Perioperative & post operative Care

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DEBRE BIRHAN UNIVERSITY
COLLEGE OF MEDICINE
Perioperative care & postoperative complicaton
By Zelalem Mekonnen (C-II)
Shegaw Merkebu (C-II)
Modulator: Dr.Addis (G. Surgeon)
September 2015 E.C

2. Outline
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 Patient evaluation/assessment: Hx + P/E+ Ix + Dx
 Specific preoperative problems and their management
 Fitness assessment
 Obtaining consent
 Wrong person, site, procedure prevention
 Psychological preparation
 Documentation.
 How to recognise and treat common postoperative complications

3. Introduction
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 Perioperative care: is the process of making sure that a
surgical patient will be safe during the perioperative period by
understanding the patient's risk & optimizing the outcome.
 Perioperative care: Preoperative + Intraoperative +
Postoperative cares.
 Any problems should be treated if possible

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 Preoperative care can be conducted during:
 Outpatient office visit
 Hospital inpatient consultation
 Emergency department evaluation of a patient

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Approaches to preoperative care
 Elective patients  all possible medical problems should be
identified & optimized before surgery.
 Critically ill/ Emergency patients  only continuous resuscitation on
the way to theatre may be the only possible care .

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Goals of preoperative care:
 Gather & record concisely all relevant information.
 Comorbidity management plan (to minimize the risk & maximize the
benefit for the patient)
 Consider possible complications (to reduce perioperative morbidity &
mortality).
 Communicate the surgical plan & ensure that everyone (including the
patient) understands it

7. Preoperative evaluation
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 The aim is not to screen for undiagnosed disease.
 Focus on  comorbidity that affects operative outcome
The detail of the evaluation is determined by:
 The planned procedure (low, medium, or high risk)
 The planned anesthetic technique

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History taking
 Do not assume that the history has already been adequately
covered previously.
 Look for overlooked or new onset symptoms and signs.
 Ask for
 Medical conditions & risk factors.
 Surgical conditions & risk factors.
 Personal or family history of anesthesia-related
complications.

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Physical Examination:
 A general PE should be performed.
 Possible DDxs should be excluded.
 Weight  for managing the postoperative fluid balance.

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Investigations
 Most hospitals use  Protocols for all elective or emergency cases.
 In general:
 Chemistries & Hgb/ Hct ≤ 1 month are acceptable ( in the stable
situation).
 Coagulation studies ≤ 1 week are acceptable.
 ECG & CXR ≤ 6 months need not be repeated (unless there is
change in status).
 ECG is routinely obtained, especially all patients older than 50 yrs.

11. Standard preoperative considerations
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 Medical mgt of comorbidities.
 Blood loss preparation.
 Smoking cessation.
 Surgical site infection prevention.
 Anesthesia fitness
assessment.
 Informed consent.
 Scheduling for OR
 Wrong person, site,
procedure prevention.
 Psychological preparation.

12. SPECIFIC PREOPERATIVE PROBLEMS
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Hypertension:
 If SBP ≥160 mmHg & DBP ≥ 95 mmHg  defer elective surgery until
BP is controlled.
 Emergency surgery  the BP needs to be controlled rapidly with Iv
medication.
 Cause of elevated BP might be Stress & anxiety.
 Managed by Anxiolytics or sedation & adequate pain control.

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Ischaemic heart disease
 Recent MI  strong contraindication to elective anesthesia
 Within 3 months of MI  mortality rate from anaesthesia is high.
 Elective surgery  delay until at least 6 months.
 If urgent surgery is required,
 Aggressive medical therapy, and
 Meticulous optimisation of oxygenation & fluid balance in ICU.

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Dysrhythmia
 Atrial fibrillation must be controlled before surgery by
medication or pacemakers.
 If digoxin is being used, regular measurement of serum
potassium
 If a pacemaker is already fitted  cardiology consultation
should be obtained.

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Cardiac failure:
 Needs careful work-up & medical specialist evaluation.
 To avoid cardiovascular depressant effects of anesthetic.
 Decompensated heart failure  defer elective procedures &
optimize cardiac performance.
 If emergency procedure  need invasive monitoring (e.g., intra-
arterial line, pulmonary artery catheter, & transesophageal
echocardiography).

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Anemia & blood transfusion
 Preoperative transfusion should be considered if Preoperative
Hgb < 8 g/dl or Patient is symptomatic & actively losing blood.
 In stable patients transfuse  a day or so before the surgery
 For major surgeries  cross-match preoperatively.
 If patients refuse blood transfusion (e.g. Jehovah’s Witnesses).
They should sign an extra consent accepting the consequences.

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Respiratory disease
 Significantly ↑ postoperative morbidity.
 ↑ risk should be made clear to the patient & mentioned in the
consent.
 If the patient smokes  stop for at least 4wks.
 Lower respiratory tract infections should be treated before surgery
except when the surgery is life-saving.
 It is reasonable to delay elective surgery in the presence of a viral
URI.

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Chronic obstructive pulmonary disease:
 Treat aggressively to achieve their best possible baseline level
of function.
 Regional anaesthetic techniques need to be considered if
possible.
 Appropriate postoperative care ( ICU bed) need to be arranged

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Surgical site infection prevention:
 Meticulous operative technique + Prophylactic antibiotics.
 skin antisepsis, hair removal, drapes, surgical hand hygiene.
 Prophylactic antibiotic are useful if  infection is an unavoidable
risk.

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Malnutrition:
 Elective surgery (nutritional support for a minimum of 2 wks)
Emergency cases incorporate the risks into the consent form
Obesity ( BMI of more than 30):
 Elective cases better to delay surgery until they have lost weight.
 Emergency cases incorporate the risks into the consent form.

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Regurgitation risk:
 Prevention methods : Keeping patient NPO, H2-receptor
blockade, Nasogastric tube.
For adults: NPO time For pediatric: NPO time
 Clear liquids up to 2 - 4 hours, and
 Solid food for a minimum of 6
hours,
 Oral preoperative medications up
to 1-2 hours before anesthesia
with sips of water.
 Clear liquids up to 2 hours,
 Breast milk up to 4 hours, and
 Solid foods, including nonhuman milk
& formula, up to 6 hours.

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Renal failure:
 Treat the cause (if possible) + Nephrology consultation needed.
 Already on dialysis  need the dialysis 24 hours before surgery
to:
 Ensure optimal fluid balance & electrolyte correction
 Further dialysis should be delayed for 24 hours after surgery if
possible.

29. Diabetes
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 Minor surgery in Type 2 diabetic can be managed by:
 Omitting their morning dose of medication,
 Listing them for early surgery, and
 Restarting treatment when they start eating
postoperatively.
 For major surgery & in Type 1 diabetic:
 Insulin infusion will be required.
 Started infusion when the patient first omits a meal &
continued until they have recovered from the surgery.

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Patients taking drugs that interfere with the clotting cascades:
 Warfarin is the commonest drug in this category.
 INR should be ≤ 1.5 before elective surgery.
 For low risk patients (simple atrial fibrillation)  stop warfarin 3–4 days  restarted
at the normal dosage level on the evening after surgery.
 For intermediate risk patients  replace with low molecular weight heparin
subcutaneous.
 For high risk patients (mechanical heart valve)  replace with an infusion of
heparin, which is stopped 2 hours before surgery  restarted immediately
afterwards.

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Acquired coagulopathy:
 Disorders such as DIC  Hematologist consultation is needed.
 Hypothermic patients  warm actively because they bleed more
than normal.
 Prolonged procedures  kept warm all patients intraoperatively.

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Neurological & psychiatric disorders
 Peripheral neuropathies & myopathies patients  prolonged
ventilation postoperatively may be needed.
 Anticonvulsants  continued perioperatively & changed to IV if
NPO time is prolonged.
 Psychiatric patients  GA than Regional anaesthesia may be
required.

33. Fitness assessment
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 The anesthesiologist should take Hx & review the surgical diagnosis,
organ systems.
 Classifies anesthetic risk of the patient & formulates an anesthetic
care plan.
 Widely used Anesthetic risk prediction method is the ASA
classification.

34. ASA classification
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37. CONSENT
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 Informed consent is more than a signature on a piece of paper.
 It is a process of discussion & a dialogue between the surgeon and patient.
Competence
 To give informed consent adults ( ≥17 years).
 Competent: can comprehend & retain the information discussed
 Children ≤ 16 years of age can only give consent if they truly understand the
nature, purpose and hazards of the treatment options.

38. Scheduling OR
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 If any special equipment is required  inform theatre scrub staff.
 If any consultants are anticipated to be needed  arrange prior to
the day of operation.

39. Wrong person, site, procedure prevention
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 WHO surgical safety checklist.
 Timeout
 Marking
 If the patient is to proceed to surgery it is good to mark the
relevant side/limb.

40. Psychological preparation
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 Psychological preparation is as important as pharmacologic
preparation for anesthesia & surgery.
 The hospitalized patient may be separated from his or her
 The surgeon’s reassurance & confident manner.

41. DOCUMENTATION
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 Ixs & Mx plan should be clearly listed for action.
 A drug chart should be completed
 Fluid charts.
 Blood & blood products preparation confirmation paper.
 Imaging results should be checked
 Informed consent should be signed & documented.

42. Intraoperative care
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 Intraoperative care is all working as a team.
 Intraoperative care include
 Monitoring the patient's vital signs ,blood oxygenation levels
 Fluid therapy,
 Medication transfusion, anesthesia

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Purpose
 To maintain patient safety and comfort during surgical procedures.
 Maintaining homeostasis during the procedure
 Maintaining strict sterile techniques to decrease the chance of cross-
infection
 Ensuring that the patient is secure on the operating table
 Taking measures to prevent hematomas from safety strips or from
positioning

44. Precautions
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 oxygenation should be monitored by continuous pulse oximetry
 Continuous ECG should be in place
 HR & BP should be monitored at least every five minutes.
 In case of an emergency backup personnel who are experts in
airway management , emergency intubation
 Advanced cardiac life support (ACLS) must be availables
 ACLS should be checked daily to ensure proper function

45. Cont..
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 Areas of the operating table that come into contact with the
patient's bony prominences must be padded to prevent skin trauma
and hematomas.
 The nurses should an accurately count of all sponges, instruments,
and sharps that may become foreign bodies upon incision closure.

46. Cont..
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 The temperature in the intraoperative room should be maintained at 20–
23°C
 Relative humidity should be 30%–60%.
 Health care personnel must not be permitted to work if they have open
lesions on the hands or arms, eye infections, diarrhoea , or respiratory
infections.
 Scrub attire must be worn by all personnel entering the operating room.
 Head and facial hair must be completely contained in a lint-free cap or
hood

47. Postoperative care & complications
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 In order to provide the patient with as quick, painless & safe a
recovery from surgery as possible
 patient’s vital signs ,level of consciousness, pain and
hydration status are monitored in the recovery room.

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 The patient can be discharged from PACU when they
fulfil the following criteria:
 Patient is fully conscious.
 Respiration and oxygenation are satisfactory.
 Patient is normothermic.
 Cardiovascular parameters are stable.
 There are no concerns related to the surgical procedure

49. Classification of postoperative
complications
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 Classification of postoperative complications of surgery:
1. Linked to time after surgery:
 Immediate (within 6 h of procedure)
 Early (6–72 h)
 Late (>72 h).
2. Generic & surgery specific

50. General postoperative complications
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Bleeding
 Most common in the immediate postoperative period.
 Caused by an arterial or venous leak, or a coagulopathy
 The treatment of haemorrhage is both to stop the bleeding and
supportive.
 Supportive treatment includes oxygen and fluid resuscitation.
 It may require correction of coagulopathy.

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Deep vein thrombosis
 well-known and, when complicated by pulmonary embolus,
potentially fatal complication of surgery
 prevention are guided by the risk score
 Doppler ultrasound and venography to assess flow and the
presence of a thrombosis
 Treatment with parenteral anticoagulation, followed by longer-
term warfarin

52. Pulmonary embolus
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 Mostly in the early postoperative period
 Signs and symptoms depend on the size of the embolus
 May range from dyspnoea, cough, and pleuritic chest pain to
sudden cardiovascular collapse
 Treatment resuscitation, anticoagulation, followed by long-term
oral anticoagulation

53. Post operative Pyrexia
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 Common causes of pyrexia
 Cut (Wound Infection)
 Collection (Pelvic or Subphrenic Abscess)
 Chest (Infection or PE )
 Cannula (Infection
 Catheter (UTI)
 Calves (DVT)

54. Wound dehiscence
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 Disruption of any or all of the layers in a wound.
 Dehiscence may occur in up to 3% of abdominal wounds and
is very distressing to the patient
 commonly occurs after 15th postoperative day when the
strength of the wound is at its weakest
 Usually presents with a serosanguinous discharge.
 patient felt a popping sensation during straining or coughing

55. Risk factors in wound dehiscence
General factor Local factor
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 Diabetes
 Obesity
 Malnourishment
 Sepsis
 Cancer
 Treatment with steroids
 Inadequate or poor closure of
wound
 Poor local wound healing, e.g.
because of infection
 Increased intra-abdominal
pressure

56. CONT…….
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Treatment
 it may be appropriate to leave the wound open and treat with
dressings
 Most patients will need to return to the operating theatre for
resuturing
 manage underlying comorbidity
 Nutrition therapy

57. Respiratory system
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Immediate respiratory complications
 Can be due to laryngospasm, soft tissue
oedema,haematoma, vocal cord dysfunction or foreign body.
 Most interventions are simple & involve manual support of the
jaw or insertion of an oral or nasal airway

58. Early and late respiratory complications
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Early and late postoperative pulmonary complications are a
significant cause of postoperative morbidity and mortality
between 5% and 70%.
 Bronchospasm
 Atelectasis
 pneumonia
 Pleural effusion
 Pneumothorax

59. Cardiovascular system
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 Hypotension
 Hypertension
 Arrhythmias
 Myocardial ischaemia
 Stroke

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Hypotension
 may be due to hypovolaemia, myocardial impairment or
vasodilatation from subarachnoid & epidural anaesthesia.
 surgical bleeding, sepsis,tension pneumothorax, pulmonary
embolism, pericardial tamponade & anaphylaxis
 Treatment should be aimed at the cause

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Hypertension
 May be due to pain, agitation,anxiety, bladder spasm
secondary to urinary catheterisation
 May be due to pre-existing poorly-controlled hypertension

62. Renal and urinary system
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Acute kidney injury

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References
1. Bailey & Love Bailey short practice of surgery 27th edition
2. Sabiston text book of surgery 19th edtition
3. AGS best practice guidelines geriatric perioperative
assesment 2012
4. Uptodate 2018

64. Thank you
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