PERIOPERATIVE

CARE
NUR AZIMAH
IZYAN IRDINA
DEFINITION OF PERIOPERATIVE CARE

• Perioperative management consists of

preoperative patient evaluation as well as
intraoperative and postoperative patient
monitoring and care.
PREOPERATIVE
CARE
• Preoperative plan for the best patient
outcomes
•
Gather and record all relevant information
●●

•
Optimise patient condition
●●

•
Choose surgery that offers minimal risk and
●●

maximum benefit
•
Anticipate and plan for adverse events
●●

•
Adequate hydration, nutrition and exercise are
●●

advised
• Obtain surgical consent.
• Obtain a thorough medical history and
perform a physical examination.
• Specific diagnostics
– Laboratory tests if indicated
– Preoperative cardiac assessment
– Preoperative pulmonary assessment
– Preoperative nutritional status assessment
 HISTORY
- should be taken each system a relevant
history
-Hx of past surgery and anaesthesia, risk factor
for DVT
-Allergy history
-Social hx : Use of recreational drug and
alcohol consumptions, smoke, ability to
communicate and mobility are important in
planning rehabilitation after surgery
PHYSICAL EXAMINATION
LEMON
LOOK
EVALUATE
MALAMMPATI SCORE
OBSTRUCTION
NECK MOBILITY
 INVESTIGATIONS
Laboratory test Indication

Full blood count

Blood grouping and crossmatching
Random blood glucose , HbAIC
•Procedures in which severe blood loss is anticipated
•Extremes of age
• those with anemia anemia
•Clinical features or history of bleeding and/or hematopoietic disorders
•Procedures in which severe blood loss is anticipated
•Risk factors, clinical features, and/or history of diabetes mellitus
•Use of hyperglycemic medications (e.g., systemic glucocorticoids)

Electrolytes and creatinine • History of hypertension, diabetes mellitus, congestive heart failure, chronic kidney

disease, and/or liver disease
• Use of certain medications (e.g., diuretics, digoxin, ACE-inhibitors
ARBs, chronic NSAID use)

Coagulation studies •Clinical features and/or a history of bleeding disorders

•Family history of bleeding disorders
•Patients on anticoagulant or antiplatelet medications
•Systemic disorders associated with increased bleeding (e.g., liver disease, hematopoietic
stem cell disorders, renal dysfunction)
•Procedures in which severe blood loss is anticipated
Urine analysis •Implantation of foreign bodies during surgery (e.g., metal implants, artificial heart valves)
•Invasive urological surgery
•Clinical features of urinary tract disease

Pregnancy test •Women of childbearing age if pregnancy would potentially alter management

ECG •Over 60 y/o

•Cardiovascular,renal and cerebrovascular involvement, DM, severe repiratory problem
 Cardiac risk stratification
•Revised cardiac risk index (RCRI)
• 1 procedure-related risk factor: intrathoracic surgery, intra-abdominal surgery, or suprainguinal vascular surgery
• 5 patient-related risk factors
• Ischemic heart disease
• Congestive heart failure
• History of stroke or TIA
• Creatinine > 2.0 mg/dL
• Insulin-dependent diabetes mellitus
•Poor functional capacity: patients who become breathless and/or have chest pain while climbing a flight of stairs, walking on level
ground at 4 km/hr, or performing heavy work around the house
Preoperative cardiac evaluation
ECG
Echocardiography
Stress test
Indications
•Patients with > 1 RCRI risk factor and one of the following:
• Age > 65 years
• COPD
• Peripheral vascular disease
• Arrhythmias
•Exacerbation or new onset of cardiac symptoms (e.g., dyspnea, chest
pain, syncope)
•Patients with moderate or severe valvular regurgitation or stenosis who have
not had an echocardiogram in the past year
•0–1 RCRI risk factor → < 1% risk of perioperative major cardiac event
(MACE) → low-risk procedures → no stress test is required
•> 1 RCRI risk factor → ≥ 1% risk of perioperative MACE (e.g., MI, ventricular
fibrillation, complete heart block) → elevated risk of a perioperative event
• If moderate or greater functional capacity: no stress test is required
• Unknown or poor functional capacity
• Patient is able to exercise: exercise stress test (e.g., exercise
stress echocardiography )
• Patient is unable to exercise: pharmacological stress
test (e.g., dobutamine stress echocardiography)
 PREOPERATIVE PULMONARY
ASSESSMENT
Assessment Indication for preoperative assessment
Chest x-ray •Surgeries of the head and neck, thorax, upper abdomen
•Clinical features and/or a history of cardiac or pulmonary
disease (e.g., COPD, congestive heart failure)
•> 60 years
•Hypoalbuminemia

Pulmonary function tests •Unexplained dyspnea or exercise intolerance in patients

Cardiopulmonary exercise test
who are about to undergo thoracic or upper abdominal
surgery
•Patients with COPD or bronchial asthma who have not had a
baseline pulmonary function test
•As a guide to plan lung resection
• FEV1 > 2.0 L and DLCO > 80%: pneumonectomy can
be tolerated
• FEV1 > 1.5 L and DLCO > 60%: Lobectomy can be
tolerated.
• FEV1 < 1.0 L: not a candidate for surgery
•Patients with abnormal pulmonary function tests
•As a guide to plan lung resection

•Patients should be asked about their smoking history and discontinue smoking 8 weeks prior to surgery.

 PREOPRATIVE NUTRITION
ASSESSMENT
• Clinical indicators of severe protein energy malnutrition (> 2 of the following)
– Body mass index <18.5
– Recent weight loss
– Bedridden or otherwise significantly reduced functional capacity
– Obvious significant muscle wasting; loss of subcutaneous fat
• Laboratory tests that can be used to assess nutritional status include:
– Lymphocyte count 
– Albumin and total serum protein 
– Cholesterol
• If a patient is found to be malnourished: Specialized nutritional
support (preferably enteral nutrition) is given prior to surgery to optimize nutritional
status.
• Malnutrition has been associated with poorer postoperative outcomes, including
increased overall morbidity and mortality, longer hospital stays, increased risk of
infection, delayed wound healing, and increased rate of ICU admissions!
• All preoperative patients should have their nutritional status assessed, with those
at greater risk or with signs of malnutrition receiving a formal nutritional
assessment!
 DISCONTINUE MEDICATIONS BEFORE SURGERY
Common long-term medications Recommendations
Antidiabetic drugs •Oral hypoglycemics
• Metformin: discontinue 2 days before and after
surgery 
• Discontinue other oral hypoglycemics on the day of
surgery and postoperatively until the patient is no
longer NPO. 
•Insulin
• Discontinue insulin on the day of surgery but
administer IV intraoperatively based on the sliding scale
or the variable rate infusion method.
• Continue insulin therapy postoperatively based on the
sliding scale or a variable rate infusion method until
glucose levels are stable and oral antihypoglycemics
can be resumed.
Antihypertensive drugs •Discontinue the following antihypertensives one day before
surgery and continue postoperatively:
• ACE inhibitors
• ARBs
• Diuretics
•Continue all other antihypertensives*
Antianginal drugs  •Continue*
Statins •Continue*
Oral contraceptives •POP – should be continue
•HRT- Discontinue 6 weeks before surgery 
 Psychiatric drugs •Benzodiazepines
• May be continued
• In patients with cardiac disease: Discontinue several days before surgery by
tapering down.
•Lithium: Discontinu 24H before surgery.
•Tricyclic antidepressants: Discontinue intraoperatively.
•Nonselective, irreversible MAO inhibitors (e.g., tranylcypromine): Discontinue 2
weeks before surgery.
•Other neuroleptics and antidepressants: case-by-case decision 

Antiepileptics •Continue*
Anticoagulant or antiplate •Antiplatelet drugs (e.g., aspirin, clopidogrel)
let drugs • Discontinue all antiplatelet drugs one week before surgery.
•Emergent surgery within one month of coronary angioplasty with a bare metal stent or
within one year with a drug-eluting stent: Continue antiplatelet drugs unless the risk of
bleeding is greater than the risk of stent stenosis.
•Anticoagulants
• Patients on direct oral anticoagulants (e.g., dabigatran, rivaroxaban)
• Discontinue medication 2 days before surgery. 
• No bridging anticoagulation
• Patients on warfarin
• Discontinue warfarin 5 days before surgery.
• Bridging anticoagulation with heparin (preferably an LMWH such
as dalteparin) when INR levels become subtherapeutic 
• Low risk of thromboembolism: no bridging anticoagulation
• High risk of thromboembolism: initiate bridging 
• Discontinue LMWH 24 hours or unfractionated heparin 4–5 hours before
the procedure
• Continue heparin and warfarin postoperatively
 Thyroxine •Discontinue intraoperatively and resume postoperatively.

NSAIDs •Short-acting NSAIDs: discontinue 2–3 days before procedure

•Long-acting NSAIDs: discontinue one week before procedure

Antianginal
medications, antiepileptics, statins, most
antihypertensive drugs (except ACE
inhibitors, ARBs, and diuretics), and
most neuroleptics(except lithium) should be
continued on the day of surgery!
• Discontinue certain medications (see discontinuation of medication prior
to surgery above).
• Fasting
– 8 hours before surgery: no meat or fried, fatty food
– 6 hours before surgery: no milk or solid food
• Breast-fed infants: no breast milk 4 hours before surgery
– 2 hours before surgery: nil per os (NPO)
• The preoperative fasting recommendations can be remembered with the
“2, 4, 6, 8 rule”!
• Anesthesia (see general anesthesia and regional anesthesia)
• Perioperative antibiotic prophylaxis
– Aim: to reduce the incidence of postoperative surgical site infections
– Antibiotic of choice
• First-line: intravenous cefazolin
– In patients with beta-lactam allergy: clindamycin or vancomycin
• Add intravenous metronidazole for:
– Patient with small intestinal obstruction
– Appendectomy
– Colorectal surgery
INTRAOPERATIVE
CARE
• TYPE OF ANAESTHESIA
- GA control ventilation and spontaneous ventilation, regional
block, local block
• MONITORING DURING OPERATION

A minimum basic monitoring of cardiovascular

parameters is
required during surgery. This includes:
Vascular:
● electrocardiogram (ECG);
● blood pressure;
Adequacy of ventilation:
● inspired oxygen concentration;
● oxygen saturation by pulse oximetry;
● end tidal carbon dioxide concentration.
Monitors of temperature, ventilation
parameters and
delivery of anaesthetic agents are also
routinely used, while
measurement of urine output and central
venous pressure are
recommended for major surgery.
Postoperative care
 Post-op care
Consists of:

• Immediate postoperative care

• System-specific post-op complications
• General post-operative complications
• Surgery-specific complications
• General post-op problems and management
• Enhanced recovery
• Discharge of patients
 Immediate postoperative care:
Post-anesthetic care unit (PACU)
• The operation theatre
team should formally The information provided should
hand over the patient to include:
the PACU staff.
- Name of patient
- Surgical procedure
Post operative observations - Existing medical problems
- Allergies
- The anesthetic and analgesics given
- Fluid replacement
• Vital signs
- Blood loss
• Level of consciousness - Urine output
• Pain - Any surgical or anesthetic problems
• Hydration status encountered or expected
 Criteria of discharge from PACU
• Patient is fully conscious
• Respiratory and oxygenation are satisfactory.
• Patient is normothermic, not in pain and not
nauseous.
• Cardiovascular parameters are stable.
• Oxygen, fluids and analgesics have been
prescribed.
• There are no concerns related to surgical
procedure.
 System-specific post operative
complications
Classified by:

1) Linked to time after surgery

• Immediate (within 6 hrs of procedure)
• Early (6-72 hrs)
• Late (72 hrs)
1) Generic and surgery specific
2) Clavian-Dindo: this system relates to surgical
complications only (used to measure the impact of
surgical complication on the outcome of procedure)
 Respiratory system
Must do periodic assessment of airway patency, respiratory rate and routine O2
saturation measurement
Immediate respiratory complications

• Upper airway obstruction - can be due to layngospasm, persisting

relaxation of airway muscles, soft tissue edema, hematoma, vocal cord
Airway dysfunction or foreign body.
• Most interventions are simple, involve manual support of the jaw or
insertion of an oral or nasal airway.
• Reduced or impaired adequacy of ventilation - can be due to the residual
effects of anesthetic drugs
Respiration
• Supplemental oxygen should be given to all pts in PACU until adequate
respiration and oxygenation are restored.
• Can be due to acute pulmonary edema (fluid overload, cardiac failure),
bronchospasm, pneumothorax, aspiration.
• Should be treated urgently
- if pt breathing sponatenously, oxygen should be administered at 15L/min
Hypoxemia
using a non-rebreathing mask.
- A head tilt chin lift or jaw thrust should relieve obstruction related to
reduced muscle tone.
- Suctioning of any blood or secretion and insertion of OPA may be needed.
 Respiratory system
• The risk of each varies with the
Early and late respiratory complications patient and the type of surgery
being performed.

• Fever (due to microatelectasis) People who are at risk

• Cough
• Dyspnea
• Bronchospasm • Obese
• Hypercapnea • Smokers
• atelectasis • Chronic lung disease
• Pleural effusion • Poor nutritional status
• Pneumothorax • Obstructive sleep apnea
 Cardiovascular system
Routine pulse, BP, and ECG monitoring to detect CVS complications.

Immediate cardiovascular complications

• May be due to hypovolemia, myocardial impairment or vasodilation from
Hypotension subarachnoid and epidural anesthesia, surgical bleeding, sepsis.
• Treatment depends on cause.
• May be due to pain, agitation, anxiety, bladder spasm secondary to
urinary cathetherisation or pre existing poorly-cntrolled hypertension.
Hypertension
• Consequemces include bleeding from vascular suture lines,
cerebrovascular hemorrhage and MI.

Myocardial • Pts with history of CVS disease or with known cardiac risk factors
ischemia undergoing major surgery are at risk.

• eg, Tachycardia (sinus/supraventricular) may occur due to anxiety, pain,

Arrythmias MI, hypovolemia. Treat underlying cause and rate controlled with B
blocker, amiodarone or cardioversion.
•A recognised complication of carotid endarterectomy surgery both early
(secondary to emboli) and later (secondary to cerbral hyperperfusion
Stroke syndrome).
• Also a recognized consequence of hypo/hypertension.
 Renal and urinary system
Acute kidney injury
Can be detected by:
• a rise in serum creatinine
of 26µmol/L or greater
within 48 hrs
• a >50% rise in serum
creatinine known or
presumed to have occured
in the past 7 days
• a fall in urine output to
less than 0.5ml/kg/h for
more than 6 hrs in adults
and more than 8 hrs in
children
• a >25% fall in estimated
GFR rate within past 7 days
Urinary retention Urinary infection
• Immunocompromised
• Pelvic and perineal
pts, diabetics and those
operations, or after
patients with history of
procedures performed
urniary retention are at
under spinal anesthesia.
higher risk.
• Pain
• Hypovolemia
•Treatment
• Lack of privacy on wards
- adequate hydration
- proper bladder drainage
-
- antibiotics
 Central nervous system
• Post-operative delirium (POD)
- 2 types - hyperactive (restlessness, incoherent
speech, agitations, hallucinations) or hypoactive
(withdrawn, depressed)
- Preoperative risk factors for POD - preexisting
cognitive impairment, dementia, Parkinsons
disease, severe illness,renal impairment
- Precipitating factors- surgery, intraop
administraton of narcotics and benzodiazepine
electrolyte imbalance, constipation
 General post-operative complications
• Bleeding
• Deep vein thrombosis
• Pulmonary embolus
• Fever
• Wound dehiscence
• Pressure sore
 1. Bleeding (post-operative
hemorrhage)
• May be caused by arterial or
venous leak, or coagulopathy.
Treatment:

Monitoring:
- Supportive treament: IV fluids, oxygen
- Regular vital signs - Correction of coagulopathy
- Inspection of dressings and drains - Blood transfusions
regularly in the first 24 hrs postop
- If hemorrhage suspected, take FBC,
coagulation profile and cross match.
- Large bore IV cannula should be
sited and IV fluids comenced.
- If source of bleeding is in doubt and
patient is stable, CT scan or
ultrasound can be done.
 2. Deep vein thrombosis
• Methods of prevention:
- Compression stockings
- Calf pumps
- Pharmacological -low molecular weight heparins
• Investigations:
- Duplex doppler ultrasound
- Venography
- D-dimer
• Treatment:
- Treat with parenteral anticoagulation initially, followed by
long term warfarin or new oral anticoagulant
 3. Pulmonary embolus
• May present with dyspnea, cough, pleuritic chest
pain, sudden cardiovascular collapse.
• If presence of cardiovascular collapse, resus is
needed, thrombolysis in massive PE, inotropes,
ICU admission.
• In less severe case, supportive manageent like
oxygen therapy and analgesia.
• Patient will need anticoagulant, initially
parenteral anticoagulant, followed by long term
oral anticoagulants.
 4. Fever
• The causes of raised temperature post-op include:
- Atelectasis of the lung
- Superficial and deep wound infection
- Chest infection, UTI, thrombophlebitis
- Wound infection, abscess
• Non-infective causes:
- DVT
- Transfusion reactions
- Wound hematomas
- Drug reactions
 5. Wound dehiscence
• A distruption of any or all of the layers in a wound.
• Most commonly occurs from the fifth to 8th post-op day
when the strength of the wound is at its weakest.
• May have underlying abscess and serosanguinous
discharge.
• Patient may have felt a popping sensation during
straining and coughing.
• Most patients will need to return to OT for resuturing.
• In some patients, it may be appropriate to leave the
wound open and treat with dressings or vacuum-assisted
closure (VAC) pumps.
 General post-operative problems and
management
• Nausea and vomiting
• Hypothermia and shivering
• Drains
• Wound care
 Post-operative nausea and vomiting
(PONV)
• Can lead to more serious
complications like
aspiration pneumonia,
precipitation of bleeding
and dehiscence of
wounds by dislodging the
clots and bursting suture
lines.
• In neurosurgical patients,
PONV may precipitate
raised ICP.
 Treatment of PONV
• Adequate treatment of pain, anxiety,
hypotension and dehydration.
• Antiemetics can be administered both
prophylactically and for treatment.
• A multimodal approach, using drugs that work at
different sites, such as HT3 receptor
antagonists(eg. ondansetron), steroids(eg.
dexamethasone), phenothiazines (eg.
prochlorperazine) and antihistamines
(eg.cyclizine) is the most effective.
 Hypothermia and shivering
• Anesthesia induces loss of thermoregulatory control.
• Exposure of skin and organs to a cold operating
environment, antiseptic skin preparation (that cools by
evaporation), and the infusion of cold IV fluids all lead to
hypothermia.
• This in turn can lead to shivering, with imbalance of
oxygen supply and demand (risking cardiac morbidity), a
hypocoagulable state and immune function impairment,
with the possibility of wound infection, dehiscence and
anastomotic breakdown.
• Active warming devices should be used to treat.
 Drains
• Used to prevent accumulation of blood,
serosanguinous or purulent fluid or to
allow the diagnosis of leaking surgical
anastomosis.
• Drains should be removed as soon as
possible and certainly once the drainage
has stopped or become less than
25mL/day.
 Wound care
• Wounds should be inspected only if there is a
concern about their condition or the dressing
needs changing.
• Inspection of the wound should be performed
under sterile conditions.
• If the wound looks inflamed, a wound swab can
be taken for microbiological examination, but this
can be unreliable.
• Infected wounds and haematomata may need
treatment with antibiotics or even wound
washout.
 Enhanced recovery
• To speed clinical recovery and reduce the cost and
length of stay of patient.
• Post operative strategies advocated by enhanced
recovery protocols include:
- Early planned physiotherapy and mobilisation.
- Early oral hydration and nourishment
- Opioid sparing analgesia regimens that include the use of
regional block, NSAIDs, and paracetamol
- Discharge planning is started before the patient is
admitted to hospital and involves support from stoma
care nurses, physiotherapists and others