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PRE AND POST-OPERATIVE CARE OF THE SURGICAL PATIENT






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PRE AND POST-OPERATIVE CARE OF THE SURGICAL PATIENT. I. Assessment of Operative Risk A. Natural History - relative harm (risk) - relative good (benefit). B. Stages of the disease - error in clinical staging produces the greatest number of controversies regarding management
PRE AND POST-OPERATIVE CARE OF THE SURGICAL PATIENT

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Slide 1

PRE AND POST-OPERATIVE CARE OF THE SURGICAL PATIENT

Slide 2

I. Assessment of Operative Risk

A. Natural History

- relative harm (risk)

- relative good (benefit)

Slide 3

B. Stages of the disease

- error in clinical staging produces the greatest number of controversies regarding management

C. Clinical Judgment

- deviations of standard treatment is associated with significant increase in mortality and morbidity

Slide 4

D. Basic Factors Affecting Operative Risk

1. Age over 70 years

2. Overall physical status

3. Elective vs. emergency surgery

4. Physiologic extent of the tumor

5. Associated illnesses

Slide 5

II. Personal Relationship

A. Genuine bond of communication and personal responsibilities.

B. Physician should not convey a sense of hurry

and inadequate time for explanations.

C. Involve physicians who have parallel skills to contribute to diagnosis and treatment.

D. Specific treatment.

E. Informed consent

Slide 6

III. General Preparation of the Patient

A. Psychological preparation

1. Pre-op steps should be enumerated, justified and explained.

2. Surgeons should not equivocate in discussing possible disfiguring operations.

Slide 7

B. Physiologic considerations

1. Blood volume considerations

a. anemia – chronic or acute

b. minimal requirement for anesthesia – 10 gm/100 ml Hgb

Slide 8

2. Determine the physiologic limit for tissue oxygen delivery.

a. tachycardia

b. increase in stroke volume

c. increase in oxygen extraction

Slide 9

3. Plasma and extracellular fluid deficit

- volume and concentration

a. hourly urine output

b. urine concentration

c. mucous membranes

d. skin turgor

Slide 10

C. Nutrition

1. Serum transferrin

2. Serum albumin

3. WBC count

D. Prevent infection

1. Treat distant infections

2. Prophylactic antibiotics

Slide 11

IV. Post-operative Care

A. Post-op fever

- elevated temperature observed in post-op patients does not necessarily signal a serious complication

- a specific cause is identified in 20% of patients with pyrexia during the initial 24 hours

- comprehensive clinical evaluation is essential

Slide 12

i

1. Infective causes of post-op fever

a. community acquired infection

b. contamination

c. inadequate blood supply

d. neonates and the elderly

e. systemic factors

i. DM II

ii. hepatic disease

iii. immunosupression

iv. malnutrition

Slide 13

v.. obesity – due to relatively poor blood supply of the large reservoirs of fat

vi. disseminated malignancy – due to the cachectic influences of the primary neoplasm and immunosuppression by chemothera peautic drugs

vii. active infection

viii. Acute and chronic alcohol intake

Slide 14

2. Diagnosis and management

- should be directed toward recognition and eradication of the primary source of exogenous pyrogens

a. Fever within 24 hours – atelectasis

b. 5th to 10th day – wound infection

c. Clinical evaluation is needed

- rales and ronchi - pneumonia

Slide 15

3. Other causes of post-op fever

a. suppurative parotitis

i. usually elderly or debilitated patients

ii. caused by dehydration and poor oral hygiene

iii. 2 weeks post-op

iv. Staph. aureus

Slide 16

b. operative site

i. must always be considered for post-op fever

ii. 5th post-op day

c. IV lines

i. request for blood culture

ii. presents as cellulitis

iii. CV line sepsis due to infected thrombus at the tip

Slide 17

d. thrombophlebitis

i. 2nd post-op day

ii. catheter should be removed at first sign of infection

iii. more frequent in the lower extremities

iv. pus may be present

v. high fever and (+) blood culture

vi. treatment consists of excising vein

Slide 18

B. Non-infective causes of Post-op Fever

1. Disseminated malignancy

2. Transfusion reaction

3. Hematoma

4. Administration of irritant fluids or drugs

5. Acute pancreatitis

6. Thyroid storm

7. Pheochromocytoma

8. Dehydration

Slide 19

C. Factors influencing likelihood of post-op infection

1. Definite decrease in host resistance

a. increasing age

b. obesity/malnutrition

c. diabetic ketoacidosis

d. acute/chronic steroid use

e. immunosuppressive drugs

f. remote infections

Slide 20

2. Possible decrease in host resistance

a. some forms of cancer

b. radiation therapy

c. adrenocortical insufficiency

d. foreign body

e. early shaving of the operative site

Slide 21

3. No effect on host resistance

a. gender

b. race

c. controlled DM

d. acute nutritional deprivation

Slide 22

C. Operations benefiting from antibiotic prophlaxis

1. Head and neck surgery with open aerodigestive tract

2. Esophageal except hiatal hernia repair

3. Gastroduodenal except for complications of uncorrected hyperacidity

Slide 23

4. Biliary tract surgery

a. patients over 70 years old

b. acute cholecystitis

c. choledochostomy

5. Bowel resection

6. Perforated or gangrenous appendicitis

7. Hysterectomy

8. Revascularization and prosthetic graft surgery

9. Orthopedic surgeries with implantation of prosthesis

Slide 24

D. Operative technique to minimize infection

1. Eliminate hair, if necessary, just prior to incision time

2. Effective skin preparation

3. Gentle and effective handling of

tissues

4. Effective hemostasis

5. Eradicate dead space

6. Minimize operative time

7. Closed suction drain a distance from the incision

Slide 25

E. Pre-operative factors associated with post-operative cardiac complication in order of discovery significance

1. Jugular vein distention or S3 gallop -

11 points

2. Myocardial infarct within 6 months or S3 gallop – 10 points

Slide 26

3. Premature atrial contractions or rhythm other than sinus on ECG – 7 points

4. 3-5 PVC’s/minute – 7 points

5. Age over 70 – 5 points

6. Significant aortic stenosis – 3 points

s

Slide 27

7. Poor general medical condition – 3 points

a. PaO2<60 mm Hg

PaCO2>50 mm Hg

b. Potassium<3 meq

Bicarbonate<20 meq

c. BUN > 50 mg/100 ml

Crea > 3.0 mg/100 ml

Slide 28

d. increased transaminases

e. signs of chronic liver disease

f. patient bedridden for non-cardiac causes

8. Operation

a. emergency – 4 points

b. intraperitoneal, intrathoracic, aortic – 3 points

TOTAL – 53 points

Slide 29

F. Pre –operative risk factors for post-operative pulmonary compilications

1. Thoracic and upper abdominal surgery

2. Pre-op history of COPD

3. Purulent productive cough

4. Anesthesia time greater than 3 hours

6. Age greater than 60 years old

Slide 30

7. Obesity

8. Poor state of nutrition

9. Symptoms of respiratory disease

10. Abnormal findings on P.E.

11. Abnormal chest film findings

Slide 31

G. Peri-operative prophlactic pulmonary maneuvers

1. Cessation of smoking

2. Bronchodilators

3. Chest physiotherapy and postural drainage

Slide 32

4. Pre-operative education and post- operative use of incentive spirometry and deep breathing excercises

5. Pre-operative antibiotics if sputum is purulent

6. Early post-operative antibiotics

Slide 33

H. A sample of pre-operative checklist

1. Operative permit – appropriately signed and witnessed

2. Dietary considerations

3. Review of life support systems

a. vital sign recordings

b. cxr and other pulmonary studies

c. ECG and other cardiac studies

d. BUN/Creatinine and other renal studies

Slide 34

4. Adequate hydration up to time of surgery

5. Area of operation to be washed and shaved with antimicrobials

6. Prepare blood for possible transfusion

7. Order that the patient void on call

8. Pre-operative medications

9. Specialmedications


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