pre operative general surgery lecture .pptx

Surgey lecture from Bailel and love

1. Preoperative Prepared by Dr.Sadiq Sarkal Cadde 6/8/2024

2. Objective Gather and record concisely all relevant information. Devise a plan to minimise risk and maximise benefit for the patient Consider possible adverse events and plan how to deal with them Communicate to ensure that everyone (including the patient) understands the surgical plan 6/8/2024

3. Patient assessment History taking Physical examination (systemically) Investigation Management after assessment Documentation Obtaining consent 6/8/2024

4. History taking Do not assume that the history has already been adequately covered previously. Take care principles of history-taking Listen Clarify Narrow the differential diagnosis Fitness 6/8/2024

5. Investigations FBC U&E LFTs Clotting screen ABGs ECG CXR Temperature U/A b-HCG HBV HCV HIV 6/8/2024

6. Management after assessment Hypertension >160/95 : Deferred of surgery till controlled well For an acute admission : control rapidly New antihypertensive agent is introduced : Stabilisation period of at least 2 weeks . Drugs β-blockers and on statins should be maintained on their medication ACE inhibitors and receptor blockers are often omitted 24 hours prior to surgery and reintroduced gradually in the postoperative period. Note : Most long-term cardiac medications should be continued over the perioperative period 6/8/2024

7. Management after assessment Myocardial infarction Delayed till 3-6 months elapsed An ejection fraction of < 30% is associated with poor patient outcomes Antiplatelet therapy Balance of risk of continuing antiplatelet agents (with Risk of increased bleeding Risk of stent thrombosis

8. Management after assessment Dysrhythmias Atrial fibrillation (start/continue) β-blockers Digoxin Calcium channel blockers Warfarin : Patients with AF should be stopped 5 days preoperatively to achieve an INR of 1.5 or less, which is safe for most surgery. Bridging therapy Unfractionated heparin or LMWH is recommended for patients with AF and a mechanical heart valve undergoing procedures that require interruption of warfarin.

9. Management after assessment Dysrhythmias Newer anticoagulants They do not have antagonists and must be stopped preoperatively, generally for 2–3 days in patients with normal renal function and longer when renal function is impaired. Examples Dabigatran (direct thrombin inhibitor) or Rivaroxaban , apixaban and edoxaban (direct factor Xa inhibitors)

10. Management after assessment Implanted pacemakers and cardiac defibrillators Checks and appropriate reprogramming should be done preoperatively by specialists. Bipolar diathermy should be made available at surgery. Symptomatic heart blocks and asymptomatic second- ( Mobitz II) and third-degree heart blocks, if discovered at preoperative assessment clinic, will need cardiology consultation and temporary or permanent pacemaker insertion.

11. Management after assessment Valvular heart disease In patients with mechanical heart valves , warfarin needs to be stopped for 5 days before surgery, and an infusion of unfractionated heparin started when the INR falls below 1.5. APTT should be monitored to keep it at 1.5 times normal and the infusion is then stopped 2 hours before surgery . Heparin and warfarin should be started in the postoperative period, and heparin is stopped when the full effect of warfarin takes effect.

12. Management after assessment Anemia Chronic anaemia Well tolerated in the perioperative period if the patient is undergoing a major procedure: preoperative transfusion may be considered. Level Transfuse <8 g/dl Administration day If possible, the transfusion should be given a day or so before the surgery. LRTI Asthma The patient’s usual inhalers should be continued. Smoking Stop at least 4 weeks before the surgery Severe cases Regional anaesthetic techniques and less invasive surgical options should be considered

13. Management after assessment Nil by mouth and regular medications Clear fluids (isotonic drinks and water) within 2 hours before anaesthesia to avoid the risk of acid aspiration syndrome. These restrictions are further reduced in infants If the surgery is delayed Oral intake of clear fluids should be allowed until 2 hours before surgery Or I.V fluids in children, elderly and diabetics. Medicines Patients can continue to take their specified routine medications with sips of water in the NBM period.

14. Management after assessment Regurgitation: High risk group of pulmonary aspiration Patients with hiatus hernia Obesity Pregnancy Diabetes Management Clear antacids may be given at an appropriate time in the preoperative period.

15. Management after assessment Liver Check presence of Ascites Oesophageal varices Hypoalbuminaemia Sodium and water retention Jaundice Vitamin K deficiency Risk of renal failure Associated sepsis (cholangitis 6/8/2024

16. Management after assessment Endocrine and metabolic disorders Malnutrition A BMI of less than 18.5 indicates nutritional impairment and a BMI below 15 is associated with significant hospital mortality . Minimum of 2 weeks before surgery is required. If a patient is unlikely to be able to eat for a significant period, arrangements should be made by the preoperative assessment team to start nutritional support in the immediate postoperative phase.

17. Management after assessment Obesity Morbid obesity can be defined as BMI of more than 35 (other definitions exist) and is associated with increased risk of postoperative complications. If possible surgery should be delayed until the patient is more active and has lost weight . If this fails, prophylactic measures need to be taken (such as preventative measures for acid aspiration and DVT ) and associated risks need to be explained prior to the surgery

18. Management after assessment Diabetic Any history of hyper- and hypoglycaemic episodes, and hospital admissions, should be noted. For elective surgery , HBA1c of <69 mmol / mol is recommended. Lipid-lowering medication should be started in patients who are in a high risk group for cardiovascular complications of diabetes.

19. Management after assessment Diabetic NIDM : omit morning dose and put theatre list early with levels should be checked 2 hourly and return medication after starting eating postopertively. IDDM : For more significant surgery , an intravenous insulin infusion will be required Note: The plasma potassium level must be closely monitored. For those on the afternoon list , breakfast can be given with half their regular dose of intermediate-acting insulin (or full dose oral antidiabetic agents) and then managed with regular blood sugar checks. 6/8/2024

20. Management after assessment Adrenocortical suppression Patients receiving oral adrenocortical steroids should be asked about the dose and duration of the medication in view of supplementation with extra doses of steroids perioperatively , to avoid an Addisonian crisis

21. Management after assessment Renal disease Estabalize underlying condition include diabetes mellitus, hypertension and ischaemic heart disease Treat acidosis, hypocalcaemia and hyperkalaemia of greater than 6 mmol /L. Continue peritoneal or haemodialysis until a few hours before surgery After the final dialysis before surgery, a blood sample should be sent for FBC and U&Es. Anemia : preoperative blood transfusion is often not necessary.

22. Management after assessment Urinary tract infection Uncomplicated UTI is common in women, while outflow uropathy with chronically infected urine is common in men. These infections should be treated before embarking on elective surgery Most centres treat such infections before high-risk elective surgery (such as joint replacement surgery) and wait for a negative result before proceeding. For emergency procedures, antibiotics should be started and care taken to ensure that the patient maintains a good urine output before, during and after surgery.

23. Management after assessment Coagulation disorders Thrombophilia Patients with a strong family history or previous personal history of thrombosis should be identified. They will need thromboprophylaxis in the perioperative period. The progesterone-only contraceptive pill should be continued Combined pill ( slight increase risk of significant thrombosis ) should be weighed against the risks of an unplanned pregnancy Estrogen-containing oral contraceptives or HRT : stop 4 weeks before surgery.

24. Management after assessment Coagulation disorders Thrombophilia Patients with a low risk of thromboembolism can be given thromboembolism-deterrent stockings to wear during the perioperative period. High-risk patients with a history of recurrent DVT, pulmonary embolism and arterial thrombosis will be on warfarin . This should be stopped before surgery and replaced by low molecular weight heparin or factor Xa inhibitors.

25. Management after assessment Neurological and psychiatric disorders In patients with a history of stroke , pre-existing neurological deficit should be recorded. These patients may be on anti-platelet agents or anticoagulants. Thrombotic risks : if low, antiplatelet agents should be withdrawn ( 7 days for aspirin, 10 days for clopidogrel ) High thrombotic risk : aspirin alone should be continued.

26. Management after assessment Neurological and psychiatric disorders Anticonvulsants and anti-Parkinson medication is continued perioperatively to help early mobilisation of the patient. Lithium should be stopped 24 hours prior to surgery; blood levels should be measured to exclude toxicity. Note: The anaesthetist should be informed if patients are on psychiatric medications such as tricyclic antidepressants or monoamine oxidase inhibitors , as these may interact with anaesthetic drugs

27. Management after assessment Musculoskeletal disorders Rheumatoid arthritis can lead to an unstable cervical spine with the possibility of spinal cord injury during intubation. Therefore, flexion and extension lateral cervical spine radiographs should be obtained in symptomatic patients

28. Management after assessment Musculoskeletal disorders Assessment of the severity of renal , cardiac valvular and pericardial involvement as well as restrictive lung disease , should be carried out. Rheumatologists will advise on steroids and disease-modifying drugs so as to balance immunosuppression (chance of infections) against the need to stabilise the disease perioperatively (stopping disease modifying drugs can lead to flare-up of the disease).

29. Management after assessment Musculoskeletal disorders In ankylosing spondylitis patients, in addition to the problems discussed above, techniques of spinal or epidural anaesthesia are often challenging. Patients with systemic lupus erythematosus may exhibit a hypercoagulable state along with airway difficulties .

30. Management after assessment Airway assessment The ability to intubate the trachea and oxygenate the patient are basic and crucial skills of the anaesthetist . The ease or difficulty encountered when performing airway manoeuvres can be predicted by simple examination findings of full mouth opening (modified Mallampati class), jaw protrusion, neck movement and thyromental distance.

31. Management after assessment Airway assessment The anaesthetist should look for: Loose teeth Obvious tumours Scars Infections Obesity Thickness of the neck When more than one of the above tests are positive, the chances of experiencing difficulty in obtaining and securing the airway become greater. To obtain the modified Mallampati class, the anaesthetist sits in front of the patient who is asked to open their mouth and protrude the tongue The higher the grade, the higher the risk in obtaining and securing an airway

32. Preoperative assessment in emergency surgery In urgent or emergency surgery the principles of preoperative assessment should be the same as in elective surgery, except that the opportunity to optimise the condition is limited by time constraints .

33. ASSESSMENT OF THE HIGHRISK PATIENT By identifying high-risk patients in the preoperative phase and planning their perioperative management, morbidity and mortality can be reduced. Patients who have a predicted mortality ≥5% should be considered as ‘high risk’. In summary: who is typical high risk patient: Elderly patient with coexisting conditions such as IHD and/or COPD undergoing major surgery. The risk will increase if the surgery is performed as an emergency.

34. Identification of the high-risk patient American Society of Anaesthesiologists system The American Society of Anaesthesiologists (ASA) scoring system is widely used. Although not designed to be used as a risk prediction score, it has a quantitative association with the predicted percentage of postoperative mortality. However, it does not account for age or nature of surgery and the term ‘systemic disease’ in ASA grading introduces an element of ‘subjectivity’.

35. Documentation Investigations Management plan Drug chart Extra medications required perioperatively should be included Bowel preparation Three doses (8-hourly) of prophylactic antibiotics should be given. Fluid charts Analgesics Anti emetics Thormbosis prophylaxis 6/8/2024

36. Obtaining consent Consent should be both voluntary and informed. Ensure competence Correct patient(check) Patient understands who you are Discuss Treatment plan and alternatives Possible risks and complications Type of anaesthesia Give the patient time and space to make the final decision . Record clearly and comprehensively what has been agreed. 6/8/2024

37. ARRANGING THEATRE LIST The date, place and time of operation should be matched with availability of personnel. Appropriate equipment and instruments should be made available. The operating list should be distributed as early as possible to all staff who are involved in making the list run smoothly. If this is done electronically, familiarity with the computer system is required. Prioritise patients, e.g. children and diabetic patients should be placed at the beginning of the list; life- and limb-threatening surgery should take priority; cancer patients need to be treated early.

38. 6/8/2024 POSTOPERATIVE CARE OF THE PATIENT

39. POSTOPERATIVE CARE OF THE PATIENT Details should be included in the operative note: Patient’s details – full name, date of birth, hospital number, address, ward. Date (and start/finish time) of operation. Operating room. Name of operation. Surgeon, assistant, anaesthetist Anaesthetic type. Patient positioning and set-up . Was a tourniquet used. Were antibiotics given. Was the patient catheterised . Type of skin preparation. Method of draping. 6/8/2024

40. POSTOPERATIVE CARE OF THE PATIENT Operative details including: Incision Approach Findings. Procedure Complications. Implants used. Closure, including suture material used. Dressing. Postoperative state (e.g. distal neurovascular status); Type of dressing used. 6/8/2024

41. POSTOPERATIVE CARE OF THE PATIENT Postoperative instructions relevant to surgery: Observations Possible complications Treatment Time lines for patient recovery. when to mobilise when to resume normal oral intake The need for physiotherapy Allowable movements Dressing changes. Discharge and follow-up details 6/8/2024

42. POSTOPERATIVE CARE OF THE PATIENT The immediate postoperative period assess: Airway Breathing freely Circulation Blood pressure Pulse Oxygen saturation Fully conscious 6/8/2024

43. POSTOPERATIVE CARE OF THE PATIENT The immediate postoperative period The theatre team should then formally hand over the care of the patient to the PACU staff .The information provided should include Name Age The Surgical Procedure Existing Medical Problems Allergies The Anaesthetic and Analgesics Given Fluid Replacement Blood Loss Urine Output Any Surgical And Anaesthetic Problems Encountered Or Expected Plan For The Management Of Pain And Nausea Or Vomiting.

44. POSTOPERATIVE CARE OF THE PATIENT The immediate postoperative period Postoperative observations Vital signs level of consciousness Pain status Hydration status Note Its given in the recovery room and supportive treatment is given.

45. POSTOPERATIVE CARE OF THE PATIENT The immediate postoperative period The patient can be discharged from PACU when they fulfil the following criteria: Patient is fully conscious . Respiration and oxygenation are satisfactory. Patient is normothermic , not in pain and not nauseous Cardiovascular parameters are stable. Oxygen, fluids and analgesics have been prescribed. There are no concerns related to the surgical procedure

46. POSTOPERATIVE CARE The aim of postoperative care is to provide the patient with as quick , painless and safe recovery from surgery as possible.

47. Patient recovery Once patients are fully conscious and comfortable and their vital functions are stable they are transferred to the general ward Patients who are at high risk may be transferred to a high-dependency or intensive care unit . While on the ward patients should be visited at least morning and evening by medical staff to ensure that there is steady progress.

48. Classification of postoperative complications There are three common approaches for the classification of postoperative complications of surgery: Linked to time after surgery : Immediate (Within 6 H Of Procedure); Early (6–72 H); Late (>72 H). Generic and surgery specific. Clavian-Dindo : This system relates to surgical complications only and is used to objectively and reproducibly measure the impact of the surgical complication on the outcome of the procedure. It is included here for completeness and will be discussed no further.

49. Classification of postoperative complications Immediate respiratory complications AIRWAY Upper airway obstruction is one of the commonest immediate postoperative complications and can be due to laryngospasm, persisting relaxation of airway muscles , soft tissue oedema , haematoma , vocal cord dysfunction or foreign body . RESPIRATION The residual effects of anaesthetic drugs (neuromuscular blockers, anaesthetic agents, opioids) can contribute to reduced or impaired adequacy of ventilation postoperatively. Continuous pulse oximetry and respiratory rate evaluation can identify Supplemental oxygen should be given to all patients in PACU until adequate respiration and oxygenation are restored.

50. Classification of postoperative complications Immediate respiratory complications HYPOXAEMIA Causes: Acute Pulmonary Oedema (Fluid Overload, Cardiac Failure, Postobstructive ) Bronchospasm Pneumothorax Aspiration Pulmonary Embolism Treatment: Oxygen Should Be Administered At 15 L/Min . A Head Tilt, Chin Lift Or Jaw Thrust Should Relieve Obstruction Related To Reduced Muscle Tone. Suctioning Of Any Blood Or Secretions Insertion Of An Oropharyngeal Airway May Be Needed

51. Classification of postoperative complications Immediate cardiovascular complications HYPOTENSION Myocardial Impairment Vasodilatation From Subarachnoid And Epidural Anaesthesia Surgical Bleeding Sepsis Arrhythmias Tension Pneumothorax Pulmonary Embolism Pericardial Tamponade Anaphylaxis

52. Classification of postoperative complications Immediate cardiovascular complications HYPERTENSION Due To Pain Agitation Anxiety Bladder Spasm Secondary To Urinary Catheterisation Pre-existing Poorly-controlled Hypertension. Consequences bleeding from vascular suture lines, cerebrovascular haemorrhage and myocardial ischaemia or infarction.

53. Classification of postoperative complications Urinary retention Common with pelvic and perineal operations as well as Procedures performed under spinal anaesthesia. Pain and Hypovolemia Problems with access to urinals and bed pans lack of privacy on wards NOTE : Catheterization should be performed prophylactically when an operation is expected to last 3 hours or longer , or when large volumes of fluid are administered.

54. Classification of postoperative complications Urinary infection Most commonly acquired infections in the postoperative period. Patients may present with dysuria and/or pyrexia . Immunocompromised patients, diabetics and those patients with a history of urinary retention are known to be at higher risk. Treatment involves adequate hydration , proper bladder drainage and antibiotics depending on the sensitivity of the microorganisms.

55. Classification of postoperative complications Postoperative delirium POD can occur during recovery from anaesthesia or a few days after surgery. The overall incidence of POD is 5–50%. It occurs more frequently in the elderly orthopaedic patient and those undergoing emergency surgical procedures.

56. Classification of postoperative complications There are two types of delirium Hyperactive (restlessness, incoherent speech, agitation, hallucinations) Hypoactive (withdrawn, poorly responsive to the environment, depressed) Preoperative risk factors for POD include Pre-existing cognitive impairment Dementia frailty*(weak) Parkinson’s disease Severe illness Renal impairment Depression. Precipitating factors include surgery, intraoperative administration of narcotics and benzodiazepines, change of medications, electrolyte and fluid abnormalities, constipation, catheterisation and an unfamiliar environment

57. GENERAL POSTOPERATIVE COMPLICATIONS

58. GENERAL POSTOPERATIVE COMPLICATIONS Bleeding Dressings and drains should be inspected regularly in the first 24 hours after surgery. If haemorrhage is suspected, blood samples should be taken for a full blood count, coagulation profile and cross match. Supportive treatment includes oxygen and fluid resuscitation. It may require correction of coagulopathy.

59. GENERAL POSTOPERATIVE COMPLICATIONS Deep vein thrombosis The symptoms and signs of DVT include calf pain, swelling, warmth, redness and engorged veins. However, most will show no physical signs. On palpation the muscle may be tender and there may be a positive Homans ’ sign

60. GENERAL POSTOPERATIVE COMPLICATIONS Pulmonary embolus Signs and symptoms depend on the size of the embolus and may range from dyspnoea , cough, and pleuritic chest pain to sudden cardiovascular collapse.

61. GENERAL POSTOPERATIVE COMPLICATIONS Fever About 40% of patients develop pyrexia after major surgery; however, in most cases no cause is found. The inflammatory response to surgical trauma may manifest itself as fever, and so pyrexia does not necessarily imply sepsis. However, in all patients with a pyrexia, a focus of infection should be sought.

62. GENERAL POSTOPERATIVE COMPLICATIONS The causes of a raised temperature postoperatively include: Atelectasis Of The Lung Superficial And Deep Wound Infection Chest Infection Urinary Tract Infection Thrombophlebitis(can be seen first few days; usually a port of saphenous vein become inflamed; Tx: warm moist packs , elevation and analgesics ) Wound Infection Anastomotic Leakage Intracavitary Collections And Abscesses.

63. GENERAL POSTOPERATIVE COMPLICATIONS The possible causes of pyrexia of a non-infective origin include: DVT Transfusion Reactions Wound Haematomas Atelectasis Drug Reactions

64. GENERAL POSTOPERATIVE COMPLICATIONS Wound dehiscence Wound dehiscence is disruption of any or all of the layers in a wound. Dehiscence may occur in up to 3% of abdominal wounds and is very distressing to the patient. Wound dehiscence most commonly occurs from the 5 th to the 8 th postoperative day when the strength of the wound is at its weakest. It may herald an underlying abscess and usually presents with a serosanguinous discharge

65. GENERAL POSTOPERATIVE COMPLICATIONS Pressure sores They particularly affect the pressure points of a recumbent patient, including the sacrum , greater trochanter and heels . Risk factors Poor nutritional status Dehydration Lack of mobility Nerve block anaesthesia technique. Prevention Early mobilisation prevents pressure sores High-risk patients may be nursed on an air mattress , which automatically relieves the pressure areas.

66. GENERAL POSTOPERATIVE COMPLICATIONS Wound infections Pre disposing factors Age General health Nutritional status Personal hygiene habits Malignancy Poor surgical technique Diagnosis : clinical Fever during the 4th to 5th day Redness or indurations at operation site

67. GENERAL POSTOPERATIVE COMPLICATIONS Hematoma, Abscess and Seromas These may occur either in the pelvis or under the fascia of abdominal rectus muscle. They are suspected during falling of hematocrite in association with low-grade fever. Small hematoma or seroma often resolve spontaneously, but some can become infected. Ultrasonography is an excellent adjunct to physical examination. Drainage of infected hematoma should be accomplished extraperitoneally

68. Post operative care A simple system for ensuring that everything is checked and recorded is represented by the acronym SOAP ( subjective, objective, assessment, plan). Subjective Objective Assessment Plan

69. Patient recovery Subjective Ask the patient how they are. Specifically, ask about pain, nausea and mobility.

70. Patient recovery Objective Check the patient’s charts for: Temperature Pulse Respiration Fluid balance Any special observations recorded by the nurses. The patient’s pressure areas should be checked Skin around the edge of the dressing should be checked for redness or blistering

71. Patient recovery Assessment Review all of the information obtained under S and O and list the problems that the patient is now facing which need addressing.

72. Patient recovery Plan Formulate and agree a plan with the patient and the staff and record that plan in the notes. These notes should be dated and signed.

73. Patient recovery Specific examinations also need to be recorded, such as: Bowel sounds after abdominal surgery Distal neurovascular status after orthopaedic procedures. Review all laboratory results and investigations. Review the drug chart. Record all relevant findings (both negative and positive) clearly in the notes.

74. Recovery from general anaesthesia

75. Recovery from general anaesthesia (Goals) P rovide a smooth, rapid return to: Consciousness S table hemodynamics Stable pulmonary function , P rotective airway reflexes C ontinued analgesia.

76. Recovery from general anaesthesia Preparation for emergence from anesthesia usually begins before surgical closure, and communication between the surgeon and anesthesiologist facilitates prompt emergence of the patient at the procedure’s termination . Patients recover from the effects of sedation or general or regional anesthesia in the post-anesthesia care unit.

77. Recovery from general anaesthesia Inadequate breathing after general anaesthesia may result from: Obstruction of the airway Central sedation from opioid drugs or anaesthetic agents H ypoxia or hypercarbia of any cause H ypocarbia from mechanical overventilation P ersistent neuromuscular blockade .

78. Recovery from general anaesthesia (Goals) Discharged to the appropriate ward or to home once: T hey are oriented Comfortable H emodynamically stable Ventilating adequately Without signs of anesthetic or surgical complications