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.

1. PERIOPERATIVE
MANAGEMENT
MANIRABONA E. MD, PGY-2 General Surgery

2. SCOPE
• Introduction
• History Taking and Physical Examination
• Investigation
• High Risk Patient
• Perioperative medical optimization
• Take Home Message
• References
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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3. Introduction
• Every surgical procedure involves some risk of significant
postoperative complications or death
• Early identification and optimal care of the high-risk surgical
patient will result in a substantial reduction of the risk.
• Operative mortality is more meaningfully expressed in terms of
deaths occurring during surgery and up to 30 days after surgery.
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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4. History Taking
• Do not assume that history has
been adequately covered
previously
• Important points may have
been overlooked in a busy OPD
• Standard history focuses on
the patient’s hopes and
expectations
Principles of history taking
• Listen: What is the problem?
(Open questions)
• Clarify: What does the patient
expect? (Closed questions)
• Narrow: Differential diagnosis
(Focused questions)
• Fitness: Comorbidities (Fixed
questions)
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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5. Past Medical History
CARDIOVASCULAR
• Ischemic heart disease
• Myocardial infarction
• Hypertension or HF
• Peripheral vascular disease
• Deep vein thrombosis and PE
RESPIRATORY
• COPD and Asthma
• Respiratory infections
GIT
• PUD and GERD
• Liver disease
GUT
• UTI ,RF and Prostatism
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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6. Past Medical History
Endocrine and metabolic
• Diabetes
• Thyroid dysfunction
• Phaeochromocytoma
Previous surgery
• Problems encountered
• Family history of problems
with anaesthesia
Other
• Human immunodeficiency
virus
• Malignancy
• Allergy
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7. Physical Examination
General
• Anaemia, Jaundice, Cyanosis,
Nutritional status
• Infection source (teeth, feet, leg
ulcers)
CVS
• Pulse, BP, heart sounds
• Peripheral oedema
Respiratory
• RR and effort, chest expansion
• Percussion note breath sounds
and oxygen saturation
GIT
• Abdominal masses, ascites,
bowel sounds
• Hernia and genitalia
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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8. INVESTIGATIONS
FBC
• Major operations in elderly
and in those with anemia
• Pathology with ongoing
blood los
Low risk of bleeding: No
tests required.
Urea and electrolytes
• Major operation and >60
years old patient
• Cardiovascular, renal and
endocrine disease
• Anticipated blood loss
• Medication : NSAID,
diuretics, steroids
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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9. INVESTIGATIONS
ECG
• Patients aged over 60 years
• Cardiovascular, renal and DM
β-Human chorionic
gonadotrophin
• Pregnancy needs to be ruled
out in all women of childbearing
age.
CXR
• Cardiac failure and smokers
• COPD and Acute respiratory
symptoms
Blood glucose and HbA1c
• DM or family history
• Obese or poor nutrition
• Steroid use
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10. Factors that predispose patients to a
high risk of morbidity and mortality
Patient factors
• History of severe cardiac disease (IHD, MI, cardiac Failure)
• Severe respiratory disease (COPD, respiratory failure)
• Aged >70 years with limited physiological reserve in vital organs
• Metabolic disease (renal failure, poorly controlled diabetes)
• Morbid obesity or Poor nutrition
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11. Surgical factors
• Prolonged duration of surgery (>1.5 hours)
• Extensive surgery (e.g. esophagectomy, gastrectomy)
• Type of surgery (thoracic, abdominal, vascular)
• Emergency surgery or Acute massive blood loss (>2.5 liters)
• Septicemia (positive blood cultures or septic focus)
• Multiple trauma e.g. >3 organs or >2 systems or 2 body cavities
open
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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12. Perioperative care factors
• Inadequate critical care facilities
• Insufficient patient monitoring
• Lack of early intervention as complications develop
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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13. Identification of high risk Patient
Risk scoring systems have been developed over the years
with the aim of identifying high-risk patients
• ASA is simple, but subject to user interpretation
• MET measures exercise tolerance related to daily living
• RCRI used to predict cardiac risk for non-cardiac surgery
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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14. ASA grade Operative mortality
risk prediction
• American Society of
Anesthesiologists scoring
system is widely used
• It is simple and related to
operative mortality
• It does not take into account
age or nature of surgery and
it is operator dependent
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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15. Metabolic equivalent of task
• 1 MET = eating and dressing
• 4 MET = climbing two flights of stairs
• 6 MET = short run
• >10 MET = able to participate in
strenuous sport
Patient with ≥4 METS have lower risk of
perioperative mortality
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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16. The revised cardiac risk index of
Lee Thomas
• Goldman cardiac risk index
and the revised cardiac risk
index (RCRI) of Lee
• Designed to predict cardiac
morbidity
• May also be used to stratify
the risk of mortality
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17. Management of pre-existing
medical conditions
• Coexisting disease processes should be reviewed and optimized
• Action taken include stopping smoking, reducing alcohol intake,
losing weight, improving nutrition and/or hemoglobin levels
• AAA surgery repair may require complex investigations like carotid
duplex scans. If the scans reveal a significant blockage, carotid
endarterectomy is done prior to AAA repair to reduce stroke risk
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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18. Minimizing myocardial ischaemia
• Anesthesia should avoid tachycardia, hypertension and
hypotension
• Pain control is important
• Oxygen supplementation is advisable for 3–4 days postoperatively
• Perioperative b-blockade should be considered
• Elective postoperative critical care admission should be
considered
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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19. Optimizing perioperative
respiratory function
• Preoperative pulmonary function needs testing to assess
functional status
• Consider bronchodilator ± steroid therapy
• Arrange pre- and postoperative chest physiotherapy and
breathing exercises
• Consider regional anesthesia
• Give good quality pain relief
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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20. DM Patient optimization
• Patients with diet-controlled diabetes require no special
preoperative treatment
• Patients on oral hypoglycaemics or subcutaneous insulin should
stop therapy the night before surgery and put on a glucose and
insulin infusion
• Long-acting insulin should be avoided the night before major
surgery
• Patients with diabetes should be placed first on the operating list
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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21. Patient with Bleeding disorders
or on anticoagulation
• These Patients sometimes need hematologist consultation
• Hemophilic disorder patients require replacement with specific
clothing factors
• Patients on warfarin should be converted to heparin
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22. Medication to STOP
• NSAIDS - anti-platelet effect, discontinued before surgery 5-7 days.
• Clopidogrel – stopped 7 days prior to surgery due to bleeding risk.
• Hypoglycaemics –
• Oral contraceptive pill (OCP) or Hormone Replacement Therapy
(HRT) – stopped 4 weeks before surgery due to DVT risk and PE
• Warfarin – usually stopped 5 days prior to surgery due to bleeding
risk and commenced on therapeutic dose LMWH
o INR < 1.5 or warfarinisation with Vitamin K
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23. Antibiotic Prophylaxis
• SSI occurs at or near surgical incision within 30 days of the procedure or
within one year if an implant is left in place
• Prophylactic antibiotics should be initiated within 1h before surgical incision
or two hours if the patient is receiving vancomycin or fluoroquinolones
• Patients should receive prophylactic antibiotics appropriate for their specific
procedure
• Prophylactic antibiotics is discontinued 24 hours of surgery completion
(within 48 hours for cardiothoracic surgery)
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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24. Prophylactic Antibiotics
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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25. Take Home Message
• Postoperative complications and deaths after surgery occur in the
high-risk patient
• Mortality results ultimately either from a cardiac event or
multiorgan dysfunction and poor tissue oxygenation
• Identification of high risk patient and perioperative management is
essential to prevent post-operative complications
• Multidisciplinary team approach is crucial to successful
management.
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26. References
1. Bailey And Love's Short Practice of Surgery 25th and 26th editions
2. Am Fam Physician 2011;83(5):585-590 Copyright © 2011 American Academy
of Family Physicians.)
3. Schwartz's Principles of Surgery, 10th edition
4. SABISTON TEXTBOOK of SURGERY, 20th edition , The BIOLOGICAL BASIS of
MODERN SURGICAL PRACTICE
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery
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27. THANK YOU
Comments, Inputs and
Suggestions
welcome
Perioperative Management by Dr MANIRABONA Emmanuel, MD, PGY 2 General Surgery27