Transcript pre and post-operative care of the surgical patient

PRE AND POST-OPERATIVE
CARE OF THE SURGICAL
PATIENT
I. Assessment of Operative Risk
A. Natural History
- relative harm (risk)
- relative good (benefit)
B. Stages of the disease
- error in clinical staging produces the
greatest number of controversies regarding
management
C. Clinical Judgment
- deviations of standard treatment is
associated with significant increase in
mortality and morbidity
D. Basic Factors Affecting Operative Risk
1. Age over 70 years
2. Overall physical status
3. Elective vs. emergency surgery
4. Physiologic extent of the tumor
5. Associated illnesses
II. Personal Relationship
A. Genuine bond of communication and personal responsibilities.
B. Physician should not convey a sense of hurry
and inadequate time for explanations.
C. Involve physicians who have parallel skills to contribute to diagnosis
and treatment.
D. Specific treatment.
E. Informed consent
III. General Preparation of the Patient
A. Psychological preparation
1. Pre-op steps should be enumerated,
justified and explained.
2. Surgeons should not equivocate in
discussing possible disfiguring
operations.
B. Physiologic considerations
1. Blood volume considerations
a. anemia – chronic or acute
b. minimal requirement for
anesthesia – 10 gm/100 ml Hgb
2. Determine the physiologic limit for
tissue oxygen delivery.
a. tachycardia
b. increase in stroke volume
c. increase in oxygen extraction
3. Plasma and extracellular fluid deficit
- volume and concentration
a. hourly urine output
b. urine concentration
c. mucous membranes
d. skin turgor
C. Nutrition
1. Serum transferrin
2. Serum albumin
3. WBC count
D. Prevent infection
1. Treat distant infections
2. Prophylactic antibiotics
IV. Post-operative Care
A. Post-op fever
- elevated temperature observed in post-op
patients does not necessarily signal a serious
complication
- a specific cause is identified in 20% of patients
with pyrexia during the initial 24 hours
- comprehensive clinical evaluation is essential
i
1. Infective causes of post-op fever
a. community acquired infection
b. contamination
c. inadequate blood supply
d. neonates and the elderly
e. systemic factors
i. DM II
ii. hepatic disease
iii. immunosupression
iv. malnutrition
v.. obesity – due to relatively poor blood
supply of the large reservoirs of fat
vi. disseminated malignancy – due to the
cachectic influences of the primary
neoplasm and immunosuppression by
chemothera peautic drugs
vii. active infection
viii. Acute and chronic alcohol intake
2. Diagnosis and management
- should be directed toward recognition and
eradication of the primary source of exogenous
pyrogens
a. Fever within 24 hours – atelectasis
b. 5th to 10th day – wound infection
c. Clinical evaluation is needed
- rales and ronchi - pneumonia
3. Other causes of post-op fever
a. suppurative parotitis
i. usually elderly or debilitated
patients
ii. caused by dehydration and
poor oral hygiene
iii. 2 weeks post-op
iv. Staph. aureus
b. operative site
i. must always be considered
for post-op fever
ii. 5th post-op day
c. IV lines
i. request for blood culture
ii. presents as cellulitis
iii. CV line sepsis due to infected
thrombus at the tip
d. thrombophlebitis
i. 2nd post-op day
ii. catheter should be removed
at first sign of infection
iii. more frequent in the lower
extremities
iv. pus may be present
v. high fever and (+) blood culture
vi. treatment consists of excising
vein
B. Non-infective causes of Post-op Fever
1. Disseminated malignancy
2. Transfusion reaction
3. Hematoma
4. Administration of irritant fluids or
5. Acute pancreatitis
6. Thyroid storm
7. Pheochromocytoma
8. Dehydration
drugs
C. Factors influencing likelihood of post-op
infection
1. Definite decrease in host resistance
a. increasing age
b. obesity/malnutrition
c. diabetic ketoacidosis
d. acute/chronic steroid use
e. immunosuppressive drugs
f. remote infections
2. Possible decrease in host resistance
a. some forms of cancer
b. radiation therapy
c. adrenocortical insufficiency
d. foreign body
e. early shaving of the operative
site
3. No effect on host resistance
a. gender
b. race
c. controlled DM
d. acute nutritional deprivation
C. Operations benefiting from antibiotic prophlaxis
1. Head and neck surgery with open
aerodigestive tract
2. Esophageal except hiatal hernia repair
3. Gastroduodenal except for
complications of uncorrected hyperacidity
4. Biliary tract surgery
a. patients over 70 years old
b. acute cholecystitis
c. choledochostomy
5. Bowel resection
6. Perforated or gangrenous appendicitis
7. Hysterectomy
8. Revascularization and prosthetic graft surgery
9. Orthopedic surgeries with implantation of prosthesis
D. Operative technique to minimize infection
1. Eliminate hair, if necessary, just prior to incision time
2. Effective skin preparation
3. Gentle and effective handling of
tissues
4. Effective hemostasis
5. Eradicate dead space
6. Minimize operative time
7. Closed suction drain a distance from the incision
E. Pre-operative factors associated with postoperative cardiac complication in order of
discovery significance
1. Jugular vein distention or S3 gallop 11 points
2. Myocardial infarct within 6 months or S3
gallop – 10 points
3. Premature atrial contractions or
rhythm other than sinus on ECG – 7
points
4. 3-5 PVC’s/minute – 7 points
5. Age over 70 – 5 points
6. Significant aortic stenosis – 3 points
7. Poor general medical condition – 3 points
a. PaO2<60 mm Hg
PaCO2>50 mm Hg
b. Potassium<3 meq
Bicarbonate<20 meq
c. BUN > 50 mg/100 ml
Crea > 3.0 mg/100 ml
d. increased transaminases
e. signs of chronic liver disease
f. patient bedridden for non-cardiac
causes
8. Operation
a. emergency – 4 points
b. intraperitoneal, intrathoracic, aortic – 3 points
TOTAL – 53 points
F. Pre –operative risk factors for postoperative pulmonary compilications
1. Thoracic and upper abdominal surgery
2. Pre-op history of COPD
3. Purulent productive cough
4. Anesthesia time greater than 3 hours
6. Age greater than 60 years old
7. Obesity
8. Poor state of nutrition
9. Symptoms of respiratory disease
10. Abnormal findings on P.E.
11. Abnormal chest film findings
G. Peri-operative prophlactic pulmonary
maneuvers
1. Cessation of smoking
2. Bronchodilators
3. Chest physiotherapy and postural
drainage
4. Pre-operative education and postoperative use of incentive spirometry
and deep breathing excercises
5. Pre-operative antibiotics if sputum is
purulent
6. Early post-operative antibiotics
H. A sample of pre-operative checklist
1. Operative permit – appropriately
signed and witnessed
2. Dietary considerations
3. Review of life support systems
a. vital sign recordings
b. cxr and other pulmonary studies
c. ECG and other cardiac studies
d. BUN/Creatinine and other renal studies
4. Adequate hydration up to time of surgery
5. Area of operation to be washed and shaved with
antimicrobials
6. Prepare blood for possible transfusion
7. Order that the patient void on call
8. Pre-operative medications
9. Special medications