PRE AND POST-PRE AND POST-OPERATIVE CARE OF OPERATIVE CARE OF

THE SURGICAL PATIENTTHE SURGICAL PATIENT

I. Assessment of Operative RiskI. Assessment of Operative Risk

A. Natural HistoryA. Natural History

- relative harm (risk)- relative harm (risk)

- relative good (benefit)- relative good (benefit)

B. Stages of the diseaseB. Stages of the disease- error in clinical staging produces the - error in clinical staging produces the greatest number of controversies greatest number of controversies regarding managementregarding management

C. Clinical JudgmentC. Clinical Judgment- deviations of standard treatment is - deviations of standard treatment is associated with significant increase in associated with significant increase in mortality and morbiditymortality and morbidity

D. Basic Factors Affecting Operative D. Basic Factors Affecting Operative RiskRisk

1. Age over 70 years1. Age over 70 years

2. Overall physical status2. Overall physical status

3. Elective vs. emergency surgery 3. Elective vs. emergency surgery

4. Physiologic extent of the tumor4. Physiologic extent of the tumor

5. Associated illnesses5. Associated illnesses

II. Personal RelationshipII. Personal Relationship

A. Genuine bond of communication and personal A. Genuine bond of communication and personal responsibilities.responsibilities.

B. Physician should not convey a sense of hurry B. Physician should not convey a sense of hurry and inadequate time for explanations.and inadequate time for explanations.

C. Involve physicians who have parallel skills to contribute to C. Involve physicians who have parallel skills to contribute to diagnosis and treatment.diagnosis and treatment.

D. Specific treatment.D. Specific treatment.

E. Informed consentE. Informed consent

III. General Preparation of the PatientIII. General Preparation of the Patient

A. Psychological preparationA. Psychological preparation

1. Pre-op steps should be 1. Pre-op steps should be enumerated, enumerated, justified and explained.justified and explained.

2. Surgeons should not equivocate 2. Surgeons should not equivocate in in discussing possible disfiguring discussing possible disfiguring operations.operations.

B. Physiologic considerationsB. Physiologic considerations1. Blood volume considerations1. Blood volume considerations

a. anemia – chronic or acutea. anemia – chronic or acuteb. minimal requirement for b. minimal requirement for

anesthesia – 10 anesthesia – 10 gm/100 ml Hgbgm/100 ml Hgb

2. Determine the physiologic limit 2. Determine the physiologic limit for for tissue oxygen delivery.tissue oxygen delivery.

a. tachycardiaa. tachycardia

b. increase in stroke volumeb. increase in stroke volume

c. increase in oxygen c. increase in oxygen extractionextraction

3. Plasma and extracellular fluid 3. Plasma and extracellular fluid deficitdeficit

- volume and concentration- volume and concentration

a. hourly urine outputa. hourly urine output

b. urine concentrationb. urine concentration

c. mucous membranesc. mucous membranes

d. skin turgord. skin turgor

C. NutritionC. Nutrition1. Serum transferrin1. Serum transferrin2. Serum albumin2. Serum albumin3. WBC count3. WBC count

D. Prevent infectionD. Prevent infection1. Treat distant infections1. Treat distant infections2. Prophylactic antibiotics2. Prophylactic antibiotics

IV. Post-operative CareIV. Post-operative Care

A. Post-op feverA. Post-op fever

- elevated temperature observed in post-op - elevated temperature observed in post-op patients does not necessarily signal a serious patients does not necessarily signal a serious complicationcomplication

- a specific cause is identified in 20% of patients - a specific cause is identified in 20% of patients with pyrexia during the initial 24 hourswith pyrexia during the initial 24 hours

- comprehensive clinical evaluation is essential- comprehensive clinical evaluation is essential

ii

1. Infective causes of post-op fever1. Infective causes of post-op fever

a. community acquired infection a. community acquired infection b. contamination b. contamination c. inadequate blood supplyc. inadequate blood supplyd. neonates and the elderlyd. neonates and the elderlye. systemic factorse. systemic factors

i. DM IIi. DM IIii. hepatic diseaseii. hepatic diseaseiii. immunosupressioniii. immunosupressioniv. malnutritioniv. malnutrition

v.. obesity – due to relatively poor v.. obesity – due to relatively poor blood blood supply of the large supply of the large reservoirs of fatreservoirs of fat

vi. disseminated malignancy – due to vi. disseminated malignancy – due to the the cachectic influences of the primary cachectic influences of the primary

neoplasm and immunosuppression neoplasm and immunosuppression by by chemothera peautic drugschemothera peautic drugs

vii. active infectionvii. active infection

viii. Acute and chronic alcohol intakeviii. Acute and chronic alcohol intake

2. Diagnosis and management2. Diagnosis and management

- should be directed toward recognition - should be directed toward recognition and and eradication of the primary source of eradication of the primary source of exogenous exogenous pyrogenspyrogens

a. Fever within 24 hours – atelectasisa. Fever within 24 hours – atelectasis

b. 5b. 5thth to 10 to 10thth day – wound infection day – wound infection

c. Clinical evaluation is needed c. Clinical evaluation is needed

- rales and ronchi - pneumonia- rales and ronchi - pneumonia

3. Other causes of post-op fever3. Other causes of post-op fever

a. suppurative parotitisa. suppurative parotitis

i. usually elderly or i. usually elderly or debilitated debilitated patientspatients

ii. caused by dehydration ii. caused by dehydration and and poor oral hygienepoor oral hygiene

iii. 2 weeks post-opiii. 2 weeks post-op

iv. Staph. aureus iv. Staph. aureus

b. operative siteb. operative sitei. must always be considered i. must always be considered

for post-op feverfor post-op feverii. 5ii. 5thth post-op day post-op day

c. IV linesc. IV linesi. request for blood culturei. request for blood cultureii. presents as cellulitisii. presents as cellulitisiii. CV line sepsis due to iii. CV line sepsis due to

infected infected thrombus at the thrombus at the tiptip

d. thrombophlebitisd. thrombophlebitisi. 2i. 2ndnd post-op day post-op dayii. catheter should be removed ii. catheter should be removed

at first sign of infectionat first sign of infectioniii. more frequent in the lower iii. more frequent in the lower extremitiesextremitiesiv. pus may be presentiv. pus may be presentv. high fever and (+) blood v. high fever and (+) blood

cultureculturevi. treatment consists of excising vi. treatment consists of excising

veinvein

B. Non-infective causes of Post-op FeverB. Non-infective causes of Post-op Fever1. Disseminated malignancy1. Disseminated malignancy2. Transfusion reaction2. Transfusion reaction3. Hematoma3. Hematoma4. Administration of irritant fluids or 4. Administration of irritant fluids or drugsdrugs5. Acute pancreatitis5. Acute pancreatitis6. Thyroid storm6. Thyroid storm7. Pheochromocytoma7. Pheochromocytoma8. Dehydration8. Dehydration

C. Factors influencing likelihood of post-op C. Factors influencing likelihood of post-op infectioninfection

1. Definite decrease in host resistance1. Definite decrease in host resistancea. increasing age a. increasing age b. obesity/malnutritionb. obesity/malnutritionc. diabetic ketoacidosisc. diabetic ketoacidosisd. acute/chronic steroid used. acute/chronic steroid usee. immunosuppressive drugse. immunosuppressive drugsf. remote infectionsf. remote infections

2. Possible decrease in host 2. Possible decrease in host resistanceresistance

a. some forms of cancera. some forms of cancer

b. radiation therapyb. radiation therapy

c. adrenocortical insufficiencyc. adrenocortical insufficiency

d. foreign bodyd. foreign body

e. early shaving of the e. early shaving of the operative operative sitesite

3. No effect on host resistance3. No effect on host resistance

a. gendera. gender

b. raceb. race

c. controlled DMc. controlled DM

d. acute nutritional d. acute nutritional deprivationdeprivation

C. Operations benefiting from antibiotic C. Operations benefiting from antibiotic prophlaxisprophlaxis

1. Head and neck surgery with open 1. Head and neck surgery with open aerodigestive tractaerodigestive tract

2. Esophageal except hiatal hernia repair2. Esophageal except hiatal hernia repair

3. Gastroduodenal except for 3. Gastroduodenal except for complications of uncorrected hyperaciditycomplications of uncorrected hyperacidity

4. Biliary tract surgery4. Biliary tract surgerya. patients over 70 years olda. patients over 70 years oldb. acute cholecystitisb. acute cholecystitisc. choledochostomyc. choledochostomy

5. Bowel resection5. Bowel resection

6. Perforated or gangrenous appendicitis6. Perforated or gangrenous appendicitis

7. Hysterectomy7. Hysterectomy

8. Revascularization and prosthetic graft surgery8. Revascularization and prosthetic graft surgery

9. Orthopedic surgeries with implantation of prosthesis9. Orthopedic surgeries with implantation of prosthesis

D. Operative technique to minimize infectionD. Operative technique to minimize infection1. Eliminate hair, if necessary, just prior 1. Eliminate hair, if necessary, just prior to incision timeto incision time

2. Effective skin preparation2. Effective skin preparation

3. Gentle and effective handling of 3. Gentle and effective handling of tissuestissues

4. Effective hemostasis4. Effective hemostasis

5. Eradicate dead space5. Eradicate dead space

6. Minimize operative time6. Minimize operative time

7. Closed suction drain a distance from the incision7. Closed suction drain a distance from the incision

E. Pre-operative factors associated with E. Pre-operative factors associated with post-operative cardiac complication in order post-operative cardiac complication in order of discovery significanceof discovery significance

1. Jugular vein distention or S3 gallop - 1. Jugular vein distention or S3 gallop -

11 points11 points

2. Myocardial infarct within 6 months 2. Myocardial infarct within 6 months or or S3 S3 gallop – 10 pointsgallop – 10 points

3. Premature atrial contractions or 3. Premature atrial contractions or rhythm other than sinus on rhythm other than sinus on ECG – 7 ECG – 7 pointspoints

4. 3-5 PVC’s/minute – 7 points4. 3-5 PVC’s/minute – 7 points

5. Age over 70 – 5 points5. Age over 70 – 5 points

6. Significant aortic stenosis – 3 points6. Significant aortic stenosis – 3 points

ss

7. Poor general medical condition – 3 7. Poor general medical condition – 3 pointspoints

a. PaO2<60 mm Hga. PaO2<60 mm Hg PaCO2>50 mm HgPaCO2>50 mm Hg

b. Potassium<3 meqb. Potassium<3 meq Bicarbonate<20 meqBicarbonate<20 meq

c. BUN > 50 mg/100 mlc. BUN > 50 mg/100 ml Crea > 3.0 mg/100 mlCrea > 3.0 mg/100 ml

d. increased transaminasesd. increased transaminases

e. signs of chronic liver diseasee. signs of chronic liver disease

f. patient bedridden for non-cardiac f. patient bedridden for non-cardiac causescauses

8. Operation8. Operationa. emergency – 4 pointsa. emergency – 4 points

b. intraperitoneal, intrathoracic, aortic – b. intraperitoneal, intrathoracic, aortic – 3 points3 points

TOTAL – 53 pointsTOTAL – 53 points

F. Pre –operative risk factors for post-F. Pre –operative risk factors for post-operative pulmonary compilicationsoperative pulmonary compilications

1. Thoracic and upper abdominal 1. Thoracic and upper abdominal surgerysurgery

2. Pre-op history of COPD2. Pre-op history of COPD

3. Purulent productive cough3. Purulent productive cough

4. Anesthesia time greater than 3 4. Anesthesia time greater than 3 hourshours

6. Age greater than 60 years old6. Age greater than 60 years old

7. Obesity7. Obesity

8. Poor state of nutrition8. Poor state of nutrition

9. Symptoms of respiratory disease9. Symptoms of respiratory disease

10. Abnormal findings on P.E.10. Abnormal findings on P.E.

11. Abnormal chest film findings11. Abnormal chest film findings

G. Peri-operative prophlactic G. Peri-operative prophlactic pulmonary pulmonary maneuversmaneuvers

1. Cessation of smoking1. Cessation of smoking

2. Bronchodilators2. Bronchodilators

3. Chest physiotherapy and 3. Chest physiotherapy and postural postural drainagedrainage

4. Pre-operative education and post-4. Pre-operative education and post-operative use of incentive operative use of incentive

spirometry spirometry and deep breathing and deep breathing excercisesexcercises

5. Pre-operative antibiotics if sputum 5. Pre-operative antibiotics if sputum is is purulentpurulent

6. Early post-operative antibiotics6. Early post-operative antibiotics

H. A sample of pre-operative checklistH. A sample of pre-operative checklist

1. Operative permit – appropriately 1. Operative permit – appropriately signed and signed and witnessedwitnessed

2. Dietary considerations2. Dietary considerations

3. Review of life support systems3. Review of life support systemsa. vital sign recordingsa. vital sign recordingsb. cxr and other pulmonary studiesb. cxr and other pulmonary studiesc. ECG and other cardiac studiesc. ECG and other cardiac studiesd. BUN/Creatinine and other renal studiesd. BUN/Creatinine and other renal studies

4. Adequate hydration up to time of surgery 4. Adequate hydration up to time of surgery

5. Area of operation to be washed and shaved with 5. Area of operation to be washed and shaved with antimicrobialsantimicrobials

6. Prepare blood for possible transfusion6. Prepare blood for possible transfusion

7. Order that the patient void on call7. Order that the patient void on call

8. Pre-operative medications8. Pre-operative medications

9. Special9. Special medicationsmedications