Perioperative ManagementPerioperative 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. Emergency surgery

Perioperative Assessment

• To confirm the diagnosis

• To assess the risk of operation

• To assess the general condition and function

of important organs

• The endurance of the patient to operation be evaluated

General PreparationPsychological 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 increases the morbidity and

mortality of operations dramatically

• 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 reasonablly

be controlled under 160/100 mmHg.

Cardiovascular disease

1. Ischaemic heart disease

2. Cardiac failure

3. Arrhythmias

4. Valvular heart disease

5. Cerebrovascular disease

Cardiac risk index system

see table 16-1

Angina

Previous infarction

Stable angina poses little increased risk

during operation but unstable angina is as

dangerous as recent myocardial 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 in 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.

The main postoperative complications:• Atelectasis• Chest infection• Aspiration pneumonitis• Pneumonia

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 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 insufficiencyis hypothalamo-pituitary-adrenal suppression bylong-term corticosteroid therapy.

The lack of adrenal response in these patients maycause acute post-operative cardiovascular collapse withhypotension and shock.

For any steroid-dependent patient, a doctor should

write clearly in the note “Treat any unexplained collapsewith 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.

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

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.

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 VomitingDrugs (opiates, erythromycin, metronidazole)

Bowel obstruction mechanical obstruction Adynamic bowel Hypokalaemia faecal impaction

Systemic disorders electrolyte disturbances Uraemia raised intracranial pressure

Abdominal distension

More common after abdominal surgery

Hiccup

• 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.

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

Minor wound infections

localized pain, redness and a slight discharge

Wound Cellulitis and Abscess

cellulitis treated by antibiotics abscess treated by surgical drainage

Wound Infection

Atelectasis• 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

• postoperative mobilization• adequate hydration• avoiding calf pressure

Prevention

for high risk cases• low dose subcutaneous heparin• calf compression devices• graded-compression ‘anti-embolism’ stockings• Intravenous dextran• Warfarin anticoagulation