lecture x - pre and post-operative care of the surgical patient

8/13/2019 Lecture x - Pre and Post-operative Care of the Surgical Patient

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Dr. Hartwinder singhDr. Hartwinder singh


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I. Assessment of Operative RiskI. Assessment of Operative Risk

A. Natural HistoryA. Natural History

- relative harm (risk- relative harm (risk

- relative good (!enefit- relative good (!enefit


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". #tages of the disease". #tages of the disease

- error in $lini$al staging produ$es the- error in $lini$al staging produ$es thegreatest num!er of $ontroversies regardinggreatest num!er of $ontroversies regarding

managementmanagement

%. %lini$al &udgment%. %lini$al &udgment

- deviations of standard treatment is- deviations of standard treatment isasso$iated with signifi$ant in$rease inasso$iated with signifi$ant in$rease inmortality and mor!iditymortality and mor!idity


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D. "asi$ 'a$tors Affe$ting Operative RiskD. "asi$ 'a$tors Affe$ting Operative Risk

. Age over )* years. Age over )* years

+. Overall physi$al status+. Overall physi$al status,. le$tive vs. emergen$y surgery,. le$tive vs. emergen$y surgery

. /hysiologi$ e0tent of the tumor. /hysiologi$ e0tent of the tumor

1. Asso$iated illnesses1. Asso$iated illnesses


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II. /ersonal RelationshipII. /ersonal Relationship

A. 2enuine !ond of $ommuni$ation and personal responsi!ilities.A. 2enuine !ond of $ommuni$ation and personal responsi!ilities.

". /hysi$ian should not $onvey a sense of hurry". /hysi$ian should not $onvey a sense of hurry

and inade3uate time for e0planations.and inade3uate time for e0planations.

%. Involve physi$ians who have parallel skills to $ontri!ute to diagnosis%. Involve physi$ians who have parallel skills to $ontri!ute to diagnosisand treatment.and treatment.

D. #pe$ifi$ treatment.D. #pe$ifi$ treatment.

. Informed $onsent. Informed $onsent


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III. 2eneral /reparation of the /atientIII. 2eneral /reparation of the /atient

A. /sy$hologi$al preparationA. /sy$hologi$al preparation. /re-op steps should !e enumerated4. /re-op steps should !e enumerated4

5ustified and e0plained.5ustified and e0plained.

+. #urgeons should not e3uivo$ate in+. #urgeons should not e3uivo$ate indis$ussing possi!le disfiguringdis$ussing possi!le disfiguring

operations.operations.


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". /hysiologi$ $onsiderations". /hysiologi$ $onsiderations

. "lood volume $onsiderations. "lood volume $onsiderations

a. anemia 6 $hroni$ or a$utea. anemia 6 $hroni$ or a$ute

!. minimal re3uirement for!. minimal re3uirement foranesthesia 6 * gm7** ml Hg!anesthesia 6 * gm7** ml Hg!


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+. Determine the physiologi$ limit for+. Determine the physiologi$ limit for

tissue o0ygen delivery.tissue o0ygen delivery.

a. ta$hy$ardiaa. ta$hy$ardia

!. in$rease in stroke volume!. in$rease in stroke volume

$. in$rease in o0ygen e0tra$tion$. in$rease in o0ygen e0tra$tion


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,. /lasma and e0tra$ellular fluid defi$it,. /lasma and e0tra$ellular fluid defi$it

- volume and $on$entration- volume and $on$entration

a. hourly urine outputa. hourly urine output!. urine $on$entration!. urine $on$entration

$. mu$ous mem!ranes$. mu$ous mem!ranes

d. skin turgord. skin turgor


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%. Nutrition%. Nutrition

. #erum transferrin. #erum transferrin

+. #erum al!umin+. #erum al!umin

,. 8"% $ount,. 8"% $ount

D. /revent infe$tionD. /revent infe$tion

. 9reat distant infe$tions. 9reat distant infe$tions

+. /rophyla$ti$ anti!ioti$s+. /rophyla$ti$ anti!ioti$s


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I:. /ost-operative %areI:. /ost-operative %are

A. /ost-op feverA. /ost-op fever

- elevated temperature o!served in post-op- elevated temperature o!served in post-op

patients does not ne$essarily signal a seriouspatients does not ne$essarily signal a serious

$ompli$ation$ompli$ation

- a spe$ifi$ $ause is identified in +*; of patients- a spe$ifi$ $ause is identified in +*; of patientswith pyre0ia during the initial + hourswith pyre0ia during the initial + hours

- $omprehensive $lini$al evaluation is essential- $omprehensive $lini$al evaluation is essential


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ii

. Infe$tive $auses of post-op fever. Infe$tive $auses of post-op fever

a. $ommunity a$3uired infe$tiona. $ommunity a$3uired infe$tion

!. $ontamination!. $ontamination

$. inade3uate !lood supply$. inade3uate !lood supplyd. neonates and the elderlyd. neonates and the elderly

e. systemi$ fa$torse. systemi$ fa$tors

i. D< IIi. D< IIii. hepati$ diseaseii. hepati$ disease

iii. immunosupressioniii. immunosupression

iv. malnutritioniv. malnutrition


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v.. o!esity 6 due to relatively poor !loodv.. o!esity 6 due to relatively poor !loodsupply of the large reservoirs of fatsupply of the large reservoirs of fat

vi. disseminated malignan$y 6 due to thevi. disseminated malignan$y 6 due to the$a$he$ti$ influen$es of the primary$a$he$ti$ influen$es of the primaryneoplasm and immunosuppression !yneoplasm and immunosuppression !y$hemothera peauti$ drugs$hemothera peauti$ drugs

vii. a$tive infe$tionvii. a$tive infe$tion

viii. A$ute and $hroni$ al$ohol intakeviii. A$ute and $hroni$ al$ohol intake


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+. Diagnosis and management+. Diagnosis and management

- should !e dire$ted toward re$ognition and- should !e dire$ted toward re$ognition and

eradi$ation of the primary sour$e of e0ogenouseradi$ation of the primary sour$e of e0ogenous

pyrogenspyrogens

a. 'ever within + hours 6 atele$tasisa. 'ever within + hours 6 atele$tasis

!. 1!. 1thth

to *to *thth

day 6 wound infe$tionday 6 wound infe$tion$. %lini$al evaluation is needed$. %lini$al evaluation is needed

- rales and ron$hi - pneumonia- rales and ron$hi - pneumonia


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,. Other $auses of post-op fever,. Other $auses of post-op fever

a. suppurative parotitisa. suppurative parotitis

i. usually elderly or de!ilitatedi. usually elderly or de!ilitatedpatientspatients

ii. $aused !y dehydration andii. $aused !y dehydration and

poor oral hygienepoor oral hygieneiii. + weeks post-opiii. + weeks post-op

iv. #taph. aureusiv. #taph. aureus


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!. operative site!. operative site

i. must always !e $onsideredi. must always !e $onsideredfor post-op feverfor post-op fever

ii. 1ii. 1 ththpost-op daypost-op day

$. I: lines$. I: lines

i. re3uest for !lood $ulturei. re3uest for !lood $ulture

ii. presents as $ellulitisii. presents as $ellulitisiii. %: line sepsis due to infe$tediii. %: line sepsis due to infe$tedthrom!us at the tipthrom!us at the tip


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d. throm!ophle!itisd. throm!ophle!itis

i. +i. +ndndpost-op daypost-op day

ii. $atheter should !e removedii. $atheter should !e removed

at first sign of infe$tionat first sign of infe$tioniii. more fre3uent in the loweriii. more fre3uent in the lowere0tremitiese0tremities

iv. pus may !e presentiv. pus may !e present

v. high fever and (= !lood $ulturev. high fever and (= !lood $ulture

vi. treatment $onsists of e0$isingvi. treatment $onsists of e0$isingveinvein


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". Non-infe$tive $auses of /ost-op 'ever". Non-infe$tive $auses of /ost-op 'ever

. Disseminated malignan$y. Disseminated malignan$y

+. 9ransfusion rea$tion+. 9ransfusion rea$tion

,. Hematoma,. Hematoma. Administration of irritant fluids or. Administration of irritant fluids or drugsdrugs

1. A$ute pan$reatitis1. A$ute pan$reatitis

>. 9hyroid storm>. 9hyroid storm). /heo$hromo$ytoma). /heo$hromo$ytoma

?. Dehydration?. Dehydration


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%. 'a$tors influen$ing likelihood of post-op%. 'a$tors influen$ing likelihood of post-opinfe$tioninfe$tion

. Definite de$rease in host resistan$e. Definite de$rease in host resistan$e

a. in$reasing agea. in$reasing age!. o!esity7malnutrition!. o!esity7malnutrition

$. dia!eti$ ketoa$idosis$. dia!eti$ ketoa$idosis

d. a$ute7$hroni$ steroid used. a$ute7$hroni$ steroid use

e. immunosuppressive drugse. immunosuppressive drugs

f. remote infe$tionsf. remote infe$tions


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+. /ossi!le de$rease in host resistan$e+. /ossi!le de$rease in host resistan$e

a. some forms of $an$era. some forms of $an$er

!. radiation therapy!. radiation therapy$. adreno$orti$al insuffi$ien$y$. adreno$orti$al insuffi$ien$y

d. foreign !odyd. foreign !ody

e. early shaving of the operativee. early shaving of the operativesitesite


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,. No effe$t on host resistan$e,. No effe$t on host resistan$e

a. gendera. gender!. ra$e!. ra$e

$. $ontrolled D


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%. Operations !enefiting from anti!ioti$ prophla0is%. Operations !enefiting from anti!ioti$ prophla0is

. Head and ne$k surgery with open. Head and ne$k surgery with open

aerodigestive tra$taerodigestive tra$t

+. sophageal e0$ept hiatal hernia repair+. sophageal e0$ept hiatal hernia repair

,. 2astroduodenal e0$ept for,. 2astroduodenal e0$ept for$ompli$ations of un$orre$ted hypera$idity$ompli$ations of un$orre$ted hypera$idity


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. "iliary tra$t surgery. "iliary tra$t surgery

a. patients over )* years olda. patients over )* years old

!. a$ute $hole$ystitis!. a$ute $hole$ystitis

$. $holedo$hostomy$. $holedo$hostomy

1. "owel rese$tion1. "owel rese$tion

>. /erforated or gangrenous appendi$itis>. /erforated or gangrenous appendi$itis

). Hystere$tomy). Hystere$tomy

?. Revas$ulari@ation and prostheti$ graft surgery?. Revas$ulari@ation and prostheti$ graft surgery

. Orthopedi$ surgeries with implantation of prosthesis. Orthopedi$ surgeries with implantation of prosthesis


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D. Operative te$hni3ue to minimi@e infe$tionD. Operative te$hni3ue to minimi@e infe$tion

. liminate hair4 if ne$essary4 5ust prior. liminate hair4 if ne$essary4 5ust prior to in$ision timeto in$ision time

+. ffe$tive skin preparation+. ffe$tive skin preparation

,. 2entle and effe$tive handling of,. 2entle and effe$tive handling oftissuestissues

. ffe$tive hemostasis. ffe$tive hemostasis

1. radi$ate dead spa$e1. radi$ate dead spa$e

>. .


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. /re-operative fa$tors asso$iated with post-. /re-operative fa$tors asso$iated with post-

operative $ardia$ $ompli$ation in order ofoperative $ardia$ $ompli$ation in order of

dis$overy signifi$an$edis$overy signifi$an$e

. &ugular vein distention or #, gallop -. &ugular vein distention or #, gallop -

points points

+. months or+. months or #,#,

gallop 6 * pointsgallop 6 * points


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,. /remature atrial $ontra$tions or,. /remature atrial $ontra$tions orrhythm other than sinus on %2 6 )rhythm other than sinus on %2 6 )

pointspoints

. ,-1 /:%Bs7minute 6 ) points. ,-1 /:%Bs7minute 6 ) points

1. Age over )* 6 1 points1. Age over )* 6 1 points

>. #ignifi$ant aorti$ stenosis 6 , points>. #ignifi$ant aorti$ stenosis 6 , points


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). /oor general medi$al $ondition 6 , points). /oor general medi$al $ondition 6 , points

a. /aO+C>* mm Hga. /aO+C>* mm Hg

/a%O+1* mm Hg/a%O+1* mm Hg

!. /otassiumC, me3!. /otassiumC, me3

"i$ar!onateC+* me3"i$ar!onateC+* me3

$. "EN 1* mg7** ml$. "EN 1* mg7** ml

%rea ,.* mg7** ml%rea ,.* mg7** ml


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d. in$reased transaminasesd. in$reased transaminases

e. signs of $hroni$ liver diseasee. signs of $hroni$ liver disease

f. patient !edridden for non-$ardia$f. patient !edridden for non-$ardia$$auses$auses

?. Operation?. Operation

a. emergen$y 6 pointsa. emergen$y 6 points

!. intraperitoneal4 intrathora$i$4 aorti$ 6 , points!. intraperitoneal4 intrathora$i$4 aorti$ 6 , points

9O9AF 6 1, points9O9AF 6 1, points


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'. /re 6operative risk fa$tors for post-'. /re 6operative risk fa$tors for post-

operative pulmonary $ompili$ationsoperative pulmonary $ompili$ations

. 9hora$i$ and upper a!dominal surgery. 9hora$i$ and upper a!dominal surgery

+. /re-op history of %O/D+. /re-op history of %O/D

,. /urulent produ$tive $ough,. /urulent produ$tive $ough

. Anesthesia time greater than , hours. Anesthesia time greater than , hours>. Age greater than >* years old>. Age greater than >* years old


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). O!esity). O!esity

?. /oor state of nutrition?. /oor state of nutrition

. #ymptoms of respiratory disease. #ymptoms of respiratory disease

*. A!normal findings on /..*. A!normal findings on /..

. A!normal $hest film findings. A!normal $hest film findings


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2. /eri-operative prophla$ti$ pulmonary2. /eri-operative prophla$ti$ pulmonary

maneuversmaneuvers

. %essation of smoking. %essation of smoking

+. "ron$hodilators+. "ron$hodilators

,. %hest physiotherapy and postural,. %hest physiotherapy and posturaldrainagedrainage


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. /re-operative edu$ation and post-. /re-operative edu$ation and post-

operative use of in$entive spirometryoperative use of in$entive spirometry andand

deep !reathing e0$er$isesdeep !reathing e0$er$ises

1. /re-operative anti!ioti$s if sputum is1. /re-operative anti!ioti$s if sputum is

purulentpurulent

>. arly post-operative anti!ioti$s>. arly post-operative anti!ioti$s


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lecture x - pre and post-operative care of the surgical patient

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