Perioperative care

1. Perioperative care
Presenter: Dr.S.Siva sankar .
Post graduate resident
General Surgery
SMVMCH puducherry

2. Preoperative plan for the best patient outcomes
● Gather and record all relevant information
● Optimise patient condition
● Choose surgery that offers minimal risk and maximum benefit
● Anticipate and plan for adverse events
● Adequate hydration, nutrition and exercise are advised

3. Principles of history-taking
● Listen. What is the problem?
● Clarify. What does the patient expect?
● Narrow. Differential diagnosis
● Fitness. Comorbidities

4. Past History:

6. Medical examination.
General : Anaemia, jaundice, cyanosis, nutritional status, sources of infection
(teeth, feet, leg ulcers)
Cardiovascular : Pulse, blood pressure, heart sounds, bruits,peripheral oedema
Respiratory : Respiratory rate and effort, chest expansion and percussion note,
breath sounds, oxygen saturation
Gastrointestinal : Abdominal masses, ascites, bowel sounds,hernia, genitalia
Neurological : Consciousness level, cognitive function, sensation, muscle power,
tone and reflexes
Airway assessment

7. Examination
●● General. Positive findings even if not related to the proposed
procedure should be explored further
●● Surgery related. Type and site of surgery, complications
occurred due to underlying pathology
●● Systemic. Comorbidities and extent of limitation of each organ
function
●● Specific. For example, suitability for positioning during surgery

8. Examination specific to surgery
At preoperative assessment, the clinical findings, site, side,
specific imaging or investigation findings related to the
pathology for which the surgery is proposed should be noted.
Suitability of the patient for the proposed surgical option and
vice versa should also be assessed.

9. Investigations
Routine Basic Investigations :
● Complete Blood Count
● Blood glucose and HbA1c
● Electrolytes
● ECG
● Chest xray
● Clotting screen
● Blood grouping and typing
● Urinalysis
● Liver function tests
● ABG
Other investiations specific to the surgery and System specific risk factors

10. SPECIFIC PREOPERATIVE
PROBLEMS AND MANAGEMENT
Preoperative management of patients with systemic disease
●● Capacity: Baseline organ function capacity should be assessed
●● Optimisation: Medication, lifestyle changes, specialist referral will improve
organ capacity
●● Alternative: Minimally impacting procedure, appropriate postoperative care will
improve outcomes
●● Theatre preparations: Timing, teamwork, special instruments and equipment

11. Cardiovascular disease:
The patient should be referred to a cardiologist if:
●● A murmur is heard and the patient is symptomatic.
●● The patient is known to have poor left ventricular function or cardiomegaly.
●● Ischaemic changes can be seen on ECG even if the patient is not symptomatic
(silent ischaemia, silent MIs are frequent).
●● There is an abnormal rhythm on the ECG, for example tachy-/bradycardia or
heart block.

12. Hypertension, ischaemic heart disease (IHD) and coronary stents:
● Prior to elective surgery blood pressure should be controlled
to near 160/100 mmHg. If a new antihypertensive agent is
introduced, a stabilisation period of at least 2 weeks should
be allowed.
Patients on β-blockers and on statins should be maintained on their medication.
Most long-term cardiac medications should be continued over the perioperative
period.
Angiotensin-converting enzyme (ACE) inhibitors
and receptor blockers are often omitted 24 hours prior to surgery

13. Myocardial Infarction:
After a proven myocardial infarction , elective
surgery should be postponed for 3–6 months to reduce
the risk of perioperative reinfarction
If surgery is absolutely necessary within the period of dual antiplatelet therapy,
the management strategy should be decided jointly by surgeon,
cardiologist, anaesthetist and patient.

14. If surgery cannot be postponed and the risk of significant
perioperative bleeding is low, dual antiplatelet therapy can
be continued during surgery. If the benefits of surgery can be
negated by bleeding in closed cavities (spinal, intracranial,
cardiac, posterior chamber of the eye and prostate surgery)
clopidogrel or ticagrelor therapy may have to be stopped and,
if possible, aspirin continued. However, a cardiology opinion should be sought.

15. Dysrhythmias
In patients with atrial fibrillation, β-blockers, digoxin or calcium channel blockers
should be started preoperatively (or continued if the patient is already on such
medication) in order to control rate and possibly rhythm.
Warfarin in patients with atrial fibrillation (AF) should be stopped 5
dayspreoperatively to achieve an international normalised ratio (INR) of 1.5 or
less, which is safe for most surgery.
Bridging therapy with unfractionated heparin or low molecular weight heparin
(LMWH) is recommended for patients with AF and a mechanical heart valve
undergoing procedures that require interruption of warfarin

16. Implanted pacemakers and cardiac
defibrillators
Monopolar diathermy activity during surgery may be sensed by the pacemaker as
ventricular fibrillation.
Therefore, cardioversion and overpace modes must be turned off (and switched
on after surgery) or
converted to ‘ventricle paced, not sensed with no response
to sensing’ (VOO) mode. Bipolar diathermy should be made available at surgery.

17. Valvular heart disease
In patients with mechanical heart valves, warfarin needs
to be stopped for 5 days before surgery, and an infusion of
unfractionated heparin started when the INR falls below 1.5.
Heparin and warfarin
should be started in the postoperative period, and heparin is
stopped when the full effect of warfarin takes effect.

18. Anaemia and blood transfusion
Patients found to be anaemic at preoperative assessment should be investigated
for the cause of their anaemia.
They should be treated with iron and vitamin supplements.
If the patient is undergoing a major procedure preoperative
transfusion may be considered.
If excessive bleeding is expected, then a preoperative ‘group and save’ should be
performed and an appropriate number of units of blood crossmatched

20. Respiratory disease:
The patient should be referred to a respiratory physician if:
●● There is a severe disease or significant deterioration.
●● Major surgery is planned in a patient with significant
respiratory comorbidities.
●● Right heart failure is present – dyspnoea, fatigue, tricuspid
regurgitation, hepatomegaly and oedematous feet.
●● The patient is young and has severe respiratory problems

21. Gastrointestinal disease
Nil by mouth and regular medications:
Patients are advised not to take solids within 6 hours and clear fluids (isotonic
drinks and water) within 2 hours before anaesthesia to avoid the risk of acid
aspiration syndrome.
If the surgery is delayed, oral intake of clear fluids should be allowed until 2 hours
before surgery or intravenous fluids should be started, especially in vulnerable
groups of patients, e.g. children, the elderly and diabetics.
Patients can continue to take their specified routine medications with sips of water
in the NBM period.

22. Regurgitation risk
Patients with hiatus hernia, obesity, pregnancy and diabetes
are at high risk of pulmonary aspiration, even if they have
been NBM before elective surgery. Clear antacids, H2-receptor
blockers, e.g. ranitidine, or proton pump inhibitors, e.g.
omeprazole, may be given at an appropriate time in the preoperative
period.

23. Liver disease
In patients with liver disease, the cause of the disease needs to be known, as well
as any evidence of clotting problems, renal involvement and encephalopathy.
Elective surgery should be postponed until any acute episode has settled
(e.g. cholangitis).
The blood tests that need to be performed include liver function tests, coagulation
profile and blood glucose .
.The presence of ascites, oesophageal varices, hypoalbuminaemia and sodium
and water retention should be noted, as all can influence the choice and outcome
of anaesthesia and surgery.

24. Renal disease
Underlying conditions leading to chronic renal failure such as diabetes mellitus,
hypertension and ischaemic heart disease, should be stabilised before elective
surgery.
Appropriate measures should be taken to treat acidosis, hypocalcaemia and
hyperkalaemia of greater than 6 mmol/L.
Arrangements should be made to continue peritoneal or haemodialysis until a few
hours before surgery. After the final dialysis before surgery, a blood sample
should be sent for CBC and U&Es.
Chronic renal failure patients often suffer chronic microcytic anaemia that is well
tolerated; therefore, preoperative blood transfusion is often not necessary.

25. Diabetes mellitus
Diabetes and associated cardiovascular and renal complications should be
controlled to as near normal level as possible before elective surgery.
HbA1c levels should be checked.
For elective surgery, HBA1c of <69 mmol/mol is recommended.
Lipid-lowering medication should be started in patients who are in a highrisk
group for cardiovascular complications of diabetes.

26. Patients with diabetes should be first on the operating list and, if the operation is in
the morning, advised to omit the morning dose of medication and breakfast.
Though tight control of blood sugar is not needed, the patient’s blood sugar levels
should be checked 2 hourly.
An intravenous insulin sliding scale should be started for
insulin-dependent diabetes mellitus patients undergoing major
surgery, or if blood sugar is difficult to control for other reasons.

27. Coagulation disorders
Patients with a strong family history or previous personal history of thrombosis
should be identified They will need thromboprophylaxis in the perioperative period.
The progesterone-only contraceptive pill should be continued.
Consider stopping oestrogen-containing oral contraceptives or hormone
replacement therapy 4 weeks before surgery
Patients with a low risk of thromboembolism can be given thromboembolism-
deterrent stockings to wear during the perioperative period.
High-risk patients with a history of recurrent DVT, pulmonary embolism and
arterial thrombosis will be on warfarin. This should be stopped before surgery and
replaced by low molecular weight heparin or factor Xa inhibitors.

28. Neurological and psychiatric disorders
In patients with a history of stroke, pre-existing neurological deficit should be
recorded.
If it is felt that the neurological and cardiovascular thrombotic risks are low,
antiplatelet agents should be withdrawn (7 days for aspirin, 10 days for
clopidogrel).
Anticonvulsants and anti-Parkinson medication is continued perioperatively to help
early mobilisation of the patient.
Lithium should be stopped 24 hours prior to surgery; blood levels should be
measured to exclude toxicity. The anaesthetist should be informed if patients are
on psychiatric medications such as tricyclic antidepressants or monoamine
oxidase inhibitors, as these may interact with anaesthetic drugs.

29. Airway assessment
Airway assessment (Samsoon and Young
modified Mallampati test).
●● Fauces, pillars, soft palate and uvula seen Grade 1
●● Fauces, soft palate with some part of uvula seen Grade 2
●● Soft palate seen Grade 3
●● Hard palate only seen Grade 4

30. Preoperative assessment in
emergency surgery:
Preoperative assessment for emergency surgery
●● Start: Similar principles to that for elective surgery
●● Constraints: Time, facilities available
●● Consent: May not be possible in life-saving emergencies
●● Organisational efforts: For example, local/national algorithms
for treatment of the patient with multiple injuries

31. ASSESSMENT OF THE HIGH RISK PATIENT

33. A practical approach to the care for the High-risk Patient
●● Identify the high-risk patient
●● Assess the level of risk
●● Detailed preoperative assessment
●● Adequate :resusciatation
●● Optimise medical management
●● Investigation to define the underlying surgical problem
●● Immediate and definitive treatment of underlying problems
●● Consider admission to a critical care facility postoperatively

34. Identification of the high-risk patient
A number of scoring systems have been developed over the years with the aim of
identifying high-risk patients:
American Society of Anaesthesiologists System
Metabolic equivalent
ACS NSQIP score
POSSUM score
Cardiopulmonary exercise testing

37. Sepsis
Sepsis needs urgent identification and treatment, as if not
treated early it can lead to either a prolonged admission to
a critical care unit or death. Early resuscitative measures in
sepsis include administering broad spectrum antibiotics and
treating hypotension, hypovolemia and elevated lactate levels
with appropriate intravenous fluids. It is also important to
deal with the source of sepsis as early as possible.

38. CONSENT
The guidance outlines the key principles
of consent and how the discussion should:
● give the patient the information required to make a
decision;
● be tailored to the individual patient;
● explain all reasonable treatment options
● discuss all material* risks.

39. ARRANGING THEATRE LIST
The operating list should be distributed as early as possible to all staff who are
involved in making the list run smoothly
Prioritise patients, e.g. children and diabetic patients should be placed at the
beginning of the list; life- and limb-threatening surgery should take priority; cancer
patients need to be treated early.

40. Postoperative care
Aim of postoperative care is to provide the patient with
as quick, painless and safe a recovery from surgery as
possible.
This requires the appropriate knowledge and skills to manage
medical, as well as surgical, postoperative problems

41. ● Immediate postoperative care
Postoperative observations
The patient’s vital signs (including pulse, blood pressure and
pulse oximetry reading), level of consciousness, pain and hydration
status are monitored in the recovery room and supportive
treatment is given.

42. Postoperative period
●● All anaesthetised patients should be recovered in a dedicated
PACU
●● All vital parameters should be monitored and documented
according to local protocols
●● Treat pain and nausea/vomiting
●● Observe for complications

43. GENERAL POSTOPERATIVE COMPLICATIONS
•Bleeding
•Deep vein thrombosis
•Pulmonary embolus
•Fever
•Wound dehiscence
•Pressure sores

44. Bleeding
Postoperative haemorrhage is most common in the immediate postoperative
period. It may be caused by an arterial or venous leak, but also by a generalised
ooze or a coagulopathy.
All patients must have their vital signs (pulse rate, blood pressure, oximetry,
central venous pressure, if available, and urine output) monitored regularly.
Dressings and drains should be inspected regularly in the first 24
hours after surgery. If haemorrhage is suspected, blood samples
should be taken for a full blood count, coagulation profile and
cross match.

45. If the source of bleeding is in doubt and the patient is stable, an ultrasound or
computed tomography (CT) scan may be required to determine the nature
of the bleed (most commonly if a haematoma is suspected in
the days following surgery).
If the patient’s cardiovascular system is unstable or compromised in any way they
should be taken back to the operating theatre immediately.
The treatment of haemorrhage is both to stop the bleeding and supportive.
Supportive treatment includes oxygen and fluid resuscitation
The decision about when to transfuse should be based on the individual patient; in
general, however, the accepted transfusion trigger is Hb 7.5 g/dl

46. Surgical haemorrhage
●● Reactionary: occurs 4–6 hours after surgery and is caused
by ligature slippage, clot displacement or cessation of
vasospasm after mobilisation or coughing
●● Secondary: occurs more than 24 hours after surgery and is
due to infection eroding a vessel

47. Deep vein thrombosis and Pulmonary embolus
Deep vein thrombosis (DVT) is a well-known and, when complicated by pulmonary
embolus, potentially fatal complication of surgery
Methods of prevention are guided by the risk score and include the use of
compression stockings, calf pumps and pharmacological agents, such as low
molecular weight heparin.
The symptoms and signs of DVT include calf pain, swelling,
warmth, redness and engorged veins. However, most will show
no physical signs.

48. On palpation the muscle may be tender and there may be a positive Homans’
sign (calf pain on dorsiflexion of the foot),
Duplex Doppler ultrasound and venography can be used to assess flow and the
presence of a thrombosis.
Other investigations include D-dimer. If a significant DVT is found treatment with
parenteral anticoagulation initially, followed by longer-term warfarin
or new oral anticoagulant . In some patients with a large
DVT, a caval filter may be required to decrease the possibility
of pulmonary embolism.

51. Pulmonary embolus
Signs and symptoms depend on the size of the embolus and may range from
dyspnoea, cough, and pleuritic chest pain to sudden cardiovascular collapse.
Diagnosis of PE begins with history (including risk factors and recent
surgery) and physical examination (which may include signs
of DVT). Investigations may include, depending on the presentation,
ECG, chest radiograph, blood tests (arterial blood
gas and d-dimer) and radiological tests (usually CT pulmonary
angiography).

52. If the presentation includes cardiovascular collapse, resuscitation will be needed.
Thrombolysis can be considered with massive PE causing cardiovascular
collapse, but this should include senior clinical opinion and
would generally follow appropriate guidelines.
The patient may need inotropes and admission to the intensive care unit.

53. Fever
The inflammatory response to surgical trauma may manifest itself as fever, and so
pyrexia does not necessarily imply sepsis.
However, in all patients with a pyrexia, a focus of infection should be sought.

54. The causes of a raised temperature postoperatively include:
●● atelectasis of the lung;
●● superficial and deep wound infection;
●● chest infection, urinary tract infection and thrombophlebitis;
●● wound infection, anastomotic leakage, intracavitary collections
and abscesses.

55. The possible causes of pyrexia of a non-infective origin
include:
●● DVT;
●● transfusion reactions;
●● wound haematomas;
●● atelectasis;
●● drug reactions.
Patients with a persistent pyrexia need a thorough review.
Relevant investigations include full blood count, urine culture, sputum microscopy
and blood cultures.

63. Wound dehiscence
Wound dehiscence is disruption of any or all of the layers in a wound.
Wound dehiscence most commonly occurs from the fifth to the eighth
postoperative day when the strength of the wound is at its weakest.
It may herald an underlying abscess and usually presents with a serosanguinous
discharge.
Most patients will need to return to the operating theatre for resuturing. In some
patients it may be appropriate to leave the wound open and treat with dressings or
vacuum-assisted closure (VAC) pumps.

65. Pressure sores
Patients undergoing surgery for a prolonged period of time are vulnerable to the
development of a pressure sore or to worsening of a pre-existing sore
Careful positioning and padding of the patient is standard practice intraoperatively
to reduce risk. They particularly affect the pressure points of a recumbent patient,
including the sacrum, greater trochanter and heels.
Risk factors are poor nutritional status, dehydration and lack of mobility and nerve
block anaesthesia technique.
Early mobilisation prevents pressure sores. Highrisk patients may be nursed on an
air mattress, which automatically relieves the pressure areas.

66. GENERAL POSTOPERATIVE
PROBLEMS AND MANAGEMENT
● Pain
● Nausea and vomiting
● Urinary Retension
● Drains
● Wound care
● Hypothermia and shivering

68. Nausea and vomiting
Postoperative nausea and vomiting (PONV) are unpleasant for patients, can delay
recovery and prolong length of stay.
They can lead to more serious complications including aspiration
pneumonia, precipitation of bleeding and dehiscence
of wounds by dislodging the clots and bursting suture lines.
In neurosurgical patients PONV may precipitate raised intracranial
pressure with disastrous effects

70. Treatment of PONV includes adequate treatment of pain, anxiety, hypotension
and dehydration.
Antiemetics can be administered both prophylactically and for treatment.
A multimodal pharmacological approach, using drugs that work at different sites,
such as HT3 receptor antagonists (e.g. ondansetron),
steroids (e.g. dexamethasone), phenothiazines (e.g. prochlorperazine)
and antihistamines (e.g. cyclizine), is the most effective.

71. Urinary retention
Inability to void after surgery is common with pelvic and perineal operations, or
after procedures performed under spinal anaesthesia.
Pain, hypovolaemia, problems with access to urinals and bed pans and a lack of
privacy on wards may contribute to the problem of urine retention.
The diagnosis of retention may be confirmed by clinical examination and by using
ultrasound imaging.
Catheterisation should be performed prophylactically when an operation is
expected to last 3 hours or longer, or when large volumes of fluid are administered

72. Drains
Drains are used to prevent accumulation of blood, serosanguinous
or purulent fluid or to allow the early diagnosis of a leaking surgical anastomosis.
Complications of drains include trauma to surrounding tissues
and infection.
The quantity and character of drain fluid can be used to identify an abdominal
complication such as fluid leakage (e.g. bile or pancreatic fluid) or bleeding.
Drains should be removed as soon as possible and certainly
once the drainage has stopped or become less than 25 mL/day.

73. Wound care
Within hours of the wound being surgically closed, the dead space fills up with an
inflammatory exudate.
Within 48 hours of closure a layer of epidermal cells from the wound edge
bridges the gap. Consequently, sterile dressings applied in
theatre should not be removed before this time.
Inspection of the wound should be performed under sterile conditions. If the
wound looks inflamed, a wound swab can be taken and sent for microbiological
examination, Infected wounds and haematomata mayneed treatment with
antibiotics .

74. Depending on location, the wound may require packing if it is contaminated or if
non-viable tissue remains.
The dressing should then be changed regularly until the wound is clean.
Skin sutures or clips are usually removed between 6 and
10 days after surgery. The period can be shorter in wounds on
the face or neck, and are left longer if the incision has been
closed under tension. Wound healing is delayed in patients
who are malnourished, or have vitamin A and C deficiency.

75. Steroids also inhibit the adequate healing of wounds as they
inhibit protein synthesis and fibroblast proliferation.
Poorly- controlled diabetes delays wound healing and increases the
risk of infection at the surgical site.

76. Hypothermia and shivering
Anaesthesia induces loss of thermoregulatory control.
Exposure of skin and organs to a cold operating environment, antiseptic skin
preparation (that cools by evaporation), and the infusion of cold intravenous fluids
all lead to hypothermia.
This in turn can lead to shivering, with imbalance of oxygen supply and demand
(risking cardiac morbidity), a hypocoagulable state and immune function
impairment, with the possibility of wound infection, dehiscence and anastomotic
breakdown..
Active warming devices should be used to treat hypothermia

77. SURGERY-SPECIFIC COMPLICATIONS
Abdominal surgery
The abdomen should be examined daily for excessive distension, tenderness or
drainage from wounds or drain sites.
The main complications after abdominal surgery
●● Paralytic ileus
●● Bleeding or abscess
●● Anastomotic leakage

78. Paralytic ileus
Paralytic ileus may present with nausea, vomiting, loss of appetite, bowel
distension and absence of flatus or bowel movements. Following laparotomy,
gastrointestinal motility temporarily decreases.
Treatment is usually supportive, with maintenance of adequate hydration and
electrolyte levels.
However, intestinal complications may present as prolonged ileus and so should
be actively sought and treated.
Return of function of the intestine occurs in the following order: small bowel, large
bowel and then stomach.
Thispattern allows the passage of faeces despite continuing lackof stomach
emptying and, therefore, vomiting may continue even when the lower bowel has
already started functioning

79. Localised infection
An abscess may present with persistent abdominal pain, focal tenderness and a
spiking fever. If the abscess is deep-seated these symptoms maybe absent.
The patient will have a neutrophilic leucocytosis and may have positive blood
cultures.
An ultrasound or CT scan of the abdomen should identify any suspicious
collection and will identify a subphrenic abscess, which can otherwise be difficult
to find.

80. Neck surgery
Patients having neck surgery, e.g. thyroid surgery, must be
observed for accumulation of blood in the wound, which
may cause rapid asphyxia. Another potential complication is damage to the
recurrent laryngeal nerve, which can produce voice change.

81. Neurosurgery
A rise in intracranial pressure may be signalled by a deterioration in the state of
consciousness, as well as by neurological signs. Some patients may have an
intracranial monitoring device to allow for more sensitive monitoring.
Vascular surgery
The patency of grafts and anastomoses, for example femoropopliteal bypasses
and abdominal aneurysmal, needs to be checked by regular clinical assessment
of the limbs and by Doppler ultrasound in the postoperative phase.
Plastic surgery
The viability of flaps is crucial and the perfusion needs to be monitored regularly.
The blood supply may be compromised by position, dressings or collection of
fluids or blood beneath the flap.

82. Urology
Catheter patency must be checked regularly following urological surgery. In
patients who have undergone transurethral resection of the prostate (TURP),
continuous bladder irrigation may be used.

83. SYSTEM SPECIFIC POSTOPERATIVE COMPLICATIONS
Respiratory system
●● Respiratory complications can occur either immediately or a few days later on
the ward
●● Obesity, smoking, chronic lung disease, poor nutritional status and obstructive
sleep apnoea predispose to a higher risk of respiratory complications
●● Early intervention and multidisciplinary involvement can prevent life-
threatening respiratory complications

84. Complications include fever (due to microatelectasis), cough, dyspnoea,
bronchospasm, hypercapnoea, atelectasis, pneumonia ,pleural effusion,
pneumothorax and respiratory failure.
The risk of each varies with the patient and the type of surgery being
performed.
Thoracic or abdominal surgery carries the highest risk.

85. Cardiovascular system
●● Hypotension and hypertension in the postoperative period
can be multifactorial and result in serious morbidity
●● Arrhythmias can be prevented and corrected by treating
hypotension and electrolyte imbalance
●● Arrhythmias, myocardial ischaemia/infarction and stroke
will need management with the help of cardiologists and
neurologists

86. Renal and urinary system
●● Postoperative renal failure is associated with high mortality
●● Prophylactic measures to prevent renal failure should be taken in high-risk
cases
●● Urinary retention and infection are common problems postoperatively

87. Central nervous system
Postoperative delirium
POD can occur during recovery from anaesthesia or a few days after surgery. The
overall incidence of POD is 5–50%. It occurs more frequently in the elderly
orthopaedic patient and those undergoing emergency surgical procedures.
Treatment :Correcting any reversible cause, involving relatives or friends whom
the patient knows and pain control can all contribute to reducing the impact and
duration of delirium.
As a last option, haloperidol may be given .

88. Nutrition and fluid therapy
Fluid therapy and nutritional support are fundamental to good surgical practice.
Accurate fluid administration demands an understanding of maintenance
requirements and an appreciation of the consequences of surgical disease on fluid
losses.
This requires knowledge of the consequences of surgical intervention and, in
particular, intestinal resection.

89. A clinical assessment of nutritional status involves a focused history and physical
examination, an assessment of risk of malabsorption or inadequate dietary intake
and selected laboratory tests aimed at detecting specific nutrient deficiencies.

90. FLUID AND ELECTROLYTES
Fluid intake is derived from both exogenous (consumed liquids) and endogenous
(released during oxidation of solid foodstuffs) fluids. The average daily water
balance of a healthy adult

91. Fluid losses occur by four routes:
1 Lungs. About 400 mL of water is lost in expired aireach 24 hours. This is
increased in dry atmospheres or in patients with a tracheostomy, emphasising the
importance of humidification of inspired air.
2 Skin. In a temperate climate, skin (i.e. sweat) losses are between 600 and 1000
mL/day.
3 Faeces. Between 60 and 150 mL of water are lost daily in patients with normal
bowel function.
4 Urine. The normal urine output is approximately 1500 mL/day and, provided that
the kidneys are healthy, the specific gravity of urine bears a direct relationship to
volume. A minimum urine output of 400 mL/day is required to excrete the end
products of protein metabolism

92. Various formulae are available for calculating fluid replacement based on a
patient’s weight or surface area.
For example, 30–40 mL/kg gives an estimate of daily requirements.
The following are the approximate daily requirements of some electrolytes in
adults:
●● sodium: 50–90 mM/day;
●● potassium: 50 mM/day;
●● calcium: 5 mM/day;
●● magnesium: 1 mM/day.
The nature and type of fluid replacement therapy will be determined by individual
patient needs.

93. The composition of some commonly used intravenous fluids

94. A typical daily maintenance fluid regimen would consist of a combination of
5% dextrose with normal saline to a volume of 2 litres
In addition to maintenance requirements, ‘replacement’ fluids are required to
correct pre-existing deficiencies and‘supplemental’ fluids are required to
compensate for anticipated additional intestinal or other losses.

95. The nature and volumes of these fluids are determined by:
●● A careful assessment of the patient including pulse, blood pressure and central
venous pressure, if available. Clinical examination to assess hydration status
(peripheries, skin turgor, urine output and specific gravity of urine), urine and
serum electrolytes and haematocrit.
●● Estimation of losses already incurred and their nature: for example, vomiting,
ileus, diarrhoea, excessive sweating or fluid losses from burns or other serious
inflammatory conditions.
●● Estimation of supplemental fluids likely to be required in view of anticipated
future losses from drains, fistulae, nasogastric tubes or abnormal urine or faecal
losses

96. Macronutrient requirements
Energy
The total energy requirement of a stable patient with a normal
or moderately increased need is approximately 20–30 kcal/kg
per day. in the majority of hospitalised patients in
whom energy demands from activity are minimal, total energy
requirements are approximately 1300–1800 kcal/day.

97. Carbohydrate
There is an obligatory glucose requirement to meet the needs of the central
nervous system and certain haematopoietic cells, which is equivalent to about 2
g/kg per day. 45 to 65% of total daily intake
Fat 20 to 30 % of total daily intake
Protein 0.8 to 1 gm/kg/day 10 to 35 % total daily intake
Vitamins, minerals and trace elements

98. FLUID AND NUTRITIONAL CONSEQUENCES OF INTESTINAL RESECTION.
Effects of resection:
Resection of proximal jejunum results in no significant alterations in fluid and
electrolyte levels as the ileum and colon can adapt to absorb the increased fluid
and electrolyte load.
Following ileal resection, the colon receives a much larger volume of fluid and
electrolytes and it also receives bile salts, which reduce its ability to absorb salt
and water, resulting in diarrhoea.
Even the loss of 100 cm of ileum may cause steatorrhoea,
With larger resections (>100 cm) dietary fat restriction may be necessary
Regular parenteral vitamin B12 is required.

99. Complications of short bowel syndrome include peptic ulceration related to gastric
hypersecretion, cholelithiasis because of interruption of the enterohepatic cycle of
bile salts and hyperoxaluria as a result of the increased absorption
of oxalate in the colon predisposing to renal stones.

100. ARTIFICIAL NUTRITIONAL SUPPORT
The indications for nutritional support are simple. Any patient who has sustained 5
days of inadequate intake or who is anticipated to have no or inadequate intake
for this period should be considered for nutritional support.
The periods may be less in patients with pre-existing malnutrition
● Enteral nutrition
● Sip feeding
● Tube-feeding techniques
● Fine-bore tube insertion
● Gastrostomy
● Jejunostomy

103. Enteral nutrition
The term ‘enteral feeding’ means delivery of nutrients into
the gastrointestinal tract. The alimentary tract should be
used whenever possible. This can be achieved with normal
food, oral supplements (sip feeding) or with a variety of tubefeeding
techniques delivering food into the stomach, duodenum or jejunum
A variety of nutrient formulations are available for enteral
feeding. These vary with respect to energy content, osmolarity,
fat and nitrogen content and nutrient complexity; most
contain up to 1–2 kcal/mL and up to 0.6 g/mL of protein.

104. Tube-feeding techniques
Enteral nutrition can be achieved using conventional nasogastric
tubes (Ryle’s), fine-bore feeding tubes inserted into
the stomach, surgical or percutaneous endoscopic gastrostomy
(PEG) or, finally, postpyloric feeding utilising nasojejunal
tubes or various types of jejunostomy
Conventionally, 20–30 mL are administered
per hour initially, gradually increasing to goal rates
within 48–72 hours. In most units, feeding is discontinued for
4–5 hours overnight to allow gastric pH to return to normal.

105. If feeding is maintained for more than a week or so, a finebore feeding tube is
preferable and is likely to cause fewer gastric
and oesophageal erosions.
These are usually made from
soft polyurethane or silicone elastomer and have an internal
diameter of <3 mm.

106. Fine-bore tube

107. Gastrostomy
The placement of a tube through the abdominal wall directly
into the stomach is termed ‘gastrostomy’ ,
performed by percutaneous insertion underendoscopic control using local
anaesthesia, known as PEG (percutaneous endoscopic gastrostomy) tubes.
Two methods of PEG are commonly used. The first is
called the ‘direct-stab’ technique in which the endoscope is
passed and the stomachpassed and the stomach filled with air. The endoscopist
thenwatches a cannula entering the stomach having been inserted directly
through the anterior abdominal wall. A guidewire is then passed through the
cannula into the stomach. A gastrostomy tubemay then be introduced
into the stomach through a ‘peel away’ sheath.

108. The alternative technique is the transoral or push-through technique,
whereby a guidewire or suture is brought out of the stomach by the endoscope
after transabdominal percutaneous insertion and is either attached to a
gastrostomy tube or the tube is pushed over a guidewire. The abdominal end of
the wire is then pulled, advancing the gastrostomy tube through the
oesophagus and into the stomach. Continued pulling abuts it
up against the abdominal wall.
If patients require enteral nutrition for prolonged periods
(4–6 weeks), then PEG is preferable to an indwelling nasogastric
tube;

110. Complications
Necrotising fasciitis
Intra-abdominal wall abscess
Sepsis around the PEG site
A persistent gastric fistula can occur on removal of a PEG

111. Jejunostomy
This can be achieved using nasojejunal tubes or by placement of needle
jejunostomy at the time of laparotomy.
Nasojejunal tubes often necessitate the use of fluoroscopy
or endoscopy to achieve placement, which may delay
commencement of feeding.
Surgical jejunostomies, even using commercially available needle-insertion
techniques, do involve creating a defect in the jejunum, which can leak or
be associated with tube displacement; both of these complications result in
peritonitis.

114. Complications of enteral nutrition

115. Total parenteral nutrition (TPN)
Total parenteral nutrition (TPN) is defined as the provision of
all nutritional requirements by means of the intravenousroute
and without the use of the gastrointestinal tract.
Parenteral nutrition is indicated when energy and protein
needs cannot be met by the enteral administration of these
substrates. The most frequent clinical indications relate to
those patients who have undergone massive resection of the
small intestine, who have intestinal fistula or who have
prolonged intestinal failure. for other reasons.

120. carbohydrates, fats and amino acids to be mixed
in single containers; and a recognition that the provision of
energy during parenteral nutrition should be a mixture of glucose
and fat and that energy requirements are rarely in excess of
2000 kcal/day (25–30 kcal/kg per day)

121. Peripheral
Peripheral feeding is appropriate for short-term feeding of up
to 2 weeks. Access can be achieved either by means of a dedicated
catheter inserted into a peripheral vein and manoeuvred
into the central venous system (peripherally inserted central
venous catheter (PICC) line) or by using a conventional short
cannula in the wrist veins
Central
When the central venous route is chosen, the catheter can
be inserted via the subclavian or internal or external jugular
vein.

122. Complications of parenteral nutrition :
●● Related to nutrient deficiency
Hypoglycaemia/hypocalcaemia/ hypophosphataemia/hypomagnesaemia
(refeeding syndrome)
Chronic deficiency syndromes (essential fatty acids, zinc,mineral and trace
elements)
●● Related to overfeeding
Excess glucose: hyperglycaemia, hyperosmolar dehydration, hepatic steatosis,
hypercapnia, increased sympathetic activity, fluid retention, electrolyte
abnormalities

123. Excess fat: hypercholesterolaemia and formation of lipoprotein
X,hypertriglyceridaemia, hypersensitivity reactions
Excess amino acids: hyperchloraemic metabolic acidosis, hypercalcaemia,
aminoacidaemia, uraemia
Related to sepsis Catheter-related sepsis
Possible increased predisposition to systemic sepsis
●● Related to line On insertion: pneumothorax, damage to adjacent artery,
air embolism, thoracic duct damage, cardiac perforation or
tamponade, pleural effusion, hydromediastinum
Long-term use: occlusion, venous thrombosis

124. Refeeding syndrome
characterised by severe fluid and electrolyte shifts in malnourished patients
undergoing refeeding. It can occur with either enteral or parenteral nutrition, but is
more common with the latter.
It results in hypophosphataemia, hypocalcaemia and hypomagnesaemia.
results in altered myocardial function, arrhythmias, deteriorating respiratory
function, liver dysfunction, seizures,confusion, coma, tetany and death.
Treatment involves matching intakes with requirements and assiduously avoiding
overfeeding.
Calorie delivery should be increased slowly and vitamins administered regularly.
Hypophosphataemia and hypomagnesaemia require treatment.

125. ENHANCED RECOVERY
It is designed to speed clinical recovery of the patient and reduce both the cost
and the length of stay of the patient in the hospital.
It is achieved by optimising the health of the patient before surgery through
prehabilitation and then delivering evidence-based best care in the perioperative
period.

126. Postoperative strategies advocated by enhanced recovery protocols include:
●● Early planned physiotherapy and mobilisation.
●● Early oral hydration and nourishment.
●● Opioid-sparing analgesia regimens that include the use of
regional blocks, regular non-steroidal anti-inflammatory
drugs and paracetamol.
●● Discharge planning is started before the patient is admitted
to hospital and involves support from stoma care nurses,
physiotherapists and other community care workers.

127. Discharge letter
Diagnosis
Treatment
Laboratory results
Complications
Discharge plan
Support needed
Follow-up

129. Definition of terms used in ambulatory surgery
●● Outpatient surgery: not admitted to a ward facility
●● Procedure room surgery: surgery not requiring full sterile
theatre facilities
●● Day or same-day surgery: admitted and discharged within the
12-hour day
●● Overnight stay: 23-hour admission with early morning
discharge
●● Short-stay surgery: admission of up to 72 hours

130. Day surgery
Day surgery is defined as the admission and discharge of a
patient for a specific procedure within the 12-hour working
day. Where a patient requires an overnight admission, then
the term ‘23 hour stay’ should be used.

131. Selection criteria for day surgery
●● Medical: use physiological rather than chronological age ASA status over 2
requires careful review
Provided that the BMI is under 40, this alone is not a contraindication
●● Social: a responsible adult carer must be available for the first 24 hours, for the
elderly and patients at risk of covert bleeding
home conditions need to be suitable
ability to contact hospital in an emergency
●● Surgical: operations up to 2 hours
recognised day surgery procedures
ability to eat and drink within a reasonable timescale

132. ELECTIVE DAY SURGERY:

133. EMERGENCY DAY SURGERY:

134. Successful day surgery requirements
●● Minimal access techniques
●● Good haemostasis
●● Avoidance of unnecessary tissue handling or tension

135. PERIOPERATIVE MANAGEMENT
● Scheduling
● Anaesthesia and analgesia
● Postoperative complications

136. Optimal analgesia and anaesthesia
●● Multimodal analgesia with paracetamol and NSAIDs (if not
contraindicated) should be given preoperatively
●● Use long-acting local anaesthetic infiltration of the surgical
wound
●● Careful dosing of inhalational or intravenous agents should be
used to maintain anaesthesia
●● Avoid long-acting opiates such as morphine, to reduce the
incidence of sedation and PONV

137. Patient with PONV
Give intravenous fluids to hydrate the patient (10–15 mL/kg over 1 hour) and
intravenous antiemetic,
e.g. cyclizine, prochlorperazine
Review after 1 hour
If still a problem then give a second antiemetic of
different type, e.g. ondansetron, dexamethasone
Patient is hydrated and can be reassured that
no further active management is possible
Offer choice if admission or to be discharged home

138. DISCHARGE CRITERIA