Perioperative Management

Perioperative Management

Affiliated Hospital of Jining Medical College Dep. Mammary and Thyroid Surgery Zhu Kunbing 朱坤 兵

Operation is a dominant method in surgery,but surgical operation can result in some physiological influence to the whole body. Major operations create surgical wounds and cause severe stress,subjecting the patients to the hazard of infection metabolic and other derangements.

Appropriate preoperative preparation facilities wound healing and systemic recovery by making certain that the patients condition is optimal. We must understand some kind of preoperative and postoperative management to recover physiologic function of the body .

Type of surgical operations

(According to the timing) 1)Selective surgery (subtotal gastrectomy…)

2)Subselective surgery (malignant tumors resection…)

3)Emergency surgery (spleen rupture…)

Preoperative preparation

Content

Postoperative management

Postoperative complication

First part

Preoperative preparation 1.General Health Assessment 2.Special preparation

General Health Assessment a complete history and physical examination Complete blood counts Serum electrolyte The chest x-ray Electrocardiogram ECG The function of liver and kidney

General Health Assessment Bleeding tendencies Medications being taken:aspirin Allergies and reactions to antibiotics Phychiatric consultation Neurologic examintion Peripheral arterial pulses

General Health Assessment  Rectal

examination  Pelivic examination  Papanicolaou smear of cervix  Sigmoidoscope of rectal or colonic biospy

Physiologic preparation 1)adapt to postoperative changes 2)Blood replacement preparation 3)prophylactic management 4)nutritional support 5)gastrointestinal preparation 6)protein, vitamin,energy preparation 7)others

Special preparation Diabetes mellitus  Nutritional system  Hypertension  Cardiac disease  Respiratory system  Kidney and liver function  Immunological system 

Diabetes mellitus  Blood

glucose concentration  A thorough physical examination to discover occult Infection ECG a complete urinalysis serum potassium serum creatinine levels

Diabetes mellitus  the

level of serum glucose a ideal level:100-200mg/dl a safe level :350-400mg/dl  Stop to take the drugs:sulfonylureas etc.  Use the regular insulin to controll glucose

Type 2 diabetes mellitus 

Small doses of insulin Measure the glucose level every 3-4h

Type 1 diabetes mellitus 



Require insulin during surgery subcutaneous mangement of longacting insulin constant infusion of a mixture of glu and RI separate infusions of glu and insulin Monitore the glu level every 2 h to aviod the hypoglycemia (<60mg/dl) hyperoglycemia(>250mg/dl)

Nutritional states Mulnutrition

blood volume decreased

protein deficiency tissue edema

Endurance ability of blood loss or shock decreased

wound healing delayed

Preparation : protein blood transfusion vitamin intake others

severe sepsis septic shock

Hypertension Hypertension

Brain vascular accident preparation : furosomide hydrochlorothiazide nifedipine catopril

Congestive heart failure in a certain degree not neccesary decreased to normal

Cardiac disease  ECG  Echocardiography

LEF:ejection fraction>50%  DCG:dynamic electrocardiogram Arrhythmia PVC:premature ventricualr contraction

Cardiac disease

Mortality Cardiac patients

noncardiac patients 2.8times

Approximately 8 million surgeries in the United States are performed on patients with known or suspected cardiac disease. Preoperative evaluation can help stratify risk.

The Relation Between Cardiac Disease and Operation Endurance Type of cardiac disease Acynotic congenital heart disease Rheumatic heart disease Hypertension but no cardiac failure Coronry artery disease atrioventricular block Easily result in cardiac arrest Acute mycarditis acute mycardial infarction cardiac failure

operation endurance

good

poor full scale preparations

very poor surgery delayed (exept of lifesaving)

The Goldman index Useful in predicting cardiac events in an unselected, random group of patients. The type and extent of surgery anticipated needs to be taken into account when one is interpreting the results of the Goldman index.

Functional status If patient can walk up stairs while carrying a load (functional status class I and II), has a low Goldman index and no known cardiac disease, there is a very low risk of cardiac complications.

ECG routine Ischemia on a resting ECG is suggestive of a worse outcome. However, exercise tolerance appears to be more important than ECG changes in predicting outcomes.

Echocardiography 1.those with murmurs that have not been previously evaluated 2.diastolic versus systolic versus valvular

History of Mycardial infarction

<3 weeks 25% mortality At 3 months 10% mortality At 6 months 5% mortality At 1 year

same risk

urgent procedure only semivrgent procedures elective as asymptomatic patient with cardiac disease

Hematologic diseases A.Positive sickle cell screen. Needs Hb electrophoresis. If majority is Hb S will need partial exchange transfusion before surgical procedure B.Coagulation disorders May need evaluation, treatment . C.Anemia Ideally HCT >30%, with Hb >10 g/dl at surgery. No evidence that anemia contributes to surgical morbidity in the wellhydrated, hemodynamically stable patient with a Hb >7.0 g/dl.

Integument(skin) disorders If possible, avoid operating when there are active skin infections present. Chronic skin disorders should be optimally controlled for postoperative healing. For those who form keloids, may need to consider different closure techniques.

Obesity Weight loss to improve cardiopulmonary status and decrease problems with healing. liquescence

Special medications Patient’s routine medications ( IM or IV ) Increased steroids Pain medications Antibiotics

steroid dependent needed as indicated for infection and sepsis or prophylaxis of endocarditis, Indwelling hardware or graft placement.

Antibiotics Preoperative antibiotics are most effective when given within 2 hours before surgery. Cefotaxime 1 g IV or cefoxitin 2 g IV reduce infection rates for intra-abdominal surgery

Antibiotics There is no evidence that continuing "prophylactic" antibiotics postoperatively is helpful. However, antibiotics should be continued in underlying conditions: 1)active infection 2)contamination 3)artificial material 4)long time operations 5)gastrointestinal operation 6)cancer or vascular operations

Prep for surgery bowel preps antiseptic shower hair clipping Premedication by anesthesia to lower anxiety, lower secretions, and interact with narcotics for sedation.

Second part

A.postoperative orders 1)Admit to ward, ICU, or recovery room. 2)Diagnosis Operation 3)Vital signs:BP,P,R every 15-30minutes 4)Allergies 5)Activity Bedrest until fully awake; up walking that night or next morning depending on surgery.

6)Diet NPO(nil per os,nothing by mouth) until nausea resolves or resumption of bowel activity as determined by bowel sounds, passing gas, or having bowel movement. Patients undergoing thoracic or abdominal surgery and critically ill patients should NPO until normal gastrointestinal function returned . In general,after 3 days:completely fluid ;after 6 days semifluid;after 9 days normal diet.

7)Pulmonary function. Deep breathing Incentive spirometry

8)Intake and output. Record intake or output every shift or more frequently Potassium(K) is normally included in replacement solutions but is excluded from maintenance solutions until normal renal function is established. Colloids do not provide any survival benefit and are expensive.

Different tube management 1)gastric suction tube 2)bladder catheter 3)CVP:central venous pressure

B.Monitoring 1.vital sign 2.CVP(Central Venous pressure) 3.renal and bladder function 4. fluid and electrolytes 5.drain tubes

C.Nursing. Encourage turning coughing deep breathing incentive spirometry Dressing changes Any uncofortablity fever hypertension hypotension tachycardia bradycardia bleeding pain

D.Medications 1)antibiotics 2)sedatives 3)pain relief drugs.

Pain medications PCA :patient-controlled analgesia provides better analgesia, and patients generally require less narcotic than with IM treatment; If cannot use PCA 1)morphine (2-5 mg IV/hr) 2)meperdine(50mg IM) 3)tramadol

Drug dose of PCA Morphine: 0.05 to 0.1 mg/kg IM Q3-6h. Meperidine: 0.5 to 1.0 mg/kg IM Q3-6h.

postanesthetic nausea Cause: hypotension stress reactions Management: droperidol

Antibiotics Routine medications infection

Suture removal time General guidelines for suture removal: Face Scalp trunk arms legs joints dorsal surface

3 to 5 days 7 to 10 days 7 to 10 days 7 to 10 days 10 to 14 days 14days 14 days

Third part

Common Postoperative complication 1)postoperative bleeding 2)wound infection 3)wound dehiscence 4)Atelectasis 5)Urinary infection 6)fat embolism

Special postoperative complications

Wound complication 1)hematoma 2)seroma 3)postoperative wound infection 4)wound dehiscence

Respiratory complications 1)atelectasis 2)pulmonary aspirations 3)postoperative pneumonia 4)postoperative pleural effusion and pneumothorax

Cardiac complications 1)Arrhythmias 2)Postoperative mycardial infarction 3)Postoperative cardiac failure

Urinary complications 1)postoperative urinary retention 2)urinary tract infection 3)postoperative oliguria,anuresis prerenal reason blood loss acute tubolar necrosis postrenal reason obstruction 4)renal failure

Cerebral complication postoperative cerebrovascular accidents

Postoperative hepatic dysfunction 1)prehepatic jaundice 2)hepatocellular insufficiency 3)benign postoperative intrahepatic cholestasis 4)extrahepatic obstruction

Postoperative Fevers

Respiratory resean of postoperative fever Early fever

secondary to aspiration

Fever at 24 to 48 hours atelectasis (Do not ignore an emerging pneumonia) After 48 hours

pneumonia.

Wound infection reasons postoper fever First 24 hours 48 to 72 hours 4days

Clostridium Streptococci Enteric aerobes Anaerobes Staphylococci

vascular reason of postoper fever

Thrombophlebitis Occurs intraoperatively, and fever usually begins after 24 hours.

Urinary reason of postoper fever Urinary tract infections Usually related to instrumentation or indwelling Foley catheter and occurs after 24 hours. Remove Foley as soon as possible.

Less common causes of perioperative fever 1.Transfusion reaction Immediate 2.Malignant hyperthermia anesthetic drugs 3.Drug reaction 4.Endocrine such as thyroid storm 5.Thrombophlebitis from IV site 6.Intraabdominal abscess

Postoperative Ileus

reason: operation management: Maintain NPO with NG suction Check electrolytes including calcium potassium Avoid blockers.

anticholinergic narcotics calcium channel

B.If prolonged Consider pancreatitis peritonitis Intra-abdominal abscess pneumonia Free blood in the peritoneum