Pre and postoperative care of a surgical

patient
Dr Hailu Wondimu
Consultant GI and general surgeon
Assistant professor of surgery
♦ Approaches to preoperative evaluation differ
significantly, depending on
– the nature of the complaint
– the proposed surgical intervention,
– patient health and assessment of risk factors, and
– the results of directed investigation and interventions to
optimize the patient's overall status and readiness for
surgery.
♦ Once the decision has been made to proceed with
operative management, a number of considerations
must be addressed regarding
– the timing and site of surgery,
– the type of anesthesia, and
– the preoperative preparation necessary to understand the
patient's risk and optimize the outcome.
♦ These components of risk assessment take into
account both
– the perioperative (intraoperative period through 48 hours
postoperatively) and
– the later postoperative (up to 30 days) periods and seek to
identify factors that may contribute to patient morbidity
during these periods.
Preoperative Evaluation
♦ The aim of preoperative evaluation is not to screen
broadly for undiagnosed disease but rather to identify
and quantify any comorbidity that may have an impact
on the operative outcome
♦ This evaluation is driven by findings on the history and
physical examination suggestive of organ system
dysfunction or by epidemiologic data suggesting the
benefit of evaluation based on age, gender, or
patterns of disease progression.
♦ The goal is to uncover problem areas that may require
further investigation or be amenable to preoperative
optimization
♦ The preoperative evaluation is determined in light of
the planned procedure (low, medium, or high risk), the
planned anesthetic technique, and the postoperative
disposition of the patient (outpatient or inpatient,
ward bed, or intensive care
♦ In addition, the preoperative evaluation is used to
identify patient risk factors for postoperative
morbidity and mortality.
PREOPERATIVE CHECKLIST
♦ preoperative evaluation concludes with a review of all
pertinent studies and information obtained from
investigative tests. Documentation of this review is
made in the chart, which represents an opportunity to
ensure that all necessary and pertinent data have been
obtained and appropriately interpreted
♦ Informed consent
♦ gives the surgeon an opportunity to review the need
for β-blockade, DVT prophylaxis, and prophylactic
antibiotics.
Antibiotic Prophylaxis
♦ Appropriate antibiotic prophylaxis in surgery depends on the most likely
pathogens encountered during the surgical procedure.
♦ The type of operative procedure is helpful in deciding the appropriate
antibiotic spectrum and is considered before ordering or administering any
preoperative medication.
♦ Prophylactic antibiotics are not generally required for clean (class I)
cases, except in the setting of indwelling prosthesis placement or when
bone is incised. Patients who undergo class II procedures benefit from a
single dose of an appropriate antibiotic administered before the skin
incision.
♦ The appropriate antibiotic is chosen before surgery and administered
before the skin incision is made Repeat dosing occurs at an appropriate
interval, usually 3 hours for abdominal cases or twice the half-life of the
antibiotic, although the patient's renal function may alter the timing
Review of Medications

♦ Careful review of the patient's home

medications is a part of the
preoperative evaluation before any
operation; the goal is to appropriately
use medications that control the
patient's medical illnesses while
minimizing the risk associated with
anesthetic-drug interactions or the
hematologic or metabolic effects of
some commonly used medications and
therapies
♦ In general, patients taking cardiac drugs, including β-
blockers and antiarrhythmics, pulmonary drugs such as
inhaled or nebulized medications, or anticonvulsants,
antihypertensives, or psychiatric drugs are advised to
take their medications with a sip of water on the
morning of surgery.
♦ Parenteral forms or substitutes are available for many
drugs and may be used if the patient remains NPO for
any significant period postoperatively. It is important to
return patients to their normal medication regimen as
soon as possible
♦ Two notable examples are the additional cardiovascular morbidity
associated with the perioperative discontinuation of β-blockers
and rebound hypertension with abrupt cessation of the
antihypertensive clonidine.
♦ Medications such as lipid-lowering agents or vitamins can be
omitted on the day of surgery.
♦ Some drugs are associated with an increased risk for perioperative
bleeding and are withheld before surgery. Drugs that affect
platelet function are withheld for variable periods: aspirin and
clopidogrel (Plavix) are withheld for 7 to 10 days, whereas NSAIDs
are withheld between 1 day (ibuprofen and indomethacin) and 3
days (naproxen and sulindac), depending on the drug's half-life
Preoperative Fasting
♦ The standard order of “NPO past midnight” for preoperative
patients is based on the theory of reduction of volume and
acidity of the stomach contents during surgery. Recently,
guidelines have recommended a shift to allow a period of
restricted fluid intake up to a few hours before surgery
♦ The ASA recommends that adults stop intake of solids for at
least 6 hours and clear fluids for 2 hours. When the literature
was recently reviewed by the Cochrane group, they found 22
trials in healthy adults that provided 38 controlled comparisons.
♦ There is also increasing evidence that preoperative
carbohydrate supplementation is safe and may improve a
patient's response to perioperative stress
Systemic approach

♦ Cardiac
♦ Pulmonary
♦ Renal
♦ Hepatic
♦ Endocrine
Cardiovascular
♦ Cardiovascular disease is the leading cause of death in
the industrialized world, and its contribution to
perioperative mortality during noncardiac surgery is
significant.
♦ Of the 27 million patients undergoing surgery in the
United States every year, 8 million, or nearly 30%,
have significant coronary artery disease or other
cardiac comorbid conditions.
ASA
One of the first anesthesia risk categorization systems
was the ASA classification. It has five stratifications:
I—Normal healthy patient
II—Patient with mild systemic disease
III—Patient with severe systemic disease that limits
activity but is not incapacitating
IV—Patient who has incapacitating disease that is a
constant threat to life
V—Moribund patient not expected to survive 24 hours
with or without an operation
Cardiac parameters
♦ Once these data have been obtained, the surgeon and
consultants need to weigh the benefits of surgery
against the risk and determine whether any
perioperative intervention will reduce the probability
of a cardiac event
♦ The optimal timing of a surgical procedure after
myocardial infarction (MI) is dependent on the
duration of time since the event and assessment of
the patient's risk for ischemia, either by clinical
symptoms or by noninvasive study
Any patient can be evaluated as a surgical candidate
after an acute MI (within 7 days of evaluation) or a
recent MI (within 7-30 days of evaluation). The
infarction event is considered a major clinical
predictor in the context of ongoing risk for ischemia
The risk for reinfarction is generally considered low in
the absence of such demonstrated risk. General
recommendations are to wait 4 to 6 weeks after MI to
perform elective surgery
♦ Improvements in postoperative care have centered on
decreasing the adrenergic surge associated with
surgery and halting platelet activation and
microvascular thrombosis
♦ Perioperative risk for cardiovascular morbidity and
mortality was decreased by 67% and 55%,
respectively, in ACC/AHA-defined medium- to high-
risk patients receiving β-blockers in the perioperative
period versus those receiving placebo.
Calculator: Cardiovascular risk assessment in
adults
♦ An easy, inexpensive method to determine
cardiopulmonary functional status for noncardiac
surgery is the patient's ability or inability to climb two
flights of stairs.
♦ Two flights of stairs is needed because it demands
greater than 4 metabolic equivalents (METs).
– In a review of all studies of stair climbing as preoperative
assessment, prospective studies have shown it to be a good
predictor of mortality associated with thoracic surgery. In
major noncardiac surgery, an inability to climb two flights of
stairs is an independent predictor of perioperative
morbidity, but not mortality.
Pulmonary
♦ Preoperative evaluation of pulmonary
function may be necessary for either
thoracic or general surgical procedures.
♦ Adults with an FEV1 of less than 0.8 L/sec, or 30% of
predicted, have a high risk for complications and
postoperative pulmonary insufficiency. Pulmonary
resections need to be planned so that the
postoperative FEV1 is greater than 0.8 L/sec, or 30%
of predicted. Such planning can be done with the aid
of quantitative lung scans, which can indicate which
segments of the lung are functional
♦ General factors that increase risk for postoperative
pulmonary complications include increasing age, lower
albumin level, weight loss, and possibly obesity
♦ Concurrent comorbid conditions such as impaired sensorium,
previous stroke, congestive heart failure, acute renal
failure, chronic steroid use, and blood transfusion are also
associated with increased risk for postoperative pulmonary
complications
♦ Specific pulmonary risk factors include chronic obstructive
pulmonary disease, smoking, preoperative sputum production,
pneumonia, dyspnea, and obstructive sleep apnea.
♦ Preoperative interventions that may
decrease postoperative pulmonary
complications include smoking cessation (>2
months before the planned procedure),
bronchodilator therapy, antibiotic therapy
for preexisting infection, and pretreatment
of asthmatic patients with steroids.
♦ Perioperative strategies include the use of
epidural anesthesia, vigorous pulmonary
toilet and rehabilitation, and continued
bronchodilator therapy.
Renal
♦ Approximately 5% of the adult population have some
degree of renal dysfunction that can affect the
physiology of multiple organ systems and cause
additional morbidity in the perioperative period.
♦ In fact, a preoperative creatinine level of 2.0 mg/dL
or higher is an independent risk factor for cardiac
complications
♦ Identification of coexisting cardiovascular,
circulatory, hematologic, and metabolic derangements
secondary to renal dysfunction are the goals of
preoperative evaluation in these patients

♦ Diagnostic testing for patients with renal dysfunction

include an electrocardiogram (ECG), serum chemistry
panel, and complete blood count (CBC).
♦ If physical examination findings are suggestive of
heart failure, a chest radiograph may be helpful
♦ Patients with chronic end-stage renal
disease undergo dialysis before surgery
to optimize their volume status and
control the potassium level.
Intraoperative hyperkalemia can result
from surgical manipulation of tissue or
transfusion of blood. Such patients are
often dialyzed on the day after surgery
as well
Hepatobiliary
♦ Hepatic dysfunction may reflect the common pathway
of a number of insults to the liver, including viral-,
drug-, and toxin-mediated disease.
♦ A patient with liver dysfunction requires careful
assessment of the degree of functional impairment, as
well as a coordinated effort to avoid additional insult
in the perioperative period
♦ A patient with liver dysfunction undergoes standard
liver function tests.
♦ Elevations in hepatocellular enzymes may suggest a
diagnosis of acute or chronic hepatitis, which can be
investigated by serologic testing for hepatitis A, B, and
C. Alcoholic hepatitis is suggested by lower
transaminase levels and an aspartate/alanine
transaminase ratio (AST/ALT) greater than 2
♦ Laboratory evidence of chronic hepatitis or clinical
findings consistent with cirrhosis is investigated with
tests of hepatic synthetic function, notably serum
albumin, prothrombin, and fibrinogen
♦ Patients with evidence of impaired hepatic synthetic
function also have a CBC and serum electrolyte analysis.
♦ Type and screen is indicated for any procedure in
which blood loss could be more than minimal.
♦ A patient with cirrhosis may be assessed with the Child-Pugh
classification, which stratifies operative risk according to a score
based on abnormal albumin and bilirubin levels, prolongation of the
prothrombin time (PT), and the degree of ascites and
encephalopathy
♦ This scoring system was initially applied to predict mortality in
cirrhotic patients undergoing portacaval shunt procedures, although
it has been shown to correlate with mortality in cirrhotic patients
undergoing a wider spectrum of procedures as well.
♦ Other factors that affect outcomes in these patients are the
emergency nature of a procedure, prolongation of the PT greater
than 3 seconds above normal and refractory to correction with
vitamin K, and the presence of infection
Endocrine
♦ A patient with an endocrine condition such as diabetes
mellitus, hyperthyroidism or hypothyroidism, or
adrenal insufficiency is subject to additional
physiologic stress during surgery.
♦ The preoperative evaluation identifies the type and
degree of endocrine dysfunction to permit
preoperative optimization.
♦ Careful monitoring identifies signs of metabolic stress
related to inadequate endocrine control during surgery
and throughout the postoperative course.
a diabetic patient
♦ The evaluation of a diabetic patient for surgery
assesses the adequacy of glycemic control and
identifies the presence of diabetic complications,
which may have an impact on the patient's
perioperative course.
♦ The patient's history and physical examination
document evidence of diabetic complications, including
cardiac disease, circulatory abnormalities, and the
presence of retinopathy, neuropathy, or nephropathy
♦ Preoperative testing may include fasting and postprandial
glucose and hemoglobin A1c levels.
♦ Serum electrolyte, blood urea nitrogen, and creatinine levels
are obtained to identify metabolic disturbances and renal
involvement. Urinalysis may reveal proteinuria as evidence of
diabetic nephropathy.
♦ An ECG is considered in patients with long-standing disease.
♦ The existence of neuropathy in diabetics may be accompanied
by cardiac autonomic neuropathy, which increases the risk
for cardiorespiratory instability in the perioperative period.
♦
♦ A diabetic patient requires special attention to optimize
glycemic control perioperatively. Non–insulin-dependent
diabetics need to discontinue long-acting sulfonylureas
such as chlorpropamide and glyburide because of the
risk for intraoperative hypoglycemia; a shorter-acting
agent or sliding-scale insulin coverage may be
substituted in this period.
♦ The use of metformin is stopped preoperatively because
of its association with lacticacidosis in the setting of
renal insufficiency. An insulin-dependent diabetic is told
to withhold long-acting insulin preparations (Ultralente
preparations) on the day of surgery; lower dosages of
intermediate-acting insulin (NPH or Lente) are
substituted on the morning of surgery
♦ These patients are scheduled for early morning surgery,
when feasible. During surgery, a standard 5% or 10%
♦ Frequent assessments of glucose levels are continued
through the postoperative period. Current recommendations
are to maintain the perioperative glucose level between 80
and 150 mg/dL, even in patients not previously diagnosed as
being diabetic. Adequate hydration must be maintained with
avoidance of hypovolemia.
♦ Postoperative cardiac events can occur with unusual
manifestations in these patients. Although chest pain needs
to be evaluated with ECG and serum troponin levels, this
same evaluation may need to be done for new-onset
dyspnea, blood pressure alterations, or a decrease in urine
output
♦ Adequate prophylaxis for deep venous thrombosis (DVT) is
essential because of the increased risk for thrombosis. The
adequacy of perioperative glycemic control has an impact on
wound healing and the risk for surgical site infection
thyroid disease
♦ patient with known or suspected thyroid disease is
evaluated with a thyroid function panel. Evidence of
hyperthyroidism is addressed preoperatively and
surgery deferred until a euthyroid state is achieved,
when feasible
♦ These patients need to have their electrolyte levels
determined and an ECG performed as part of their
preoperative evaluation. In addition, if the physical
examination suggests signs of airway compromise,
further imaging may be warranted
♦ A patient with hyperthyroidism who takes antithyroid medication such as
propylthiouracil or methimazole is instructed to continue this regimen on the
day of surgery
♦ The patient's usual doses of β-blockers or digoxin are also continued. In the
event of urgent surgery in a thyrotoxic patient at risk for thyroid storm, a
combination of adrenergic blockers and glucocorticoids may be required and
are administered in consultation with an endocrinologist
♦ Patients with newly diagnosed hypothyroidism generally do not require
preoperative treatment, although they may be subject to increased
sensitivity to medications, including anesthetic agents and narcotics
♦ Severe hypothyroidism can be associated with myocardial dysfunction,
coagulation abnormality, and electrolyte imbalance, notably hypoglycemia.
Severe hypothyroidism needs to be corrected before elective operations
Hematologic
♦ Hematologic assessment may lead to the identification
of disorders such as anemia, inherited or acquired
coagulopathy, or a hypercoagulable state.
♦ Substantial morbidity may derive from failure to
identify these abnormalities preoperatively.
♦ The need for perioperative prophylaxis for venous
thromboembolism must be carefully reviewed in every
surgical patient.
♦ Anemia is the most common laboratory abnormality
encountered in preoperative patients. It is often
asymptomatic and can require further investigation to
understand its cause. The history and physical examination
may uncover subjective complaints of energy loss, dyspnea,
or palpitations, and pallor or cyanosis may be evident
♦ Patients are evaluated for lymphadenopathy, hepatomegaly,
or splenomegaly, and pelvic and rectal examinations are
performed. A CBC, reticulocyte count, and serum iron, total
iron-binding capacity, ferritin, vitamin B12, and folate
levels are obtained to investigate the cause of anemia.
♦ The decision to transfuse a patient perioperatively is made
with consideration of the patient's underlying risk factors
for ischemic heart disease and the estimated magnitude of
blood loss during surgery.
♦ Generally, patients with normovolemic anemia without
significant cardiac risk or anticipated blood loss can be
managed safely without transfusion, with most healthy
patients tolerating hemoglobin levels of 6 or 7 g/dL
♦ Measure the hemoglobin concentration: <6 g/dL, transfusion
usually required; 6-10 g/dL, transfusion dictated by clinical
circumstance; >10 g/dL, transfusion rarely required
ADDITIONAL PREOPERATIVE
CONSIDERATIONS

♦ Older adults account for a

disproportionate percentage of surgical
patients. Risk assessment must
carefully consider the effect of
comorbid illness in this population.
Although age has been reported as an
independent risk factor for
postoperative mortality, this
observation may represent the
unmeasured aspects of comorbid
disease and the severity of illness.
♦ In an older adult patient, the preoperative evaluation seeks to
identify and quantify the magnitude of comorbid disease and
optimize the patient's condition before surgery when possible.
Preoperative testing is based on findings suggested in the
history and physical examination.
♦ Generally, elderly patients have an ECG, chest radiograph, CBC,
and determination of glucose, creatinine, blood urea nitrogen, and
albumin levels. Additional preoperative studies are based on the
criteria discussed earlier for evaluation of patient and
procedural risk.
♦ Predicting and preventing postoperative delirium are important
aspects of the perioperative care of the elderly.
Nutritional Status
♦ Evaluation of the patient's nutritional status is part of the
preoperative evaluation. A history of weight loss greater
than 10% of body weight over a 6-month period or 5% over a
month is significant.
♦ Albumin or prealbumin levels and immune competence (as
assessed by delayed hypersensitivity reaction) may help
identify patients with some degree of malnutrition, and
physical findings of temporal wasting, cachexia, poor
dentition, ascites, or peripheral edema may be corroborative.
♦ The degree of malnutrition is estimated on the basis of
weight loss, physical findings, and plasma protein assessment
♦ Patients with severe malnutrition (as defined by a
combination of weight loss, visceral protein indicators,
and prognostic indices) appear to benefit most from
preoperative parenteral nutrition, as demonstrated in
study groups treated with total parenteral nutrition
for 7 to 10 days before surgery for gastrointestinal
malignancy
♦ Generally, nutritional support begins within 5 to 10
days after surgery in all patients unable to resume
their normal diet. Such support may take the form of
nasoenteric feeding, parenteral nutrition, or a
combination of the two
Obesity
♦ The perioperative mortality rate is significantly increased in
patients with clinically severe obesity (body mass index [BMI] >40
kg/m2 or BMI >35 kg/m2 with significant comorbid conditions).
The goal of preoperative evaluation of an obese patient is to
identify risk factors that might modify perioperative care of the
patient.
♦ Clinically severe obesity is associated with a higher frequency of
essential hypertension, pulmonary hypertension, left ventricular
hypertrophy, congestive heart failure, and ischemic heart disease
♦ Patients with no or one of these risk factors receive a β-blocker
preoperatively for cardioprotection. Patients with two or more
risk factors undergo noninvasive cardiac testing preoperatively
♦ Obesity is also a risk factor for postoperative wound
infection. The rate of wound infections is much lower
with laparoscopic surgery in this group, which could
have a bearing on selection of the operative approach.
♦ Obesity is an independent risk factor for DVT and PE;
therefore, appropriate prophylaxis is instituted in
these patients.
Post-operative care
♦ Aim is to provide quick, painless, and safe recovery
– Immediate post-anaestetic phase
– Intermediate hospital stay
– Convalescent after discharge to full recovery
Immediate phase
♦ Discharge from recovery should be after complete
stabilization of cardio-vascular,pulmonary and
neurological functions which usually takes 2-4 hours.
♦ If not special ICU care is required
Aim of immediate and intermediate phase
♦ Homeostasis
♦ Treatment of pain
♦ Prevention, early detection and treatment of
complications
♦Thank you