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peri-operative care

Preoperative & Postoperative care


Shaikah A.O.B

Objective :
1. 2. 3. 4.

Outline type ,class and grade of surgery. Define the perioperative . Discuses the general preoperative care . Overview the anesthetic status classification and airway evaluation . Discuses the common medical problems affecting a patients fitness for operation. ( specific

5.

pre- op Assessment )
6. 7. 8.

Notes about inter- operative complication . Discuses the post-operative care . Minchin the postoperative possible complications .

Surgery
Clean Surgery.

Clean-Contaminated.

Contaminated.

Dirty.

PHASES OF SURGERY
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Pre-operative from the time of pxs decision for surgical intervention to the pxs tranference to the OR. Intra-operative px is received in the OR (with physical preparation) unto the admission in the RR. Post-operative pxs admission in the RR until the follow-up evaluation.

Effects of Surgery
` ` ` ` `

Stress Response Activation (SRA) Decreased resistance to infection Alteration in the vascular and respiratory function Vital organ function (VOF) is altered Psychologic effects (common fears r/t SRA)

Types of surgery
1- According to pt. A-In pt. surgery : pt. expected to remain in the hospital fore more than 24
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hrs.

B-0ut pt. surgery : ambulatory surgery same day surgery pt. return to his
home in the same day of surgery.

2- According to their urgency A-optional : at the request of pt. as cosmetic surgery . B-Elective : planned the convenience of pt. as removal of cyst C- required : should be done promptly as removal of cataract d-Urgent : required promptly within 24-48 hrs as malignant tumor E-Emergency : Immediately for survival as intestinal obstruction
appendectomy

Classification
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Clean Clean Contaminated Contaminated Dirty

Grades of Surgery
Grade I (Minor) Excision of a skin lesion or drainage of abscess. Grade II (Intermediate) Tonsillectomy, correction of nasal septum, arthroscopy. Grade III (Major) Thyroidectomy, total abdominal hysterectomy. Grade IV (Major+) Radical neck dissection, joint replacement, lung operations

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peri-operative care

Three Phases of peri-operative care


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Perioperative Period: Period of the time that constitute the surgical experience, include :Pre-operative . Inter- operative. Post operative .

Definition : Pre operative care :

is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation

purpose of preoperative evaluation


` ` `

Establish baseline history and physical. Identify previously undetected disease. Assess operative risk. Should the patient proceed with

elective surgery?  Provide high-quality and safe patient care .  Improve patient satisfaction and set foundation for optimum outcomes
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Make specific recommendations regarding preoperative treatment that might lower the risk of surgery. Give suggestions regarding intraoperative and postoperative care.

Pre-operative Care

Assessment (evaluation). History


Examination Investigations

Pro-op preparation .
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Psychological preparation ` Physical preparation Physiological preparation

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Counseling. On going to theater.

History and Physical Examination


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Diagnosis of current condition Identifies associated risk factors:


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Age of the patient (Extremes of age) Co-morbid conditions Previous surgery

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Determines current medications Reviews past medical history Determines physical status:
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American Society of Anesthesiologists (ASA) Physical Status Assessment

Key topics to review when taking the past medical history


Cardiovascular Respiratory Gastrointestinal Genitourinary tract Neurological Endocrine/metabolic Locomotor system Infectious diseases Previous surgery Types of anaesthetic and any problems encountereda Have any members of the patients family had particular problems with anaesthesia?

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Key topics in the general medical examination General


` ` ` ` ` ` ` ` ` ` ` ` ` `

Anaemia, jaundice, cyanosis, nutritional status, teeth, feet, leg ulcers (sources of infection) Cardiovascular Pulse, blood pressure, heart sounds, bruits, peripheral pulses, peripheral oedema Respiratory Respiratory rate and effort, chest expansion and percussion note, breath sounds, oxygen saturation Gastrointestinal Abdominal masses, ascites, bowel sounds, bruits, herniae, genitalia Neurological Conscious level, any pre-existing cognitive impairment or confusion, deafness, neurological status of limbs

American Society of Anesthesiologists Patient Classification


1 =A normal healthy patient 2 =A patient with a mild systemic disease 3 = A patient with a severe systemic disease that limits activity, but is not incapacitating 4 =A patient with an incapacitating systemic disease that is a constant threat to life 5 =A moribund patient not expected to survive 24 hours with or without operation

ASA 1 ` A normal, healthy patient. The pathological process for which surgery is to be performed is localized and does not entail a systemic disease. Example: An otherwise healthy patient scheduled for a cosmetic procedure.

ASA 2 ` A patient with systemic disease, caused either by the condition to be treated or other pathophysiological process, but which does not result in limitation of activity. Example: a patient with asthma, diabetes, or hypertension that is well controlled with medical therapy, and has no systemic sequelae

ASA 3 ` A patient with moderate or severe systemic disease caused either by the condition to be treated surgically or other pathophysiological processes, which does limit activity. Example: a patient with uncontrolled asthma that limits activity, or diabetes that has systemic sequelae such as retinopathy

ASA 4 ` A patient with severe systemic disease that is a constant potential threat to life. Example: a patient with heart failure, or a patient with renal failure requiring dialysis.

ASA 5 ` A patient who is at substantial risk of death within 24 hours, and is submitted to the procedure in desperation. Example: a patient with fixed and dilated pupils status post a head injury.

Emergency Status (E)


This is added to the ASA designation only if the patient is undergoing an emergency procedure. Example: a healthy patient undergoing sedation for reduction of a displaced fracture would be an ASA1 E.

Investigation :
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The request for pre-operative investigations should be based on:Factors apparent from the clinical assessment The likelihood of asymptomatic abnormalities The severity of the surgery contemplated Pre-operative investigations rarely uncover unsuspected medical conditions Inefficient as a means of screening for asymptomatic disease 5% of patients have abnormalities on investigations not predicted by a clinical assessment 0.1% of these investigations ever change the patients management 70% of pre-operative investigations could be eliminated without adverse effect

` ` ` ` `

General Ix :` ` ` ` ` ` ` ` ` `

Full blood count (for example to test for anaemia) Haemostasis (to test how well the blood clots) Renal function Random blood glucose (to test for diabetes) Urine analysis (for example to test for urinary infections or kidney problems) Plain chest X-ray (radiograph) Resting electrocardiogram (ECG) Blood gases (to test for cardiovascular or lung problems) Lung function Pregnancy

Indications for preoperative investigations


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Full blood count


All adult women Men over the age of 60 years Cardiovascular or haematological disease

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Urea & electrolytes


All patients over 60 years Cardiovascular and renal disease Diabetics Patients on steroids, diuretics, ACE inhibitors

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` ` `

Chest X-ray
Cardiovascular and respiratory disease Malignancy Major thoracic and upper abdominal surgery

ECG
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Indicated :` ` ` ` ` `

Men > 45 y - Women > 55 y . Known cardiac disease . H&P suggesting possibility of cardiac disease . Electrolyte imbalance risk (ie diuretic use) . DM/HTN . Candidates for major surgeries .

NOTE ECG :
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Low likelihood of changing management Recent MI important to detect Cardiac event risk increased by:
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Non-sinus rhythm PACs - Premature atriale contractions >5 PVCs - Premature ventricle contractions

No risk increase with BBB

NOTE:
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 as Jaundice, Bleeding tendency 6.Chronic drug medication as Oral contraceptive pills.
     

Anticoagulants Tranquilizers (hypnotic as benzodiazepine) Antibiotics aminoglycosides Diuretics Antihypertensives Long term steroid therapy

(P.S ) : Blood volume considerations:a. anemia chronic or acute b. minimal requirement for anesthesia 10 g/dl Hgb

NOTE:
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Problems in elderly:
` ` ` ` `

Tolerate hypo tension, tachycardia, over and under-hydration poorly Usually emphysema, they are used to a high level of PCO2 which leads to respiratory acidosis Atherosclerosis makes their CVS very fragile any sudden increase in B.P. can cause cerebral haemorrhage. Sluggish peripheral circulation higher chances of Thromboembolism and Pulmonary embolism Poorly tolerate acid-base imbalance They have a raised BMR lot of carbohydrates preoperatively and quick feeding postoperatively Very high incidence of Respiratory tract infection Poorly tolerate fever and cold

Problems of children:
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Airway evaluation
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History of difficult intubation Head and neck examination for airway evaluation Face Oral cavity : mouth opening
mandibular space tongue teeth Mallampati classification

Mallampati classification

Airway evaluation
` ` ` ` `

Mentothyroid distance : normal 6 cm. Mentosternal distance : normal 15 cm Mentohyoid distance : normal 3 FB Neck movement: flexion and extension of neck, history of radiation Nasal cavity

Thyromental distance

Difficult intubation
` ` ` ` ` ` `

Mouth opening less than 3 cm. Limitation of neck movement Micrognatia Macroglossia Protusion of teeth Short neck Morbid obesity

Wilson Risk Test

specific pre- op Assessment

Specific Risks
` ` ` ` ` `

Pulmonary Cardiac Hepatic Hematologic Endocrine Thromboembolism Prophylaxis

Pulmonary Risks
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Complications
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Hypoventilation Pneumonia Atelectasis

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Occur in about a third of patients Accounts for half of perioperative mortality

Whos at Risk
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Smokers COPD Obesity ` q lung capacity, FRC,VC ,Hypoxemia Age > 70 Procedure related risks: ` Type of anesthesia ` GETA alone q FRC 11% ` inhibited coughing peri-op ` Surgical site Thoracic surgery Upper abdominal surgery ` Duration of surgery > 2 hours

Pulmonary Assessment :
Patient History: ` unexplained dyspnea, cough, reduced exercise tolerance ` Physical Exam: ` wheeze, rhonchi, o exp time, q Birthing Sound ` Pre-operative CXR: ` Mandatory in patients over 40 yo ` B.N ABG: no role for routine use result should not prohibit surgery
`

Pulmonary Assessment :
` ` ` ` `

Pulmonary Function test N.B FEV1 > 2L, probably safe FEV1 between 1 and 2L, increased risk FEV1 <1L, high risk

Risk Management
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Quit smoking Bronchodilator therapy PT ( physiotherapy ) . Early treatment of bronchitis Early mobilization

NOTE
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Smoking cessation
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24 hr: decrease carboxyhemoglobin 2-3 day: increase ciliary function but increase secretion 1-2 wk: decrease secretion 4-8 wks: decrease postop pulmonary complication

Cardiac Risks
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Complications
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Myocardial Infarction CHF Hypertension

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50% fatal, 60% silent Increased mortality post-op day 3

Whos at Risk
` ` ` ` `

Recent MI (Interval between MI time and surgery less than 6 mo is more likely with reinfarction) Valvular heart disease CHF Unstable angina Diabetes

Cardiac Assessment
Resting echocardiogram function ` Exercise stress testing ` Pharmacologic stress testing ` Dipyridamole or adenosine thallium ` Dobutamine echo ` Coronary angiography P.S: ` Goldman Cardiac Risk-Index for Noncardiac Surgery ` American College of Cardiology Risk Assessment
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Goldman Criteria

Points S3 gallop or jugular venous distention on preoperative physical examination Transmural or subendocardial myocardial infraction in the previous 6 months Premature ventricular beats, more than 5/min documented at any time Rhythm other than sinus or presence of premature atrial contractions on last preoperative electrocardiogram Age over 70 years Emergency operation Intrathoracic, intraperitoneal or aortic site of surgery Evidence of important valvular aortic stenosis Poor general medical condition (Ke 3, HCO3 e 20, BUN > 50, Cr > 3, pO2 < 60, pCO2> 40 Abnormal liver (oGOT), or bedridden) 11

10 7 7 5 4 3 3 3

Goldman s risk of noncardiac surgery


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Cardiac Morbidity Death Class I (0 to 5 points) Class II (6 to 12 points) Class III (12 to 25 points) Class IV (26 or more) 0.7% 5% 11% 22%

Cardiac 0.2% 2% 2% 56%

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-Predicted complication of class 4 well -Low sensitivity for identifying high-risk patient in the intermediate risk groups

Lee's Revised Cardiac Risk Index


Clinical variable Points High-risk surgery (i.e., intraperitoneal, intrathoracic, or suprainguinal vascular surgery) 1 Coronary artery disease 1* Congestive heart failure 1 History of CVD 1 Insulin for diabetes mellitus 1 Preoperative SCr > 2.0 mg/dL 1 Total:__1__

Interpretation of Risk Score


` ` ` ` `

Risk class I.Very low II. Low III. Moderate IV. High

Points 0 1 2 3

Complication* risk 0.4% 0.9% 6.6% +11.0%

*- MI, PE, VF, cardiac arrest, or complete heart block.

Risk Management
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Monitor for perioperative ischemia Repair severe aortic stenosis first Treat CHF aggresively preoperative Postpone non-emergent procedures for at least 6 months after an MI Continue medication except anticoagulant or antifibrinolytic: aspirin,warfarin,ticlopidine etc. Digitalis : discontinue except in severe arrhythmia

Patient risk for MI postop


1. 2. 3. 4. 5.

DM Peripheral vascular disease HT Tobacco used Hypercholesterolemia

Hepatic disease Assessment


` ` ` ` `

Liver is the seat of metabolism of most of the anaesthetic drugs. in the pre-operative phase it requires plenty of carbohydrates,Vitamin K and other clotting factors. Liver function tests not only reveal the state of the liver but other organs as well as the Heart. Serum Cholesterol, Triglyserides, Proteins and Albumin are routinely done. If 1gm%. Protein is less in blood 900 grams is less in the body.

Child-Pugh Criteria for Hepatic Reserve


Measure
Bilirubin Albumin Prothrombin Time (PT) increase Ascites Neuro <2.0 >3.5 1 -3

A
2 -3

B
>3.0 <2.8 >6

2.8-3.5 2.84 -6

None None

Slight Minimal

Moderate Coma

Child-Pugh Criteria for Hepatic Reserve


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Predictor of perioperative mortality:


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Class A: Class B: Class C:

0 - 5% 10 15% > 25%

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Correct what you can p vitamin K, FFP, Albumin, etc. Anticipate bleeding, complications P.S Dont operate Px with active hepatitis , Dont Op. Px with hepatic encephalopathy.

Townsend, Textbook of Surgery, 16th ed.

Hypertension
History of end organ damage: cardiac ischemia, renal, neurological ` Elective surgery should be delayed if DBP 110 mmHg with or without new onset of headache ` but if no sign of end organ damage surgery may be proceed ` In DM keep DBP < 90mmHg ` Aggressive treatment associated with reduction in long term risk ` Continue medication until day of surgery: ACEI and diuretic may be discontinue
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Renal Risk
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Not all renal failure is oliguric

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CRF CRF patient risk of congestive heart failure, hyper K, plt.dysfunction, anemia After dialysis pt at risk of hypovolumia

Assessment
` ` ` ` `

Urine analysis , creatinine , BUN dialysis, type of dialysis, last dialysis, serum K, Hct. and platelet function

Specific Factors affecting Operative Risk Renal


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Pre op. Baseline renal function studies:


` ` `

BUN Creatinine GFR

`
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Avoid rise in BP b/c it will exacerbate RF.


Assume DM have CRI ` Volume status ` Electrolytes

Careful admin. Of drugs: ` Nephrotoxicity P.S catheter drainage of an obstructed urinary

tract

How to manage patient with CRF

on dialysis previously.

OR
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Not on dialysis previously

CRF Patient on dialysis previously :


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Dialysis 24 h before surgery to minimize risk of :


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volume overload hyper K Excess bleeding.

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Check U/E ,creatinine postdialysis. CXR to exclude pulm. Edema. Post op dialysis delayed 24h.

CRF Patient NOT on dialysis previously:


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IF: -Euvolemic -No electrolyte disturbances, bleeding tendency. -responsive to diuretic .

P.S no need for dialysis before surgery. But if patient develops diuretic resistance with progressive edema pre op. dialysis is considered

Endocrine Risks
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Thyroid storm Diabetic complications

Risk Management
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Good control of thyroid function for at least 3 months prior Hold oral hypoglycemics Reduce insulin by half

The Rx goal of the preoperative management of diabetic patients


To avoid :
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Hypoglycemia Excessive hyperglycemia Electrolyte disturbance Protein catabolism

Principles of management of diabetes in pre operative period:


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the patients are insulin dependent . On oral hypoglycemic. Or controlled by diet.

Insulin dependent :
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Admit 2 days preoperatively: CXR, ECG, FBS, U&E, HbA1c. Establish good diabetic control (glucose 4-10 mmol/L). TTT : but them on Dextrose /insulin / K infusion

Insulin dependent
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Check glucose intra-operatively and U&E postoperatively. Monitor glucose regularly in early postoperative period. Continue infusion until full oral diet is establish and then reinstitute normal insulin regime.

Oral hypoglycemic
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Review control. Major surgery: convert to glucose /insulin / K infusion . Minor surgery : omit oral hypoglycemic agent. Check blood sugar. If greater than 13 mmol/l give small dose of subcutaneous insulin .

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Diabetic control by diet alone


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Review control.

if preoperative control is adequate , no other measure required other than routine check of blood sugar preand postoperatively.

Evaluation of Hemostatic Disorders


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History:
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Easy bruising, epistaxis


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Cut when shaving Heavy menstrual bleeding

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Family history of bleeding disorders ASA / NSAIDs Renal disease Hepatic disease (EtOH) Ecchymoses Hepatosplenomegaly Excessive mobility of joints or excess skin laxity Stigmata of renal or hepatic disease

Physical:
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Laboratory Tests of Bleeding Function


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Prothrombin time (PT/INR


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international normalized ratio

):

Measures factor VII and common pathway factors (factor X, prothrombin/thrombin, fibrinogen, and fibrin) Intrinsic pathway and common pathway quantifies platelets estimates qualitative platelet function

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Partial thromboplastin time (PTT):


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Platelet count:
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Bleeding time and Clotting time:


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Patients on Anticoagulants
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Aspirin (ASA) Coumadin (Warfarin) Heparin

Reasons patients are placed on anticoagulants:


Atrial fibrillation Prosthetic heart valve DVT or PE CVA or TIA Hypercoagulable state
1Ridker et

al Ann Intern Med 114:835-839, 1991.

Preoperative transfusion may:


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Induce immunosuppression Increase risk of infection Increase risk of tumour recurrence If transfusion is required it should be given at least 2 days preoperatively Blood transfused immediately prior to operation has reduced O2 carrying capacity

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Thrombembolic Prophylaxis
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Specific to surgery:
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Acute spinal cord injury Major trauma Major surgery including: - general cancer or non-cancer surgery - hip and knee arthroplasty - open gynaecological surgery - open urological surgery - prolonged surgery

Increased risk
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Elderly Obesity Prolonged anesthesia Immobility

Recommendations for thromboembolism prophylaxis


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Indications Surgical procedures generally requiring venous thromboembolism prophylaxis


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Acute spinal cord injury Major trauma Major surgery including: - general cancer or non-cancer surgery - hip and knee arthroplasty - open gynaecological surgery - open urological surgery - prolonged surgery

Surgical procedures generally not requiring venous thromboembolism prophylaxis when no additional risk factors are present
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Elective spine surgery Knee arthroscopy Isolated lower extremity injuries Laparoscopic surgery Transurethral surgery Vascular surgery Congestive heart failure Severe respiratory disease Immobility plus: - cancer - previous venous thromboembolism - sepsis - acute neurological disease - inflammatory bowel disease

Medical conditions generally requiring venous thromboembolism prophylaxis


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Risk factors for DVT


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Age >40 years Obesity Varicose veins High oestrogen pill Previous DVT or PE Malignancy Infection Heart failure / recent infarction Polycythaemia /thrombophilia Immobility ( bed rest over 4 days) Major trauma Duration of surgery.

Patients who are malnourished


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Proteins are essential for healing and regenerating tissue Malnourished patients have
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Higher wound complications (dehiscence in which a wound breaks open along surgical suture) and greater anastomotic leak rate More postoperative muscle weakness (diaphragm) Longer time in rehabilitation

Nutritional assessment
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Clinical assessment
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Weight loss 10% =mild malnutrition 30% = severe malnutrition BMI Triceps skin fold thickness Mid arm circumference Hand grip strength Reduced serum albumin, prealbumin or transferrin Lymphocyte count

Anthropometric assessment
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Blood indices
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End-of-bedogram No index of nutritional assessment shown to be superior to clinical assessment

Methods of nutritional support


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Use gastrointestinal tract if available Prolonged post-operative starvation is probably not required Early enteral nutrition reduced post-operative morbidity

P.S. ` Indications for total parenteral nutrition

Absolute indications
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Enterocutaneous fistulae Moderate or severe malnutrition Acute pancreatitis Abdominal sepsis Prolonged ileus Major trauma and burns Severe inflammatory bowel disease

Relative indications
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Pre-operative preparation
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NPO Bowel Preparation Skin preparation Pre-op medications (Pharmocology). Blood availability Venous access Remove any artificial things Thromboembolic prophylaxis Wound infection prophylaxis

Patient Preparation
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Psychological:
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Acceptance and positive outlook , decrease Anxiety . Skin preparation Bowel preparation Opiates Anticholinergics Barbiturates Prophylactic antibiotics Correcting associated co-morbid conditions Patient optimization

Physical: Preaneasthetic medications


   

Physiological:
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A. Blood Orders: 1. Type and screen or type and cross for number of units appropriate to the procedure B. Skin Preparation: 1. Hair removal best performed on day of surgery with an electric clipper 2. Pre-operative scrub or shower of the operative site with a germicidal soap. C. Pre-operative antibiotics: 1. Administer prophylactic antibiotics 30 min prior to incision

D. Respiratory Care: 1. Pre-operative spirometry on the evening prior to surgery when indicated 2. Bronchodilators for moderate to severe COPD

E. Decompression of GI tract: 1. NPO after midnight

NPO Guideline
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NPO 6-8 hr. before surgery Clear liquid diet for 2 hr.
Age Solids Clear 4h 6h 6h Liquids Clear 2h 3h 2h

Children
 Clear

liquid 2 hr <6 months  Breast milk 4 hr 6- 36 month  Infant formula 6 hr > 36 month  solid diet 8 hr. Guideline used for patient with no proble with gastric emptying time

5% Dextrose in Lactated Ringer's Injection (D5LR):Hypertonic (cells shrink), Uses: hypertonic hydration; provides some calories; replace electrolytes and ECF losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis), the dextrose minimizes glycogen depletion, Complications: Same as LR - not enough electrolytes for maintenance; patients with hepatic disease have trouble metabolizing the lactate; do not use if lactic acidosis is presen

F. Intravenous fluids: 1. Maintenance rate overnight (D5LR) 2. Plasma and extracellular fluid deficit- volume and concentration a. hourly urine output b. urine concentration c. mucous membranes d. skin turgor G. Access and Monitoring lines: 1. At least one ga.18 IV needed for initiation of anesthesia 2. Arterial catheters and central or pulmonary artery catheters when indicated

H. Thromboembolic prophylaxis: 1. When indicated (those predispose to deep venous thrombosis) I. Pre-operative sedation: 1. As ordered by the anesthesiologist

J. Special Consideration: 1. Maintenance medication 2. Pre-operative diabetic management 3. Other prophylactic medications 4. Peri-operative steroid coverage (if needed) K. Skin Marking: 1. For Plastic/Reconstructive Surgeries 2. Marking of stoma sites P. Pre-operative notes

Intraoperative

Intraoperative Care -Complication


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Hypoventilation Oral Trauma endotracheal intubation Hypotension

Cardiac dysrhythmia Hypothermia Peripheral nerve damage Malignant hyperthermia

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Malignant hyperthermia - due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased muscle contraction. Signs and Symptoms - high fever, tachycardia, muscle rigidity, heart failure, pseudotetany, and CNS damage.

Treatment of Malignant Hyperthermia

` ` ` ` ` ` `

discontinue inhalent anesthetic, Give Dantrium, oxygen, dextrose 50%, diuretic, antiarrhythmics, sodium bicarbonate, and hypothermic measures-cooling blanket, iced IV saline or iced saline lavage of stomach, bladder, rectum

Postoperative care

Definition :
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is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery

Perioperative Care Immediate Anesthetic Care (PACU)


Respiratory Status - patent airway Cardiovascular - regular, strong heart rate and stable BP (VS); peripheral pulses; Homans Sign Neurological level of consciousness; orientation, sensation Fluid and Electrolyte, Acid Base Balance

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Post operative note and orders


` ` ` ` ` ` ` ` ` ` ` `

The patient should be discharged to the ward with comprehensive orders for the following: Vital signs Pain control Rate and type of intravenous fluid Urine and gastrointestinal fluid output Other medications Laboratory investigations The patients progress should be monitored and should include at least: A comment on medical and nursing observations A specific comment on the wound or operation site Any complications Any changes made in treatment

Aftercare: Prevention of complications


1 Encourage early mobilization: ` o Deep breathing and coughing ` o Active daily exercise ` o Joint range of motion ` o Muscular strengthening ` o Make walking aids such as canes, crutches and walkers available and provide instructions for their use 2 Ensure adequate nutrition 3 Prevent skin breakdown and pressure sores: ` o Turn the patient frequently ` o Keep urine and faeces off skin 4 Provide adequate pain control

Discharge not
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On discharging the patient from the ward, record in the notes: Diagnosis on admission and discharge Summary of course in hospital Instructions about further management, including drugs prescribed. Ensure that a copy of this information is given to the patient, together with details of any follow-up appointment

Postoperative Management
If the patient is restless, something is wrong. Look out for the following in recovery: Airway obstruction Hypoxia Haemorrhage: internal or external Hypotension and/or hypertension Postoperative pain Shivering, hypothermia Vomiting, aspiration Falling on the floor Residual narcosi
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Postoperative Management
The recovering patient is fit for the ward when: ` Awake, opens eyes ` Extubated ` Blood pressure and pulse are satisfactory ` Can lift head on command ` Not hypoxic ` Breathing quietly and comfortably ` Appropriate analgesia has been prescribed and is safely established

Post Operative Complications:

Immediate
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Primary haemorrhage: either starting during surgery or following post-operative increase in blood pressure replace blood loss and may require return to theatre to re-explore wound. Basal atelectasis: minor lung collapse. Shock: blood loss, acute myocardial infarction, pulmonary embolism or septicaemia. Low urine output: inadequate fluid replacement intra- and post-operatively

Early
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Acute confusion: exclude dehydration and sepsis Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileus Fever Secondary haemorrhage: often as a result of infection Pneumonia Wound or anastomosis dehiscence Deep vein thrombosis (DVT) Acute urinary retention Urinary tract infection (UTI) Post-operative wound infection Bowel obstruction due to fibrinous adhesions Paralytic Ileus

Late
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Bowel obstruction due to fibrous adhesions Incisional hernia Persistent sinus Recurrence of reason for surgery, e.g. malignancy

Post-operative fever
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Days 0 to 2: Mild fever (T <38 C) (Common) Tissue damage and necrosis at operation site Haematoma Persistent fever (T >38 C) Atelectasis: the collapsed lung may become secondarily infected Specific infections related to the surgery, e.g. biliary infection post biliary surgery, UTI post-urological surgery Blood transfusion or drug reaction

` ` ` ` `

Days 3-5: Bronchopneumonia Sepsis Wound infection Drip site infection or phlebitis Abscess formation, e.g. subphrenic or pelvic, depending on the surgery involved DVT

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After 5 days: Specific complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation After the first week Wound infection Distant sites of infection, e.g. UTI DVT, pulmonary embolus (PE)

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Post Operative Complications:


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Days 0-1 day 2-21 days

Local Haemorrhage (reactionary) Paralytic ileas (day 1-3) Infections (day 4-6) Secondary haemorrhage (day 12-15) Wound dehiscence (8-12 days) Flap loss (1-3 days) Incisional Hernia Adhesive intestinal obstruction

> 21 days

Systemic Shock and Asphyxia Urine obstruction Pulmonary complications (day 3) Deep vein thrombosis (day 7-10) in those who are obese, diabetic and cardiac cases Fat embolism Pneumonias pain, dependency Urinary tract infection Inadequate reconstruction Morbidity of loss of body part

Recurrence of disease Pressure sores ____________________________________________________________________________

PERIOPERATIVE CARE Summary


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Specific Nursing Duties for each phase:


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Preoperative, Intraoperative, Postoperative

Throughout Perioperative Care, the nurse will always:


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Monitor patients response to therapeutic regime, prevent complications, patient education and promote optimum wellbeing

Case
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A 72-year-old man is being evaluated prior to a right inguinal herniorrhaphy. He has osteoarthritis but is otherwise healthy and jogs 3 to 5 miles several times a week. He takes no medications and has no known drug allergies

What your next step after taking the history prior to surgery?

Is pt fit for surgery ? And why?

Case
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76y male with debilitating Rt hip OA


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Scheduled for Rt Total Hip

s/p inferior MI 1yr ago TPA, resolution No tobacco use No CVD, no DM, EF wnl, Bun/Cr wnl Walked 1-2 mi/day until 2mo ago pain Simvastatin, HCTZ, Rxd Atenolol, stopped after bronchitis 2 wks ago BP 157/92; Exam wnl; ECG =inf Q waves

Case
` ` ` ` `

a 68 year old man with diabetes, COPD, osteoarthritis, who is scheduled for hip replacement in two weeks. He has a 56-pack year smoking history. Meds include glyburide, albuterol, ibuprofen. On exam, he has occasional wheezes, barrel shaped chest

Whats pt surgical risk in general ? How to reduce risk of pt with pulmonary risk? How you can decrease complication ?

Case
` ` ` ` ` ` ` ` `

52 y.o. man referred to the office for evaluation of abnormal PTT prior to planned total knee replacement Had undergone prior limited procedures to knee without unusual bleeding complications No other prior major surgery No history of abnormal bleeding No family history of bleeding No prior clotting studies could be foundI

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Initial Laboratory Values CBC normal PT/INR: 12.1sec/1.0 PTT: 42 sec (normal up to 37) Your next step ?

.Generally accepted indications for mechanical ventilatory support include Pao2 of less than 70 kpa and Paco2 of greater than 50 kpa while breathing room air Alveolar-arterial oxygen tension difference of 150 kpa while breathing 100% O2 Vital capacity of 40 to 60 mL/kg Respiratory rate greater than 35/min A dead space-tidal volume ratio (VD/VT) less than 0.6

A. B. C. D. E.

ANSWER: D

Explanation: Anticipation and early aggressive treatment of pulmonary insufficiency by mechanical ventilatory support are critical in managing the seriously ill patient. Readily measured changes that can be used to determine either the need for intubation or the appropriate time for wearing from mechanical respiratory support include arterial blood gas levels, dead space-tidal volume ratio (VD/VT) , alveolararterial oxygen tension difference [(A-a) DO2], vital capacity, and respiratory rate. Indications for mechanical ventilation include a respiratory rate over 35/min, vital capacity less than 15 mL/kg, (A-a)DO2 greater than 350 kPa after 15 min on 100% oxygen, VD/VT greater than 0.6, PaO2 less than 60 kPa, and Paco2 greater than 60 kPa.

5. Dopamine is a frequently used drug in critically ill patients because At high doses it increases splanchnic flow At high doses it increases coronary flow At low doses it decreases heart rate At low doses it lowers peripheral resistance It inhibits catecholamine release

A. B. C. D. E.

ANSWER: B

Explanation: Dopamine has a variety of pharmacologic characteristics that make it useful in critically ill patients. In low doses [1 to 5 mg/(kg.min)], dopamine affects primarily the dopaminergic receptors. Activation of these receptors causes vasodilation of the renal and mesenteric vasculature and mild vasoconstriction of the peripheral bed, which thereby redirects blood flow to kidneys and bowel. At these low doses, the net effect on the overall vascular resistance may be slight. As the dose rises [2 to 10 mg/(kg.min)], B1-receptor activity predominates and the inotropic effect on the myocardium leads to increased cardiac output and blood pressure. Above 10 mg/(kg.min), a-receptor stimulation causes peripheral vasoconstriction, shifting of blood from extremities to organs, decreased kidney function, and hypertension. At all doses, the diastolic blood pressure can be expected to rise; since coronary perfusion is largely a result of the head of pressure at the coronary ostia, coronary blood flow should be increased.

to prepare for operating on a patient with a blooding history diagnosed as von willebrands High-purity factor VIII:C concentrates Low-molecular-weight dextran Fresh frozen plasma (FFP) Cryoprecipitate whole blood

A. B. C. D. E.

ANSWER: D