Perioperative Care

Dr. Thuc The BachHuntington Memorial HospitalPasadena, California

Perioperative Care Consists of:

Preoperative CarePreoperative PlanningPreoperative EvaluationsPostoperative ManagementPostoperative ProblemsPostoperative Complications

Preoperative Care

Diagnostic Work UpPreoperative EvaluationsPreoperative Preparations

Diagnostic Workup

Determine the cause and extent of the illness

Preoperative Evaluations

Overall assessment of patient’s healthIdentify significant abnormalities that may increase operative riskShould begin with a complete history and physical evaluationRoutine laboratories pertinent to surgeryEvaluation by the anesthesiologist

Specific Factors Affecting the Surgery

History of angina or infarctionHistory of anemia, lung disease, kidney disease, bleeding problemsNutritional status

Factors Affecting Wound Healing

SteroidsMalnutrition RadiationDiabetes

Factors Leading to PostopInfection

DiabetesRenal failureSteroid medicationsImmunosuppressive agentsSmokingPreoperative infection

Special Problems

DiabetesThyroid DiseaseHeart DiseaseRespiratory DiseaseKidney DiseaseHematologic Disease

AnemiaThrombocytopeniaAbnormal bleedingMedications (coumadin etc)

Dangerous Preoperative Herbal Medications

Ask about all Herbal medications !Herbs that may interfere with bleeding time

GingkoFeverfewGingerVitamin E

Dangerous Preoperative Herbal Medications

Herbs that may trigger high blood pressureGinseng

Herbs that may lower blood pressureGarlic

Herbs that can intensify or prolong anesthesia

St. John’s wortKava kava

Preoperative Preparations

Informing the patient about the risks and benefits of the surgeryProviding necessary pain control and discussing pain control options

Preoperative Preparations

Patient should quit smoking at least 2 weeks before surgeryPatient should quit herbal supplements mentioned at least 2 weeks before surgeryBowel preparation in advance might be helpful

Orders

Nothing by mouth at least 8 hours before surgeryLabs and xraysPrepare blood (if necessary)Sedation and pre-op anesthetic medsHydration and IV accessEnema, foley catheterProphylactic antibioticsInvasive cathetersConsent for surgery

Immediate Postoperative Period: First 1-2 hours

Anesthesiologist in charge of cardiopulmonary functionsSurgeon responsible for all the rest

Surgeon’s Responsibilities

Monitor vital signsCVP, Swan-Ganz reading, ICP, distal pulseFluid balance, electrolytesRespiratory carePosition in bedMobilizationDrainage tubesMedicationsDiet

Postoperative Pain Control

Parenteral opioidMorphine 10 mg q 3-4° given IV or IMMeperidine 75 – 100 mg q 3°Hydromorphone 1-2 mg IM q 2-3°

Non-opioid analgesicToradol 30 mg (no respiratory side-effects)

Epidural anesthesia

Postoperative Pain Control

Oral analgesicsTylenol #3 (with codeine)Darvocet N-50 (propoxyphene)Vicodin (hydrocodone)

Patient-controlled analgesiaIntercostal nerve block

Postoperative Complications

Wound complicationsHematomaSeromaWound dehiscenceInfection

Postoperative Complications

Pulmonary ComplicationsAtelectasisAspirationsPneumoniaPost-operative pleural effusionPneumothorax

Postoperative Complications

Fat embolismCardiac complications

ArrhythmiaFrequently due to hypoxemia, hypokalemia, alkalosis

Postoperative myocardial infarctionCardiac failure

Urinary complicationsRetentionAcute tubular necrosisUrinary tract infection

Postoperative Complications

Peritoneal complicationsHemoperitoneumPeritonitis

Cerebral complicationsCerebrovascular accidentConvulsions

Psychiatric complicationsICU syndromeDeleriumSexual dysfunctionDelerium tremens (alcohol withdrawal)