Pre- & Post-OP Care.pptPre- & Post-OP Care.ppt

Pre- & Post-OP Care.ppt

1. Pre- & Post-OP Care
Dawit Desalegn (M.D)
Gynecologist & Obstetrician
A.A.U. – M.F
Oct, 2007

2. Preoperative evaluation and preparation of women
for gynecologic surgery
•addresses issues that will potentially affect the woman
during her surgical procedure and recovery.
•Rationale:-
•Many postoperative problems can be anticipated
preoperatively, and eliminated or minimized
•may result in a shorter hospitalization with fewer
complications and a more satisfied patient.

3. •The surgeon should use this time to:-
review the patient's history and physical
examination,
identify physical limitations,
gather information required to plan
surgery,
optimize medical status, and
educate about what to expect from the
procedure and during the recovery period.

4. History and Physical examination
•Should include any medical illnesses that
might be aggravated by surgery or
anesthesia

5. Hx. & P/E Cont…
•Medication history
–ASA, COC, Anti-HPT,
•Known allergy
–Penicillin, Iodine
•Previous surgical procedures
–Records, response to anesthesia,
•Family history
–Bleeding diathesis,
•Symptoms of other major organ systems
–Cardiac, pulmonary
•Exercise capacity
•Age & Obesity

6. ROUTINE LABORATORY EVALUATION IN
HEALTHY PATIENTS
•prevalence of unrecognized disease that impacts upon surgical risk
is very low in healthy individuals.
•But, many tests done = habit and medico legal concern,
•little benefit and a high false positive results.
•selective Vs random use of laboratory tests ( + 2SD)
•A selective approach to screening based upon known or clinically
suspected illness has been supported in several studies

7. General recommendations for routine
preoperative laboratory studies
•Depends on the extent of surgery & medical status
1. Complete blood count
•Anemia = 1 percent of asymptomatic patients
•30 day mortality 1.3 % Vs 33 % (>12 Vs < 6 g/dl)
•WBC, Platelet = no sign. Cost
•BG & Rh for all

8. 2. Renal function Test
•Asymptomatic = 0.2 % & increases with age
•creatinine > 2.0 mg/dL = predicted postop- cardiac
complications
•necessitates dosage adjustment eg, muscle relaxants
•reasonable to obtain:-
–> 50 years
–major surgery,
–when hypotension is likely, or
–when nephrotoxic medications will be used.

9. 3. Liver function tests
•Asymptomatic = 0.3 %
•only 0.1 percent of all routine preoperative liver function
tests changed preoperative management
•Clinically significant liver disease would most likely be
suspected on the basis of the history and physical
examination;
•thus, routine liver enzyme testing is not recommended.

10. 4. Coagulation Tests
•routine preoperative tests of hemostasis are not
recommended.
•Their use should be restricted to patients with a
known bleeding diathesis or an illness
associated with bleeding tendency.

11. 5. Electrocardiogram
•have a low likelihood of changing perioperative
management in the absence of known cardiac disease.
•But, detecting a recent myocardial infarction is important
since it is associated with high surgical morbidity and
mortality
•prevalence of abnormal ECGs increases with age (>40)
•a preoperative ECG can be important as a baseline

12. 6. CXR
•Abnormal chest x-rays are seen with increasing
frequency with age
•0.1 percent of all routine chest x-rays influenced
management.
• preoperative chest x-rays should not be routinely
performed.
•An exception is:-
–age > 60 years and
–those with suspected cardiac or pulmonary disease.

13. 7. Pregnancy test
•should be performed shortly before surgery on all fertile
women who could be pregnant.
•particularly crucial before procedures that are likely to
adversely affect pregnancy outcome eg,
–hysterectomy,
–cervical conization,
–oophorectomy,
–curettage

14. INFORMED CONSENT
•Postoperative misunderstandings can often be
prevented by educating a woman and her family
preoperatively.
•A thorough and well-documented consent helps
to insure that the patient's expectations for her
surgery, recovery, and final outcome are
realistic and appropriate.

15. INFORMED CONSENT cont…
•The informed consent discussion should
include the following:
1.Nature & extent of disease
2.Actual operation proposed & potential
modifications
3.Anticipated benefits
4.Risks & potential complications
5.Alternative methods
6.Results likely if she is not treated

16. •Informed refusal —
•In such cases, the chart should document
–the explanation for the need for treatment,
–a description of the consequences of
declining the diagnostic/therapeutic plan,
–the reasons for the patient's refusal

17. General Considerations
Malnutrition
•Careful Hx & P/E
–Muscle wasting, ascites, edema, Ht, Wt
•>12 % ideal weight loss = support
•Quick assessment of malnutrition
–Wt loss > 3Kg/3wks,
–anorexia,
–albumin < 3.5g/dl

18. Malnutrition cont…
•Why worry?
•Contribute to post op-complication:-
–Altered immune function
–Chronic anemia
–Impaired wound healing
–MOF & death
•Surgery increases requirement further
–NPO, protein catabolism

19. Fluid & Electrolyte
•A critical role of the kidneys is
–to maintain the effective circulating volume and plasma
osmolarity of the body within relatively narrow limits,
–to maintain electrolyte homeostasis
•55 % of women's wt water
•ICV (2/3) & ECV (1/3);
•ECV = ¾ (interstitial) & ¼ (plasma)
•Osmolarity in ECV = sodium & chloride
•Osmolarity in ICV = Potassium, Mg++, phosphate

20. •Normal adults have obligatory fluid intake of
approximately 1600 mL per day, composed of the
following:
–Ingested water - 500 mL
–Water in food - 850 mL
–Water of oxidation - 350 mL
•There is a similar obligate water output:
–Urine - 500 mL
–Skin - 500 mL
–Respiratory tract - 400 mL
–Stool - 200 mL

21. Fluid therapy — two components :
•Maintenance therapy:- replaces the ongoing losses of
water and electrolytes under normal physiologic
conditions,
–via urine, sweat, respiration, and stool.
•Replacement therapy corrects any existing water and
electrolyte deficits.
–from gastrointestinal, urinary, or skin losses, bleeding, and third-
space sequestration.
•Correction of any existing abnormality

22. MAINTENANCE THERAPY
•when not expected to eat or drink normally
•The goal:- to preserve water and electrolyte balance
•A normal plasma [sodium] = is in water balance
•but does not provide any information on volume status:-
•Weighing daily,
–(unpredictable insensible loss)
•Clinical signs of:-
–volume excess (edema) or
–volume depletion (eg, skin turgor, fall in BP)

23. •2L/day day are sufficient for adults of normal body size
•intake from food & oxidation are reduced = NPO
•Maintenance affected by clinical factors:-
•Increased water intake is required
–fever, sweating, RR, drains, polyuria, GI loss.
–100 to 150 mL/day for each of body T >37ºC.
•Decreased water intake is required
–ARF, edema, and hypothyroidism.

24. •Formula for estimating maintenance water requirements in
adults:-
•1500 mL plus 20 mL/kg for any increment of weight over 20
kg, up to a maximum of 2400 mL.
•Thus, an individual who weighs 60 kg would receive
–1000 mL (10 x100 mL) plus
–500 mL (10 x 50 mL) plus
–800 mL (40 x 20 mL) = 2300 mL per day (95 mL/h).
•Any combination of IV fluids can be used (eg. 3lit):-
–2lit of D5/.45 normal saline + 20mEq KCL followed by
–1lit of D5W + 20mEq KCL
–Exeption = KCL in immediate post operation

25. Post operative period:- Water & Na+ Retention
•Stress of surgery + hypotension (intra operative-)
↓
•↑ADH & Aldosterone → Na+ & H20 retention
Plus
•Catabolism (1ml for each 1gm tissue)
•Tissue breakdown (several hundreds ml)
•Sequestration in 3
rd
space (ileus – 1-3lit)
•But, kidneys don’t retain potassium & 30-60 mEq/d lost
•Yet in the 1
st
POD, K+ is maintained by catabolism &
tissue breakdown
No need of KCL supplement in maintenance fluid POD-1

26. •REPLACEMENT THERAPY —
•The goal is to correct existing abnormalities
in plasma electrolytes and volume status.
•type of fluid given dep. type of fluid lost and
any concurrent disorders
•Diff to estimate volume lost (insensible loss)
–Weight loss >300gm Vs gain >150gm

27. Type of fluid choice
•Fever =
•Acute blood loss =
•Vomiting or NGO =
•Diarrhea =
•D5W (1/3 osmolarity)
•N/S or RL or Plasma
expanders (isotonic)
•D5/o.45 NS + KCL
•N/S or RL (isotonic)

28. Prophylactic Antibiotics
•The goal = eradicate or retard the growth of endogenous
microorganisms that may cause surgical site infection.
•should be used:-
–contaminated wounds (TAH,VH, IA,Ca.) and
–the incidence of postoperative infection is high.
•The antibiotic chosen should be:-
1.effective against bacteria found in most gynecological
infections,
2.not an agent used routinely for treatment of serious
infectious complications
3.low toxicity and cost
4.able to achieve appropriate tissue levels in the surgical
field.

29. •Benefits:-
•Decrease overall cost
•Decrease pelvic infection
–TAH = 21% Vs 9%; VH = 25% Vs 5%
•The drugs of choice in hysterectomy :-
–Cephalosporins (cefazolin 1 or 2 g, cefoxitin 1 to 2 g)
•Other options include:-
–clindamycin plus gentamicin
–aztreonam (1 to 2 g IV), or
–ciprofloxacin (400 mg IV);
–metronidazole + gentamicin or ciprofloxacin;
–clindamycin monotherapy.

30. •Timing & Doses
•a single IV dose 30 minutes prior to the incision
•should be repeated to maintain tissue levels if:-
–procedure extends beyond three hours or
–blood loss is greater than 1500 mL.
•Regimens that continue prophylaxis postoperatively do
not confer any additional benefit.
•Advantage of single dose:-
–Low cost - low toxicity
–Low resistance - low interaction with flora

31. •ACOG recommends antibiotic
prophylaxis
1.Vaginal and abdominal hysterectomy
2.Hysterosalpingogram
3.Induced abortion

32. Other control measures to prevent SSI
1.Preop showering with antimicrobial
soaps
2.Avoid shaving
3.Use of antiseptics to the skin of the
patient
4.Washing and gloving of surgeon's hands
5.Use of sterile drapes, gowns and masks
6.Delayed primary closure

33. Bowel preparation
• Proper bowel preparation can
–limit fecal spillage,
–reduce the risk of infection,
–avoid the need for colostomy
–Allows more room in the abdomen
•Two components:-
1.Mechanical bowel preparation
2.Antibiotic bowel preparation
•Aim = to reduce the bacterial burden

34. Mechanical bowel preparation
•Enemas and/or cathartics.
•Liquid diets - an extended (eg, 48 to 72 hours).
•Whole gut irrigation with a variety of solutions
–(NS, RL, polyethylene glycol, manitol)
The use of a bowel preparation does not affect the need
for prophylactic antibiotics.
•Complications:-
•Dehydration
•Fecal contamination during RV surgery

35. Antibiotic bowel preparation
•Anaerobes outnumber aerobes by 1000:1
•Most commonly given drugs orally:-
1.Neomycin,
2.Erythromycin,
3.Metronidazole

36. Thromboembolic disease prophylaxis
•Risk of thrombosis is significantly increased during surgery
•Risk factors associated include:-
–older age,
–previous venous thromboembolism,
–coexistence of malignancy or medical illness
–Thrombophilias, and
–longer surgical and immobilization times.
•Without prophylaxis, there is a markedly increased risk of
both venous thrombosis and pulmonary embolism (PE).

37. • Risk Categories
1. Low risk
– DVT < 1.0 %, and fatal PE < 0.01 %.
2. Moderate risk
– DVT 2 to 10 %, and fatal PE 0.1 to 0.7 %.
3. High risk
– DVT 10 to 20 % and fatal PE 1.0 to 5.0 %
•Low risk women =
–do not require heparin, early ambulation is advised.
–graduated thigh-high compression stockings.
• Moderate and high risk =
–give pharmacologic therapy combined with intermittent
pneumatic compression.

38. Moderate risk surgical patients
•Subcutaneous LDUH 5000 units every 12 hours two hours
preoperatively and then every 8 or 12 hours post-op, or
•Subcutaneous LMWH is recommended for patients
undergoing general abdominal, or gynecologic surgery
High risk surgical patients
• treated with subcutaneous LMWH.
•Prophylaxis is ideally started before or shortly after surgery
and continued until the patient is fully ambulatory or,
• Prophylaxis should be continued for seven to ten days

39. Peri-operative pain Mx
•30 – 40% suffer pain despite available drugs
•MEAC = serum concentration of a drug below which very
little analgesia is achieved
•Difficult to achieve MEAC with intermittent IM injections
–b/c unpredictable absorption
•Small IV injections = good titration Vs frequent dosing
•Large IV injections = CNS & Respiratory depression
•PCA = better analgesia achieved
•Front loading appears crucial

40. •Type of analgesia
1.Narcotics
2.NSAID = as effective & less side effects
3.Epidural analgesia = >24hrs
4.Intrathecal analgesia = high complication

41. Endocrinopathy
Diabetes mellitus
•75% of DM > 50 years will have surgery
• Surgery and GA = hyperglycemia via “CRH”
•Goal:-
•Avoidance of marked hyperglycemia
•Avoidance of hypoglycemia
•It is the direct effect of DM that determines the risk of
surgery = look for vasculopathies
•Hyperglycemia:-
–High infection rate, poor wound healing
–Metabolic asidosis,

42. Perioperative management
•Type II
–IV fluids without dextrose
–No insulin intra operatively
–D/C OHA 24 hours before surgery
–Treat hyper- with regular insulin >250mg/dl
•Type I
–2/3 – 1/2 of daily insulin (intermediate)
–5% DW infusion intra operatively
–Regular insulin Vs continuous infusion of glucose & insulin
Post operatively
–Monitor every 6hrs = glucose < 250mg/dl (sliding scale)

43. Hypertension
•Ideally = normalize BP for several months prior
•No need to post pond = < 170/110mmHg
•Well-controlled HPT preoperatively = No complication
•Hypertensive cardiac disease = consultation!!
•Continue anti hypertensive drugs
•B- blockers and “CAA” should not be stopped acutely
• reasonable to stop diuretic therapy 48 hours prior to
surgery
•Chronic HPT = loss of auto regulation
•Induction of anesthesia = spikes

44. Asthma
•Perioperative systemic corticosteroids for
asthmatics with
wheezing,
productive cough,
chest tightness, or
shortness of breath while on their usual outpatient
therapy
 Women who received greater than 20 mg of
prednisone per day for more than three weeks in
the six months prior to surgery

45. Anemia
•decision to transfuse = based upon the "10/30
rule“
• blood-borne pathogens and efforts at cost
containment caused a reexamination of
transfusion practices
• no single criterion should be used as an
indication
• hemoglobin less than 7 gm/dL (preiop) =
transfuse