Introduction to surgical posting MBBS

2. General Surgery
Peri-operative Management
27th October 2020
Dr Mohd Firdaus Che Ani
MB BCh BAO LRCPI&SI (RCSI), Doctor of General Surgery (UKM)
Lecturer & General Surgeon
Department of Surgery
Faculty of Medicine
UiTM Sungai Buloh Campus
firdaus7431@uitm.edu.my

3. Content Outline:
Introduction & Definition
Phases of Peri-operative care
•Pre-Operative Care
•Intra-Operative care
•Post-Operative Care
Common Post Op Complication and Approach

4. What is
Peri-
Operative
Care
•A term used to describe:
“care of the entire span
of surgery; before,
during and after the
mentioned
surgery/operation”

5. Why peri-operative care is important???
• Principal:
• Surgical Risk Assessment
• Optimize patient’s condition for surgery and Anaesthesia
• The rationale
• Make advanced preparation and organization
• Enhance patient safety and minimize error
• Alleviate patient’s anxiety
• Anticipate difficulties

6. Phases of Peri-
operative Care
Post-operative begins with admission to the recovery area
and continues until the client receives a follow up
evaluation at home or is discharged to a rehabilitation unit.
Intra-operative: the entire duration of the surgical
procedure, until transfer of the client to the recovery area.
Preoperative: starts with the decision to perform surgery
and continues until the client has reached the operating
area.

7. Pre-operative
Care &
Assessment
Clinical
History &
Examination
Review
Decision for
Surgery;
emergency vs
elective
Review pre-
operative
assessments
results &
Fitness for
surgery
Nutritional
Assessment
Assess
physical
needs
Assess
psychological
needs
Assess
cultural
needs

8. Pre-operative
Care &
Assessment
Preparation
• Situation
• Emergency/urgent/elective
• Nature of surgery
• Minor/major,
local/regional/general
anaesthesia
• Location
• Endoscopy/theatre/casualty
department
• Facilities available
• Required equipment's

9. Pre-operative Care &
Assessment
Corrections of deficiencies
• Nutrition
• Blood volume
• Fluid & Electrolyte
• Coagulation

10. Important Baseline Health Status
Co-morbidities
• Cardiovascular
• Respiratory
• Endocrinological
• Renal
• Hepatic
• Neurological
• Psychiatric
• Musculoskeletal
• Immunodeficient
Health background
• Medical history
• Anaesthetic history
• Drug history
• Social history

11. Pre-operative Care
& Assessment
Fitness for surgery assessment
•Assessment of operative risks
and review of surgical
options:
•NYHA (Cardiac Risk)
•Modified Lee’s Criteria for
non-cardiac surgery
(Cardiac Risk for GA)
•Goldman (SOPD)
•ASA (Anesthesiology GA
Risk)

12. Pre-operative
Care &
Assessment
• Surgical Consent
•Natural course of
disease
•Indication
•Option
•Procedure
•Complication
•Eligibility of consent
taking and giving

13. Pre-operative Care & Assessment
•General preparation for surgery
• Pre-medication
• Anxiolysis
• Sedation
• Enhancement of hypnotic effect of GA
• Amnesia
• Drying of secretion
• Antiemesis
• Vagal tone increment
• Fasting & fluid supplement

14. Pre-operative
Care &
Assessment
• Institution of prophylactic measures against
common post-operative complications
• Infection
• Atelectasis
• DVT
• Reasonable estimate of blood requirement and
adequacy of equipment and instrument
• Specific preparation for surgery; bowel prep
• Anticipation of likely post-operative course
and need for intensive care facilities
• Psychological preparation of patient for surgery

15. Intra-operative
Phase
• Skin preparation: shower, shaving, skin
disinfection
• Positioning: exposure, padding, DVT
• Anesthesia
• Monitoring
• Fluid Balance
• Safety: diathermy, wires and lines, anaesthetic
gas, universal precaution, sterility, identification
and labelling
• Operation: incision, complexity, duration,
technique, haemodynamic stability of patient
• Theatre set-up: humidity, temperature, air
flow, staffing, organisation and cleanliness

16. Post-operative
Care
Monitoring aiming for:
•Pain relief
•Detection of complication
•Correction of abnormality
•Optimizing nutrition
•Wound dressing
•Rehabilitation

17. Nature of post operative pain
• Four out or five patients undergoing surgery
experiences postoperative pain
– 86% of these patient rating
 Moderate
 Severe
 Extreme pain
• > 50% of patients report inadequate pain relief
• 10% to 50% acute post operative pain may become
chronic, depending on the surgical procedure

18. Pain
Call for Nurse
Nurse Responds
Screening
Sign out Medication
Prepare Medication
Administer Med (im)
Absorption from site
Pain Relief
Sedation
PCA
Traditional pain relief vs PCA

19. Multimodal
Analgesia
• Administration of two or
more drugs that act by
different mechanism it can
be:
• The same or different
routes
• Provide additive or
synergic effect
• Minimal side effect
• Should be given by
around the clock (ATC)
Main goals of Multimodal Analgsia is to
reduce the amount of Opioid

20. 1Kehlet H et al. Anesth Analog. 1993;77:1048-1056.
Potentiation
• Reduced doses of each
analgesic
• May reduce side effects
of each drug
• Improved pain relief due
to synergistic or additive
effects
Opioids
NSAIDs,
acetaminophen,
nerve blocks

21. Post-operative complication
Classifications:
• Timing
• Immediate: 24hr
• Early: within hospital stay or 30days
• Late: post-discharge or >30days
• General vs specific to type of surgery
• Procedure-related /anaesthetic-related /contrast-related

22. Post-Operative Bleeding
•Bleeding
•Primary: during procedure
•Reactionary: within 24 hour
•Secondary: after 24 hour

23. Atelectasis
• Collapse or closure of the lung resulting in
reduced or absent gas exchange
• occurs frequently in the postoperative setting
or in people who are immobilized and have a
shallow, monotonous breathing pattern (Post
laparotomy)
• Prevention:
• Incentive spirometry
• Chest Physiotherapy
• Mucolytics - Bisolvan

24. Post-Operative: Surgical Site
Infection
• Surgical site infections are defined as infections that
occur 30 days after surgery with no implant, or
• within 1 year if an implant is placed and infection
appears to be related to surgery.
• Classification:
• incisional infections
• Superficial
• Deep
• organ/space infections

25. Wound Type:

26. Deep Venous
Thrombosis (DVT
& Pulmonary
Embolism (PE)
• Identify risk Factor group
• Appropriate DVT Prophylaxis
• Adequate hydration
• Mechanical: TED Stockings,
early ambulation, pneumatic
cuff compression
• Pharmacological: Heparin,
Low Molecular Weight
Heparin, etc

28. Suggested
reading
• MRCS Core Modules Essential
Revision Notes
• Revision Notes on Principles of
Surgery
• Fundamentals of Surgical Practice
• The Washington Manual of Surgery
• CPG Prevention and Treatment of
Venous Thromboembolism 2013
• WHO guidelines for safe surgery :
2009 :safe surgery saves lives