Perioperative Management

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

2. 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

3. 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

4. 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

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

6. 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

7. 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.

8. 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

9. Angina 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.

10. 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)

11. 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

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

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

14. 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

15. 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

16. 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.

17. 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.

18. 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

19. 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”.

20. 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

21. 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.

22. 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

23. 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.

24. 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.

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

26. 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

27. 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

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

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

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

31. 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

32. 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

33. 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

34. 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

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

36. 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

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

38. 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