PRE AND POST-OPERATIVE CARE OF THE SURGICAL PATIENT

1. PRE AND POST-OPERATIVE CARE OF THE SURGICAL PATIENT

2. I. Assessment of Operative Risk A. Natural History - relative harm (risk) - relative good (benefit)

3. 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

4. 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

5. 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

6. 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.

7. B. Physiologic considerations 1. Blood volume considerations a. anemia – chronic or acute b. minimal requirement for anesthesia – 10 gm/100 ml Hgb

8. 2. Determine the physiologic limit for tissue oxygen delivery. a. tachycardia b. increase in stroke volume c. increase in oxygen extraction

9. 3. Plasma and extracellular fluid deficit - volume and concentration a. hourly urine output b. urine concentration c. mucous membranes d. skin turgor

10. C. Nutrition 1. Serum transferrin 2. Serum albumin 3. WBC count D. Prevent infection 1. Treat distant infections 2. Prophylactic antibiotics

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. B. Non-infective causes of Post-op Fever 1. Disseminated malignancy 2. Transfusion reaction 3. Hematoma 4. Administration of irritant fluids or drugs 5. Acute pancreatitis 6. Thyroid storm 7. Pheochromocytoma 8. Dehydration

19. 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

20. 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

21. 3. No effect on host resistance a. gender b. race c. controlled DM d. acute nutritional deprivation

22. 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

23. 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

24. 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

25. E. Pre-operative factors associated with post-operative 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

26. 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 s

27. 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

28. 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

29. F. Pre –operative risk factors for post-operative 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

30. 7. Obesity 8. Poor state of nutrition 9. Symptoms of respiratory disease 10. Abnormal findings on P.E. 11. Abnormal chest film findings

31. G. Peri-operative prophlactic pulmonary maneuvers 1. Cessation of smoking 2. Bronchodilators 3. Chest physiotherapy and postural drainage

32. 4. Pre-operative education and post- operative use of incentive spirometry and deep breathing excercises 5. Pre-operative antibiotics if sputum is purulent 6. Early post-operative antibiotics

33. 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

34. 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. Specialmedications