This document discusses preoperative preparation for gastrointestinal surgery. It outlines factors that influence surgical outcomes such as patient age, comorbidities, and complexity of the procedure. It recommends conducting an interdisciplinary risk assessment and optimizing patient physical condition and medications preoperatively. Routine diagnostic tests like blood tests, ECG, and chest x-ray are outlined. Risk scoring systems and evaluating cardiac and pulmonary risk are discussed. Guidelines are provided for continuing medications like beta blockers, diuretics, and antiplatelets preoperatively based on literature recommendations.
The document discusses the perioperative management of surgical patients. It covers topics like history taking, physical examination, identifying high-risk patients, optimizing medical conditions, and postoperative care. The goal of perioperative management is to reduce the risk of complications and mortality through early identification of risk factors, treatment of medical issues, and a multidisciplinary approach to care.
This document discusses consent in surgical patients, including:
- The history of consent from ancient Greece to modern informed consent laws established after Jerry Canterbury's paralysis from surgery complications.
- Types of consent including implied, expressed, verbal, written, and blanket consent.
- Elements of valid consent including disclosure, comprehension, voluntariness, competence, and agreement.
- Situations where consent is required at our hospital, who can provide consent, and how consent can be withdrawn.
- Special considerations for consent in emergencies, unexpected findings, children, and different cultures.
This document discusses day care or ambulatory surgery. It defines day care surgery as when a patient is admitted and discharged within a 12-hour period for a specific procedure. The document outlines the advantages of day care surgery such as reduced costs and stress. It discusses selection criteria for patients, including medical, social, and surgical factors. It also covers the preoperative, perioperative, and postoperative management of patients undergoing day care surgery. The key requirements for successful day care surgery are also summarized.
Principles of surgery. Day case surgery is a rapidly evolving surgical sub speciality that seeks to eliminate the need for prolonged admission in surgical patients and the attendant complications of prolonged immobilization. It is based on the documented evidence that most post op patients does not require specialised post op care and hence can be allowed to recover at home. This form of surgery appeals to patients and their families due to the fact that it allows only minimal interruption of patient's social life
Damage control surgery involves rapidly controlling hemorrhaging and contamination through temporary closure of injuries to stabilize critically injured patients, followed by resuscitation and definitive repair once physiology is restored. It aims to prevent the lethal triad of hypothermia, acidosis, and coagulopathy. The approach has three stages - initial laparotomy and packing, ICU resuscitation, and planned reoperation once metabolic conditions improve. It has been shown to improve survival rates for severely injured trauma patients compared to traditional surgery.
This document discusses laparoscopic cholecystectomy (LC), including:
- The history and development of LC since its invention in 1985.
- The standard four-port technique for LC and strategies to minimize bile duct injuries like adopting the Critical View of Safety method.
- Potential complications of LC like hemorrhage, bile leak, and bile duct injury which can occur if the hepatocystic triangle anatomy is not correctly identified.
- Techniques to help identify anatomy like intraoperative cholangiography and using landmarks like Rouviere's sulcus and the epicholedochal plexus.
A surgical site infection occurs when bacteria enter through an incision made during surgery. It can lead to increased morbidity, mortality, hospital stay, and costs. There are three types - superficial, deep, and organ/space infections. Risk factors include patient comorbidities, local wound factors, and microbes. Prevention focuses on proper patient preparation, aseptic technique during surgery, and postoperative wound care. Signs of severe infection include systemic inflammatory response syndrome and sepsis, which can progress to multiple organ dysfunction syndrome and death if not properly treated.
The document discusses the perioperative management of surgical patients. It covers topics like history taking, physical examination, identifying high-risk patients, optimizing medical conditions, and postoperative care. The goal of perioperative management is to reduce the risk of complications and mortality through early identification of risk factors, treatment of medical issues, and a multidisciplinary approach to care.
This document discusses consent in surgical patients, including:
- The history of consent from ancient Greece to modern informed consent laws established after Jerry Canterbury's paralysis from surgery complications.
- Types of consent including implied, expressed, verbal, written, and blanket consent.
- Elements of valid consent including disclosure, comprehension, voluntariness, competence, and agreement.
- Situations where consent is required at our hospital, who can provide consent, and how consent can be withdrawn.
- Special considerations for consent in emergencies, unexpected findings, children, and different cultures.
This document discusses day care or ambulatory surgery. It defines day care surgery as when a patient is admitted and discharged within a 12-hour period for a specific procedure. The document outlines the advantages of day care surgery such as reduced costs and stress. It discusses selection criteria for patients, including medical, social, and surgical factors. It also covers the preoperative, perioperative, and postoperative management of patients undergoing day care surgery. The key requirements for successful day care surgery are also summarized.
Principles of surgery. Day case surgery is a rapidly evolving surgical sub speciality that seeks to eliminate the need for prolonged admission in surgical patients and the attendant complications of prolonged immobilization. It is based on the documented evidence that most post op patients does not require specialised post op care and hence can be allowed to recover at home. This form of surgery appeals to patients and their families due to the fact that it allows only minimal interruption of patient's social life
Damage control surgery involves rapidly controlling hemorrhaging and contamination through temporary closure of injuries to stabilize critically injured patients, followed by resuscitation and definitive repair once physiology is restored. It aims to prevent the lethal triad of hypothermia, acidosis, and coagulopathy. The approach has three stages - initial laparotomy and packing, ICU resuscitation, and planned reoperation once metabolic conditions improve. It has been shown to improve survival rates for severely injured trauma patients compared to traditional surgery.
This document discusses laparoscopic cholecystectomy (LC), including:
- The history and development of LC since its invention in 1985.
- The standard four-port technique for LC and strategies to minimize bile duct injuries like adopting the Critical View of Safety method.
- Potential complications of LC like hemorrhage, bile leak, and bile duct injury which can occur if the hepatocystic triangle anatomy is not correctly identified.
- Techniques to help identify anatomy like intraoperative cholangiography and using landmarks like Rouviere's sulcus and the epicholedochal plexus.
A surgical site infection occurs when bacteria enter through an incision made during surgery. It can lead to increased morbidity, mortality, hospital stay, and costs. There are three types - superficial, deep, and organ/space infections. Risk factors include patient comorbidities, local wound factors, and microbes. Prevention focuses on proper patient preparation, aseptic technique during surgery, and postoperative wound care. Signs of severe infection include systemic inflammatory response syndrome and sepsis, which can progress to multiple organ dysfunction syndrome and death if not properly treated.
This document discusses intestinal anastomosis, which involves creating a connection between intestinal loops or ends. Intestinal anastomosis is commonly performed for elective and emergency cases involving conditions like cancer, infections, or obstructions. The key factors for a successful anastomosis are minimal contamination, good blood supply, and tension-free apposition of the intestinal ends. The document compares hand-sewn and stapled techniques, noting that while staplers are faster, studies have found no difference in outcomes between the two methods. Proper patient factors and surgical technique are more important than the specific method used.
The document discusses enhanced recovery after surgery (ERAS) programs. It describes how ERAS utilizes a multimodal approach involving surgeons, nurses, dietitians and others to optimize patient care and recovery through measures like preoperative counseling and nutrition, minimal invasive surgery when possible, reduced use of tubes/drains, early mobilization and feeding, and well-managed postoperative pain control. The goal is to reduce length of stay without increasing complications through evidence-based practices compared to traditional postoperative care methods. Studies show ERAS programs can achieve these outcomes safely and cost-effectively across several surgery types.
This document provides guidance on preoperative preparation for general surgery patients. It discusses defining the preoperative period, objectives of preoperative assessment, types of patients, principles of history taking and medical examination, common investigations, optimizing medical conditions, obtaining consent, and organizing the operating theatre list. The key aspects of preoperative preparation covered include gathering relevant patient information, assessing and optimizing the patient's medical status, anticipating and planning for risks, and informing all parties involved in the patient's care.
The principles of vascular repair with sutures were established in the first decade of the 20th century by Alexis Carrel, who in 1912 was awarded the Nobel Prize for medicine for his work .Since then, technical refinements of suture materials have made possible surgical reconstruction of most arteries from the root of the aorta to microvascular anastomosis or repair of the smallest vessels, e.g., digital arteries or those on the surface of the brain.
Damage control surgery (DCS) is an approach used for severely injured trauma patients that focuses on rapidly addressing life-threatening issues like hemorrhage rather than fully repairing anatomy. It aims to prevent the lethal triad of hypothermia, acidosis, and coagulopathy that can result from long operations and blood loss. Key aspects of DCS include temporary measures like packing bleeding liver injuries; stapling but not repairing some intestinal injuries; leaving unrepaired vascular injuries clamped; and rapidly closing the abdomen with clips rather than drains to allow reoperation once the patient is stabilized. The goal is definitive repair within 24 hours once the patient's physiology is corrected.
This document discusses principles of bowel anastomosis, including types of anastomoses, indications for anastomoses, pre-operative preparation, intra-operative techniques, post-operative care, complications, and controversies. It covers topics such as hand-sewn versus stapled anastomoses, single versus double layer closure, inversion versus eversion of tissue, and use of abdominal drains and NG tubes. The goal of bowel anastomosis is to successfully rejoin bowel segments through meticulous surgical technique and postoperative management in order to restore intestinal continuity.
A Prospective Study of Evaluation of Operative Duration as a Predictor of Mortality in Pediatric Emergency Surgery: Concept of 100 Minutes Laparotomy in Resource-limited Setting
Liver resection indications & methodsDr Harsh Shah
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
Damage Control Resuscitation (DCR) is a systematic approach for managing major trauma patients at risk of exsanguinating hemorrhage. It incorporates permissive hypotension to minimize blood loss while hemorrhage is uncontrolled, haemostatic resuscitation using blood products instead of crystalloids to prevent coagulopathy, and early hemorrhage control through surgery. DCR aims to decrease mortality and morbidity by recognizing patients at risk of hemorrhagic shock, providing adequate tissue oxygenation through hypotensive resuscitation while limiting further blood loss and clot disruption, and preventing the triad of hypothermia, acidosis and coagulopathy through haemostatic resuscitation and blood product administration according to a
Postoperative complications and managementyoursshijo
This document discusses postoperative complications, their management, and assessments. It notes that complications can be general, like fever or infection, or specific to the type of surgery. Key time periods for complications are immediate postoperative, days 3-5, and after 5 days. The first postoperative assessment establishes baseline status and identifies any issues. Ongoing assessments monitor for complications and guide treatment. Factors like blood pressure, pain, and fluid balance must be considered.
Surgical audit is a process that systematically analyzes surgical care quality against standards to improve patient outcomes. It involves collecting data on parameters like mortality, complications and outcomes and comparing results to peers to identify areas for improvement. The goal is continuous quality improvement through a non-punitive, educational process. Surgical audit has existed for centuries but modern methods began in the early 1900s and involve retrospective review of existing data to guide practice changes.
1. The Advanced Trauma Life Support (ATLS) protocol focuses on simultaneously identifying and treating life-threatening injuries within the crucial "Golden Hour" period after trauma.
2. The ATLS protocol involves two surveys - the Primary Survey to address airway, breathing, circulation, disability, and exposure issues, and the Secondary Survey for a full history and physical exam after initial resuscitation is complete.
3. Key components of the Primary Survey include assessing the airway, identifying tension pneumothorax and hemorrhage, and providing spinal immobilization, followed by full exposure to identify all injuries.
LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
This document discusses day case surgery (DCS). It begins with an introduction on the prevalence of DCS internationally. It then covers the definition, history, merits and demerits of DCS. Key aspects of setting up and running a successful DCS unit are described, including space requirements, staffing, suitable procedures, pre-op preparation, and discharge criteria. The document concludes with a discussion on audit and special considerations for DCS in children and emergencies.
The document discusses the ATLS (Advanced Trauma Life Support) concept for managing trauma. It describes ATLS as an internationally recognized system that teaches a methodical approach to rapidly assess and treat life-threatening injuries in trauma patients. The steps include: (1) conducting a primary survey to evaluate the patient's airway, breathing, circulation, disability and exposure; (2) performing a secondary survey involving a full physical exam and history; and (3) re-evaluating the patient to ensure all injuries are identified and managed. The goal of ATLS and trauma management overall is to prevent death by treating life-threatening conditions as the top priority, especially within the "Golden Hour" period after injury.
Open right hemicolectomy is performed to treat malignant tumors, polyps, and other conditions in the ileocecal region, ascending colon, and hepatic flexure. The procedure involves mobilizing the right colon, ligating blood vessels, resecting the involved bowel segments, and creating an ileocolic or ileotransverse anastomosis. Key steps include careful dissection to avoid injury to nearby structures like the duodenum and ureter, and ensuring a well-vascularized, tension-free anastomosis to minimize risks of leakage. Post-operative care focuses on early ambulation and advancing diet based on progress.
This document provides an overview of day care or ambulatory surgery. It discusses the history and development of day care surgery. Key points include that day care surgery aims to have patients discharged on the same day of surgery. Patient selection involves assessing medical, social and surgical factors to identify appropriate candidates. The document also outlines common procedures performed in day care settings and considerations for anesthesia, analgesia, and post-operative recovery and discharge criteria. The overall goal of day care surgery is to provide surgical care without an overnight hospital stay when possible.
The document discusses principles of safe surgery and outlines three phases of surgical safety: pre-operative, intra-operative, and post-operative. It notes that complications occur in up to 25% of patients after surgery and half of adverse surgical events are considered preventable. The World Health Organization introduced a surgical safety checklist to encourage safety checks and minimize preventable patient harm during procedures. Barriers to fully implementing safety standards include inconsistent application of principles and checklists across healthcare settings.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Cardiac risk ,lecture presented at Palermo,Italy 2009Claudio Melloni
This document discusses key considerations for cardiac risk stratification in patients undergoing noncardiac surgery. It emphasizes that a risk assessment tool should accurately predict perioperative cardiac events and non-events. It also should influence outcomes by identifying high-risk patients for whom surgery should be cancelled or treatment changed, and subgroups that do or do not benefit from proven therapy. The tool must also have a favorable balance of benefits and harms. It then provides details on the Goldman cardiac risk index and revised Lee cardiac risk index used to stratify patients into different risk levels.
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
This document discusses intestinal anastomosis, which involves creating a connection between intestinal loops or ends. Intestinal anastomosis is commonly performed for elective and emergency cases involving conditions like cancer, infections, or obstructions. The key factors for a successful anastomosis are minimal contamination, good blood supply, and tension-free apposition of the intestinal ends. The document compares hand-sewn and stapled techniques, noting that while staplers are faster, studies have found no difference in outcomes between the two methods. Proper patient factors and surgical technique are more important than the specific method used.
The document discusses enhanced recovery after surgery (ERAS) programs. It describes how ERAS utilizes a multimodal approach involving surgeons, nurses, dietitians and others to optimize patient care and recovery through measures like preoperative counseling and nutrition, minimal invasive surgery when possible, reduced use of tubes/drains, early mobilization and feeding, and well-managed postoperative pain control. The goal is to reduce length of stay without increasing complications through evidence-based practices compared to traditional postoperative care methods. Studies show ERAS programs can achieve these outcomes safely and cost-effectively across several surgery types.
This document provides guidance on preoperative preparation for general surgery patients. It discusses defining the preoperative period, objectives of preoperative assessment, types of patients, principles of history taking and medical examination, common investigations, optimizing medical conditions, obtaining consent, and organizing the operating theatre list. The key aspects of preoperative preparation covered include gathering relevant patient information, assessing and optimizing the patient's medical status, anticipating and planning for risks, and informing all parties involved in the patient's care.
The principles of vascular repair with sutures were established in the first decade of the 20th century by Alexis Carrel, who in 1912 was awarded the Nobel Prize for medicine for his work .Since then, technical refinements of suture materials have made possible surgical reconstruction of most arteries from the root of the aorta to microvascular anastomosis or repair of the smallest vessels, e.g., digital arteries or those on the surface of the brain.
Damage control surgery (DCS) is an approach used for severely injured trauma patients that focuses on rapidly addressing life-threatening issues like hemorrhage rather than fully repairing anatomy. It aims to prevent the lethal triad of hypothermia, acidosis, and coagulopathy that can result from long operations and blood loss. Key aspects of DCS include temporary measures like packing bleeding liver injuries; stapling but not repairing some intestinal injuries; leaving unrepaired vascular injuries clamped; and rapidly closing the abdomen with clips rather than drains to allow reoperation once the patient is stabilized. The goal is definitive repair within 24 hours once the patient's physiology is corrected.
This document discusses principles of bowel anastomosis, including types of anastomoses, indications for anastomoses, pre-operative preparation, intra-operative techniques, post-operative care, complications, and controversies. It covers topics such as hand-sewn versus stapled anastomoses, single versus double layer closure, inversion versus eversion of tissue, and use of abdominal drains and NG tubes. The goal of bowel anastomosis is to successfully rejoin bowel segments through meticulous surgical technique and postoperative management in order to restore intestinal continuity.
A Prospective Study of Evaluation of Operative Duration as a Predictor of Mortality in Pediatric Emergency Surgery: Concept of 100 Minutes Laparotomy in Resource-limited Setting
Liver resection indications & methodsDr Harsh Shah
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
Damage Control Resuscitation (DCR) is a systematic approach for managing major trauma patients at risk of exsanguinating hemorrhage. It incorporates permissive hypotension to minimize blood loss while hemorrhage is uncontrolled, haemostatic resuscitation using blood products instead of crystalloids to prevent coagulopathy, and early hemorrhage control through surgery. DCR aims to decrease mortality and morbidity by recognizing patients at risk of hemorrhagic shock, providing adequate tissue oxygenation through hypotensive resuscitation while limiting further blood loss and clot disruption, and preventing the triad of hypothermia, acidosis and coagulopathy through haemostatic resuscitation and blood product administration according to a
Postoperative complications and managementyoursshijo
This document discusses postoperative complications, their management, and assessments. It notes that complications can be general, like fever or infection, or specific to the type of surgery. Key time periods for complications are immediate postoperative, days 3-5, and after 5 days. The first postoperative assessment establishes baseline status and identifies any issues. Ongoing assessments monitor for complications and guide treatment. Factors like blood pressure, pain, and fluid balance must be considered.
Surgical audit is a process that systematically analyzes surgical care quality against standards to improve patient outcomes. It involves collecting data on parameters like mortality, complications and outcomes and comparing results to peers to identify areas for improvement. The goal is continuous quality improvement through a non-punitive, educational process. Surgical audit has existed for centuries but modern methods began in the early 1900s and involve retrospective review of existing data to guide practice changes.
1. The Advanced Trauma Life Support (ATLS) protocol focuses on simultaneously identifying and treating life-threatening injuries within the crucial "Golden Hour" period after trauma.
2. The ATLS protocol involves two surveys - the Primary Survey to address airway, breathing, circulation, disability, and exposure issues, and the Secondary Survey for a full history and physical exam after initial resuscitation is complete.
3. Key components of the Primary Survey include assessing the airway, identifying tension pneumothorax and hemorrhage, and providing spinal immobilization, followed by full exposure to identify all injuries.
LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
This document discusses day case surgery (DCS). It begins with an introduction on the prevalence of DCS internationally. It then covers the definition, history, merits and demerits of DCS. Key aspects of setting up and running a successful DCS unit are described, including space requirements, staffing, suitable procedures, pre-op preparation, and discharge criteria. The document concludes with a discussion on audit and special considerations for DCS in children and emergencies.
The document discusses the ATLS (Advanced Trauma Life Support) concept for managing trauma. It describes ATLS as an internationally recognized system that teaches a methodical approach to rapidly assess and treat life-threatening injuries in trauma patients. The steps include: (1) conducting a primary survey to evaluate the patient's airway, breathing, circulation, disability and exposure; (2) performing a secondary survey involving a full physical exam and history; and (3) re-evaluating the patient to ensure all injuries are identified and managed. The goal of ATLS and trauma management overall is to prevent death by treating life-threatening conditions as the top priority, especially within the "Golden Hour" period after injury.
Open right hemicolectomy is performed to treat malignant tumors, polyps, and other conditions in the ileocecal region, ascending colon, and hepatic flexure. The procedure involves mobilizing the right colon, ligating blood vessels, resecting the involved bowel segments, and creating an ileocolic or ileotransverse anastomosis. Key steps include careful dissection to avoid injury to nearby structures like the duodenum and ureter, and ensuring a well-vascularized, tension-free anastomosis to minimize risks of leakage. Post-operative care focuses on early ambulation and advancing diet based on progress.
This document provides an overview of day care or ambulatory surgery. It discusses the history and development of day care surgery. Key points include that day care surgery aims to have patients discharged on the same day of surgery. Patient selection involves assessing medical, social and surgical factors to identify appropriate candidates. The document also outlines common procedures performed in day care settings and considerations for anesthesia, analgesia, and post-operative recovery and discharge criteria. The overall goal of day care surgery is to provide surgical care without an overnight hospital stay when possible.
The document discusses principles of safe surgery and outlines three phases of surgical safety: pre-operative, intra-operative, and post-operative. It notes that complications occur in up to 25% of patients after surgery and half of adverse surgical events are considered preventable. The World Health Organization introduced a surgical safety checklist to encourage safety checks and minimize preventable patient harm during procedures. Barriers to fully implementing safety standards include inconsistent application of principles and checklists across healthcare settings.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Cardiac risk ,lecture presented at Palermo,Italy 2009Claudio Melloni
This document discusses key considerations for cardiac risk stratification in patients undergoing noncardiac surgery. It emphasizes that a risk assessment tool should accurately predict perioperative cardiac events and non-events. It also should influence outcomes by identifying high-risk patients for whom surgery should be cancelled or treatment changed, and subgroups that do or do not benefit from proven therapy. The tool must also have a favorable balance of benefits and harms. It then provides details on the Goldman cardiac risk index and revised Lee cardiac risk index used to stratify patients into different risk levels.
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
The STITCH trial evaluated the effect of CABG plus optimal medical therapy (OMT) versus OMT alone on mortality in patients with left ventricular dysfunction and coronary artery disease. A sub-study examined the role of assessing myocardial viability to identify patients who benefit most from CABG. Of 601 patients who underwent viability testing, 487 had viable myocardium and 114 did not. There was no significant interaction between viability status and treatment assignment on mortality or other outcomes. Assessing viability did not identify patients with differential survival benefit from CABG versus OMT alone.
This document discusses oral anticoagulants and hand surgery. It presents several case studies and findings that show elective hand surgery can be performed safely in patients taking oral anticoagulants like warfarin as long as their INR is below 3.0. Minor bleeding complications were observed but were consistent with minor surgical procedures. The studies found stopping anticoagulation therapy before hand surgery is unnecessary and can increase risks from discontinuing important long-term medications. Clinical judgement should be used to determine risks for individual patients.
This document summarizes the career and research of Dr. Eulogio García focusing on primary angioplasty for acute myocardial infarction. It details his early work in the 1990s establishing primary angioplasty programs in Spain and conducting randomized trials comparing it to thrombolysis. It describes his later involvement in large international multicenter trials that helped establish best practices in primary angioplasty and demonstrated benefits in subgroups. The document outlines over 150 publications and highlights his role in increasing acceptance of primary angioplasty in clinical guidelines.
Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major vascular surgery. In a retrospective case-control study of 2816 patients, statin use was associated with a 78% reduced risk of perioperative mortality. Patients taking statins had over a four-fold lower risk of death compared to non-users. The protective effect of statins was consistent regardless of cardiac risk factors or beta-blocker use.
Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major vascular surgery. In a retrospective case-control study of 2816 patients, statin use was associated with a 78% reduced risk of perioperative mortality. Patients taking statins had over a four-fold lower risk of death compared to non-users. The protective effect of statins was consistent regardless of cardiac risk factors or beta-blocker use.
Refractory heart failure - Diagnosis, Management, Device TherapyImran Ahmed
This document summarizes information about heart failure (HF), including:
1) HF is a major public health problem worldwide, affecting over 23 million people, with rates increasing with age.
2) Stages of HF range from risk factors to end-stage disease and influence treatment approaches.
3) Implantable devices like ICDs and CRT have been shown to improve symptoms and reduce mortality in HF, though guidelines around their use continue to be refined.
4) Ongoing research is exploring expanding the use of CRT to additional patient populations like those with narrow QRS complexes or milder disease.
Carotid revascularization in cad patientsDIPAK PATADE
Carotid artery disease is common in patients with coronary artery disease undergoing coronary artery bypass grafting (CABG). The incidence of perioperative stroke after CABG is around 1.6-3.1%, with risks increased by factors like aortic atherosclerosis, atrial fibrillation, prior stroke, and carotid stenosis. Strokes are often embolic and occur during or soon after surgery. Asymptomatic carotid stenosis alone may not increase stroke risks significantly, but bilateral or recently symptomatic stenosis does. Careful screening and management of atherosclerotic risk factors can help reduce perioperative stroke risks in patients with coexisting carotid and coronary artery disease.
Hypertrophic cardiomyopathy (HCM) is characterized by thickening of the left ventricle in the absence of other cardiac causes. It has diverse morphological presentations and is the most common genetic cardiovascular disease. Symptoms include heart failure, chest pain, and syncope. Treatment involves managing symptoms through medications, surgery such as septal myectomy for obstruction, and implantable cardioverter-defibrillators for high-risk patients. Screening of family members is recommended due to its genetic basis. HCM has variable clinical outcomes ranging from few symptoms to sudden cardiac death.
This document summarizes a study on the use of beta-blockers perioperatively in patients undergoing noncardiac surgery to reduce cardiac risks and events. It reviews 5 randomized controlled trials from 1988-2000 with under 600 patients total finding beta-blockers reduced postoperative ischemia and cardiac death. It specifically examines the Mangano et al. 1996 study of 200 patients finding atenolol reduced mortality rates up to 2 years post-surgery, though potential confounding factors were not fully addressed. The review recommends differentiating risk levels and considering beta-blockers pre- and post-surgery for higher-risk patients, though larger studies are still needed.
This document summarizes the cardiovascular benefits of evolocumab, a PCSK9 inhibitor, based on the FOURIER trial. The FOURIER trial found that adding evolocumab to moderate or high-intensity statin therapy reduced major cardiovascular events like heart attack, stroke, and coronary revascularization by 20% over 2 years compared to placebo in high-risk patients. Evolocumab lowered LDL cholesterol by 60% on average and had an acceptable safety profile with only injection site reactions occurring in more than 2% of patients. While evolocumab did not reduce overall or cardiovascular mortality, it provides an effective additional option to further lower LDL and reduce cardiovascular risk when added to statin therapy.
Impact of statins and beta-blocker therapy on mortality after coronary artery...Paul Schoenhagen
Abstract
Background: We conducted a retrospective cohort study of patients after first-time isolated coronary artery bypass graft surgery (CABG) and assessed the impact of a discharge regimen including beta-blockers and statin therapy and their relationship to long-term all cause mortality and major adverse cardiovascular events (MACE).
Methods: We identified patients age >18 years, undergoing first time isolated CABG from 1993 to 2005. Patients were identified using the Cardiovascular Information Registry (CVIR). We collected follow-up information at 30, 60, 90 days and yearly follow-up. The registry is approved for use in research by the institutional review broad.
Results: We identified 5,205 patients who underwent single isolated CABG between January 1993 and December 2005. The mean age was 64.5±9.7 years and over 70% were male. There was a significant difference in the low density lipoproteins (LDL) concentration between those with or without statin medications (134±41.9 mg/dL) (no statin) vs. 126±44.8 mg/dL (with statin), P=0.001. A discharge regimen with statin therapy was associated with and overall reduction in 30 day, 1 year and long-term mortality. In addition, overall the triple ischemic endpoint of death, myocardial infarction (MI) and stroke was also significantly lower in the statin vs. no-statin group. In addition, statin and beta-blockers exerted synergistic effect on overall mortality outcomes short-term and in the long-term. We note that the predictors of overall death include no therapy with statin therapy and age [hazard ratios (HR) 1.1, 95% CI: 1.04-1.078, P<0.001] and presence of renal failure (HR 2.0, P=0.005). The estimated 11-year Kaplan Meier curves for mortality between the two groups starts to diverge immediately post discharge after single isolated CABG and continue to diverge through out the follow-up period.
Conclusions: A post-discharge regimen of statins independently reduces overall and 1 year mortality. These results confirm those of earlier studies within a contemporary surgical population and support the current clinical guidelines.
Impact of statins and beta-blocker therapy on mortality after coronary artery...Paul Schoenhagen
Background: We conducted a retrospective cohort study of patients after first-time isolated coronary artery bypass graft surgery (CABG) and assessed the impact of a discharge regimen including beta-blockers and statin therapy and their relationship to long-term all cause mortality and major adverse cardiovascular events (MACE).
Methods: We identified patients age >18 years, undergoing first time isolated CABG from 1993 to 2005. Patients were identified using the Cardiovascular Information Registry (CVIR). We collected follow-up information at 30, 60, 90 days and yearly follow-up. The registry is approved for use in research by the institutional review broad.
Results: We identified 5,205 patients who underwent single isolated CABG between January 1993 and December 2005. The mean age was 64.5±9.7 years and over 70% were male. There was a significant difference in the low density lipoproteins (LDL) concentration between those with or without statin medications (134±41.9 mg/dL) (no statin) vs. 126±44.8 mg/dL (with statin), P=0.001. A discharge regimen with statin therapy was associated with and overall reduction in 30 day, 1 year and long-term mortality. In addition, overall the triple ischemic endpoint of death, myocardial infarction (MI) and stroke was also significantly lower in the statin vs. no-statin group. In addition, statin and beta-blockers exerted synergistic effect on overall mortality outcomes short-term and in the long-term. We note that the predictors of overall death include no therapy with statin therapy and age [hazard ratios (HR) 1.1, 95% CI: 1.04-1.078, P<0.001] and presence of renal failure (HR 2.0, P=0.005). The estimated 11-year Kaplan Meier curves for mortality between the two groups starts to diverge immediately post discharge after single isolated CABG and continue to diverge through out the follow-up period.
Conclusions: A post-discharge regimen of statins independently reduces overall and 1 year mortality. These results confirm those of earlier studies within a contemporary surgical population and support the current clinical guidelines.
The document discusses Abbott's bioabsorbable everolimus-eluting stent and its potential advantages over drug-eluting stents. It proposes a clinical trial to test the bioabsorbable stent in diabetic patients to demonstrate improved safety and efficacy compared to drug-eluting stents in a high risk population. Quantitative analyses estimate the cost-effectiveness and return on investment of the bioabsorbable stent if thrombosis and revascularization rates are reduced compared to drug-eluting stents.
In this ppt, I am going to discuss the role of ICD in the patient with Non-ischemic cardiomyopathy. I am going to discuss all the major trials done in the patient with non-ischemic cardiomyopathy.
Ponencia presentada por el Dr. J. Raúl Moreno Gómez en el directo 'Controversias en tratamiento antitrombótico – Parte II', realizado el 6 de abril de 2021
Similar to Perioperative Care in surgical patients (20)
- Gallbladder polyps are common findings that require evaluation to determine if they are true polyps with malignant potential or pseudopolyps which are benign.
- Transabdominal ultrasound is usually the initial imaging study, while EUS may help in certain cases, though evidence is limited.
- Polyps greater than 10mm or those exhibiting certain high risk features like being sessile or in patients over 50 years old typically warrant cholecystectomy.
- For smaller polyps, follow up imaging is reasonable if they lack concerning characteristics, though risk of malignancy increases with size.
This document discusses surgical approaches for esophageal cancer. It covers:
- Esophageal anatomy, blood supply, lymph drainage
- Staging of esophageal cancer and criteria for resection
- Preoperative evaluation including imaging, biopsy, and laparoscopy
- Surgical procedures for cervical, thoracic, and esophagogastric junction cancers including transhiatal esophagectomy, Ivor-Lewis procedure, and tri-incisional esophagectomy
- Oncologic principles for lymphadenectomy and margins during resection
Benign liver tumors present diagnostic challenges due to overlap between lesions on imaging and clinical features. Hemangiomas are typically the only clearly diagnosed tumors without biopsy. Biopsy or laparoscopy are reasonable invasive approaches for diagnostic uncertainty. The predominant treatment is observation, except for adenomas which often require surgery due to malignant potential. Diagnostic uncertainty is an acceptable indication for surgical intervention.
Role of laparoscopic surgery in colorectal cancerDr Amit Dangi
Laparoscopic surgery for colorectal cancer has been studied extensively. Early studies showed potential short-term benefits of laparoscopy over open surgery but also raised concerns about port site tumor recurrence. Later randomized controlled trials demonstrated laparoscopy is oncologically equivalent to open surgery for colon cancer with some short-term recovery benefits. Studies of laparoscopy for rectal cancer found short-term benefits but higher rates of positive margins, though long-term oncologic outcomes were similar. New techniques like robotic surgery are being explored but have not proven more cost-effective than laparoscopy.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
The liver has significant anatomic variability. It develops from the foregut and is divided into lobes based on vascular and biliary anatomy. The caudate lobe is located posteriorly between the IVC and other lobes. It has complex vascular and biliary drainage patterns. The liver is commonly divided into segments based on Couinaud's or Brisbane's classifications to describe resection types. The caudate lobe specifically can be further divided into the Spiegel lobe, caudate process, and paracaval portion.
Rectal prolapse: Do we really have a perfect surgical solution? pptx copyDr Amit Dangi
Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
This document discusses technical aspects of ileal pouch-anal anastomosis (IPAA). It describes the different types of pouches that can be constructed, including W and J pouches. It also discusses the surgical techniques for performing a laparoscopic IPAA, including port placement, mobilization of different parts of the colon, and creating the ileal-anal anastomosis. The document notes that a stapled anastomosis may have better outcomes than a hand sewn one. It also discusses topics like managing an emergency colectomy, the optimal site of the anastomosis, and techniques to lengthen the small bowel mesentery.
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAPDr Amit Dangi
THIS PRESENTATION DESCRIBES THE NOVEL SURGICAL TECHNIQUE OF TOTAL ANORECTAL RECONSTRUCTION WITH ANTROPYLORUS TRANSPOSITION AND GLUTEOPLASTY AND ITS RESULTS.
The document summarizes the key steps and considerations in evaluating potential living liver donors. The evaluation involves a multi-stage process including medical history, physical exam, imaging to assess liver volume and anatomy, and further tests as needed. Factors like obesity, steatosis, and variant anatomy require special consideration. The goals are to ensure the donor's safety, obtain an adequate graft for the recipient, and identify any contraindications to donation.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
Recent Update on Management of Ulcerative ColitisDr Amit Dangi
Recent update on the surgical and medical management of ulcerative colitis, including various controversies regarding IPAA and recent medical management incorporating the role of biologicals
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
The document discusses metabolic surgery as a treatment for type 2 diabetes. It notes that gastric bypass surgery was found to result in diabetes remission in 78% of patients in early studies. This catalyzed research into the mechanisms by which bariatric surgery improves glucose control. Worldwide obesity and diabetes prevalence is increasing significantly. Metabolic surgery is the most effective means of substantial and durable weight loss, and results in better glycemic control and reduced cardiovascular risk factors compared to medical therapy alone. The mechanisms of diabetes improvement after surgery extend beyond just weight loss and include effects on incretin hormones, insulin secretion, and insulin sensitivity.
Timing of repair in bile duct injury is still debated and questioned. Delayed repair is considered standard practice whereas early repair in selected patients in specialist HPB units.
Peritoneal Carcinomatosis : Dr Amit DangiDr Amit Dangi
Here are the key steps:
1. The left subphrenic space is entered by incising the peritoneum overlying the left hemidiaphragm.
2. The peritoneum is dissected off the left hemidiaphragm in a cephalad direction towards the diaphragmatic crus.
3. The peritoneum is then stripped down the left paracolic gutter towards the pelvis, removing all peritoneal surfaces.
4. The left subphrenic peritonectomy is then completed, exposing the left hemidiaphragm and removing all peritoneal surfaces in the left subphrenic space.
Biological therapy for Ulcerative colitisDr Amit Dangi
The document discusses biological therapy options for ulcerative colitis (UC), including anti-TNF agents. It summarizes key trials on infliximab, adalimumab, and golimumab. The ACT1 and ACT2 trials found infliximab effective for inducing and maintaining remission in moderate-to-severe UC. The ULTRA1 and ULTRA2 trials showed adalimumab induced remission and was effective for maintenance therapy. The PURSUIT trials found golimumab induced clinical response and remission in UC patients. Anti-TNF agents are effective treatment options for moderate-to-severe UC when conventional therapies are inadequate.
This document outlines the plan for a presentation on Budd-Chiari syndrome. It begins with a brief history of the syndrome dating back to 1842. It then covers the definition, etiology, pathogenesis, clinical presentation, diagnosis and imaging. Etiology sections discuss hypercoagulable causes like myeloproliferative disorders and acquired causes such as oral contraceptives and pregnancy. Clinical presentation varies from acute to chronic forms. Imaging plays an important role in diagnosis, with ultrasound Doppler being the first-line investigation to assess patency of hepatic veins and inferior vena cava. The document is organized into two parts, with part A covering background information and part B to focus on management.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
2. FACTORS INFLUENCING OUTCOME
• AGE
• COMORBIDITIES OF THE PATIENT
• THE COMPLEXITY OF THE DISEASE AND SURGICAL PROCEDURE
• THE MANAGEMENT OF POSTOPERATIVE RECOVERY.
GHAFERI AA, BIRKMEYER JD, DIMICK JB (2009) VARIATION IN HOSPITAL MORTALITY ASSOCIATED WITH
INPATIENT SURGERY. N ENGL J MED 361(14):1368–1375
CLOSE COOPERATION BETWEEN SURGEONS AND ANAESTHESIOLOGISTS (JOINT RISK
ASSESSMENT) IS CRITICAL.
MODERN PERIOPERATIVE MANAGEMENT : HIGHLY MULTIDISCIPLINARY TASK
3. BASIC PRINCIPLES OF MODERN PERIOPERATIVE
MANAGEMENT TO IMPROVE PATIENT OUTCOME
AFTER MAJOR GASTROINTESTINAL SURGERY
PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE
• INFORMED PATIENT
CONSENT AND
MOTIVATION
• INTERDISCIPLINARY RISK
ASSESSMENT
• OPTIMISED PHYSICAL
CONDITION AND
MEDICATION
• ATRAUMATIC SURGICAL
TECHNIQUE
• COMBINED GENERAL AND
EPIDURAL ANAESTHESIA
• OPTIMISED AIRWAY
MANAGEMENT AND
VENTILATION
• GLUCOSE CONTROL
• OPTIMISED FLUID
MANAGEMENT
• AVOIDANCE OF
HYPOTHERMIA
• MODERN OPIOD SPARING
ANALGESIA
• EARLY MOBILISATION,
PREVENTION OF VTE
• EXTENDED LUNG
EXPANSION EXERCISES
• EARLY REMOVAL OF
TUBES, CATHETERS, AND
DRAINS.
• EARLY ORAL NUTRITION
• EARLY DETECTION OF
COMPLICATIONS
4. PREOPERATIVE MANAGEMENT
A. PREOPERATIVE HISTORY AND CLINICAL ASSESSMENT : IDENTIFY PATINET RISK
FACTORS
B. ROUTINE DIAGNOSTIC TESTS :
LABS :
STANDARD BLOOD COUNTS
INR/ APTT
RFT/SE/RBS/LFT
ON DAY OF SURGEY: POTTASSIUM LEVELS AFTER EXTENSICE MBP/ GLUCOSE LEVELS IN
DM PATIENTS
5. • RECENT DATA HAVE INDICATED THAT AN ELEVATED PREOPERATIVE LEVEL OF BRAIN
NATRIURETIC PEPTIDE IS ASSOCIATED WITH INCREASED CARDIAC MORBIDITY AFTER
MAJOR SURGERY, BUT IT REMAINS TO BE SEEN WHETHER THIS LEVEL WILL BE
ROUTINELY DETERMINED FOR PATIENTS WITH CARDIAC RISK FACTORS.
RYDING AD, KUMAR S, WORTHINGTON AM, BURGESS D (2009) PROGNOSTIC VALUE OF BRAIN NATRIURETIC PEPTIDE IN NONCARDIAC SURGERY: A
META-ANALYSIS. ANESTHESIOLOGY 111(2):311–319
CUTHBERTSON BH, AMIRI AR, CROAL BL, RAJAGOPALAN S, ALOZAIRI O, BRITTENDEN J, HILLIS GS (2007) UTILITY OF B-TYPE NATRIURETIC PEPTIDE IN
PREDICTING PERIOPERATIVE CARDIAC EVENTS IN PATIENTS UNDERGOING MAJOR NON-CARDIAC SURGERY. BR J ANAESTH 99(2):170–176
FERINGA HH, SCHOUTEN O, DUNKELGRUN M, BAX JJ, BOERSMA E, ELHENDY A, DE JONGE R, KARAGIANNIS SE, VIDAKOVIC R, POLDER- MANS D (2007)
PLASMA N-TERMINAL PRO-B-TYPE NATRIURETIC PEPTIDE AS LONG-TERM PROGNOSTIC MARKER AFTER MAJOR VASCULAR SURGERY. HEART
93(2):226–231
6. • ECG :
• ALLOWS SCREENING / SERVES AS CONTROL
• SHOULD BE PERFORMED FOR PATIENTS:
ARE >40 YEARS OLD
HAVE RELEVANT CARDIAC DISORDERS (E.G. CORONARY ARTERY DISEASE, HEART
INSUFFICIENCY, HEART RHYTHM DISTURBANCES OR VALVE DISORDERS)
HAVE A PACEMAKER (PM) OR IMPLANTED CARDIOVERTER/ DEFIBRILLATOR (ICD)
HAVE NEWLY DEVELOPED PULMONARY OR CARDIAC SYMPTOMS
ARE RECEIVING PREOPERATIVE CHEMOTHERAPY OR CHEMORADIOTHERAPY
• HIGH RISK PATIENTS : HIGH RISK SURGERY IN CAD PATIENTS : AN ADDITIONAL ECG SHOULD BE
OBTAINED IMMEDIATELY AFTER SURGERY AS WELL AS ON DAYS 1 AND 2 POSTOPERATIVELY.
(NOT A ROUTINE PRACTICE)
7. • CXR:
LOW SENSITIVITY IN ASYPTOMATIC PATIENTS
BASIS OF COMPARISON
NO RECOMMENDATION IN ASA SCORE 1-2
• INDICATED FOR PATIENTS WHO
SUFFER FROM SEVERE CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DEVELOPED YET UNKNOWN PULMONARY OR CARDIAC SYMPTOMS
HAVE GASTROINTESTINAL MALIGNANCIES (SCREENING FOR PULMONARY
METASTASES)
8. ADVANCED DIAGNOSTIC TESTS
ECHOCARDIOGRAPH
Y
• HAVE NEWLY OCCURRING
DYSPNOEA OF UNKNOWN
ORIGIN
• HAVE KNOWN HEART
INSUFFICIENCY WITH SYMPTOMS
OF DETERIORATION
• HAVE CARDIOMYOPATHY AND
HAVE UNDERGONE
PREOPERATIVE
• CHEMOTHERAPY WITH
EPIRUBICIN
CAROTID DOPPLER
USG
• HAD EXPERIENCED TIA OR
STROKE WITHIN THE PRECEDING
3 MONTHS IF THE EPISODE HAD
OCCURRED WITHOUT PROPER
FOLLOW-UP MEDICAL
ASSESSMENT OR DIAGNOSIS
• HAD EXPERIENCED TIA OR
STROKE WITHIN THE PRECEDING
3 MONTHS IF SYMPTOMS OF
DETERIORATION HAVE
APPEARED
PULMONARY
FUNCTION TEST
• ELDERLY PATIENTS
• PREEXISTING RESTRICTIVE AND
OBSTRUCTIVE LUNG DISEASES
• PROLONGED SURGERY
• SURGERIES REQUIRING SINGLE
LUNG VENTILATION
• PRIOR TO THORCOTOMIES AND
MAJOR SURGERY NEAR
DIAPHRAGM
9. PREOPERTIVE RISK ASSESSEMENT
DEFINITION OF HIGH RISKS
CLINICAL CONDITIONS THAT CHARACTERISE
HIGH-RISK SURGICAL PATIENTS UNDERGOING
MAJOR GASTROINTESTINAL SURGERY
CORONARY ARTERY DISEASE
HEART INSUFFICIENCY
RENAL FAILURE
POORLY CONTROLLED DIABETES MELLITUS
OLDER AGE
TOP 10 CLINICAL CONDITIONS THAT INFLUENCE
30-DAY MORTALITY AND LONG-TERM
MORTALITY AFTER MAJOR GASTROINTESTINAL
SURGERY
30 DAY MORTAILITY LONG TERM SURVIVAL
Any complication
ASA class
Emergency surgery
Albumin concn (g/dl)
RBC units transfused
intraoperatively
Older age
Sodium concn <135 nmol/l
Disseminated cancer
Blood urea nitrogen concn >40
mg/dl
SGOT >40 IU/ml
Older age
Albumin concn (g/dl)
Any complication
ASA class
Blood urea nitrogen concn >40 mg/dl
COPD
Smoking Diabetes Functional status
Disseminated cancer
Ackland GL, Edwards M (2010) Defining higher-risk surgery. Curr Opin Crit Care 16(4):339–346
Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ (2005) Determinants of long-term survival after
major surgery and the adverse effect of postoperative complica- tions. Ann Surg 242(3):326–341, discussion 341–323
10. RISK SCORES
• WELL-KNOWN SYSTEMS INCLUDE : AMERICAN SOCIETY OF ANESTHESIOLOGISTS CLASSIFICATION OF
PHYSICAL STATUS, THE KAPLAN FEINSTEIN INDEX, THE ADULT COMORBIDITY EVALUATION , AND
THE CHARLSON COMORBIDITY INDEX
THE PHYSIOLOGICAL AND OPERATIVE SEVERITY SCORE FOR THE ENUMERATION OF MORTALITY AND
MORBIDITY (POSSUM)
ESTIMATION OF PHYSIOLOGIC ABILITY AND SURGICAL STRESS SCORE (E-PASS).
• HOWEVER THEIR IMPLEMENTATION INTO ROUTINE CLINICAL PRACTICE HAS PROVEN TO BE
DIFFICULT.
• SURGEONS GUT FEELING
• MORE RECENTLY, A RISK CALCULATOR FOR COLORECTAL SURGERY HAS BEEN DEVELOPED BY THE
NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM REGISTRY OF THE AMERICAN COLLEGE OF
SURGEONS.
• AFTER A PATIENT'S VARIABLES ARE ENTERED, THE RISK PROBABILITIES FOR ADVERSE OUTCOME ARE
CALCULATED. HOWEVER, ONLY REGISTRY MEMBERS CAN ACCESS THE CALCULATOR, AND IT IS NOT
CLEAR WHETHER THIS US HOSPITAL-BASED TOOL IS APPLICABLE TO EUROPEAN INSTITUTIONS.
13. CARDIAC RISK EVALUATION
• OVERALL GI SURGERY IS ASSOCIATED WITH MEDIUM CARDIAC RISK
FROEHLICH JB, FLEISHER LA (2009) NONCARDIAC SURGERY IN THE PATIENT WITH HEART DISEASE. ANESTHESIOL CLIN 27(4):649–671
• POST SURGICAL CARDIAC COMPLICATIONS : LEADING CAUSE OF MORBIDITY AND
MORTAILITY
(CARDIAC INSUFFICIENCY > IHD)
HAMMIL BG, CURTIS LH, BENNETT-GUERRERO E, O'CONNOR CM, JOLLIS JG, SCHULMAN KA, HERNANDEZ AF (2008) IMPACT OF HEART FAILURE ON
PATIENTS UNDERGOING MAJOR NONCARDIAC SURGERY. ANESTHESIOLOGY 108(4):559–567
• INCREASED CARDIAC RISK
CORONARY ARTERY DISEASE
HEART INSUFFICIENCY
SEVERE AORTIC STENOSIS
PERIPHERAL ARTERY DISEASE
CEREBROVASCULAR INSUFFICIENCY
RENAL FAILURE
DIABETES MELLITUS
14. PULMONARY RISK EVALUATION
• LATE POSTOPERATIVE PULMONARY COMPLICATIONS ARE THE SECOND-LEADING CAUSE OF MORBIDITY AND
MORTALITY AFTER MAJOR SURGERY
• CLINICAL PARAMETERS THAT REPRESENT RISK FACTORS FOR PULMONARY COMPLICATIONS
PATIENT-RELATED FACTORS
CONGESTIVE HEART FAILURE
ASA SCORE ≥2
AGE >60 YEARS
COPD
FUNCTIONAL DEPENDENCE
PROCEDURE-RELATED FACTORS
ABDOMINAL SURGERY THORACIC SURGERY
SURGERY LASTING >3 H EMERGENCY SURGERY
GENERAL ANAESTHESIA
LABORATORY-TEST-RELATED FACTORS
SERUM ALBUMIN CONCN <3.0 G/DL
SMETANA GW, LAWRENCE VA, CORNELL JE (2006) PREOPERATIVE PULMONARY RISK STRATIFICATION FOR NONCARDIOTHORACIC SURGERY:
SYSTEMATIC REVIEW FOR THE AMERICAN COLLEGE OF PHYSICIANS. ANN INTERN MED 144(8):581–595
15. MEDICATIONS
CLEAR LIQUID INTAKE (E.G. WATER OR TEA BUT NOT MILK) IS ALLOWED UNTIL 2 H
BEFORE ANAESTHESIA
SOLID FOOD INTAKE IS RECOMMENDED FOR UP TO 6 H PRIOR TO ANAESTHESIA
1. BETA ADRENERGIC BLOCKERS:
• FAVOURABLE EFFECT ON THE SUPPLY AND DEMAND RATIO OF MYOCARDIAL
OXYGEN.
• SHOULD BE CONTINUED PERIOPERATIVELY
• IF A PATIENT WHO IS SCHEDULED FOR ELECTIVE GASTROINTESTINAL SURGERY
REQUIRES A NEW PRESCRIPTION, IT SHOULD BE STARTED AT LEAST 1 MONTH
BEFORE THE PROCEDURE TO ALLOW FOR DOSE ADJUSTMENT
Fleischmann KE, Beckman JA, Buller CE, Calkins H, Fleisher LA, Freeman WK, Froehlich JB,
Kasper EK, Kersten JR, Robb JF, Valentine RJ (2009) 2009 ACCF/AHA focused update on
perioperative beta blockade. J Am Coll Cardiol 54 (22):2102–2128
16. 2. DIURETICS
• AVOIDED ON DAY OF SURGERY (INCREASED RISK OF INTRAOPERATIVE HYPOVOLEMIA)
• HOWEVER, IT IS STRONGLY RECOMMENDED THAT THEIR INTAKE BE CONTINUED POSTOPERATIVELY, ESPECIALLY FOR
PATIENTS WHO HAVE HEART FAILURE.
3. METFORMIN
• INTAKE BE STOPPED 48 HRS PRIOR TO SURGERY
• RISK OF LACTIC ACIDOSIS : CONTROVERSIAL
DUNCAN AI, KOCH CG, XU M, MANLAPAZ M, BATDORF B, PITAS G, STARR N (2007) RECENT METFORMIN INGESTION DOES NOT INCREASE IN- HOSPITAL MORBIDITY OR MORTALITY
AFTER CARDIAC SURGERY. ANESTH ANALG 104(1):42–50
4. ACETYL SALICYLIC ACID AND THIENOPYRIDINE DERIVATIVES
ANTI-PLATELET THERAPY (USUALLY 100 MG OF ACETYLSALICYLIC ACID DAILY) IS STANDARD FOR MOST PATIENTS
WITH CORONARY ARTERY DISEASE.
THE 2009 EUROPEAN SOCIETY OF CARDIOLOGY GUIDELINES SUGGEST THAT TO REDUCE THE RISK OF STENT
THROMBOSIS AND MI, PATIENTS WITH A CORONARY BARE METAL STENT (BMS : 1 MONTH) OR A DRUG-ELUTING
STENT (DES : 12 MONTHS) SHOULD RECEIVE ANTI-PLATELET THERAPY WITH BOTH ACETYLSALICYLIC ACID AND A
THIENOPYRIDINE DERIVATIVE (I.E., CLOPIDOGREL OR TICLOPIDINE)
POLDERMANS D, BAX JJ, BOERSMA E, DE HERT S, EECKHOUT E, FOWKES G, GORENEK B, HENNERICI MG, LUNG B, KELM M, KJELDSEN KP, KRISTENSEN SD, LOPEZ-SENDON J, PELOSI P,
PHILIPPE F, PIERARD L, PONIKOWSKI P, SCHMID JP, SELLEVOLD OF, SICARI R, VAN DEN BERGHE G, VERMASSEN F, HOEKS SE, VANHOREBEEK I (2009) GUIDELINES FOR PRE-OPERATIVE
CARDIAC RISK ASSESSMENT AND PERIOPERATIVE CARDIAC MANAGEMENT IN NON-CARDIAC SURGERY: THE TASK FORCE FOR PREOPERATIVE CARDIAC RISK ASSESSMENT AND
PERIOPERATIVE CARDIAC MANAGEMENT IN NON-CARDIAC SURGERY OF THE EUROPEAN SOCIETY OF CARDIOLOGY (ESC) AND EUROPEAN SOCIETY OF ANAESTHESIOLOGY (ESA). EUR
HEART J 30(22):2769–2812
17. FOR PATIENTS WHO CURRENTLY RECEIVE ANTI-PLATELET THERAPY AND ARE
SCHEDULED FOR GASTROINTESTINAL SURGERY, THE FOLLOWING WAIT TIMES
UNTIL SURGERY ARE RECOMMENDED:
• AFTER PTCA WITHOUT STENT IMPLANTATION: 2 WEEKS
• AFTER BMS IMPLANTATION: 6 WEEKS, BUT 3 MONTHS PREFERRED
• AFTER DES IMPLANTATION: 1 YEAR
Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennerici MG, Lung B, Kelm M, Kjeldsen KP,
Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OF, Sicari R, Van den Berghe
G, Vermassen F, Hoeks SE, Vanhorebeek I (2009) Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative
Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and European Society of
Anaesthesiology (ESA). Eur Heart J 30(22):2769–2812
18. FOR HIGH-RISK CARDIAC PATIENTS (I.E. PATIENTS WITH RECENT ACUTE
CORONARY SYNDROME, RECURRENT ANGINA PECTORIS OR RECENT SURGICAL
AND CONSERVATIVE CORONARY INTERVENTION) WHO REQUIRE MAJOR SURGERY
THAT CANNOT BE POSTPONED, THIENOPYRIDINE DERIVATIVES SHOULD BE
STOPPED 7–10 DAYS BEFORE THE SURGERY, WHEREAS ACETYLSALICYLIC ACID
SHOULD BE CONTINUED DURING THE ENTIRE PERIOPERATIVE PERIOD
• THIS RECOMMENDATION ALSO APPLIES TO PATIENTS WHO REQUIRE AN
EPIDURAL CATHETER.
Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennerici MG, Lung B, Kelm M, Kjeldsen KP,
Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OF, Sicari R, Van den Berghe
G, Vermassen F, Hoeks SE, Vanhorebeek I (2009) Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative
Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and European Society of
Anaesthesiology (ESA). Eur Heart J 30(22):2769–2812
19. PACEMAKERS OR
IMPLANTABLE
CARDIOVERTER/D
EFIBRILLATOR
RESPECTIVE PM/ICD PASS MUST BE
AVAILABLE TO HEALTH CARE
PROVIDERS
ELECTROMAGNETIC INTERFERENCES
DURING SURGERY REQUIRE CERTAIN
SAFETY ARRANGEMENTS FOR THE
PATIENTS
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs
AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Md RN, Ornato JP,
Page RL, Riegel B, Tarkington LG, Yancy CW (2007) ACC/AHA 2007 Guide- lines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery:
Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise
the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of
Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascu- lar
20. PACEMAKERS OR
IMPLANTABLE
CARDIOVERTER/D
EFIBRILLATOR
SAFETY RECOMMENDATIONS FOR PATIENTS WITH A PM OR ICD WHO ARE
UNDERGOING GASTROINTESTINAL SURGERY
• BIPOLAR DIATHERMY SHOULD ALWAYS BE THE METHOD OF CHOICE, AS
MONOPOLAR ELECTRODES FREQUENTLY INDUCE INTERFERENCE. AN
ULTRASONIC SCALPEL IS AN ALTERNATIVE.
• IF MONOPOLAR DIATHERMY IS NECESSARY, THE NEUTRAL ELECTRODE
SHOULD BE PLACED AS FAR AWAY FROM THE ICD SYSTEM AS POSSIBLE, AND
THE USE OF DIATHERMY WITHIN A 15-CM DIAMETER OF THE SYSTEM SHOULD
BE AVOIDED. SHORT BURSTS OF LOW ENERGY WITH INTERMITTING SHORT
BREAKS SHOULD BE USED.
• A PREOPERATIVE SYSTEM CHECK IS RECOMMENDED IF THE LAST ONE HAD
OCCURRED >1 YEAR PREVIOUSLY.
• FOR PATIENTS WHO ARE PM DEPENDENT (PERMANENT PM STIMULATION), AN
ALTERNATIVE EXTERNAL STIMULATION MUST BE AVAILABLE.
• A MAGNET SHOULD BE AVAILABLE IN CASE OF PM MALFUNCTION.
• POSTOPERATIVE PM CONTROL IS RECOMMENDED IF DIATHERMY WAS USED
TOO CLOSE TO THE PM SYSTEM.
• PREOPERATIVELY, THE ANTITACHYCARDIA FUNCTION OF THE ICD SHOULD BE
SWITCHED OFF AND THE AVAILABILITY OF AN EXTERNAL DEFIBRILLATOR
ENSURED.
• A MAGNET SHOULD BE AVAILABLE TO DISABLE THE ANTITACHYCARDIA
FUNCTION OF THE ICD.
RESPECTIVE PM/ICD PASS MUST BE
AVAILABLE TO HEALTH CARE
PROVIDERS
ELECTROMAGNETIC INTERFERENCES
DURING SURGERY REQUIRE CERTAIN
SAFETY ARRANGEMENTS FOR THE
PATIENTS
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs
AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Md RN, Ornato JP,
Page RL, Riegel B, Tarkington LG, Yancy CW (2007) ACC/AHA 2007 Guide- lines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery:
Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise
the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of
Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascu- lar
21. MECHANICAL BOWEL PREPARATION
• MORE THAN 15 YEARS AGO, KEHLET ET AL. FIRST DESCRIBED A MULTIMODAL PROGRAMME OF
ENHANCED POSTOPERATIVE RECOVERY FOR ELECTIVE SURGERY.
• A MAJOR INTERVENTION PRINCIPLE OF THIS APPROACH IS THE AVOIDANCE OF MBP, PARTICULARLY
FOR PATIENTS UNDERGOING ELECTIVE COLON SURGERY [33].
KEHLET H (1997) MULTIMODAL APPROACH TO CONTROL POSTOPERATIVE PATHOPHYSIOLOGY AND REHABILITATION.
BR J ANAESTH 78(5):606–617
KEHLET H, DAHL JB (2003) ANAESTHESIA, SURGERY, AND CHALLENGES IN POSTOPERATIVE RECOVERY. LANCET
362(9399):1921–1928
KEHLET H, WILMORE DW (2008) EVIDENCE-BASED SURGICAL CARE AND THE EVOLUTION OF FAST-TRACK SURGERY.
ANN SURG 248(2):189–198
KEHLET H (2008) FAST-TRACK COLORECTAL SURGERY. LANCET 371 (9615):791–793
22. • SEVERAL PROSPECTIVE RCT HAVE DEMONSTRATED NO DIFFERENCE IN OUTCOME BETWEEN PATIENTS
WHO UNDERWENT MBP AND THOSE WHO DONOT.
BURKE P, MEALY K, GILLEN P, JOYCE W, TRAYNOR O, HYLAND J (1994) REQUIREMENT FOR BOWEL PREPARATION IN COLORECTAL SURGERY. BR J SURG
81(6):907–910
SANTOS JC JR, BATISTA J, SIRIMARCO MT, GUIMARAES AS, LEVY CE (1994) PROSPECTIVE RANDOMIZED TRIAL OF MECHANICAL BOWEL PREPARATION IN
PATIENTS UNDERGOING ELECTIVE COLORECTAL SURGERY. BR J SURG 81(11):1673–1676
MIETTINEN RP, LAITINEN ST, MAKELA JT, PAAKKONEN ME (2000) BOWEL PREPARATION WITH ORAL POLYETHYLENE GLYCOL ELECTROLYTE SOLUTION
VS. NO PREPARATION IN ELECTIVE OPEN COLORECTAL SURGERY: PROSPECTIVE, RANDOMIZED STUDY. DIS COLON RECTUM 43(5):669– 675,
DISCUSSION 675–667
ZMORA O, MAHAJNA A, BAR-ZAKAI B, ROSIN D, HERSHKO D, SHABTAI M, KRAUSZ MM, AYALON A (2003) COLON AND RECTAL SURGERY WITHOUT
MECHANICAL BOWEL PREPARATION: A RANDOMIZED PROSPECTIVE TRIAL. ANN SURG 237(3):363–367
PENA-SORIA MJ, MAYOL JM, ANULA R, ARBEO-ESCOLAR A, FERNANDEZ-REPRESA JA (2008) SINGLE-BLINDED RANDOMIZED TRIAL OF MECHANICAL
BOWEL PREPARATION FOR COLON SURGERY WITH PRIMARY INTRAPERITONEAL ANASTOMOSIS. J GASTROINTEST SURG 12(12):2103– 2108,
DISCUSSION 2108–2109
• [IN ADDITION, EXTENSIVE MBP MAY INDUCE ABDOMINAL DISCOMFORT, NAUSEA AND PAIN; IT MAY
IMPAIR POSTOPERATIVE ORAL NUTRITION, AND IT MAY RESULT IN ELECTROLYTE IMBALANCE AND
DEHYDRATION FOR THESE REASONS, EXTENSIVE MBP IS NOT RECOMMENDED ANY MORE.
PINEDA CE, SHELTON AA, HERNANDEZ-BOUSSARD T, MORTON JM, WELTON ML (2008) MECHANICAL BOWEL PREPARATION IN INTESTINAL SURGERY: A
META-ANALYSIS AND REVIEW OF THE LITERATURE. J GASTRO- INTEST SURG 12(11):2037–2044
23. RCTS AND METAANALYSIS
STUDY RCT/METAANLYSIS RESULTS CONCLUSION
BURKE ET AL IN 1994 RCT NO INFLUENCE ON
OUTCOME
SANTOS ET AL RCT MBP IS UNNECESSARY
AND HARMFUL
PENA-SORIA ET AL IN
2007
RCT NO DIFERENCE IN SSI.
TWICE THE NUMBER OF
LEAKS AFTER MBP
SAME/WORSE OUTCOEM
AFTER MBP
CONTANT ET AL IN 2007 RCT (LARGEST) MBP BEFORE ELECTIVE
COLORECTAL SURGERY
CAN SAFELY BE
ABANDONED
SLIM ET AL IN 2004 METAANAYSIS HIGHER RATES OF LEAKS
AFTER MBP (ESPEACIALLY
AFTER PEG )
MBP USING PEG SHOULD
BE AVOIDED IN ELECTIVE
COLORECTAL SURGERY
ZHU ET AL IN 2010 METAANALYSIS NO SIGNIFICANT
DIFFERENCE IN SSI,
INFECTIONS,
MORTAILITY, LEAKS
MBP WITH PEG DOESNOT
LOWER POSTOP
COMPLICATIONS AND
MAY INCREASE LEAKS
24. • OVERALL, THERE IS SOUND EVIDENCE THAT OMITTING MBP BEFORE COLECTOMY
IS SAFE.
• THERE IS ALSO EVIDENCE THAT MBP IS NOT REQUIRED BEFORE LEFT SIDED
COLON AND RECTAL RESECTIONS (BUCHER ET AL IN 2005 AND METAANALYSIS
BY GUENAGA ET AL)
• 2 CIRCUMSTANCES WHERE BOWEL PREPARATION IS STILL PRUDENT:
SMALL UNMARKED TUMORS
INTRAOPERATIVE COLONOSCOPY
25. OTHER PREOPERATIVE CONSIDERATIONS
• SMOKING
CREATES CARDIAC STRESS
TO BE OF BENEFIT, HOWEVER, SMOKING CESSATION NEEDS TO OCCUR SEVERAL WEEKS
(4 WEEKS) PRIOR TO THE SURGERY
• NUTRITIONAL SUPPORT
• OBESITY
INCREASES PERIOPERATIVE MORBIDITY/MORTAILITY
INFECTIOUS COMPLICATIONS, DVT, PE, OBSTRUCTED SLEEP APNEA, IMPAIRED
FUNCTIONAL STATUS
26. NUTRITIONAL EVALUATION
• MALNUTRITION INCREASES RISK OF MAJOR MORBIDITY
• ASSESSMENT
A. ANTHROPOMETRIC MEASUREMENTS
B. BIOCHEMICAL
C. CLINICAL
D. DIETARY HISTORY
TOOLS : NRI (NUTRITIONAL RISK INDEX) : 15.19 X SERUM ALBUMIN(G/DL) + 41.7 X PRESENT
WEIGHT/USUAL WEIGHT.
NRI < 83 : SIGNIFICANTLY INCREASED MORTAILITY AND COMPLICATIONS
27. ASSESSMENT OF NUTRITINONAL STATUS
PROTEIN DEFICIENCY
CRITERIA
• ALBUMIN <2.2 G/DL
• TOTAL LYMPHOCYTE COUNT <800/MM OR
LESS
• WEIGHT MAINTAINED
• PERIPHERAL EDEMA
• INADEQUATE PROTEIN INTAKE (<50% OF
GOAL FOR 3 DAYS OR <75% FOR 7 DAYS)
• 4 OUT 5 ESTABLISH PROTEIN DEFICIENCY
CALORIE DEFICIENCY
CRITERIA
• WEIGHT LOSS : 5% OVER 1 MONTH/ 7.5% OVER
3 MONTHS OR 10% OVER 6 MONTHS.
• UNDERWEIGHT (<94% IDEAL BODY WEIHT)
• CLINICALLY MEASURABLE MUSCLE WASTING
• SERUM PROTEIN MAINTAINED
• INADEQUATE CALORIE INTAKE (50% FOR 3
DAYS OR <75% FOR 7 DAYS)
• 3 OUT 5 ESTABLISH CALORIE DEFICIENCY
28. CHEMOTHERAPY :
• 4 MAJOR SIDE EFFECTS
ANTHRACYCLINE EPIRUBICIN, (LOCALLY ADVANCED GASTRIC CANCER), INCREASES
THE RISK FOR CARDIOMYOPATHY AND HEART FAILURE, PARTICULARLY AMONG
ELDERLY PATIENTS WITH PRE-EXISTING CARDIAC DISEASE. ECHOCARDIOPGRAPHY
RECOMMENDED
THE PYRIMIDINE ANALOGUE 5- FLUOROURACIL, CAN INDUCE CORONARY
VASOSPAMS, MYOCARDIAL ISCHEMIA AND SUBSEQUENT INFARCTION..
TOPOISOMERASE I INHIBITOR IRINOTECAN :AT RISK FOR DIARRHOEA-INDUCED
MALNUTRITION.
RADIOTHERAPY IS A CARDIAC RISK FACTOR FOR PATIENTS WITH CANCER OF THE
LOWER OESOPHAGUS OR THE GASTROESOPHAGEAL JUNCTION, AND IRRADIATION
OF RECTAL CANCER CAN CAUSE SEVERE ENTERITIS, MALABSORPTION AND
DIARRHOEA .
29. MIXED PROTEIN CALORIE MALNUTRITION
MILD MODERATE SEVERE
WEIGHT LOSS 5-9% 10-15% 10-15% OVER 6
MONTHS
UNDERWEIGHT 94-85% 84-70% <70% IDEAL WEIGHT
ALBUMIN 2.8-3.4 2.1-2.7 <2.1
TOTAL LYMPHOCYTE
COUNT
1499-1200 199-800 <800
TRANSFERRIN 199-150 mg/dl 149-100 mg/dl <100 mg/dl
Muscle wasting
Deficient
intake(atleast 3 days)
30. • DEFICIENT NUTRITIONAL INTAKE IS EXPECTED IN POST OP PERIOD : GOAL IS TO
PROVIDE SUFFIECIENT DEXTROSE CONTAINING FLUIDS WHICH PROVIDE ENOUGH
CARBOHYDRATE TO PREVENT BREAKDOWN OF LEAN BODY MASS.
• 100 GM OF EXOGENOUS GLUCOSE : SUFFICIENT TO PREVENT BREEAKDOWN OF
LEAN MUSCLE MASS IN HEALTHY INDIVIDUAL
• NUTRITIONAL SUPPORT IN POST OP PERIOD : INDIVIDUALISED
• WHENEVER AVAILABLE, ENTERAL ROUTE IS PREFERRED
31. • NUTRITIONAL NEED OF A PATIENT
ABW (ADJUSTED BODY WEIGHT)= IBW (IDEAL BODY WEIGHT) + 0.5 (ACTUAL BODY
WEIGHT – IBW( IDEAL BODY WEIGHT
BASELINE CALORIE REQUIREMENT : 25 LCAL/KG/DAY
PROTEIN REQUIREMENT: MINIMAL DAILY REQUIREMEMT IS 0.8 GM
PROTEIN/KG/DAY
POST OP PATIENTS : 1-1.5 G/KG/DAY
SEVERELY ILL PATINETS : 2 GM/KG/DAY
• MARKERS OF NUTRITION PRE ALBUMIN. RBP, TRANSFERRIN (SHORT HALF, RAPID
TURNOVER, 2-7 DAYS.
32. INTRAOPERATIVE MANAGEMENT
• PROPHYLACTIC ANTIBIOTICS
GOAL : TO REDUCE THE INTRAOPERATIVE BACTERIAL LOAD TO A DEGREE THAT CAN BE
CONTROLLED BY THE PATIENT’S INNATE IMMUNE SYSTEM.
INCLUDED IN WHO SURGICAL SAFETY CHECKLIST
CONTROVERSIAL : TIME TO PEAK PLASMA CONCENTRATION IS KNOWN BUT TIME TO ACHIEVE
ADEQUATE CONCENTRATION IN SKIN OR ORGANS IS NOT KNOWN.
STUDIES BY STONE AND CLASSEN: BETWEEN 2 HR TO 1 HR PRIOR TO INCISION
WHO CHECKLIST : ADVOCATES 1 HR INTERVAL
CHOICE OF DRUGS : USUALLY THIRD GENERATION CEPHALOSPORINS
SECOND DOSE AFTER 3 HOURS
INSTITUTES BASED PROTOCOLS
33. • ANY APPLICATION OF ANTIMICROBIAL DRUGS AFTER CLOSURE OF THE SURGICAL
WOUND SHOULD NOT BE CONSIDERED PERIOPERATIVE PROPHYLAXIS.
• APPLICATION AFTER WOUND CLOSURE ACTUALLY INCREASES THE RISK OF SSI
FIVEFOLD AND PROMOTES THE DEVELOPMENT OF RESISTANT BACTERIAL
STRAINS.
• EVEN CORRECTLY PERFORMED “SINGLE-SHOT” PERIOPERATIVE ANTIBIOTIC
PROPHYLAXIS CAN INDUCE SEVERE CLOSTRIDIUM DIFFICILE INFECTIONS AND
DIARRHOEA WITH HIGHLY VIRULENT STRAINS
MANIAN FA, MEYER PL, SETZER J, SENKEL D (2003) SURGICAL SITE INFECTIONS ASSOCIATED WITH METHICILLIN-RESISTANT
STAPHYLOCOCCUS AUREUS: DO POSTOPERATIVE FACTORS PLAY A ROLE? CLIN INFECT DIS 36 (7):863–868
CRABTREE TD, PELLETIER SJ, GLEASON TG, PRUETT TL, SAWYER RG (1999) CLINICAL CHARACTERISTICS AND ANTIBIOTIC
UTILIZATION IN SURGICAL PATIENTS WITH CLOSTRIDIUM DIFFICILE-ASSOCIATED DIARRHEA. AM SURG 65(6):507–511,
DISCUSSION 511–502
CARIGNAN A, ALLARD C, PEPIN J, COSSETTE B, NAULT V, VALIQUETTE L (2008) RISK OF CLOSTRIDIUM DIFFICILE INFECTION
AFTER PERIOPERATIVE ANTIBACTERIAL PROPHYLAXIS BEFORE AND DURING AN OUTBREAK OF INFECTION DUE TO A
HYPERVIRULENT STRAIN. CLIN INFECT DIS 46 (12):1838–1843
34. • MRSA
CURRENT DATA DO NOT SUPPORT THE GENERAL USE OF PERIOPERATIVE
PROPHYLAXIS WITH AGENTS ACTIVE AGAINST MRSA IF THE PATIENT IS COLONISED
BY RESISTANT BACTERIA.
HOWEVER, FOR PATIENTS AT HIGH RISK OF SSI, WHO SHOULD BE IDENTIFIED IN
ADVANCE OF SURGERY, THE EXTENSION OF ANTIBIOTIC PROPHYLAXIS TO AGENTS
AGAINST MRSA AND OTHER RESISTANT BACTERIAL STRAINS MIGHT BE
CONSIDERED.
VANCOMYCIN : HIGH MOLECULAR WEIGHT, POOR PENETERATION INTO TISSUES :
NOT A DRUG OF CHOICE.
ONE CAN USE CLINDAMYCIN, RIFAMPICIN OR FOSFOMYCIN
• JOINT DECISION MAKING
35. CDC CATEGORY 1 RECOMMENDATIONS FOR
REDUCTION OF SSI
• IDENTIFY AND TREAT DISTANT INFECTIONS PRIOR TO SX
• DONOT REMOVE HAIR ROUTINELY, IF REMOVED – USE ELECTRIC CLIPPERS IMMEDIATELY
PRIOR TO SX
• CONTROL HYPERGLYCEMIA
• CEASE TOBACCO SMOKING 30 DAYS PRIOR TO SURGERY
• ANTISEPTIC SHOWER IN NIGHT PRIOR TO SURGERY
• ANTISEPTIC SKIN PREPARATION
• HAND SCRUBS BY SURGERY TEAM
• APPROPRIATE ANTIMICROBIAL PROPHYLAXIS
• SURGICAL BARRIERS (GOWNS, GLOVES, MASKS)
• DONOT CLOSE CONTAMINATED SKIN INCISIONS.
36. METHODS FOR AVOIDING POSTOPERATIVE
COMPLICATIONS
AIRWAY
MANANGEMENT
AND VENTILATION
CHOICE OF
ANAESTHETIC
AGENTS
GLUCOSE
CONTROL
FLUID
MANAGEMENT
TEMPERATURE
37. AIRWAY MANAGEMENT AND VENTILATION
• 1-5 CASES OUT OF 10000 CASES : SEVERE ASPIRATION
• MICROASPIRATION ( CAN OCCUR IN ALL PHASES OF ANAESTHESIA, FROM
INDUCTION TO RECOVERY)
• HIGHER RISK OF POSTOP PULMONARY COMPLICATIONS IN ABDOMINAL SURGERY
• ONGOING DEBATE
ORAL HYGIENE MEASURES
TYPES OF ET CUFFINGS
CUFF PRESSURE CONTROL
CONTINOUS SUPRAGLOTTIC SUCTIONING
Benington S, Severn A (2007) Preventing aspiration and regurgitation. Anaesthesia Intensive Care Med 8:368–372
Smetana GW, Cohn SL, Lawrence VA (2004) Update in perioperative medicine. Ann Intern Med 140(6):452–461
Cohn SL, Smetana GW (2007) Update in perioperative medi- cine. Ann Intern Med 147(4):263–270
Warner DO (2000) Preventing postoperative pulmonary compli- cations: the role of the anesthesiologist. Anesthesiology 92 (5):1467–1472
38. • IN A STUDY OF 86 PATIENTS WHO UNDERWENT OESOPHAGECTOMY, THE
INCIDENCE OF POSTOPERATIVE PNEUMONIA WAS SIGNIFICANTLY LOWER AMONG
PATIENTS WHO BRUSHED THEIR TEETH FIVE TIMES A DAY THAN AMONG
PATIENTS WHO USED STANDARD ORAL CARE AS USUAL.
AKUTSU Y, MATSUBARA H, SHUTO K, SHIRATORI T, UESATO M, MIYAZAWA Y, HOSHINO I, MURAKAMI K, USUI A, KANO M, MIYAUCHI H (2010) PRE-OPERATIVE
DENTAL BRUSHING CAN REDUCE THE RISK OF POSTOPERATIVE PNEUMONIA IN ESOPHAGEAL CANCER PATIENTS. SURGERY 147(4):497–502
• IN 2000, THE ARDS CLINICAL NETWORK TRIAL DEMONSTRATED FOR THE FIRST
TIME A LOWER MORTALITY IN A LARGE COHORT OF PATIENTS WITH ALI OR
ACUTE RESPIRATORY DISTRESS WHEN A PROTECTIVE VENTILATORY STRATEGY
WAS APPLIED USING SMALL TIDAL VOLUMES AND PREDEFINED POSITIVE END-
EXPIRATORY PRESSURE SETTINGS.
THE ACUTE RESPIRATORY DISTRESS SYNDROME NETWORK (2000) VENTILATION WITH LOWER TIDAL VOLUMES AS COMPARED WITH TRADITION- AL
TIDAL VOLUMES FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROME. THE ACUTE RESPIRATORY DISTRESS SYNDROME
NETWORK. N ENGL J MED 342(18):1301–1308
39. • INDUCTION OF ANAESTHESIA LEADS TO ATELECTASIS FORMATION,
PREDOMINATELY IN THE CAUDAL-DEPENDENT PARTS OF THE LUNGS.
PREVENTION AND REVERSAL OF ATELECTASIS INCREASES FRC AND IMPROVES
GAS EXCHANGE IN THE POSTOPERATIVE PERIOD .
MAGNUSSON L, SPAHN DR (2003) NEW CONCEPTS OF ATELECTASIS DURING GENERAL ANAESTHESIA. BR J ANAESTH 91(1):61–72
DUGGAN M, KAVANAGH BP (2005) PULMONARY ATELECTASIS: A PATHOGENIC PERIOPERATIVE ENTITY. ANESTHESIOLOGY 102(4):838– 854
• ROLE OF PEEP
IMBERGER G, MCILROY D, PACE NL, WETTERSLEV J, BROK J, MOLLER AM (2010) POSITIVE END-EXPIRATORY PRESSURE (PEEP) DURING ANAESTHESIA FOR THE
PREVENTION OF MORTALITY AND POSTOPERATIVE PULMONARY COMPLICATIONS. COCHRANE DATABASE SYST REV 9: CD007922
SQUADRONE V, COHA M, CERUTTI E, SCHELLINO MM, BIOLINO P, OCCELLA P, BELLONI G, VILIANIS G, FIORE G, CAVALLO F, RANIERI VM (2005) CONTINUOUS POSITIVE
AIRWAY PRESSURE FOR TREATMENT OF POSTOPERATIVE HYPOXEMIA: A RANDOMIZED CONTROLLED TRIAL. JAMA 293(5):589–595
40. CHOICE OF ANAESTHESIA
GA + TEA (THORACIC EPIDURAL
TEA : IMPROVES MESENTERIC BLOOD FLOW,
INCREASES OXYGEN SUPPLY TO THE ABDOMINAL CAVITY AND
ALLOWS SUFFICIENT PAIN CONTROL AFTER SURGERY (THE LATTER
REPRESENTS ONE OF THE CORNERSTONES OF THE FAST-TRACK
SURGERY CONCEPT).
VERY RECENT STUDIES HAVE SUGGESTED THAT FOR SOME TYPES OF
CANCER TEA MIGHT ALSO REDUCE THE RATE OF RECURRENCE
AFTER SURGICAL RESECTION.
Wuethrich PY, Hsu Schmitz SF, Kessler TM, Thalmann GN, Studer UE, Stueber F, Burkhard FC (2010) Potential influence of the anesthetic
technique used during open radical prostatectomy on prostate cancer-related outcome: a retrospective study. Anesthesiology
113(3):570–576
Snyder GL, Greenberg S (2010) Effect of anaesthetic technique and other perioperative factors on cancer recurrence. Br J Anaesth
105(2):106–115
Gottschalk A, Ford JG, Regelin CC, You J, Mascha EJ, Sessler DI, Durieux ME, Nemergut EC (2010) Association between epidural analgesia
and cancer recurrence after colorectal cancer surgery. Anesthesiology 113(1):27–34
41. GLUCOSE CONTROL
• NEGATIVE EFFECTS OF INTRA HOSPITAL HYPERGLYCEMIC
PHASES :
IMPAIRED WOUND HEALING
NOSOCOMIAL INFECTIONS
INCREASED HOSPITAL STAY AND MORTAILITY
VAN DE BERGHE INTRODUCED THE CONCEPT “INTENSIVE GLUCOSE
CONTROL FOR CRITICAL CARE PATIENTS : SERIOUS CONCERNS
REGARDING SEVERE HYPOGLYCEMIA
VAN DEN BERGHE G, WOUTERS P, WEEKERS F, VERWAEST C, BRUYNINCKX F, SCHETZ M, VLASSELAERS D, FERDINANDE P, LAUWERS P,
BOUILLON R (2001) INTENSIVE INSULIN THERAPY IN THE CRITICALLY ILL PATIENTS. N ENGL J MED 345(19):1359–1367
FINFER S, CHITTOCK DR, SU SY, BLAIR D, FOSTER D, DHINGRA V, BELLOMO R, COOK D, DODEK P, HENDERSON WR, HEBERT PC, HERITIER
S, HEYLAND DK, MCARTHUR C, MCDONALD E, MITCHELL I, MYBURGH JA, NORTON R, POTTER J, ROBINSON BG, RONCO JJ (2009)
INTENSIVE VERSUS CONVENTIONAL GLUCOSE CONTROL IN CRITICALLY ILL PATIENTS. N ENGL J MED 360(13):1283–1297
42. • CONCEPT MODIFIED TOWARDS LESS EXTREME BLOOD GLUCOSE LEVELS (110-180 MG/DL)
• GLUCOSE CONTROL PER SE : STILL REGARDED AS A GOLDEN STANDARD FOR REDUCING
PERIOPERATIVE COMPLICATIONS
FLUID CONTROL
• LIBERAL VS RESTRICTIVE FLUID THERAPY
• IN HEALTHY INDIVIDUALS: RESTRICTIVE (VERSUS MODERATELY LIBERAL) VOLUME
REPLACEMENT DOES NOT PROVIDE ANY BENEFICIAL EFFECT ON PATIENT OUTCOME.
• RESTRICTIVE (998-2740 ML) VS LIBERAL (2750-5288) : INCONSISTENT RESULTS
• “EVIDENCE-BASED GUIDELINES FOR OPTIMAL PROCEDURE-SPECIFIC PERI-OPERATIVE
FIXED-VOLUME REGIMENS CANNOT BE FORMULATED” .
• HIGH RISK SURGICAL PATIENTS : EARLY INTERVENTION AND GOAL DIRECTED
THERAPY IN PERIOPERATIVE PERIOD : OPTIMISATION OF VOLUME STATUS AND
TO ACHIEVE BEST RATE OF OXYGEN DELIVERY TO CELLS
43. • PARADIGMATIC SHIFT FROM PRESSURE TO VOLUME TARGETED PARAMETERS
• LESS INVASIVE MONITORING DEVICES
• EARLY INTERVENTION: PREOPERATIVE TRANSFER TO ICU AND TRANSFER OF AN
ALREADY OPTIMESD PATIENT TO OT
• BEST SOLUTION FOR VOLUME REPLACEMENT AND VOLUME OPTIMISATION :
COLLOIDS OR CRYSTALLOIDS
• COLLOIDS : NEGATIVE IMPACT ON PATIENT OUTCOME AND RENAL FUNCTION
PARTICULARLY SEPTICEMIC PATIENTS
• BUT COLLOIDS ACT FASTER, PARTIULARLY IMPORTANT IF A LARGE VOLUME IS LOST
DURING SURGERY
• C/I IN PATIENTS WITH RENAL DYSFUNCTION
44. SUMMARY
MODERATELY RESTRICTIVE VOLUME REPLACEMENT STRATEGY : FOR
UNCOMPROMISED PATIENTS SEEMS ADEQUATE;
EXTREME VOLUME LOADING DEFINITELY SHOULD BE AVOIDED.
HIGH-RISK SURGICAL PATIENTS : SHOULD BE IDENTIFIED EARLY, OPTIMISED FOR
VOLUME STATUS AND TO ACHIEVE BEST RATE OF OXYGEN DELIVERY TO CELLS
COLLOIDS SHOULD BE AVAILABLE FOR VOLUME REPLACEMENT DURING SURGERY
COLLOIDS USE SHOULD NOT EXCEED 20 ML/KG BODY WT/DAY
CAUTIOUS USE IN RENAL IMPAIRMENT
45. TEMPERATURE MANAGEMENT
NEGATIVE EFFECTS OF PERIOPERATIVE HYPOTHERMIA
• DURATION OF MUSCLE RELAXANTS,
• INTRAOPERATIVE BLOOD LOSS,
• TRANSFUSION REQUIREMENTS,
• SHIVERING, DISCOMFORT,
• POSTANAESTHETIC RECOVERY,
• MORBID CARDIAC EVENTS,
• SURGICAL WOUND INFECTIONS AND
• DURATION OF HOSPITALISATION.
• ADEQUATE CONTROL OF BODY TEMPERATURE, WITH WARM FORCED-AIR BLANKETS
OR WARM FLUIDS, IS THUS CRITICAL FOR PATIENT OUTCOME
FORCED AIR WARMING
BLANKETS
WARM FLUIDS
PRE WARMING OF THE PATIENT
46. INTENSIVE AND INTERMEDIATE
POSTOPERATIVE CARE
• CHALLENGED BY FAST TRACK SURGERY
• NO RATIONALE FOR TRANSFERRING AN EXTUBATED, STABLE, NORMOTHERMIC PATIENT FROM
THE OPERATING ROOM TO AN ICU.
• EVIDENCE IS GROWING THAT TRANSFER TO A NORMAL SURGICAL WARD MIGHT BE PREFERRED.
• CLOSE INTERDISCIPLINARY COOPERATION AND WELL-DEFINED PROTOCOLS
• INCREASES WORKLOAD FOR GENERAL WARD : REQUIRES HIGHLY MOTIVATED WELL TRAINED
NURSING STAFF
• INTERMEDIATE CARE WARDS ; HAEMODYNAMIC MONITORING, ABILITY TO PROVIDE 1-2 IV
DRUGS CONTINOUSLY, ABILITY TO PERFORM NON INVASIVE VENTILATION
• HIGH RISK PATIENTS UNDERGOING MAJOR ABDOMINAL SURGERY : HIGH RISK OF POOR
OUTCOME : ICU
• STEP UP STEP DOWN ICU
47. POSTOPERATIVE MANAGEMENT
• MODERN FAST TRACK PROGRAMMES
• 6 MAJOR ELEMENTS
1. MODERN OPIOID SPARING ANALGESIA
2. EARLY MOBILISATION AND PREVENTION OF VTE
3. EXTENDED LUNG EXPANSION EXERCISES
4. EARLY REMOVAL OF TUBES, CATHETERS AND DRAINS
5. EARLY ORAL NUTRITION
6. EARLY DETECTION OF COMPLICATIONS
48. 1. MODERN OPIOID SPARING ANALGESIA
REDUCE POST OPERATIVE PARALYTIC ILEUS
ENCOURAGE LUNG EXERCISES
ACCELERATE RECOVERY
• ACUTE PAIN SERVICES
• CONTINOUS ADMINISTRATION OF LA INTO SURGICAL SITES : BENEFIT REMAINS TO BE
DEMONSTRATED
2. EARLY MOBILISATION AND PREVENTION OF VTE
CRITICAL FOR POSTOP RECOVERY AND PREVENTION OF COMPLICATIONS
PARTICULARLY PULMONARY COMPLICATIONS AND VTE.
HIGH RISK OF VTE : PRESENCE OF CANCER, DISTANT METASTASIS, CHEMOTHERAPY
AND SURGERY.
49. PRACTICAL GUIDELINES ON THE
PROPHYLAXIS OF VTE
• IN THE ABSENCE OF ACUTE BLEEDING OR OTHER C/I, ALL PATIENTS
HOSPITALISED WITH AN ACUTE MEDICAL ILLNESS SHOULD RECEIVE VTE
PROPHYLAXIS THAT IS COMMENCED PREOPERATIVELY.
• LOW-RISK SURGERY + NO RISK FACTORS FOR VTE : PHARMACOLOGIC
PROPHYLAXIS IS GENERALLY NOT RECOMMENDED, ONLY GRADUATED
COMPRESSION STOCKINGS AND FREQUENT AMBULATION.
• COMMON VTE PROPHYLAXIS : LOW-DOSE UFH AND LMWH. THE LATTER IS
CONTRAINDICATED IN PATIENTS WITH RENAL INSUFFICIENCY.
• HIGH RISK FOR DEVELOPING VTE SHOULD RECEIVE HIGHER DOSES OF EITHER
UFH OR LMWH THAN MODERATE- OR LOW-RISK PATIENTS (E.G. ENOXAPARIN 40
VERSUS 20 MG DAILY).
50. • PATIENTS WITH CHRONIC ATRIAL FIBRILLATION OR A MECHANICAL HEART
VALVE OR WHO OTHERWISE REQUIRE THERAPEUTIC ANTICOAGULATION NEED
TO RECEIVE WEIGHT-ADAPTED LMWH, TWICE DAILY, OR INTRAVENOUS APTT-
ADJUSTED UFH.
• BECAUSE NONEMERGENCY SURGERY IS USUALLY SCHEDULED DURING DAYTIME
HOURS, S/C PROPHYLAXIS SHOULD BE GIVEN IN THE EVENING.
• FOR PATIENTS WHO REQUIRE THERAPEUTIC ANTICOAGULATION, LMWH SHOULD
BE PAUSED ON THE MORNING OF THE OPERATION, WHILE UFH INFUSION
SHOULD BE DISCONTINUED 4 H PREOPERATIVELY.
51. • IN PATIENTS AT LOW OR MEDIUM RISK FOR POSTOPERATIVE BLEEDING, LMWH
SHOULD BE CONTINUED ON THE EVENING AFTER SURGERY AND LAST UNTIL
DISCHARGE FROM HOSPITAL.
• IN PATIENTS WHO ARE AT HIGH RISK FOR POSTOPERATIVE BLEEDING,
INTRAVENOUS UFH SHOULD BE CONTINUED IMMEDIATELY AFTER TRANSFER TO
THE ICU (COMMONLY 100–200 U/H).
• PATIENTS WHO HAD UNDERGONE MAJOR ABDOMINAL OR PELVIC SURGERY FOR
GASTROINTESTINAL MALIGNANCY SHOULD BE CONSIDERED FOR POST
DISCHARGE VTE PROPHYLAXIS FOR UP TO 4 WEEKS AFTER SURGERY IN THE
FOLLOWING SITUATIONS: RESIDUAL OR METASTATIC DISEASE, OBESITY OR
PREVIOUS HISTORY OF VTE.Lyman GH, Khorana AA, Falanga A, Clarke-Pearson D, Flowers C, Jahanzeb M, Kakkar A, Kuderer NM, Levine MN, Liebman H, Mendelson D, Raskob
G, Somerfield MR, Thodiyil P, Trent D, Francis CW (2007) American Society of Clinical Oncology guideline: recommendations for venous
thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25 (34):5490–5505
52. 3. EXTENDED LUNG EXPANSION EXERCISES
FIRST AND MOST IMPORTANT STRATEGY FOR REDUCING POSTOPERATIVE
PULMONARY COMPLICATIONS
PATIENTS WITH RESTRICTED PULMONARY FUNCTION : SHOULD PERFORM THESE
EXERCISES BEFORE SURGERY.
SELECTIVE BUT NON ROUTINE USE OF NG TUBES IN PATIENTS WHO ARE AT HIGH
RISK OF DEVELOPING PULMONARY COMLICATIONS
4. EARLY REMOVAL OF TUBES, CATHETERS AND DRAINS
PROPHYLACTIC NG DECOMPRESSION TO REDUCE NAUSEA/VOMITING : NOT
SUPPORTED BY LITERATURE
CHEATHAM ML, CHAPMAN WC, KEY SP, SAWYERS JL (1995) A META-ANALYSIS OF SELECTIVE VERSUS ROUTINE NASOGASTRIC DECOMPRES- SION
AFTER ELECTIVE LAPAROTOMY. ANN SURG 221(5):469–476, DISCUSSION 476–468
53. • PERSISTENCE OF OTHER CATHETERS AN DRAINS : RESTRICT MOBILITY
• PLACEMENT OF DRAINS : HIGHLY DEBATED
• RATIONALE OF PLACING DRAINS :
TO SCREEN FOR POSTOPERATIVE HAEMORRHAGE,
TO IDENTIFY AN EARLY ENTERIC, BILE, PANCREATIC OR CHYLE LEAK AND
TO ALLOW EARLY INTERVENTION (E.G. TRANSFUSION, INTERVENTIONAL
TREATMENT OR REOPERATION).
IN CASES IN WHICH THE DRAIN ADEQUATELY “CONTROLS” THE LEAK,
REOPERATION OR INTERVENTION MAY EVEN BE AVOIDED
DOUGHERTY SH, SIMMONS RL (1992) THE BIOLOGY AND PRACTICE OF SURGICAL DRAINS. PART 1. CURR PROBL SURG
29(8):559–623
54. • ALTHOUGH A GROWING BODY OF EVIDENCE SUGGESTS THAT NONEMERGENCY
GASTROINTESTINAL SURGERY CAN BE PERFORMED SAFELY WITHOUT
PROPHYLACTIC INTRA-ABDOMINAL DRAINAGE .
• AND THAT DRAINAGE MAY EVEN BE HARMFUL AFTER HEPATIC RESECTION IN
CLD.
• AND AFTER APPENDECTOMY, IT REMAINS HIGHLY CONTROVERSIAL WHETHER
DRAINAGE IS DESIRABLE.
• IT ALSO REMAINS UNCLEAR, PARTICULARLY FOR PANCREATIC RESECTIONS,
WHETHER SHORT-TERM DRAINAGE IS SUPERIOR TO LONG- TERM DRAINAGE.
PETROWSKY H, DEMARTINES N, ROUSSON V, CLAVIEN PA (2004) EVIDENCE-BASED VALUE OF PROPHYLACTIC DRAINAGE IN GASTROINTESTINAL SURGERY: A
SYSTEMATIC REVIEW AND META-ANALYSES. ANN SURG 240 (6):1074–1084, DISCUSSION 1084–1075
55. 5. EARLY ORAL NUTRITION
• RECOMMENDED FOR NON EMERGENCY GI SURGERY
• STANDARD PRACTICE
NLEWIS SJ, EGGER M, SYLVESTER PA, THOMAS S (2001) EARLY ENTERAL FEEDING VERSUS "NIL BY MOUTH" AFTER GASTROINTESTINAL SURGERY: SYSTEMATIC REVIEW
AND META-ANALYSIS OF CONTROLLED TRIALS. BMJ 323(7316):773–776
• NAUSEA/ VOMITING SHOULD BE TREATED WITH SEROTONIN ANTAGONISTS, LOW
DOSE DEXAMETHASONE, DROPERIDOL OR DIMENHYDRINATE.
6. EARLY DETECTION OF COMPLICATIONS
• SMALL GROUP OF PATIENTS ACCOUNTS FOR MAJORITY OF MORBIDITY AND
MORTAILITY
• CRUCIAL TO IDENTIFY THESE
• EXTRA EFFORT SHOULD BE MADE TO PREVENT POTENTIAL COMPLICATIONS AND
TO IDENTIFY ACTUAL COMPLICATIONS AS EARLY AS POSSIBLE.
56. • ELDERLY PATIENTS
POSTOPERATIVE COGNITIVE DECLINE (POCD) : AFFECTS MEMORY ANS EXECUTIVE
FUNCTION, MAY LAST FOR WEEKS OR MONTHS
POSTOPERTAIVE DELIRIUM : CONFUSION AND ALTERED CONSCIOUSNESS THAT LASTS
FOR DAYS
UNCLEAR HOW THESE CAN BE PREVENTED
MECHANICAL TREATMENT
• INCLUDES CHEWING GUM IN IMMEDIATE POSTOP PERIOD : HYPOTHETICALLY
STIMULATES GASTROCOLIC REFLEX AND HORMANLLY INDUCED PERISTALSIS
• ASSOCIATED WITH EARLY RECOVERY OF BOWEL FUNCTION
• SAFE HARMLESS METHOD OF STIMULTNG BOWEL MOTILITY AND REDUCE DURATION
OF
57. COMPONENTS OF A STANDARD ENHANCED RECOVERY PATHWAY FOR
COLORECTAL SURGERY
ERP COMPONENTS LEVEL OF EVIDENCE
PREOPERATIVE COUNSELLING GRADE B
PREOPERATIVE FEEDING (MINIMIZATION OF FASTING) GRADE A
SYNBIOTICS NOT DISCUSSED IN CONSENSUS
REVIEW
NO BOWEL PREPARATION GRADE A
NO PREMADICATION GRADE A
FLUID RESTRICTION GRADE A
PERIOPERATIVE HIGH OXYGEN CONCENTRATION NOT DISCUSSED
ACTIVE PREVENTION OF HYPOTHERMIA GRADE A
58. EPIDURAL ANALGESIA GRADE A
MINIMALLY INVASIVE/ TRANSVERSE INCSIONS GRADE B
NO ROUTINE USE OF NASOGASTRIC TUBES GRADE A
NO USE OF DRAINS ABOVE PERITONEAL REFLECTION GRADE A
ENFORCED POSTOPERATIVE MOBILIZATION GRADE B
ENFORCED EARLY POSTOPERATIVE FEEDING GRADE A
BALANCED ANALGESIA – MULTIMODAL : LOW/NO OPIODS GRADE A
STANTARD LAXATIVES AND ANTI EMETICS GRADE B
EARLY REMOVAL OF URINARY CATHETER NOT DISCUSSED IN
CONSENSUS REVIEW
LEVEL OF EVIDENSE DERIVED FROM LASSEN K, SOOP M, NYGREN J, ET AL:
CONSENSUS REVIEW OF OPTIMAL PERIOPERATIVE CARE IN COLORECTAL SURGERY :
ENHANCED RECOVERY AFER SURGERY GROUP RECOMMENDATIONS. ARCH SURG
144:961,2009.