perioperative preparations in obstetrics and Gynecology.pptx

Perioperative care for obstetric and
gynecological cases
Prepared by:
Dr.Ekram Abdullah Nasher

Introduction
Each year, more than 30 million surgical procedures are performed.
- One million patients present with a postoperative Complication.
The surgeon should review the patient's history and physical examination, identify physical
limitations, gather information required to plan surgery, optimize medical status, and educate
about what to expect from the procedure and during the recovery period.
Many postoperative problems can be anticipated preoperatively, and eliminated or minimized, result in
a shorter hospitalization with fewer complications and a more satisfied patient.

 Surgery has three phases:
• pre-operative phase : the period before induction of anesthesia, during which the patient is
prepared for surgery on the ward or in the emergency department, including possible use of
premedication.
• Intraoperative phase: the period including total anesthesia time, from the first anesthetic intervention
through to patient transfer to the recovery area of the theatre suite.
• post-operative phase: the period after the patient has entered the recovery area of the theatre suite, the
patient should be monitored, encouraged and advised.

• Preoperative (Choose well)
• operative (Cut well)
• post operative (Get well).

intraoperative
postoperative
-It uncovers comorbidities that require further evaluation and
improvement to avert perioperative complications.
-Allows effective use of operating room resources
-To anticipate potential problems for appropriate perioperative plan.
-Despite ideal preparation, complications may still develop, and we
need to anticipate complication and provided the suitable place
,management and care for them.
-Successful outcomes depend on appropriate patient
and procedure selection, intraoperative technique or
possible complications
patient preparation
Goals of
patient
preparation

Preoperative preparation
pre-operative care
preoperative assessment

 preoperative assessment:
General & systemic
evaluation
Preoperative discussion
Anesthesiologic
preoperative examination
general principles
pre-operative care

 General &systemic evaluation
History Examination Investigations
Detailed history and general examination .
Routine screening blood tests have not been shown to influence cancellation or perioperative complications and
the majority of abnormal results could have been predicted from the history and examination.
 preoperative assessment:
pre-operative care

 History:
 It should include (medical conditions, surgical history, medications, allergies), as well as those related
to the following:
• Medical condition for which the procedure is performed.
• Medical conditions and risk factors that increase the risk of perioperative complications.
• Personal or family history or risk factors for thromboembolism.
• Personal or family history of anesthesia- related complications(as malignant hyperthermia)
 Comprehensive history is the first step helping surgeons to determine the scope of general physical
examination, laboratory and radiological tests.
pre-operative care

The important points in the history the will affect the intra and post operative outcomes:
• age: > 60 years are at increased risk of complications.
Between 60 and 69 years have a two fold increased risk. In those > 70 years the risk rises three fold.
• Smoking: It cause tachycardia, ↑ peripheral resistance, ↓ the availability of O2 by 25% and the
Respiratory complication will ↑ by 6 folds.
- It must be stopped 1 month of operation Or at least 6 hours before anesthesia .
Preoperative cessation or at least 6 to 8 weeks offers significant improvement in lung function and
reversal of smoking-related immune impairment.
Other short-term benefits related to ↓ nicotine and carboxyhemoglobin levels, improved
mucociliary function, ↓ upper airway hypersensitivity and improved wound healing.
- Stoppage for 6-month or longer have complication risks similar to who have never smoked.
 History:
pre-operative care

• Alcohol: cause induction of liver enzyme, hepatic & cardiac damage, delirium, tremors post-
operatively as result of drug withdrawal
• Exercise capacity: patient should be asked about it as patient with good exercise tolerance
generally have low risk , American heart association guideline on perioperative cardiac
evaluation recommended no testing for patient with good exercise tolerance(>4 mile per hours =
walk 4 block or 28 of stairs)
• General medical history: includes -Personal and family diseases.
Ischemic heart disease , Congestive cardiac failure , Arterial hypertension , Chronic respiratory
disease, Diabetes mellitus , Cardiac arrhythmia and anemia
 History:
pre-operative care

• Drug history: many drugs interact with the anesthesia
• Allergies to drugs, foods, and other environmental allergens
• Hospitalizations
• previous operations and tolerance of anesthetics:
- A history of previous anesthesia .
-Allergy to drugs .
-Sore throat and headache
· - Post-operative nausea or vomiting .
-·DVT or Respiratory problems .
-Difficulties with tracheal intubation
 History
pre-operative care

• Gynecologic and obstetric history :
• Major complaints of the current disease.
• past pregnancies .
• Menstrual cycle data:
- LMP (pregnancy should be excluded).
• Menopausal symptoms & HRT
• birth control methods
• sexual history : conception difficulties, infertility treatment, infections (vaginal discharge, previous
vaginal infections, sexually transmitted diseases)
 History
pre-operative care

 Physical Examination
pre-operative care

- To evaluate the patient's ability to tolerate surgery or anesthesia.
- Full physical examination is needed , must be done even if it's a
minor surgery.
- Generally : Appearance ,Consciousness , Color,
Hydration status ,Environment.
- Obesity : ↓ chest wall compliance and functional
residual capacity & BMI ≥ 30 kg/m2 ↑ intra - postoperative
complications.
- VITAL SIGNS.
pre-operative care

Systemic physical examination
• Those with more serious conditions should be examined at least a week before surgery,
allowing the time for risk assessment, specialist consultations, and preparation.
pre-operative care

 Anesthesiologic preoperative examination
why?
- To assess general health condition.
- Ability to tolerate the risks and duration of anesthesia for the planned surgery.
- Assessment of the ease of tracheal intubation.
 Overall mortality rate from surgery is 0.6% while from anaesthesia 1/1000.
 The information gathered is used to predict the patient absolute mortality.
preoperative assessment:
pre-operative care

 Risk Assessment
ASA class Status Absolute mortality
I A normal healthy patient 0.1
II Mild systemic disease 0.2
III Systemic disease that is not incapacitating 1.8
Iv Incapacitating systemic disease that is a constant threat to life 7.8
v Moribund patient who is not expect to survive in the next 24 hr with or with out operation 9.8
American Society of Anesthesiologists (ASA) Classification
pre-operative care

Common causes for postponing surgery :
• Acute upper respiratory tract infection.
• Untreated medical diseases.
• Inadequate resuscitates patient in emergency (1/3 of fluid lost) in dehydrated patient & shock pt.
• Recent ingestion of food.
• Failure to obtain informed consent.
• MI: wait 6 months
Causes of death due to anaesthesia :
• Inadequate preoperative assessment.
• Inadequate supervision & monitoring inter- operative period.
• Inadequate post-operative care.
pre-operative care

 Investigations
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pre-operative care

 The ASA does not recommend routine preoperative testing.
 Selective testing may be indicated based on information from the history and physical examination, or because
of the type or invasiveness of the planned procedure and anesthesia
 The overall risk of surgery is low in healthy individuals.
 Preoperative tests usually lead to false-positive results, unnecessary costs, and a potential delay of surgery ,
so preoperative tests should not be performed unless there is a clear clinical indication.
 Specific laboratory studies commonly ordered for preoperative evaluation include a complete blood count,
electrolytes, renal function, blood glucose, liver function studies, hemostasis evaluation and urinalysis.
The American Society of Anesthesiologists (ASA) updated their practice advisory on pre - anesthesia evaluation
pre-operative care
 Investigations

 The American College of Obstetricians and Gynecologists (ACOG) guidelines divide
patients into risk categories according to duration of surgery, age cut-offs (<40
years, 40 to 60 years, and >60 years), and individual VTE risk factors .
 All entirely laparoscopic procedures are classified as minor (regardless of duration
or complexity).
 Investigations
pre-operative care

 Investigations
pre-operative care

Surgery grades
Minor
• Abscess drainang.
• Laproscopy.
•D&C
• Polypectomy
• Cervical cerclage.
Intermediate
• Hysterectomy
• Myomectomy
• Tumors surgery
Major or complex
 Investigations
pre-operative care

Minor surgery
 Investigations
pre-operative care

Intermediate
surgery
 Investigations
pre-operative care

 Investigations
pre-operative care
Major /complex surgery

 Preoperative discussion
i. The nature and extent of disease
ii. Extent of operation proposed and any potential modifications
iii. Anticipate benefit of operation
iv. Risks and potential complications
v. Alternative methods of treatment and their risks
The surgeon should confirm that the patient has understood the discussion
and desires to proceed with the procedure.
This discussion should be documented in the medical record and on the
procedure consent form
preoperative
assessment:
pre-operative care

pre-operative care

• It is important to allow adequate time for preparation prior to surgery. This includes:
 Patient education:
• Lifestyle modifications : stopping smoking and ↓ alcohol consumption , ↓ weight, physical
activity, good nutrition, drug management, and oral and dental health.
• Preoperative fasting:
- Drink clear fluids until 2 hours before operation help ↓ headaches, nausea and vomiting.
- Carbohydrate drinks before surgery for people having abdominal major or complex surgery.
pre-operative care

 At least 50 % of patients undergoing surgery take medications on a regular basis .
Clinicians decide if chronic medications should be continued or tapered in the
perioperative period.
 Intravenous, transdermal, or transmucosal medicines should be substituted oral
medicine as absorption will be impaired
 Medications thought to increase the risk of anesthetic or surgical complications
and not essential for the short-term should be held through the perioperative
period.
Preoperative medications instructions:
pre-operative care

 Oral Anticoagulation:
• Patients take anticoagulants following a venous thromboembolism (VTE), the timing of surgery can
often lower the risk of postoperative VTE.
• After an acute VTE, the recurrence risk without anticoagulation 40 - 50 %.
• A delay in surgery and continued warfarin therapy or an additional 2 to 3 months (6 months total) ↓
the recurrence risk to 5 -10 % & avoids a need of preoperative heparin.
• Women with atrial fibrillation, mechanical heart valve , recent VTE are at ↑ risk of VTE.
• Surgeon must compromise between anticoagulant & risk of surgical bleeding.
Preoperative
preparation
pre-operative
care

 ACOG has summarized recommendations to address this balance :
• Anticoagulation is typically halted prior to surgery and started shortly postoperatively.
• Thus, patients are transitioned or “bridged” to heparin, which can be stopped and restarting more readily.
Both low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) are options .
• During bridging, warfarin is stopped several days before surgery, and heparin is begun.
• In those with a therapeutic INR (between 2-3), approximately 5 to 6 days are required to reach to 1.5.
Once this is achieved, surgery can safely proceed.
• During bridging therapy, the last dose o LMWH is administered 24 hours prior to surgery.
UFH, therapy is halted 4 to 6 hours prior to surgery.
Preoperative
preparation
pre-operative
care

Anticoagulant Management
Preoperative
preparation
pre-operative
care

• Emergency surgery may not allow time or such bridging.
• In these cases, warfarin is halted, and vitamin K is provided.
• In urgent cases, a 5- to 10-mg IV dose is suitable .
• To minimize the anaphylactic risk, vitamin K is mixed in a minimum 50 mL of IV fluid over at least 20 m
• Vitamin K requires 4 to 6 hours to achieve clinical effects.
• Fresh frozen plasma (FFP) may be added at a dose of15mL/kg,each FFP unit has a volume of
• 200-250 mL.
• Prothrombin complex concentrate (PCC) is a human-derived product containing factors II, IX, and X.
• PCC does not require thawing and may be used in place o FFP
Preoperative
preparation
pre-operative
care

Preoperative mamegment of patient on chronic Antithrombotic therapy
Protocol A: Use bridging therapy with therapeutic-dose low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH).
Therapeutic-dose enoxaparin is 1 mg/kg subcutaneously (SC) twice daily or 1.5 mg/kg once daily. Therapeutic-dose intravenous
(IV) UFH is 80 units/kg IV push, then 18 units/kg/hr.
Protocol B: Use bridging therapy with low-dose LMWH or low-dose UFH. Low-dose enoxaparin is 30 mg twice SC daily or 40 mg
once SC daily. Low-dose UFH is 5000–7500 units SC twice daily.
Protocol C: Stop long-term anticoagulation therapy. Do not use bridging therapy. Restart long-term anticoagulation after surgery.
Use mechanical prophylaxis with an intermittent compression device during surgery and until long-term anticoagulation is
therapeutic.
pre-operative
care

• Newer direct oral anticoagulants (DOACs) inhibit specific factors:
Dabigatran → factor IIa (thrombin) (1/2 life 14 hrs).
Rivaroxaban & Apixaban → factor Xa (1/2 life 9 hrs).
• Thus, in women with normal preoperative creatinine clearance (CC)→ stopping rivaroxaban and apixaban
24 hrs & dabigatran 48 hrs befor surgery.
• The withdrawal time is doubled if (CC) is < 50 mL/min or the risk o perioperative bleeding is high.
• For emergent surgery, the DOACs have no antidote, and management of life-threatening bleeding remains
empirical.
Fortunately, anticoagulant effects rapidly dissipate (drug’s short half –lives).
Preoperative
preparation
pre-operative
care

 Beta blockers : continued them (have potential beneficial effects when taken perioperatively).
It ↓ ischemia by decreasing myocardial oxygen demand & help prevent or control arrhythmias.
 calcium channel blockers : appear safe during the perioperative period & theoretic benefit recommend to be
continued.
 ACE inhibitors: Some anesthesiologists prefer to withhold these medications on the morning of surgery
based on concerns about possible hypotension & recommend resuming these agents as soon as possible
postoperatively. Failure to restart ARBs within 48 hours after surgery has been associated with increased
30-day mortality
 diuretics : advised to hold the medication on the morning of surgery
 Statins : continued them as may prevent vascular events in the perioperative period.
 H2 blockers or proton pump inhibitors: continued them in the perioperative period.
Preoperative
preparation
pre-operative
care

 Inhaled medications: used to control obstructive pulmonary disease , they recommend continuing beta agonists in the
perioperative period.
 Glucocorticoids: should be continued during the perioperative period.
Chronic glucocorticoid therapy suppress the hypothalamic-pituitary-adrenal (HPA) axis , during times of stress(surgery)
the adrenal glands may not respond appropriately.
PERIOPERATIVE GLUCOCORTICOIDS — The use of stress doses of glucocorticoids, such as 300mg/day of
hydrocortisone for several days had become a common perioperative practice for patients on glucocorticoid
therapy.
Preoperative
preparation
pre-operative
care

 Preoperative medications instructions
pre-operative
care

 Psychotropic agents:
pre-operative
care

 Oral contraceptive:
Are the most frequent cause of thrombosis in young women
Risk of thrombosis ↑ within 4 m of initiation& ↓ to previous levels within three months of stopping.
Greater estrogen content (≥35 mcg) have a higher risk of thromboembolism compared with those with lower
estrogen content (≤30 mcg).
Even the lower estrogen content pills are associated with an increased risk of thrombosis
Discontinued four weeks prior to surgery.
Other forms of contraception must be used to prevent unwanted pregnancy during this time.
pre-operative
care

 Managing iron-deficiency anaemia: Strategies to correct anemia preoperatively are:-
 Iron supplementation
 oral iron → uncomplicated iron deficiency anemia
 • IV iron is indicated for :
• patients unable to tolerate GIT side effects
• pregnant women
• individuals with GIT disorders.
• severe/ongoing blood loss
• Gastric surgery (bypass, resection) , Malabsorption syndromes (celiac disease, Whipple's disease, bacterial
overgrowth)
 Medical problems preoperative management :
pre-operative
care

 Erythropoiesis-stimulating agents
 Blood transfusion:
- Patients severely symptomatic
- life-threatening anemia : evidence of end-organ ischemia secondary to severe anemia.
- hemodynamically unstable due to active bleeding
 Managing iron-deficiency anaemia:
pre-operative
care

The goals of perioperative diabetes management include:
●Avoidance of hypoglycemia: Hypoglycemia and can be difficult to detect in sedated or anesthetized patients
●Prevention of ketoacidosis/hyperosmolar states
●Maintenance of fluid and electrolyte balance
●Avoidance of marked hyperglycemia
 Sulfonylureas: ↑ the risk of hypoglycemia.
 Metformin : ↑ the risk of renal hypoperfusion, lactate accumulation, and tissue hypoxia.
 Thiazolidinediones: worsen fluid retention & peripheral edema and precipitate congestive heart failure
 Sodium-glucose cotransporter 2 (SGLT2) inhibitors: ↑ the risk of hypovolemia , acute kidney injury and
euglycemic diabetic ketoacidosis.
 Dipeptidyl peptidase-4(DPP-4) inhibitors and GLP-1 analogs: alter gastrointestinal (GI) motility and worsen
postoperative state.
 Diabetes mellitus (DM) :
pre-operative
care

 Diabetes mellitus (DM) :
pre-operative
care

pre-operative
care

• The glucose readings must be between 110-180 mg/dL(6.1 to 10 mmol/L) during surgical procedures& post
operative.
Patients develop hyperglycemia→ short- or rapid-acting insulin SC every six hours(measured glucose levels
every 1-2 hrs) until the patient is eating and resume oral agents.
• For short procedure→ subcutaneous insulin perioperatively.
• long and complex procedures → intravenous (IV) insulin.
• For a sedated, anesthetized patient with hypoglycemia:
25 g of 50% dextrose IV (repeat blood glucose measurements in 5 to 10 minutes).
• In the awake patient with a normal swallowing mechanism and gag reflex hypoglycemia :
Treated with at least 15 g of carbohydrates (glucose tablet, sweetened fruit juice).
 DM :
pre-operative
care

Perioperative management recommendations for surgical patients with diabetes mellitus
pre-operative
care

 Management of thyroid disorder:
 Hypothyroidism:
 Subclinical hypothyroidism (↑[TSH, normal T4) do not postponing surgery.
 Moderate (overt) hypothyroidism :
Urgent surgery → do not postponing surgery & treated with thyroid hormone as soon as the diagnosis is
made :
young patients full replacement doses of T4 (1.6 mcg/kg)
older patients or patients with cardiopulmonary disease started 25 to 50 mcg daily ↑ in dose every
2-6 wks
Elective surgery→ postponing surgery until the euthyroid state is restored
pre-operative
care

 severe hypothyroidism (myxedema coma):
• Altered mentation
• Pericardial effusion
• Heart failure
• Very low levels of total T4 [less than 1.0 mcg/dL] or free T4 [, less than 0.5ng/dL])
surgery should be delayed until hypothyroidism has been treated.
If emergency surgery must be performed → treatment with both triiodothyronine (T3) and T4, rather than T4 al
one.
pre-operative
care

Hyperthyrodism:
Subclinical hyperthyroidism (↓ TSH, normal free T4 and T3) can proceed with elective or urgent surgeries.
Administrated preoperatively beta blocker to older patients or younger with cardiovascular disease:
(Untreated or poorly controlled overt hyperthyroidism : surgery can precipitate thyroid storm( postponing
surgery until achieve adequate control (usually three to eight weeks)
If emergency surgery must be performed preoperative treatment of hyperthyroidism should be initiated as soon
as possible.
 atenolol 25 to 50 mg daily and ↑ dose until rate below 80beats/minute.
 Intravenous (IV) propranolol intra operativally(0.5 to 1 mg over 10 minutes followed by 1 to 2 mg over 10
minutes every few hours)
pre-operative
care

 Informed consent
pre-operative
care
Preoperative
preparation

BENEFITS OF INFORMED CONSENT :
•Protecting the patient's right of self- determination.
•Engaging the patient in his or her health care.
•Enhancing the physician-patient relationship.
•Encouraging physicians to thoroughly review the patient's therapeutic options.
•Reducing discontent and litigation when there are complications.
pre-operative
care
Preoperative
preparation

INFORMED CONSENT AND PATIENT EXPECTATIONS :
• Should be in language the patient understands & voluntary obtained .
• Counseling of the patient regarding alternative treatment options , including expectant management
• Risks and benefits of the procedure
• Patient expectations and goals
• The expected duration and requirements of the recovery period .
• Date, time and place should be specified, Signed by the patient , the doctor and a neutral witness
• The patient must be competent ,understood for validity of consent
Personnel:
The physician must advise patients of personnel and their respective roles, including residents, students, and equ
ipment representatives.
pre-operative
care
Preoperative
preparation

FAILURE TO OBTAIN CONSENT :
Failure to provide the necessary, relevant information in a manner that truly communicates with the patient
may constitute ineffective, and therefore nonexistent, consent.
WITHDRAWAL OF CONSENT :
Patients may withdraw consent at any time during a procedure, and the physician must then engage in a new
informed consent (or informed refusal) discussion.
Physician disclosure : Physicians must answer truthfully if a patient asks questions about the number of
similar procedures performed and their success rates.
pre-operative
care
Preoperative
preparation

Consent advice:
pre-operative
care
Preoperative
preparation

Consent examples
pre-operative
care

• Collect or prepare of the blood product especially for major
operations , type and amount according to patient condition
and needs.
Blood product:
pre-operative
care
Preoperative
preparation

• Significantly ↓ hospital- acquired infections following surgery
• Single dose of antibiotics is given at anesthesia induction.
• Additional doses are in cases of blood loss > 1500 mL or duration > 3 hrs.
• Higher antibiotic dose For obese individuals.
• Endocarditis prophylaxis — The American Heart Association (AHA) guidelines do not classify any
gynecologic procedures as high risk for resulting in infective endocarditis and therefore do not
recommend routine use of antibiotic prophylaxis, even in patients with the highest risk cardiac
conditions
INFECTION PROPHYLAXIS
pre-operative
care
Preoperative
preparation

 INFECTION PROPHYLAXIS
pre-operative
care

Multiple studies found no evidence of benefit from mechanical bowel preparation.
The same with laparoscopic surgery and pelvic floor procedures, Also it does not decrease microbial
contamination after elective open colon surgery. preoperative evacuation typically delays stooling and allows
initial healing. In general:
• modify the diet.
• Increase fluid intake .
• Take laxative or bowel preparation medication Various regimens exist:
- low-residue or clear liquid diets the day(s) prior to surgery
- Oral cathartics such as 240 mL of senna extract or 240 mL o magnesium Citrate
- Sodium phosphate enemas (Fleet)
- Oral phosphates (Visicol, Fleet Phospho-soda),
- Oral polyethylene glycol solutions
pre-operative
care
Preoperative
preparation
 GASTROINTESTINAL BOWEL PREPARATION:

Patients may be premedicated on the ward before
anaesthesia using drugs such as opiates or sedatives.
The objective of pre-medication :
• Allay anxiety and fear.
• Reduce secretions.
• Enhance the hypotonic effect of anesthetic
agents.
• Reduce postoperative nausea & vomiting.
• Produce amnesia.
• Reduce the volume & increase PH of gastric
contents.
• Reduce vagal reflexes.
• Limitation of sympathoadrenal response
 Premedication:
pre-operative
care
Preoperative
preparation

 Anti cholinergic :
They are used to:
- reduce secretion
- sedative and amnesic effect
- prevention of reflex bradycardia
Atropine:
- Given IM in dose 0.6 mg for adult & 0.01 mg/kg. .
- Should not used for patient with high temperature, thyrotoxicosis, heart failure controlled by digoxin.
Scopolamine:
* Given IM, IV, or SC in a dose 0.4.
· It produce amnesia, hallucination, and reduce salivation.
· It should not be given to a patient below 6 yr and above 60 yr.
 Premedication
pre-operative
care
Preoperative
preparation

 Anti‐anxiety drugs : include benzodiazepines like( diazepam, midazolam or lorazepam)
Benzodiazepines used to :
• Relief anxiety.
• Sedation.
• Antegrade amnesia.
• Muscle relaxants.
Diazepam: 0.2 mg/kg. Iong acting, night before the operation
Midazolam: 0.1 mg/kg. shorter in action. Hepatic & non-hepatic elimination and doesn't cause thrombosis.
 Premedication
pre-operative
care
Preoperative
preparation

 Narcotic : they are used to :
• Production sedation
• Relieve pain
• lower concentration of anesthetic agent is required for maintenance of anesthesia because of its synergistic effects
with anesthetics.
·Pethidine: 1.5 mg/kg with mild atropine like action( Moderate to sever pain)
·Morphine: 0.15 mg/kg. It's more potent with incidence of vomiting.
. Omanapon: it’s extract of opiate.50% morphine like action and 25% papaverine.
 Premedication
pre-operative
care
Preoperative
preparation

• WHO launched an initiative, called ‘Safe Surgery Saves Lives’, to ensure that surgical staff apply
minimum standards
of safe surgical care universally by using a checklist.
• The use of the checklist helps to identify the necessary steps to take and why they need to be
taken.
• The SSCL has three sections: Sign In, Time Out and Sign Out.
• By following a few critical steps in a logical and planned way, healthcare professionals can
improve teamworking and minimize the most common and avoidable risks that endanger the lives
of surgical patients, which in turn improves the patients’ well‐being.
Intraoperative
preparation
 checklist

 Anesthesia
Main categories of anesthesia :
• general anesthesia
• regional anesthesia
• Epidural / Spinal Anesthesia
• local anesthesia.
The type of anesthesia depends on:
 type of procedure.
 patient’s age.
 medical history.
Intraoperative
preparation

• General anesthesia : places the entire body in a state of unconsciousness , unawareness .
Common indications :
 urgency
 maternal refusal of regional techniques
 inadequate or failed regional attempts
 regional contraindications(coagulation or spinal abnormalities)
Stages of GA:
 Unconsciousness (loss of awreness)
 Analgesia (loss of response to pain)
 Amnesia (loss of memory)
 Immobility (loss of motor reflexes)
 Paralysis (skeletal muscle relaxation and normal muscle relaxation)
 Anesthesia
Intraoperative
preparation

• Regional (or Local) Anesthesia:
the injection of a local anesthetic around major nerves or the spinal cord to block pain from a large region of the
body, such as a limb.
• Epidural/Spinal Anesthesia:
According to ASA practice guidelines, a spinal block or epidural is preferred for most cesarean deliveries because the baby
is exposed to the lowest amount of medication
These procedures require the patient to be properly hydrated
Epidural anesthesia : used for labor, cesareans (c-sections) and surgeries of the colon and gastrointestinal
tract.
Spinal Anesthesia : used for gynecologic (e.g. hysterectomies) and urologic surgeries and of the lower extremities
surgeries (e.g. knee surgery).
 Anesthesia
Intraoperative
preparation

• ASA recommends that non anesthesiologists providing sedation/analgesia have working knowledge of
commonly used intravenous agents and be prepared to rescue patients in the event of drug-induced
respiratory depression, airway obstruction, and/or cardiovascular collapse.
• Midazolam with opioids has a synergistic effect, ↑ the risk of respiratory depression.
• Midazolam & fentanyl exhibit slow effect-site equilibration times so IV doses of each should be spaced
appropriately.
• The cardiovascular system is more resistant to local anesthetic-induced toxicity vis-à-vis the central nervous
system. Bupivacaine is cardiotoxic > ropivacaine > lidocaine.
• Propofol and thiopental → general anesthesia during pregnancy.
 Anesthesia
Intraoperative
preparation

• The supine (dorsal) position : Back ache and neck ache may result from this position
Placing a support under the lumbar region to support the curve of the spine can reduce back ache.
• The Trendelenburg position : used in shocked patient.
• Reverse Trendelenburg is a head‐up position ,securing the patient to the table is essential to
prevent slippage.
• The lateral position patients lie on their side with their back slightly bent .
• lithotomy position for vaginal surgery, lower bowel surgery. This position may cause pressure on
nerves, muscles and joints, leading to postoperative pain and perhaps damage.
• Several other surgical positions exist, but in all cases the patient has to be positioned carefully and securely
to ensure that no harm is caused by unnatural positioning.
 Position
Intraoperative
preparation

 Surgical site infection prevention
Intraoperative
preparation

Preintervention steps to reduce SSI :
• Patient education( 4% chlorhexidine gluconate shower before surgery)
• assessment of preoperative patient risk (WASHING)
• Antibiotic administration
• Preoperative skin preparation with 2% chlorhexidine gluconate and 70% isopropyl alcohol (is superior to
povidone-iodine and iodine-alcohol)
• Additional measures, hair removal, surgical hand hygiene,
• surgical technique: sterile closing and staff glove change for fascia and skin closure, dressing
removal at 24 to 48 hours postoperatively, patient shower with 4% chlorhexidine gluconate after
dressing removal.
Intraoperative
preparation

 Intraoperatively:
• we use 4%chlorhexidine gluconate solution with 70 % isopropyl alcohol for preoperative skin preparation.
 Vaginal preparation :
• povidone-iodine (PVP-I) or chlorhexidine gluconate with 4% concentration of isopropyl alcohol
• Chlorhexidine commonly used because provide a greater reduction in skin flora than PVP-I & not inactivated by
blood but generalized allergic reactions, irritation, sensitivity and vaginal desquamation have been reported
bacterial counts return to baseline levels within 30 minutes after painting with PVP-I solution despite , gel lowers
bacterial counts for at least 3 hrs.
• patient allergic to PVP-I and the vaginal use of chlorhexidine is prohibited, vaginal preparation can be performed
with sterile saline or baby shampoo.
Intraoperative
preparation

Choice of incision : depend on the following considerations :
• Need for rapid entry
• adequate exposure
• Certainty of the diagnosis
• Body habitus
• Location of previous scars
• Potential for significant bleeding
• Minimizing postoperative pain
• Cosmetic outcome
Incision
Intraoperative
preparation

 The vertical medline incision:
 Advantages :
• provides the quickest entry
• best exposure and extensibility.
• Good choice for patients who are: anticoagulated, have enlarged epigastric vessels that may be injured,
have intra-abdominal infection or need an extended incision.
 Disadvantage :
• Higher rates of dehiscence
• Incisional hernia formation
• Poorer cosmetic results.
 Transverse Incisions:
 Advantages :
• Used commonly in benign gynecologic surgery.
• Follow Langer lines of skin thus offer superior cosmetic results.
• Carry low rates of incisional hernia formation .
• Less postoperative pain and improved pulmonary function compared with midline vertical incisions.
 Type of incision
Intraoperative
preparation

 Disadvantages :
• Limited exposure provided to the upper abdomen
• Limited extensibility
• Increased surgical time, and potentially larger blood loss.
 Type of incision
Intraoperative
preparation

Types:
 Monopolar surgery: electrical current goes through the patient to complete the current cycle
A return electrode monitoring system and active electrode monitoring are important safety tools during monopolar
electrosurgery.
 Bipolar surgery: the current only goes through the tissue in between the two electrodes of the instrument, ideal when
dealing with highly vascular tissue or blood vessels.
Effects :
• Cutting :generates a continuous, low-voltage current, concentrating the energy over a small area.
• Coagulation : generates an interrupted, high-voltage current, dispersed over a large surface area.
• Fulguration : Superficial necrosis of tissue. Using sparks, with a high‐power, high‐voltage intermittent waveform.
• Vaporization: causes the cell to explode and form smoke (plume), resulting from rapid heating in the cut mode with
intense vibration and heat within the cells.
• Desiccation: Coagulation of tissue and/or blood. Using a low‐power, low‐voltage, intermittent waveform
 Electrosurgery
Intraoperative
preparation

 Electrosurgery
• Vaporization / Fulguration: are noncontact methods of monopolar electrosurgery while, desiccation
/coagulation is a direct contact method of monopolar electrosurgery.
• The coagulation mode is better suited for fatty tissue and scar tissue, and when fulgurating a large surface area with
superficial bleeding
• The disappearance of water vapor is a good guide for determining when to stop the application of bipolar electrosurgical
energy.
Intraoperative
preparation

• Prior to surgery :
If a bleeding diathesis is suspected evaluation by a hematologist is indicated.
women who are not accept perioperative blood transfusion and who are anemic despite standard therapy :
• Preoperative erythropoietic agents
• Autologous blood donation
• Intraoperative blood salvag
• Intraoperative hemorrhage : ≥1000 mL blood loss; massive hemorrhage acute blood loss of ≥25 % of a
blood volume or bleeding that requires emergency intervention to save the patient's life.
 Mangement :
• apply pressure & communicate with the surgical team for a plan of action.
• Identify and control localized bleeding
• Retroperitoneal bleeding : the retroperitoneum is not open & apply direct pressure to the area of bleeding.
• If bleeding continues open the peritoneum
• If the peritoneum is already open, then the bleeding source is identified and managed
 Management of hemorrhage:
Intraoperative
preparation

- Diffuse bleeding requires evaluation for disseminated intravascular coagulation.
In women undergoing gynecologic surgery with areas of low volume bleeding, we suggest the use of topical
hemostatic agents
Topical hemostatic agents :
Gelatin , Oxidized regenerated cellulose (ORC) , Microfibrillar collagen (MC) , Topical thrombin (TT) – Bovine
or human thrombin is used , Fibrin sealant
Strategies for persistent bleeding:
 Internal iliac artery ligation
 Uterine artery ligation
 Hysterectomy or oophorectomy
 Prolonged pelvic packing:
If other measures do not control bleeding, pressure pack left in the pelvis for 48 to 72 hours.
patient is monitored closely and appropriate fluid resuscitation and blood transfusion administered in an
intensive care setting.
Intraoperative
preparation

• Postoperative bleeding : Careful inspection of all pedicles before abdominal closure is the best method
to prevent postoperative hemorrhage.
Management :
• Large-bore intravenous access should be placed
• Fluid resuscitation should be initiated
• Isotonic fluids given (normal saline or Ringers lactate) : crystalloid fluids should be replaced in a 3:1 ratio
of fluid : blood loss.
• The foley catheter reinserted
• The patient maintained nil per oral (NPO).
• Patients who are stable but anemic may be managed conservatively.
• Patients with postoperative bleeding who are hemodynamically unstable require surgical re-exploration
Management of hemorrhage
Intraoperative
preparation

Clinical Findings Associated with Increasing Severity of Hemorrhage
Intraoperative
preparation

Characteristics of Blood Components
Intraoperative
preparation

categorized as either :
• primary : used to approximate tissue layers
• Secondary: wound layers remain open and heal by a combination of contraction, granulation, and
epithelialization.
 The suture:
Types :
• Absorbable suture: with a caliber that will provide adequate strength to the wound & minimizing foreign body
content.
• Nonabsorbable
• Multifilament sutures provide better knot strength but ↑ infection and sinus formation.
• Monofilament sutures
 Wound closure
Intraoperative
preparation

 Closure:
- Several studies shown non closure of the peritoneum ↓ operating time without ↑ adhesion formation, wound
complications, or infection
- Many studies supported a continuous running-stitch closure of abdominal incisions
(faster , ↓ dehiscence, wound infection, and hernia formation)
- Subcutaneous layers >2 cm closed to decrease hematoma or seroma
- Staples, subcuticular suture, and tissue adhesives are appropriate for skin closure
 Wound closure
Intraoperative
preparation

Preoperative Diagnosis: 45 year old female, gravida 3 para 3, with menometrorrhagia unresponsive to medical
therapy.
Postoperative Diagnosis: Same as above
Operation: Total abdominal hysterectomy and bilateral salpingo-oophorectomy
Surgeon:
Assistant:
Anesthesia: General endotracheal
Findings At Surgery: Enlarged 10 x 12 cm uterus with multiple fibroids. Normal tubes and ovaries bilaterally. Frozen
section revealed benign tissue. All specimens sent to pathology.
Description of Operative Procedure: After obtaining informed consent, the patient was taken to the operating room
and placed in the supine position, given general anesthesia, and prepped and draped in sterile fashion.
A Pfannenstiel incision was made 2 cm above the symphysis pubis and extended sharply to the rectus fascia. The
fascial incision was bilaterally incised with curved Mayo scissors, and the rectus sheath was separated superiorly and
inferiorly by sharp and blunt dissection.
The peritoneum was grasped between two Kelly clamps, elevated, and incised with a scalpel. The pelvis was
examined with the findings noted above. A Balfour retractor was placed into the incision, and the bowel was packed
away with moist laparotomy sponges. Two Kocher clamps were placed on the cornua of the uterus and used for
retraction. The round ligaments on both sides were clamped, sutured with #0 Vicryl, and transected.
The anterior leaf of the broad ligament was incised along the bladder reflection to the midline from both sides, and the
bladder was gently dissected off the lower uterine segment and cervix with a sponge stick.
Total Abdominal Hysterectomy and Bilateral Salpingo-oophorectomy Operative Report

The retroperitoneal space was opened and the ureters were identified bilaterally.
The infundibulopelvic ligaments on both sides were then doubly clamped, transected, and doubly ligated with #O
Vicryl. Excellent hemostasis was observed. The uterine arteries were skeletonized bilaterally, clamped with Heaney
clamps, transected, and sutured with #O Vicryl. The uterosacral ligaments were clamped bilaterally, transected, and
suture ligated in a similar fashion
The cervix and uterus was amputated, and the vaginal cuff angles were closed with figure-of-eight stitches of #O
Vicryl, and then were transfixed to the ipsilateral cardinal and uterosacral ligament. The vaginal cuff was closed with a
series of interrupted #O Vicryl, figure-of-eight sutures. Excellent hemostasis was obtained.
The pelvis was copiously irrigated with warm normal saline, and all sponges and instruments were removed. The
parietal peritoneum was closed with running #2-O Vicryl. The fascia was closed with running #O Vicryl. The skin was
closed with stables. Sponge, lap, needle, and instrument counts were correct times two. The patient was taken to the
recovery room, awake and in stable condition.
Estimated Blood Loss (EBL): 150 cc
Specimens: Uterus, tubes, and ovaries
Drains: Foley to gravity
Fluids: Urine output - 100 cc of clear urine
Complications: None
Disposition: The patient was taken to the recovery room in stable condition

This can be divided into three phase
1. Immediate: theatre recovery;
2. Early: until discharge from hospital;
3. Late: home.
 Theatre recovery:
• (ABC) are the important parameters immediately after the operation.
• All staff should maintain life-support skills.
• Includes the relief of pain.
Postoperative care

• Ward care
• A doctor should review postoperative patients at least daily.
• A useful acronym for daily postoperative assessments is SOAP.
• Modified early warning scores (MEWS) widely used in hospitals.
• A score of 5 or more on the one shown in is associated with a statistically significant risk of admission to
intensive care or death.
 Early phase:
Postoperative care

Daily postoperative assessment (SOAP):
Subjective: how does the patient feel?
Objective: blood pressure, temperature and fluid balance
Assessment: physical examination
Plan: plan of care for the next 24 hours
 Early phase:
Postoperative care

Monitoring of fluid input and output in the postoperative period is important
Obligatory water intake approximately 1600 mL / day :
 Ingested water – 500 mL
 Water in food – 800 mL
 Water from oxidation – 300 mL
Obligatory water output :
• Urine – 500 mL
• Skin – 500 mL
• Respiratory tract – 400 mL
• Stool – 200 Ml
Replacement therapy corrects any existing water and electrolyte deficits.
Fluid balance
Postoperative care

• careless prescribing IV fluid can lead to hyponatraemia or pulmonary oedema( electrolytes should be checked
every 24–48 hrs).
• Patients requiring IV fluids for maintenance should receive 25–30 mL/kg per day of water.
• Daily requirements of sodium and potassium are 1 mmol/kg.
• Glucose 50–100 g/day should also be prescribed to limit starvation ketosis.
• DNS has no any benefit or harm compared to NS.
• DNS not be used in patients with uncontrolled diabetes mellitus or hypokalemia.
• DNS used in:
 Patients with hypoglycemia
 Alcohol or fasting ketoacidosis
 Given with insulin in patients with hyperkalemia and no hyperglycemia
• If fluid balance is difficult require central venous pressure monitoring and transfer to a high-dependency unit
(HDU) or intensive care unit (ICU).
Fluid balance
Postoperative care

Self-reporting subjective pain scales → acute pain assessment
General approach — postoperative pain control starts before the day of surgery.
Multimodal approach involves choosing drugs that act on different parts of the anatomical pain pathways.
Discussion of pain management at preoperative assessment aims to optimize patient satisfaction& ↓ SE
 Risk factors predict poor postoperative pain control :
• younger age
• female sex
• Smoking
• Depression
• Anxiety, sleep disorders
• preoperative pain; use of preoperative analgesia
• surgical factors: including type of surgery (major, emergency or abdominal) and its duration.
Postoperative pain management
Postoperative care

 Poor pain control leads to:
 Decreased satisfaction with care
 Prolonged recovery time
 Increased use of health care resources
 Increased health care costs
 Nonopioid Treatment Options:
 Paracetamol:
 paracetamol in multimodal analgesic strategies produces opioid-sparing effects.
 1 g paracetamol every 4 to 6 hrs to maximum dose 4gday , improved on combination with other
analgesics as (400mg ibuprofen, 60 mg codeine and 10 mg oxycodone).
 When given prophylactically, associated with ↓ postoperative nausea and vomiting.
 NSAIDs: .
 Diclofenac 50mg orally three times daily with meal / Ibuprofen 400mg every 4 to 6 hrs
Postoperative care

 Opioids:
• cornerstone treatment for moderate and severe acute pain.
• Morphine IV (1 to 3 mg every 5min until pain relief then every 3 to 4 hrs ), IM (5 to 10 mg every 3 to 4 hrs
• Tramadol 50 to 100 mg every 4 to 6 hrs
• Fentanyl 100 micrograms
• Continuation of opioids beyond the postoperative hospital stay represents a risk.
 Ketamine:
• its use associated with decreased morphine consumption at 24 and 48 hrs
• dose-dependent adverse effects, including hypersalivation, nausea and vomiting, hallucinations, nightmares
• Used 0.5 mg/kg IV
:
Postoperative care

 Gabapentinoids :
• Effective analgesics in most inflammatory and postoperative pain
• 300 to 600 mg orally
 Magnesium:
• Bolus doses (30–50mg/kg) alongside an intraoperative lower dose or short postoperative infusions of
magnesium (up to 48 h after surgery )
• intravenous magnesium extends the duration of sensory block with spinal anaesthesia, and reduces sub-
sequent postoperative pain and opioid requirements.
• Other types :
• Regional analgesic techniques
• Patient controlled analgesia
• Neuraxial analgesia
• Epidural or spinal analgesia
Postoperative care

Postoperative nausea & vomiting :

In the United States DVT & pulmonary thromboembolism estimated 600,000-100,000 deaths/ year
• 10 to 30 % of those die within 1 month of diagnosis.
• VTE Follow a risk based approach.
The risk of VTE is significantly ↑ during & after surgery.
Decisions regarding the method, dose, and timing of prophylaxis related to balancing a risk thrombosis
versus bleeding
Regarding laparoscopic surgery activation of the coagulation system similar to laparotomy.
As long as open surgeries( use of pneumoperitoneum reverse Trendelenburg contribute to venous stasis)
Thromboembolism prophylaxis :
Postoperative care

Caprini VTE Risk Assessment Model

.
 Prophylaxis Options:
• Early ambulation,.
• Graded compression stockings:
 prevent pooling o blood in the calves.
 If used alone DVT rates reduced 50 %
• Intermittent pneumatic compression (IPC):
 Improving venous flow.
 Effective in moderate & high-risk patients,
 Initiated prior to induction of anesthesia & continued until patients ambulated
• Pharmacologic methods of VTE prophylaxis include low-dose UFH, LMWH, and DOACs.
 Thromboprophylaxis
Postoperative care

Pretest Probability for Deep-Vein Thrombosis

Some Low-Molecular-Weight Heparins

• After surgery, heparin, either UFH or LMWH→ restarted 12 to 24 hours after major surgery.
• Oral warfarin therapy started concurrently (several days are required to regain therapeutic level).
• Once the INR ranges between 2 – 3→ heparin is discontinued.
• DOACs → restarted 24 hours following surgery.
• Antiplatelet agents → resumed 12 - 24 hours following surgery.
 In all cases anticoagulant agents begun only after surgical hemostasis is confirmed.
Postoperative Management:
Postoperative anticoagulant drugs instructions:
postoperative care

• Obstipation & intolerance of oral intake following surgery, due to non mechanical factors, primarily
inflammation of the intestinal smooth muscle→ disruption of coordinated propulsive motor activity of the GIT
• Risk factors for prolonged postoperative ileus:
 Prolonged abdominal or pelvic surgery
 Lower GIT surgery
 Delayed enteral nutrition / nasogastric tube placemen
 Intra-abdominal inflammation
 Postoperative complications
 Possibly increased body mass index
• gastric &small intestinal activity return within hrs,colonic activity returning 2-3 D of surgery
• Physiologic postoperative ileus resolves without serious sequelae.
 Postoperative ileus
postoperative care

symptoms or signs
•Abdominal distention, bloating, and "gassiness"
•Diffuse, persistent abdominal pain
•Nausea and/or vomiting
•Delayed passage of or inability to pass flatus
•Inability to tolerate an oral diet
work-up seeks to exclude other causes of ileus require surgical management or other intervention, such as small
bowel obstruction, bowel perforation, intra-abdominal abscess, or retroperitoneal bleeding.
Plain radiographs demonstrating air in the colon and rectum, with no transition zone or free air
No specific therapy, other than supportive care, to resolve prolonged postoperative ileus.
Supportive care includes
• pain control that minimizes opioid use
• intravenous fluid and electrolyte therapy,
• dietary restriction, and selective placement of a nasogastric tube for gastrointestinal decompression
Additional imaging studies are warranted if conservative measures do not improve the patient’s condition in 48 to
72 hours.
 Postoperative ileus

• Inability to void with a full bladder is a common problem after surgery
 Diagnosis :
• performing a retrograde voiding trial and obtaining an elevated postvoid residual volume (PVR) (more than
100 mL) via bladder catheterization or ultrasound.
• prefer the retrograde voiding trial to the spontaneous voiding trial because is more predictive of need for
continued catheterization
 Causes :
• bladder muscle dysfunction (e.g, anesthesia, pain medications)
• Urethral obstruction : (such as with sub urethral incontinence slings) or urethral perforation require surgical
intervention..
• failure of pelvic floor relaxation.
 Symptoms :
• A slow urine stream
• Straining to void
• A feeling of incomplete bladder emptying
• Pelvic pressure or pain
• Need to immediately re-void
• Position-dependent micturition.
 Postoperative Urinary Retention
postoperative care

 bladder drainage with clean intermittent catheterization (CIC) or an indwelling catheter to prevent
overdistention injury.
 Urodynamic testing is not used in the immediate postoperative period but may be helpful in who present
months from surgery.
 Acute overdistention injuries :
Bladder is filled > 120 %of its regular capacity (>400 to 600 mL) & associated with ischemia and reperfusion
damage to the wall
 persistent voiding dysfunction need a repeat examination for (pelvic muscle spasm or pain, new prolapse, or
urethral obstruction from a sling )& Intervention depends on the cause.
 voiding symptoms months or years after surgery examined for ( pelvic organ prolapse, mesh erosion, and
occult urethral obstruction).
 Inadequate treatment of postoperative voiding dysfunction → acute overdistention injury, long-term bladder
(detrusor) muscle hypertrophy, and overactive voiding symptoms
 Postoperative Urinary Retention
postoperative care

• Discharge should be planned.
• The patient should be aware of normal recovery rates, and be given advice about when to return to work,
social activities and sexual intercourse.
• The general practitioner (GP) should be informed of the patient’s treatment.
• An effective way to inform GPs is to give a brief discharge letter to the patient to take to the GP, followed
by a formal letter.
• The need for follow-up visits is dependent on the surgery performed.
 Advantage of follow up clinics:
• Audit
• Proactive detection of complications
• Provide ongoing treatment
• Completeness of treatment episode
 DISCHARGE
postoperative care

• Patient's Name:……………
• Chart Number: …………….
• Date of Admission: …………
• Date of Discharge: ………….
• Admitting Diagnosis:…………
• Discharge Diagnosis: ………..
• Name of Attending or Ward Service: ………
• Surgical Procedures:……….
• History and Physical Examination and Laboratory Data: Describe the course of the disease up to the time the patient came
to the hospital, and describe the physical exam and laboratory data on admission.
• Hospital Course: Describe the course of the patient's illness while in the hospital, including evaluation, treatment, outcome
of treatment, and medications given.
Discharge example :
postoperative care

• Discharged Condition: Describe improvement or deterioration in condition.
• Disposition: Describe the situation to which the patient will be discharged (home, nursing home).
• Discharged Medications: List medications and instructions.
• Discharged Instructions and Follow-up Care: Date of return for follow-up care at clinic; diet, exercise instructions.
• Problem List: List all active and past problems.
• Copies: Send copies to attending physician, clinic, consultants and referring physician.
Discharge example :
postoperative care

ER is a model of care for elective surgery, combining elements of care to form a pathway which reduces the
physiological stress response and organ dysfunction due to surgery.
This enables patients to recover more quickly.
 Enhanced Recovery in Gynecology
postoperative care

 Enhanced Recovery in Gynecology

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