preoperative & postoperative care .pptx

Surgery

1. General Preoperative &Postoperative Care of Surgical Patients

2. Hippocrates: the father of medicine and author of the Hippocratic Oath. Reproduced from iStock © wynnter . 1948 World Medical Association modern version of the Oath. Source: Davey (2014), Chapter 1, p. 2.

3. The preoperative visit: The purpose of the pre-operative visit: 1-Problems identifications 2-Risk assessment 3-Getting informed consent (involves the discussion of the anaesthetic plan in simple terms, premedication, preoperative procedures to intra/postoperative care (management of pain, nausea and vomiting). answering the patient’s questions. 4-Establish a strong doctor–patient relationship 5-Relieving the anxiety of the patient

4. PREOPERATIVE EVALUATION Hx PE LAB ROUTINE WORK UP CBC UA CXR

5. DIAGNOSTIC WORK UP DISEASE OF SURGERY : - LAB - EXTENT OF DISEASE - RADIOLOGY - HISTOPATHOLOGY

6. Patient History Explore the patient’s understanding of the need for surgery to be performed. 2. Ask about any previous surgeries and anaesthetics that the patient may have and how those procedures were tolerated 3. Ask about the patient’s family health history . Include any adverse reactions to anaesthesia , as malignant hyperthermia, when a patient reported that 10 of his family members had died undergoing anaesthesia.

7. 4. Ask about current medication use A patient who takes aspirin, Coumadin, or ibuprofen is at an increased risk for bleeding. A patient taking Coumadin will need to be told to stop this medication before surgery to decrease the risk for bleeding and will need an international normalized ratio (INR) on the day of surgery to make sure clotting studies are within normal limits before surgery. If a patient is taking medications for glucose control, it is important to obtain a fasting preoperative glucose.

8. 5. Ask about medication allergies and intolerances. On the day of surgery, make sure that a red allergy identification band is applied to the patient’s wrist. Ask about nondrug allergies, too. 6. Ask about illicit drug use, abuse, and addiction in the same way you asked about current medication use. Once you explain to patients that there are drug interactions between these drugs and anaesthetic agents, patients will usually respond honestly.

9. 7. Ask about tobacco use . Smokers also have a higher incidence of reactive airway disease, which may result in laryngospasm on induction. Encourage patients to stop smoking a minimum of 6 weeks before surgery to decrease perioperative morbidity. 8. Ask about the possibility of pregnancy, specifically to determine the date of the patient’s last menstrual period. This is needed to prevent unnecessary exposure of the foetus to anaesthetic agents, particularly during the first trimester of pregnancy.

10. Review of Systems Cardiovascular System Ask about a history of dysrhythmias, chest pain, or myocardial infarction (heart attack, MI) because of the potential for re-infarction with surgery. If had a heart attack more than 6 months , the risk of reinfarction is about 6%. If the MI was between 3 and 6 months before a procedure, the risk increases to 15%. if the surgery is within 3 months the risk increases to 30% with a 50% mortality!

11. Ask about hypertension , and if blood pressure is well controlled by medications. Patients are generally encouraged to take their blood pressure medications on the morning of surgery with a sip of water to keep pressures under control. Poorly controlled hypertension is often a precursor to renal dysfunction, So ask about a blood urea creatinine before surgery.

12. Hypertension increases the risk for coronary artery disease, stroke, congestive heart failure, and renal failure. If the hypertension is mild and controlled , the evaluation can take place up to 2 months before surgery. If moderate , evaluation and clearance should be within 2 weeks. If severe , surgery should be postponed with immediate evaluation and intervention.

13. Assess breath sounds and the lower extremities for signs of fluid retention. Listen for rales that do not clear with coughing, and for pitting oedema. Both are a sign of symptomatic congestive heart failure, and surgery will be postponed until the patient’s symptoms have been controlled.

14. Respiratory System: Ask about dyspnea both at rest and with exertion. Ask about the presence of a cough, and if the cough is productive . This can be a clue to an upper respiratory infection, which commonly leads to cancellation of surgery, especially if an elective procedure. Patients with an upper respiratory infection are at a greater risk for perioperative bronchospasm, laryngospasm, decreased oxygen saturations, and problems with secretions. A dry cough may simply be a side effect to the use of an angiotensin-converting enzyme (ACE) inhibitor medication used to treat hypertension. Ask about a history of chronic obstructive pulmonary disease ( COPD) , and any current treatment including antibiotics, bronchodilators or nebulizer treatments, or use of home oxygen therapy. Ask the patient what medications are used to control the asthma, The anaesthesia provider may give the patient a nebulizer treatment before induction.

15. HIGH RISK PATIENTS OBESITY MALNUTRITION ANEMIA PULMONARY DYSFUNCTION ELDERLY INFANT PREGNANCY

16. An E is added to the status number to designate an emergency operation

17. PREOPERATIVE PREPARATION INFORMING THE PATIENT OPERATIVE PERMIT PREOPERAIVE ORDER

18. What is consent? Consent is essentially gaining permission from a patient. Gaining consent is required by law, prior to any intervention An intervention is basically defined as anything you ‘do’ to a patient, no matter how small it may seem. Consent is only valid if it is given voluntarily, and if the patient has capacity at the time when they are giving it

19. In order to give consent, the patient must: Be free from, act voluntarily Have capacity In order to be deemed as having capacity , the patient must be able to: • Understand the information given • Retain the information given • Weigh the information in the balance, considering all aspects and implications of each outcome • Communicate their decision

20. Surgical Scheduling: Ambulatory surgery , also known as day surgery, is designed for patients to be admitted from home on the morning of surgery to an OR, and to be discharged to home following surgery. 23-hour surgery refers to ambulatory surgery followed by up to 23 hours of monitored care by nurses. Examples of 23-hour surgery include the following e.g. Tonsillectomy or Cardiac catheterization

21. Surgical Scheduling: Same-day admission surgery has the patient admitted as a planned admission to an inpatient room following elective or semi-elective surgery. Examples • Total hip replacement • Coronary artery bypass graft . All preprocedural work-ups are done in advance of surgery. This decreases costs

22. Surgical Scheduling: Inpatient, hospital-based surgery has the patient being sent to surgery from an inpatient bed, or emergency room with a plan to return to an inpatient bed or intensive care unit (ICU) Exploratory laparotomy following admission for gastrointestinal (GI) bleed Tracheotomy placement after prolonged intubation in ICU Amputation following admission for a motor vehicle accident

23. Timing of Surgery: Elective surgery Is surgery to improve a patient’s quality of life—either physically or psychologically. The surgery may be medically indicated, such as a cataract removal or repair, or may be optional and desired by the patient, such as breast augmentation. !! Elective Appendectomy??

24. Timing of Surgery: Semi-elective surgery is more time sensitive than elective surgery. Although not required within 24 hours, scheduling should be considered a priority Examples • Cholecystectomy for gallstones and repeated episodes of cholecystitis • Uterine artery ablation for postmenopausal bleeding from fibroids

25. Timing of Surgery: Urgent surgery I s surgery required within 24 hours of diagnosis, and is done so to prevent unnecessary complications Hip fracture • Appendectomy Emergency surgery will be scheduled within 2 hours. Any delay may promote critical injury or systemic deterioration Stable GI bleed • Subdural hematoma The preoperative goal is stabilization before admission to the OR to prevent threats to life or well-being. This urgency may prevent adequate patient preparation and evaluation .

26. Timing of Surgery: Salvage surgery I s required when cardiopulmonary resuscitation is in progress on the way to the OR or in the OR itself. Either a patient’s life or limb is threatened, requiring immediate surgery for survival. Examples include the following: • Penetrating trauma • Ruptured aneurysm • Perforated ulcer Death is an inevitable outcome

27. Ingested material Minimum fasting period (hr) Clear liquids 2 Breast milk 4 Infant formula 6 Nonhuman milk 6 Light meal (toast and clear liquids) 6 Fasting Recommendation

28.   HbA1c test : Haemoglobin A1c or glycated haemoglobin  test , is blood  test  that gives a good indication of how well your diabetes is being controlled. Together with the fasting plasma glucose  test , the  HbA1c test  is one of the main ways in which type 2 diabetes is diagnosed. HbA1c is your average blood glucose (sugar) levels for the last two to three months. If you have diabetes, an ideal HbA1c level is 48mmol/mol (6.5%) or below. If you're at risk of developing type 2 diabetes, your target HbA1c level should be below 42mmol/mol (6%).

29. Preoperative Preparation of the Surgical Patient Review the patient's history and physical examination, and write a preoperative note assessing the patient's overall condition and operative risk. 2. Preoperative laboratory evaluation: Electrolytes, BUN, creatinine, INR/PTT, CBC, platelet count, UA, ABG, pulmonary function test. Chest x-ray (>35 yrs old), EKG (if older then 35 yrs old or if cardiovascular disease). Type and cross for an appropriate number of units of blood. No screening laboratory tests are required in the healthy patient.

30. 3. Skin preparation: Patient to shower and scrub the operative site with germicidal soap ( Hibiclens ) on the night before surgery. On the day of surgery, If hair must be removed, it should be clipped in the operating room. Shaving hair from the operative site, particularly on the evening before surgery or immediately before the wound incision, increases the risk for wound infection. Povidone iodine and chlorhexidine/alcohol should be allowed to dry. 4. Prophylactic antibiotics or endocarditis prophylaxis if indicated. 5. Preoperative incentive spirometry on the evening prior to surgery may be indicated for patients with pulmonary disease. 6. Thromboembolic prophylaxis should be provided for selected, high-risk patients

31. 7. Diet: NPO after midnight. 8. IV and monitoring lines: At least one 18-gauge IV for initiation of anaesthesia. 9. Medications. Preoperative sedation as ordered by anaesthesiologist. Maintenance medications to be given the morning of surgery with a sip of water. Diabetics should receive one half of their usual AM insulin dose, and an insulin drip should be initiated with hourly glucose monitoring. Anticoagulants : Discontinue Coumadin 5 days preop and check PT; stop IV heparin 6 hours prior to surgery.

32. Psychological support (to release fear and anxiety) . Removal of cosmetics, contact lenses, dentures, etc. Menstruation is not a contraindication; the operation need not be postponed.

33. Bowel preparation Bowel preparation Is required for upper or lower GI tract procedures. Mechanical Prep: Day 1: Clear liquid diet, laxative (milk of magnesia 30 cc or magnesium citrate 250 cc), tap water or Fleet enemas until clear. Day 2: Clear liquid diet, NPO, laxative. Day 3: Operation. Oral Antibiotic Prep: One day prior to surgery, after mechanical or whole gut lavage, give neomycin 1 gm and erythromycin 250 mg at 1 p.m., 2 p.m., 11 p.m.

34. Admitting and Preoperative Orders Admit to Ward, ICU, or preoperative room. Frequency of vital signs; input and output recording; neurological or vascular checks. Notify physician if blood pressure <90/60, >160/110; pulse >110; pulse <60; temperature >101.5; urine output <35 cc/h for >2 hours; respiratory rate >30. Activity: Bed rest or ambulation; bathroom privileges. Diet: Ensure NPO IV Orders: D5 1/2 NS at 100 cc/hour. Oxygen: 6 L/min by nasal canula.

35. BEDTIME PREANESTHETIC MEDICATION SPECIAL ORDERS - BLOOD TRANSFUTION - VENOUS ACCESS HEMODYNAMIC MONITORING - NG TUBE - BLADDER CATHETER - PREOPERATIVE HYDRATION

36. Recovery: is an ongoing process that begins at the end of intra-operative care and continues until patient return to their pre-operative physiological state. • Recovery is divided into 3 phases: • 1. Early recovery: from discontinuation of anesthetic agents to recovery of protective reflexes and motor function. • 2. Immidiate recovery : when patients achieves criteria for discharge. • 3. Late recovery: When patient returns to pre-operative physiological state.

37. Postoperative Orders Transfer: From recovery room to surgical ward when stable. Vital Signs: q4h, I&O q4h x 24h. Activity: Bed rest; ambulate in 6-8 hours if appropriate. Incentive spirometer q1h while awake. Diet: NPO x 8h, then sips of water. Advance from clear liquids to regular diet as tolerated. IV Fluids: IV D5 LR or D5 1/2 NS at 125 cc/h (KCL, 20 mEq /L if indicated). Medications:

38. Postoperative day number 1 A. Assess the patient’s level of pain, lungs, cardiac status, flatulence, and bowel movement. Examine for distension, tenderness, bowel sounds; wound drainage, bleeding from incision. B. Discontinue IV infusion when taking adequate PO fluids. Discontinue Foley catheter, and use in-and out catheterization for urinary retention. C. Ambulate as tolerated; incentive spirometer. D. Consider prophylaxis for deep vein thrombosis

39. For patients who may be limited to bed, or who have limited mobility , incentive spirometry will be instituted to promote deep breathing, to increase lung volume, and to encourage coughing to clear mucus from the airway. To promote deep breathing by teaching the patient to “ splint ” the chest and abdomen with a pillow when coughing or forcibly exhaling, by squeeze the pillow tightly against the abdomen or chest as a means of decreasing pain. A final step in the prevention of atelectasis and pneumonia is progressive and early ambulation.

40. Postoperative day number 2 If passing gas or if bowel movement, advance to regular diet unless bowel resection. Laxatives: Dulcolax suppository prn or Fleet enema prn or milk of magnesia, 30 cc PO prn constipation. Postoperative day number 3-7 A. Check pathology report. B. Remove staples and place steri -strips. C. Consider discharge home on appropriate medications; follow up in 1-2 weeks for removal of sutures. D. Write discharge orders (including prescriptions)

41. COMMON POSTOPERATIVE COMPLICATIONS

42. GENERAL COMPLICATIONS: IMPAIRED CONCIOUSNESS POSTOPERATIVE PYREXIA

43. First 48hrs Atelectasis Transfusion rxn Pre-existing infection 3-7 days : infections UTI, wound infection, pneumonia, anastomotic leakage About 7 days onwards Infections Abscess formation DVT/PE

44. RESPIRATORY COMPLICATION : ATELECTASIS PULMONARY ASPIRATION POSTOPERATIVE PNEUMONIA POSTOPERATIVE PLEURAL EFFUSION PNEUMOTHORAX FAT EMBOLISM FAT EMBOLI SYNDROME

45. CADIOVASCULAR COMPLICATION : HEMORRHAGE MASSIVE BLOOD TRANSFUTION BLOOD TRANSFUTION REACTION MYOCARDIAL INFARCTION CARDIAL FAILURE THROMBO PHLEBITIS DVT

46. GASTROINTESTINAL COMPLICATION POSTOPERATIVE ILEUS PROLONG ILEUS AND INTESTINAL OBSTRUCTION GASTRIC DILATATION POSTOPERATIVE FECAL IMPACTION POSTOPERATIVE DIARRHEA POSTOPERATION PAROTITIS: Acute bacterial suppurative parotitis is caused most commonly by  Staphylococcus aureus  and mixed oral aerobes and/or anaerobes. It often occurs in the setting of debilitation, dehydration, and poor oral hygiene, particularly among elderly postoperative patients. COMPLICATION OF DRAINS:

47. URINARY COMPLICATIONS POSTOPERATIVE URINARY RETENSION URINARY TRACT INFECTION

48. WOUND COMPLICATIONS: HEMATOMA SEROMA WOUND DEHISCENCE WOUND INFECTION

49. SURGICAL DRAINS Passive drain gauze drain Penrose drain Cigarette drain Active drain Sump drain Jackson Pratt drain Radivac drain

50. How do you assess a diabetic patient in the clinic?

51. Take a history of the type of diabetic control used, the dosage schedule and the adequacy of control. Particular attention is paid to the propensity to develop hyperglycaemia, ketosis and hypoglycaemia. Ask specifically about the complications of diabetes: nephropathy, sensory and autonomic neuropathy, hypertension, peripheral and coronary arterial disease and retinopathy. The patient looking for these complications is then examined. Look for ongoing infection.

52. How do you manage the diabetic patient once they are on the ward?

53. Patients with diabetes often have gastroparesis, and they should fast at least 12 hours before elective surgery. Always try to put the patient first on the list. Patients with diet-controlled diabetes usually just require glucose monitoring. Patients on oral hypoglycaemic agents should have those agents discontinued on the day of surgery. Sulphonyl urea drugs should be withheld at least 1 day before surgery, because of their long half-life. For those on insulin prescribe 5% dextrose with potassium and start sliding scale insulin infusion. Continue the insulin and dextrose infusion until the patient has had a second meal with their normal dose of subcutaneous insulin post-operatively

54. What are the potential operative complications in the diabetic patient?

55. Infections: diabetics are prone to infection at the surgical site and elsewhere. ● Wound healing: this is impaired in diabetics due in part to microvascular disease. ● Cardiovascular complications: due to microvascular disease

56. Which patients undergoing surgery are at risk of deep vein thromboses ?

57. ● Elderly patients. ● Pregnant patients. ● Patients on the oral contraceptive pill (OCP). ● Patients undergoing orthopaedic or pelvic surgery. ● Patients with malignancy. ● Obese patients. ● Immobile patients. ● Patients with thrombophilia. ● Patients with a previous history of deep vein thrombosis (DVT)

58. How do you reduce this risk?

59. Treat avoidable risk factors: mobilise patients early, use intermittent pneumatic pressure on the legs, use thrombo-embolism deterrent (TED) stockings and use low molecular weight heparin (LMWH

60. What are the complications of a DVT?

61. ● Pulmonary embolism. ● Post- phlebitic syndrome. ● Phlegmasia alba dolens . ● Phlegmasia caerulea dolens

62. How do you investigate a suspected DVT?

63. ● Laboratory tests: D-dimer estimation is sensitive enough to rule out the diagnosis. ● Imaging: Duplex ultrasound or venography. ● Others: impedance plethysmography, which measures the variations in the volume of calf blood on releasing a blood pressure cuff placed so as to cause temporary thigh venous occlusion.

64. How do you treat a proven DVT?

65. Anticoagulate with LMWH and then warfarin for 3–6 months. Thrombolyis may be considered if the DVT is so extensive to cause phlegmasia caerulea dolens . If anticoagulation is contraindicated, then an inferior venacava (IVC) filter may be placed radiologically to prevent pulmonary embolism.

66. How do you classify post-operative complications?

67. Complications may be local (at the operation site) or general (affecting any other system of the body). They may be classified according to how soon they occur after surgery: immediate – within the first 24 hours, early – within the first 4 weeks and late – 4 weeks post-operatively.

68. If a patient has a fever post-operatively how would you proceed?

69. Most patients will develop a transient fever approximately 24–48 hours post-operatively. Due to basal atelectasis of the lungs. However, the patient should be fully examined for a source of infection. Inspecting the wound and examining the respiratory system. Sputum and urine samples can be sent for microscopy and culture. If the temperature is very high, or persistent, then the patient should be examined for further signs of sepsis and blood cultures should be sent to the laboratory

70. What are the possible reasons for a patient being hypoxic post-operatively?

71. ● Reduced alveolar ventilation: hypoventilation (airway obstruction, excess opioids), atelectasis, bronchospasm and pneumothorax. ● Decreased diffusion across the alveolar membrane: pneumonia, pulmonary oedema and acute respiratory distress syndrome (ARDS). ● Lack of alveolar perfusion: pulmonary embolus, tension pneumothorax and cardiac failure.

72. What are the possible reasons for a patient being hypotensive post-operatively?

73. ● Hypovolaemia. ● Cardiac failure. ● Dysrhythmias ● Effects of medication. ● Spinal or epidural anaesthesia.

74. T H A N K S