Preoperative Patient Evaluation

Intraop and Post Op Management

Preoperative Patient Evaluation
AIM
1. It uncovers comorbidities that will require
further evaluation and optimization
to avert/prevent perioperative
complications

2. Evaluation allows improved use of operating

room resources
Preoperative Patient Evaluation
1.Medical Consultation
Gynecologist: is obliged to perform a
thorough pre-operative history and PE

Consultation with an internist is beneficial:

undiagnosed medical illnesses
poorly controlled medical condition
 Preoperative Patient Evaluation
• The purpose of a preoperative internal medicine
consultation is not to obtain “medical clearance”
• to provide a risk assessment of the patients
current medical state
• With consultation, a summary of the surgical illness
is provided, and clear questions are posed to the
consultant
Preoperative Patient Evaluation
A. Pulmonary Evaluation
• Common postoperative pulmonary morbidities:
• atelectasis
• pneumonia
• exacerbation of chronic lung diseases.
Incidence of complications: 20 – 70 %
Preoperative Patient Evaluation

• Risk Factors for Pulmonary Complications-

A. Procedure-Related Factors

B. Patient-related Factors
Preoperative Patient Evaluation
A. Procedure-Related Factors

I.UPPER ABDOMINAL INCISIONS

a. Intraoperatively: stimulation of the viscera leads to decreased
phrenic motoneuron output which then lessens diaphragmatic
descent.
b. disruption of abdominal wall muscles can hinder effective
respiratory efforts.
c. pain may limit effective voluntary use of respiratory muscles 
poor diaphragmatic function may produce persistent decrease:
• vital capacity VC
• functional residual capacity FRC
Predispose patients to HYPOVENTILATION

ATELECTASIS
PreoperativePatientEvaluation
A. Procedure-RelatedFactors

2. Duration of Surgery
Patients on general anesthesia for 3H or more
are assd with Twofold postop pulmonary
complications
Emergency surgery is an independent predictor of postoperative
pulmonary complications

Procedure-related risk factors are largely unmodifiable, an

appreciation of their associated sequelae should prompt increased
postoperative vigilance.
PreoperativePatientEvaluation
B. Patient-RelatedFactors

1. Age:
Patients 60 years > increased risk for
postop pulmonary complications
Pxs 60 - 69 years- twofold increased risk
. 70 years - threefold risk (Qaseem, 2006)
Any changes in the postoperative sensorium may be an early
indicator of pulmonary function compromise following surgery
PreoperativePatientEvaluation
A. Patient-RelatedFactors

2. Smoking
• Smoking Hx > 20-pack-year :
Increased Incidence of postop pulmonary
complications.
Fortunately, can be reduced with smoking abstinence for at least 4 to
8 weeks
But if the smoking cessation 6 months or more: risk of complication
similar to those who have never smoked.
PreoperativePatientEvaluation
A. Patiente-RelatedFactors

• Benefits of Smoking abstinence

Reduced nicotine and carboxyhemoglobin
levels:
- improved mucociliary function
- decreased upper airway hypersensitivity
- improved wound healing
• Patients often see surgery as an opportunity for positive
change

• Education may prompt successful behavior modification

 • Chronic Obstructive Pulmonary Disease (COPD).
Incentive spirometry:
inspiratory muscle training
postoperative physiotherapy
- reduce the frequency of complications

Well-controlled asthma is not a risk factor for postop pulmonary

complications
• Asthma and COPD: a rise in C-reactive protein indicates the
presence of acute inflammation
• CRP is an acute-phase reactant
Preoperative Patient Evaluation
A. Patient-Related Factors

3. Obesity BMI 30 kg/m2

- Decrease in chest wall compliance
- Decrease functional residual capacity FRC
Predispose to intra- and postoperative
atelectasis
• American Society of Anesthesiologist
(ASA) Classification
• - to help predict perioperative
mortality rates
- to assess px risks for cardiovascular and
pulmonary complications
History and Physical Examination

. poor exercise tolerance

1

2. chronic cough
3. unexplained dyspnea
4. PE findings: decreased breath
sounds dullness to percussion, rales,
wheezes, rhonchi,
a prolonged expiratory phase
.
Sixfold increase in pulmonary complications
Diagnostic Testing
Pulmonary Function Tests
is requested in COPD, unexplained dyspnea,
Exercise intolerance

Chest Radiography: not routinely done

Indications:
acute or chronic cardiovascular/pulmonary dis.
cancer, ASA status 3, heavy smoking,
immunosuppression, history of recent chest
radiation therapy, recent emigration from areas
w endemic pulmonary disease, and recent sx
suggestive of cardiopulmonary disease.
Biochemical Markers.

• Serum albumin:
< than 35 mg/dL: assd with increased perioperative/
pulmonary MMR

- Marker of malnutrition and other disease

- not routinely recommended for All gynecologic
surgery
- predictive in the elderly, or pxs with comorbidities.

-
Prevention of Pulmonary Complications
Lung Expansion Modalities
• Deep breathing exercises:
Take five sequential deep breaths every hour
while awake and hold for 5 seconds
• Incentive spirometry
provide direct visual feedback of her effort
• Early ambulation

Enhance lung expansion

Early ambulation prevent DVT
Cardiac Evaluation

• Coronary heart disease :

- leading cause of death in most
industrialized countries
- contributes to perioperative mortality rates
in patients undergoing cardiac and
noncardiac surgery
Risk Factors for Cardiac Complications

1. Valvular Heart Disease

Careful chest auscultation: heart murmurs,
irregular HR and rhythm suspicious for valvular
lesions.
Most common found defects:
aortic stenosis - highest risk for perioperative
complications
Indicators of RISK: Degree of heart failure
Associated cardiac arrhythmia
ECG and echocardiography
Guidelines for endocarditis prophylaxis

• No longer recommended by the American Heart Association

• The transient enterococcal bacteremia caused by these

procedures has not been irrefutably/uncertain correlated to
the development of infective endocarditis.
• Hence, antibiotic prophylaxis directed at preventing infective
endocarditis after GI or GU tract procedures
is no longer recommended by the American
Heart
Association
• (Wilson, 2007).
Cardiac Evaluation
• Heart Failure.
Cardiologist will advised strategies in
maximizing hemodynamic function:
preoperative coronary revascularization
perioperative medical therapy

Allow the use of diuretics but avoid

intraoperative hypovolemia and related
hypotension.
Cardiac Evaluation
• Arrhythmias
May indicate symptoms of underlying
cardiopulmonary disease or electrolyte
abnormalities

Preoperative management:
correct the primary process
treat prior to surgery- Need for pacemakers and
implantable cardioverter- defibrillators
Electrosurgery (ESU)
• Patients with pacemakers in place:
• electrosurgery can create electromagnetic
• interference even during noncardiac
surgical and endoscopic procedures
• Newer devices: interference can lead to pacing failure or
complete system malfunction
Patients w/pacemakers in place,
The current guidelines recommendation:
- All systems be evaluated by an appropriately trained
physician before and after any invasive procedure
- The surgeon should minimize the chance for
electromagnetic interference by using bipolar
electrosurgery
- if possible, use short intermittent bursts of
electrosurgical energy at the lowest possible energy
levels
Patients w/pacemakers in place,

- Maximizing the distance between the

electrosurgical tool and the cardiac device

Placing the grounding pad in a position to

minimize current flow toward the device.
Hypertension

• The blood pressure should be lowered several months prior to

an anticipated procedure to lower postoperative cardiac
complications related to hypertension
• Hypertension is not predictive of perioperative cardiac events
EXCEPT if the setting of Bp 180/ 110 mm Hg
• Surgical intervention should be not postpone
Hypertension.

• ACE inhibitors and angiotensin- receptor antagonists:

- should with-hold their morning dose
- to avoid post-induction hypotension

• All patients w HPN:

• - Intra operatively: avoiding hypo- or HPN
• - Careful postoperative monitoring.
• - Conditions exacerbate postoperative HPN:
Intravascular volume expansion, pain and
aggitation
Hepatic Evaluation
• Liver :
• - plays a central role in drug metabolism
• - synthesis of CHON, CHO, and coagulation factors
• - excretion of endogenous compounds

Patients suspected w/ hepatic disease:

inquiry on family Hx of jaundice or anemia
recent travel history
exposure to alcohol/ hepatotoxins, and medication use

Physical findings suggestive of underlying liver disease:

jaundice, scleral icterus, spider angiomas, ascites,
hepatomegaly, asterixis, and cachexia.
Hepatic Evaluation
Commonly encountered:
• acute and chronic hepatitis
Supportive care and delay of elective surgical
intervention until the acute process has
subsided
• Pxs w suspected / known liver disease:
• liver function tests,
• pro- thrombin time (PT)
• partial thromboplastin time (PTT)
• serum albumin level
Hepatic Evaluation

• Child-Pugh score:
• A tool used to assess the prognosis of chronic liver disease
mainly cirrhosis
• to predict perioperative survival rates on these pxs
undergoing abdominal surgery
• The risk of mortality based on Child-Pugh class is as follows:
class A—10 percent; class B—30 percent; class C—70 percent
Renal Evaluation
The kidney:
• excretion of metabolic waste
• hematologic processes
• fluid and electrolyte balance.
Serum chemistry panel and complete blood count (CBC) evaluated
prior to surgery
Chronic anemia due to renal insufficiency:
- preoperative administration of erythropoietin or
- perioperative transfusion depends on the procedure
degree of anemia
Dialysis patients: intensive pre- and postoperative
surveillance for signs of electrolyte abnormalities and
fluid overload.
Hematologic Evaluation

• Anemia
• most common laboratory abnormalities seen
• preoperatively among pxs for gynecologic surgery

Further evaluation is necessary to correct reversible causes /

etiology
Anemia
• Signs of symptomatic anemia:
- fatigue, dyspnea with exertion, and
palpitation
Identify risk factors: CVD - anemia is less well
tolerated
Do through PE, Pelvic, rectal examination and
stool exam for occult blood/
guaiac testing
Anemia
Mild anemia: CBC
Profound anemia, unresposive to iron Rx
test: CBC, serum iron level, total iron binding capacity (TIBC),
ferritin level, reticulocyte count, and vitamin B12 and folate
levels.
Classic Fe deficiency anemia:
• Elevated - TIBC
• LOW - CBC-hemoglobin, hematocrit
red cell indices,
serum iron
ferritin levels
• TX : elemental iron -150 and 200 mg daily.
e.g.ferrous sulfate, 325 mg 3x daily
ferrous fumarate, 200 mg 3x daily
Anemia
Perioperative decision: Transfusion
• - depends on patient’s cardiac status
• - no ongoing blood loss in a healthy woman
She can tolerate a postoperative
hemoglobin level as low as 6 to 7 g/dL
• When is Transfusion indicated?
hypotension develops and tachycardia fail to respond to
mcrystalloid / colloid volume expansion
Preoperative Management of Oral Anticoagulation

• Indications: atrial fibrillation

mechanical heart valve
recent venous thromboembolism - increased
risk for VTE
- Patients are on chronic oral warfarin therapy
The need for anti- coagulation is balanced against the risk of
bleeding complications from surgery
Endocrine Evaluation
Pathophysiologic stress of surgery can exacerbate endocrine
conditions:
thyroid dysfunction, diabetes mellitus, and
adrenal insufficiency

Hyperthyroidism and Hypothyroidism

- have anesthetic and metabolic derangements
Aims to achieve a euthyroid state before surgery.
 Endocrine Evaluation

•Hyperthyroidism: carries the risk of developing thyroid

storm perioperatively

•Large goiter: cause airway compromise

•P.E: evaluate for tracheal deviation

Request: thyroid function tests
• electrocardiogram (EKG)
• serum electrolyte levels – predict signs of
preexisting metabolic stress
 Endocrine Evaluation

•Patients advised to maintain their usual

medications at prescribed dosages
until the day of surgery

•Newly diagnosed hypothyroidism: preoperative

therapy NOT needed except in cases of severe
disease with signs of cardiac depression,
electrolyte irregularities, and hypoglycemia
Diabetes Mellitus
Long-term complications:
• vascular, neurologic, cardiac, and renal
dysfunction
• A vigilant preoperative risk assessment of these comorbidities is
essential

• EFFECTS OF Stress induced by surgery and anesthesia:

- elevations in catecholamine levels
- relative insulin deficiency and hyperglycemia
Diabetes Mellitus --Increased postoperative morbidity:
- poor preoperative glycemic control
glucose levels 200 mg/dl
HbA1C >7
- increased rates of postoperative wound infection

Diagnostic tests-- serum electrolytes, urinalysis, EKG

screen: metabolic disturbances,

undiagnosed nephropathy
unrecognized cardiac ischemia
Diabetes Mellitus
• AIM : avoid Overt hyperglycemia minimize postop
complications:
dehydration, electrolyte abnormalities
poor wound healing
ketoacidosis in T1DM
• Aim for glucose readings below 200 g/dL
• Lab tests: CBC, blood typing, HbsAg,
urinalysis, electrolyte panel,
FBS, HbA1c, BUN, creatinine levels

• women of reproductive age: Pregnancy test

Adrenal Insufficiency
• Seen in patients who are on chronic steroids--- effects secondary
suppression of HPA axis ( hypothalamic-pituitary-adrenal)
 perioperative HYPOTENSION
Corticosteroid users:
• - minor surgical procedures
• - lower doses < 5 mg of prednisone/day not more than 2
weeks
• corticosteroid therapy is not recommended
Adrenal Insufficiency
• Steroid users: risk for HPA-axis suppression
- on 5 to 20 mg of prednisone/day
- on TX > 3 weeks
Mgnt -ACTH testing
- continue the daily dose of
corticosteroids perioperatively

Close hemodynamic monitoring; signs of HPON

- hydrocortisone, 100 mgs IV q8H and titrated
Gastrointestinal Bowel Preparation

• Routine use should be limited

- Mechanical bowel preparation: preferred
- advanced laparoscopic procedures
- - female pelvic reconstructive procedures
involving the posterior vaginal wall and
anal sphincter
Hormone Discontinuation

• Combined oral contraceptive pills (COCs):DVT - induce

hypercoagulable changes
• stop 6 weeks prior to surgery

• Postmenopausal hormone replacement therapy (HRT) appears to

increase the incidence of postsurgical VTE : fivefold
increase
SPECIAL CONSIDERATIONS
Surgical Site Infection Prophylaxis
• Appropriate antibiotic prophylaxis:
can reduce hospital-acquired infections following
gynecologic surgery.

• A single dose of antibiotics is given:

- after anesthesia induction
- Additional doses: blood loss 1500 mL
duration longer than 3 hours.
• Obese pxs should received higher antibiotic dose
INFORMED CONSENT

Obtaining informed consent is a process and

not merely a medical record document
This conversation will enhance a woman’s
awareness of her diagnosis

Written documentation serves as a historical

record of a patient’s understanding and
agreement
INFORMED CONSENT

• Contain: a discussion of medical and surgical

care alternatives, procedure goals,
limitations, and surgical risks.
• When unable to obtained from the patient:
an independent surrogate should be
identified to represent the patient’s best
interest and wishes..
POSTOPERATIVE CONSIDERATIONS

- A Thorough preoperative planning

- Awareness of common post- operative
complications
• - Vigilance to details will ensure successful
convalescence for most patients.
OR Theater
• POST OP ORDERS

• Operative record

• BIOPSY Form
Postoperative Nausea and Vomiting
• - most common complaints ff. surgery -
incidence: 30 to 70 %
High risk : females, nonsmokers
history of motion sickness
extended surgeries
laparoscopic or other gynecologic surgery

Prevention: Before anesthesia induction- 4 - 8 mg of

dexamethasone
Toward the end of surgery - less than 1 mg of
droperidol (Inapsine
4 mg of ondansetron
(Zofran)
This pretreatment significantly reduces symptoms by 25 %
Pain Management

Poor pain control :

• - decreased satisfaction with care
• - prolonged recovery time
• - increased use of health care resources
• - increased health care costs
Nonopioid Treatment Options

Acetaminophen and NSAIDs If given preoperatively:

• - NSAIDs reduce postoperative pain
• - lower the amount of required opiates
• - decrease the incidence of PONV 30%
Opioid Treatment Options

Common side effects that all opiates share:

- respiratory depression
- nausea and vomiting

Opiate therapy: primary choice for managing

moderate to severe pain
Three most common opiates for gynecologic
surgeries: morphine, fentanyl, and
hydromorphone
Complications
Oliguria
• Postoperative oliguria: u.o. < 0.5 mL/kg/hr
Causes: prerenal, intrarenal/postrenal insult
Prerenal Oliguria
• - Physiologic response to hypovolemia
• S/sx: tachycardia and orthostatic hypotension
• - reflect the volume depletion
Causes of hypovolemia: acute hemorrhage
Complications:Prerenal Oliguria
Causes of hypovolemia:
- acute hemorhage, vomiting, severe diarrhea,
and inadequate intraoperative volume
replacement
Body’s response : Activation of the renin- angiotensin
system – release of ADH (antidiuretic hormone)
---prompt reabsorption of sodium and water by the
renal tubules
MGNT: correcting the patient’s volume status
accurate assessment of the fluid deficit
Add: EBL (estimated blood loss)
intra- operative fluid logs kept by the anesthesiologist
Insensible loss: open abdominal surgery is 150 mL/hr.
Intrarenal Oliguria
Ischemic injury: lead to necrosis of the renal tubules
decreased filtration
- more common in a pre- renal setting- renal tubules are more
vulnerable to insult from nephrotoxic agents:
NSAIDs, aminoglycosides, and contrast media.

Prerenal oliguria can be achieved by calculating the fractional excretion of

sodium (FENa). This is defined as:
• (Urine Na level/plasma Na level) divided by (Urine creatinine level/plasma
creatinine level).

• A ratio of <1 suggests a prerenal source

• ratio of >3 indicates an intrarenal insult
Another difference: urine sodium levels
• prerenal oliguria, it is < 20 mEq/L
• intrarenal states, it is >80 mEq/L
Postrenal Oliguria

Causes
- urinary catheter obstruction: most common
- ligation or laceration to the ureter / bladder

partial or unilateral obstruction may exist

despite adequate urine output
Findings: hematuria, flank or abdominal pain,
ileus, or signs of uremia.
Postrenal Oliguria

• Diagnosis: hydronephrosis
• renal sonography-highly sensitive and specific
Additional diagnostic tools: ureteral obstruction
computed tomography (CT) with IV contrast
retrograde pyelography
caution: IV contrast- nephrotoxic
measure serum crea
Obstruction may be relieved with ureteral stenting
alone or may require surgical repair
Postoperative Urinary Retention

• Inability to void with a full bladder:

common problem after a gynecologic surgery.
• Incidences: 7 to 80 percent depends on the surgical
procedure
• Overdistension: lead to prolonged difficulty with
micturition
• -permanent detrusor damage
• - patient discomfort
• - recatheterization to treat retention
increases the risk of urinary tract infection
and may extend hospitalization.
Postoperative Urinary
Retention
Three major factors:
1) increased risk age older than 50 years
2) intraoperative fluid administration > 750ml
3) bladder urine volume >270 mL measured upon entry to the
recovery room.
• Once retention is identified: catheterization and bladder
drainage should follow
Gastrointestinal Considerations
Resumption of Bowel Function

- Following abdominal surgery:

Dysfunction of enteric neural activity
w disruption of normal propulsion
Resumption of GI activity: within 24 hours
First in the stomach, small intestine -
normal function may be delayed 3 to 4 days

- Rhythmic colonic motility: resumes 4 days after

Passage of flatus -marks the return of function
Passage of stools follows in 1 to 2 days.
Resumption of Diet

• Early initiation of feeding: Early feeding

proven to be most effective
Benefits: improve wound healing
stimulate gut motility
decrease intestinal stasis
increase splanchnic blood flow
stimulate reflexes that will illicit/release
secretion of GI hormones that can
shorten postoperative ileus
Ileus
Postoperative ileus (POI):
- is a transient impairment of GI activity
- leads to abdominal distension, hypoactive bowel b s
nausea and/vomiting: accumulation of GI gas and fluid
delayed passage of flatus and/or stool
• Pathogenesis of POI: multifactorial
- bowel manipulation during surgery leads to: production (1)
neurogenic factors related to sympathetic overactivity,
(2) hormonal factors: release of hypothalamic corticotropin-
releasing factor, key role in the stress response
(3) inflammatory factors
Ileus
Management: No single treatment
- Electrolyte repletion and intravenous fluids
to reestablish a euvolemic state
- Routine NGT decompression: unsuccessful
postop NGT: recommended only for
symptomatic relief of
abdominal bloating and
recurrent vomiting
Postoperative Fever Evaluation

Most common problem encountered in the

post-operative period
Fever may reflect an infectious process, most
are self-limited
Persistent symptoms: needs patient evaluation
in order to identify inflammatory
causes
Pathophysiology of the Febrile Response

• Fever: a response to inflammatory mediators,

pyro- gens: originate either endogenously or exogenously
• Circulating pyrogens: lead to the production of prostaglandins
(primarily PGE2), which elevates the thermoregulatory set
point –Temp elevation
Pathophysiology of the Febrile Response

Inflammatory cascade: produces of cytokines-

• (IL-1, IL-6, TNF-α) found in the circulation
after a variety of events—surgery, cancer, trauma, and infection
(Wortel, 1993).
• Differential diagnosis of a postoperative fever:
include noninfectious and infectious causes
Etiology of Postoperative fever

Fever that develop > 2 days post op are likely to be infectious

“Five Ws,” : wind, water, walking, wound, and “wonder”

1.Pneumonia should be considered, and women
w/ mechanically ventilators use for prolonged period,
NGT in place, or have preexisting COPD
2 Catheterization: longer duration places women at risk for UTI;
3 Venous thromboembolic disease: present with low-grade fever
4.Wound: surgical site infections- develops 5 to 7 days after surgery
pelvis( pelvic abscess, vaginal cuff cellulitis), SSI
5. Medications commonly used postop: such as heparin, beta-lactam
antibiotics, and sulfonamide antibiotics— may cause a rash,
eosinophilia, or drug fever.
Postoperative Wound

• Acute Wound Healing

• three-phase process—
1. inflammatory reaction: Hemostasis by coagulation
2. proliferation: infiltration of leukocytes and release of
cytokines
Two activities happen simultaneously:
- growth of granulation tissue to fill the wound
along with
- the formation of epithelium to cover the wound
surface
3. remodeling: restores the structural integrity and functional
aptitude of the new tissue.
Wound Dehiscence

• Prolongs hospital stays and requires labor-intensive care

separation may also include the abdominal wall fascia
Fascial dehiscence: occurs less frequently
- fatal in nearly 25 percent of cases
- Infection or sutures held under too much tension
lead to fascial necrosis
Sutures remain poorly anchored in necrotic fascia
• These layers then separate with only minimal increase in the
intraabdominal pressure
Prevention of Post op Morbidity

General patient health condition

• correct anemia
• Rx pulmonary disease
• build up nutrition
• avoid obesity
• good glucose control

conditions affects post op course:

• malignancy
• hypertension
Proper surgical technique
• - observe hemostasis • - placement of
closed suction
• - gentle tissue drains (JP) if indicated
• handling • - sustained
- removal of normothermia
devitalized tissue
• - closure of dead space
• - use of monofilament
suture
Prevention of Post op Morbidity

Observe hemostasis:
Use of electrosurgery instead of scalpel
for abdominal entry is common
Advantage: speed, hemostasis,
comparable wound healing,
decreased requirements for
postoperative analgesia
Cautery equipments
Thank U everyone!