventing postoperative ileus
Fluid “overloading” during and after surgery impairs gastrointestinal function and should be avoided.
Avoidance of nasogastric decompression may reduce the duration of postoperative ileus

14. Post-Op Pain Combination of : Narcotic NSAIDS Paracetamol
FUTURE : Bupivacaine extended-release liposome injection (Exparel, Pacira Pharmaceuticals)   Liposome particles that contain encapsulated bupivacaine that is released by diffusion during an extended period and provides analgesia for up to 72 hours.
Pain control for 72 hrs. after surgery

15. PONV
PONV affects 25–35 % of all surgical patients and is a leading cause of patient dissatisfaction and delayed discharge from hospital
The etiology of PONV is multifactorial and can be classified into three factors: patient, anesthetic and surgical.
Female patients, non-smokers and those with a history of motion sickness are at particular risk.

16. PONV
Administer antiemetic prophylaxis to all patients who are having inhalational anesthesia, opiates or major abdominal surgery
This approach is gaining popularity among the anesthetists given that the cost and side-effect profile of commonly used antiemetic drugs is small

17. PONV
The avoidance of emetogenic stimuli such as inhalational anesthetics, and the increased use of propofol for the induction and maintenance of anesthesia.
Minimal preoperative fasting, carbohydrate loading and adequate hydration of patients can also have a beneficial effect.

18. FLUIDS
If the patient is normovolemic, blood pressure should be maintained using vasopressors to avoid fluid overload.

19. Post-Op Fluids
In open surgery, patients should receive intraoperative fluids (colloids and crystalloids) guided by flow measurements to optimize cardiac output.
Fluid shifts should be minimized if possible. That is,
avoiding bowel preparation,
maintaining hydration by giving oral preload up to 2 h before surgery,
minimizing bowel handling and
exteriorization of the bowel outside the abdominal cavity and avoiding blood loss.

20. ASANTE SANA