Peri-Operative Care

Introduction

Perioperative management consists of preoperative patient evaluation as well as intraoperative and postoperative patient monitoring and care.

The perioperative period is the time period of a patient’s surgical procedure.

Components of Perioperative care

Peri-operative Care consists of:

1. Pre-operative care
2. Intra-operative care
3. Post-operative care

Perioperative care is targeted at ensuring that the patient is fit for anaesthesia and intended surgical procedure, as well as prevent complications after surgery.

The focus on peri-operative care is based on the evidence that majority of complications and mortality following elective surgery are avoidable and can be prevented.

It involves what happens to the patient
before going into the operating room, what happens in the operating room and what happens after the patient leaves the
operating room.

Goals of Perioperative care

The goals of peri-operative care include:

1. Prevent avoidable complications
2. Ensure early identification of
   complications and prompt treatment
3. Prevent avoidable mortality
4. Ensure quick recovery and return to activities
5. Ensure safe and smooth surgery
6. Ensure optimal patient outcomes

1. Pre-operative care

The goal is to prevent and/or minimize the risk of adverse cardio-pulmonary events during and after surgery.

Clinical evaluation

Efforts should be made to identify the
following by history and physical
examination:

1. Cardiopulmonary disorders:

• Cough
• Chest infection
• Bronchial asthma
• Chronic obstructive airways disease
• Hypertension
• Cardiac failure

2. Metabolic disorders:

• Diabetes mellitus

3. Haematologic disorders:

• Sickle cell disease

4. Allergy:

• Drug allergies (e.g. penicillins, talc,
  elastoplast, antiseptics etc.)

5. Drug history:

• Propranolol, diuretics, steroids and other hormonal agents; prednisolone, oral contraceptives; tricyclic antidepressants

6. Social habits:

• Cigarette smoking, alcohol use

6. Previous anaesthetic experience:

• How long ago, type of anaesthesia

Investigations

1. Cardiopulmonary:

• Chest radiograph: especially for patients 60 years and above, and those with chest infection
• Look for evidence of chest infection and cardiomegaly

2. Electrocardiogram:

• especially for patients over 60 years and those with heart disease or
  hypertension

Pulmonary function tests may be necessary in patients with obstructive airways disease

3. Metabolic:

• Urine sugar to exclude diabetes mellitus
• All adults and patients with history suggestive of diabetes mellitus

4. Serum Electrolytes and Urea

5. Haematologic:

• Haemogram/packed cell volume
• Haemoglobin genotype
• Clotting profile (prothrombin time and kaolin cephalin clotting time) where there is suspicion of bleeding diathesis e.g. in jaundiced patients

Others:

• Other investigations as may be indicated by individual clinical circumstances.

Correction of abnormalities and preparation for surgery

1. Cardiopulmonary:

• Rehydrate patientbadequately, using appropriate fluids
• Control blood pressure
• Treat/control chest infections with appropriate antibiotics
• Control obstructive airways disease

2. Metabolic conditions and derangements:

• Correct electrolyte deficits, especially hypokalaemia
• Acidosis is usually corrected by adequate rehydration (provided the patient has no renal disease)
• Diabetes should be controlled
• Patients already controlled will need their therapy to be converted to soluble insulin for long surgical procedures (this should be done in conjunction with the physician and anaesthetist)

3. Haematological:

• Correct anaemia
• Cause(s) of anaemia should be identified and treated
• The minimum haemogram for a patient undergoing elective surgery should be 10 g/dL
• Haemogram 6-9g/dL: correction may be achieved by haematinics; reschedule surgery
• Haemogram <6 g/dL: correction may require blood transfusion

4. Emergency surgery:

• correct anaemia by blood transfusion
• Blood transfusion should be avoided as much as practicable.
• Patient with sickle cell anaemia:
  haemogram should be brought up to 8 g/dL
• These patients must be adequately
  hydrated to avoid sickling and sludging
  within the bloodstream

4. Short day case procedure:

• It is imperative to admit the patient with sickle cell anaemia at least a day before surgery to achieve adequate hydration

5. Suspected bleeding diathesis

• Intramuscular vitamin K (10 mg daily), at least 48-72 hours before:
  surgery
• For major surgery, blood should be
  grouped, cross-matched and stored

Other disorders:

• Any associated medical condition should be treated controlled before embarking on surgery
• This should be done in conjunction with the physician as much as possible

Patients who require nutritional
rehabilitation

• If surgery is elective reschedule it, and give adequate time to achieve improved nutritional status, otherwise morbidity and mortality may be increased

High-risk patients:

• At high risk of developing postoperative complications
• Deliberate and meticulous efforts should always be made to adequately evaluate them and ensure optimal fitness for surgery

Elderly patients (age >60 years):

• risk of deep vein thrombosis, atelectasis

Obesity

•  risk of deep vein thrombosis,
  atelectasis

Cancer

• risk of deep vein thrombosis,
  atelectasis, haemorrhage

Women on oral contraceptive pills

• risk of deep vein thrombosis

Co-existing chronic medical conditions

• risk of wide ranging complications

Sickle cell anaemia

• risk of sickling crises, deep vein thrombosis

Consent for surgery

Details of the surgery should always be
explained to the patient (or relatives) in very simple language before surgery

• A signed consent should be obtained, in the presence of a witness (usually a nurse)
• Obtaining consent should be done by the surgeon himself
• It should include a mention of the
  possible/common complications
• There are a number of evidence-based risk stratification to guide in predicting the risk of adverse events and help in instituting appropriate measures to prevent these events (Tables 1 and 2).

Table 1:Cardiac risk stratification in patients undergoing non-cardiac surgery

• Cardiac events include fatal and nonfatal cardiac events
• Incorporates perioperative cardiovascular events within 30 days after surgery

Table 2: American Society of Anaesthesiologist physical status classification system

The addition of “E” denotes Emergency
surgery: (An emergency is defined as
existing when delay in treatment of the
patient would lead to a significant increase in the threat to life or body part)

Intra-operative care

The focus of intra-operative care is to ensure a safe and smooth surgical procedure.

The entire team in the operating room, including surgical team, anaesthesia team and perioperative nursing team, should work together as a team and take responsibility for intra-operative care to ensure a smooth and safe operation.

The World Health Organisation’s ‘Surgical Safety Checklist’ is a helpful guide for safe and effective intra operative care.

This checklist can be modified to suit each hospital based on local realities.

Post-operative care

An excellently performed operation can be marred by poor post-operative care and inadequate attention to patient’s post operative needs.

Meticulous and efficient care in the
postoperative period is paramount for
adequate patient recovery and success of
surgery.

A well-planned and supervised
postoperative care ensures a smooth
recovery, and helps to prevent or limit
postoperative morbidity and mortality.

Preoperative, intraoperative and
postoperative care is a continuum and
interlinked.

Many of the instructions and therapy.
started in the preoperative period may
need to be continued into the
postoperative period.

The surgeon himself must be involved in the postoperative care and not leave it to others, who may not have much ideas or information about the surgery

Initial recovery

Close monitoring and observation:

• The first 4-6 hours after a major surgery and general anaesthesia are critical
• The patient is still drowsy and recovering from the effects of anaesthesia
• The cardiopulmonary status (pulse rate, blood pressure, respiration) needs to be monitored very closely (every 15 minutes) in order to promptly detect any abnormality
• Where available, electronic monitors with an alarm system should be used

Airways management

• The patient may still be under some effect of anaesthesia
• Airways need to be kept patent
• Prevent the tongue from falling backwards by positioning patient in the left lateral position
• The neck should be prevented from falling on itself as this can occlude the airway
• Secretions should also be cleared using a low pressure suction

Nursing position

• Different operations require specific positioning in the postoperative period to
  reduce venous pressures, keep airways patent, enhance drainage etc.
• The surgeon should be conversant with the specific positions and give appropriate instructions

Analgesia

• Pain is a most undesirable effect of surgery
• Patients should not be allowed to suffer from pain unduly
• The appropriate analgesic technique should be chosen for the nature of surgical procedure
  performed
• Adequate analgesia will ensure early ambulation and help to limit atelectasis

The following principle should guide the use of analgesia for control of postoperative pain:

• Multimodal approach: should be preemptive and preventative

Use of local anaesthetics:

• Improve analgesia
• Decrease opioid requirements
• Decrease opioid-related side effects

Can be given via:

• Wound infiltration
• Epidural
• Peripheral nerve blocks

Opioids remain the mainstay of
surgical pain control
Pain should be continuously evaluated using appropriate pain assessment tools to help in ensuring adequate and appropriate management
The following analgesic guide is helpful in the control of postoperative pain.

Nasogastric decompression

• The stomach may need to be kept
  decompressed for 24 – 48 hours, particularly following gastrointestinal surgery

Decompression:

• Prevents abdominal distension and
• Prevents tension on abdominal fascial closure
• Prevents splinting of the diaphragm and atelectasis
• The widest possible bore of nasogastric tube for patient’s age should be chosen
• The nasogastric tube should be removed as soon as it is no longer needed, evidenced by:
  • Progressively diminishing effluent (<500 mL/24 hours in an adult)
  • Change from bilious colour to clear colour of gastric juice

Fluid and electrolyte balance

• Ensure that the patient receives adequate amounts of intravenous fluids if oral intake is
  prohibited
• Choose an appropriate fluid to provide enough calories and electrolytes
• Glucose 5% in sodium chloride 0.9% or lactated Ringer’s solution is appropriate for most adults
• After the 48 hours, the daily requirement of potassium should be provided if oral intake is still prohibited, especially if nasogastric drainage is ongoing
• This should be in form of potassium
  chloride added to intravenous fluids
• Assess fluid and electrolyte balance on a daily basis and correct deficits
• All intake (intravenous fluids, drugs, blood etc.) and output (urine, nasogastric drainage, other tubes, etc.) as well as insensible losses should be carefully recorded

Nutrition

• Following major surgery, adequate nutrition should be provided for the patient, particularly if oral intake is going to be prohibited for more than 48-72 hours
• This can be done in the form of parenteral nutrition

Chest physiotherapy:

• Bed-ridden patients and patients who have had chest or upper abdominal surgery are prone to basal atelectasis and hypostatic
  pneumonia.
• These should be prevented by
  appropriate chest physiotherapy
• Ensure adequate analgesia to enhance chest excursion
• Encourage coughing and expectoration, with a hand supporting any abdominal
  wound
• Periodic chest percussion to loosen bronchial secretions
• Ambulate as early as possible

Mobilization and ambulation

• Mobilize and ambulate patients as early as is practicable to avoid the complications of prolonged recumbency
• Ambulation should be gradual: prop up in bed, sit out of bed, short walks etc.)
• Early ambulation should help prevent hypostatic pneumonia and deep vein thrombosis (very important in obese and elderly patients)

Antibiotics

• Appropriate antibiotics as indicated.
• Irrational or indiscriminate use is not to be encouraged

Wound care

• Specific surgical wounds are cared for in different ways
• Clean surgeries: do not open wound (unless indicated) until day 5-7
• Inspect wounds immediately if there are features suggestive of surgical site (wound) infection
  • Undue pain
  • Undue swelling
  • Discharge of serosanguinous fluid or pus

Infected wounds:

• Wound swab for microbiological culture and sensitivity tests
• Adequate local wound care
• Appropriate antibiotics
• If there are systemic features (e.g. fever,anorexia) systemic treatment with antibiotics may be necessary

Care of indwelling tubes, catheters and drains

• All indwelling catheters, tubes and drains should be monitored and appropriately managed to avoid infection, dislodgement/ displacement
• They should be removed as soon as they have served their purpose(s)

General complications in the postoperative period

• Look out for general complications and treat accordingly
• Postoperative pyrexia may be due to:
  • Malaria
  • Atelectasis and hypostatic
  • Wound infection
  • Urinary tract infection
  • Deep vein thrombosis
  • Wound infection