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preoperative preparation and postoperative care


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prepoerative and post operative care

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preoperative preparation and postoperative care

  4. 4. PATIENT ASSESSMENT • Aims: – look actively at risks – proper management of risks – enabling safe surgery • Usually done by surgical team, nursing team and anaesthetic team • Standard history taking
  5. 5. • Proper physical examination • Investigations needed (NICE guidelines) • Airway assessment and evaluation
  6. 6. RISK ASSESSMENT AND CONSENT • ASA classification • Explain on the advantages, side effects and, and prognosis • Taking comprehensive valid consent – given voluntarily by a competent and informed person
  7. 7. ARRANGING THE THEATRE LIST • Confirm it is the right date, time, and place of operation • Personnel availability • Appropriate equipment and instruments should be made available • Operating list should be distributed early • Priorities to children, diabetic patients, cancer patients, and life threatening patients
  8. 8. BEFORE THEATRE • Must be seen by anaesthetist and operating surgeon in charge • Keep in view for specific requirement • Arrange the theatre list appropriately
  9. 9. SURGICAL SAFETY CHECKLIST Introduced by WHO in 2008, a guideline recommended practices to reduce rate of preventable surgical complications and death worldwide. • Prelist briefing • Sign in • Antibiotic • Monitoring • Operating theatre environment • Diathermy • Torniquets • Time outs • Temperature control • Hair removal • Glycaemic control • Infection control
  10. 10. SCRUBBING UP • Process of washing of hands and arms and putting on gloves and gown • 2 standard scrub solutions include -2% chlorhexidine -7.5% povidone-iodine -alcohol
  11. 11. • Hat, mask and eye protection should be worn and jewellery should be removed • Nails and deep skin crease should be clean for 1-2 mins using brush • Hands and forearms wash systematically 3 times • Hands and arms are dried from distal to proximal using sterile towel • Folded gown lifted away from trolley, allowed to unfold • Arms inserted into armholes, hands remain inside gowns until gloves are donned, secure the gown • Gloves are put on, hands remain above waist level at all times.
  14. 14. INTRODUCTION OPreoperative problems – certain specific medical conditions encountered during preoperative assessment OShould be corrected to the best possible level to eliminate serious complications OPatients with severe disease will need to be referred to specialists and the referral letter should include all the details ( history , examination and investigation results ).
  15. 15. 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
  17. 17. CARDIOVASCULAR DISEASE OIdentify patients who have a high preoperative risk of MI and make arrangements to reduce the risk OInclude those who have suffered coronary artery disease, CCF , arrhythmias , severe peripheral vascular disease , CVD or renal failure OPatients with IHD – left ventricular status can be evaluated using a stress test
  18. 18. O Patients with symptomatic valvular heart disease or poor left ventricular function – an echo should be performed (ejection fraction less than 30% - poor outcomes) O Referred to cardiologist if : - murmur heard and patient is symptomatic - poor left ventricular function or cardiomegaly - ischaemic changes on ECG even if patient is not symptomatic (silent MI) - abnormal rhythm on ECG , tachy/bradycardia or a heart block
  19. 19. HYPERTENSION , IHD AND STENTS OPrior to surgery blood pressure should be controlled to 160/90 mmHg OStabilisation period of 2 weeks if new antihypertensive is introduced OPatients with angina – investigated further by a cardiologist if not well controlled - some may need thrombolysis , stents or bypass surgery prior to non-cardiac surgery
  20. 20. OPatients who have had stents inserted for IHD, should be asked for the effectiveness of the treatment and concurrent antiplatelet medication (clopidogrel and/or aspirin) ORisk of stent thrombosis with consequences of MI and death is reduced if elective surgery is postponed until after dual antiplatelet therapy is stopped OIf cannot be postponed and risk of perioperative bleeding is low – dual antiplatelet therapy can be continued during surgery
  21. 21. DYSRHYTHMIAS OPatients with atrial fibrillation -B-blockers, digoxin and CCB started preoperatively - warfarin stopped 5 days preoperatively OImplanted pacemaker and cardiac defibrillator checks and appropriate reprogramming done OSymptomatic heart blocks and asymptomatic second and third degree heart blocks need cardiology consultation
  22. 22. VALVULAR HEART DISEASE O Patients with severe mitral and aortic stenosis may benefit from valvuloplasty before elective non-cardiac surgery O Patients with mechanical heart valves- - warfarin stopped 5 days prior to surgery and infusion of unfractionated heparin ( INR <1.5) - APTT kept at 1.5 times normal and stopped 2 hours before surgery - Heparin and warfarin postoperatively and heparin stopped once full effect of warfarin realised
  23. 23. ANAEMIA AND BLOOD TRANSFUSION OAnaemic at preoperative assessment treated with iron and vitamin supplements OChronic anaemia well tolerated in the perioperative period O if major procedure, preoperative transfusion if Hb below 8g/dL
  24. 24. RESPIRATORY DISEASE OCurrent respiratory status should be compared with their normal state ORegular treatment, PEFR , steroids use , CPAP should be taken note of OEncourage patients to be compliant with medications, exercise , consume balanced diet and stop smoking
  25. 25. REFER TO RESPIRATORY PHYSICIANS IF : - Severe disease or significant deterioration from usual condition - Major surgery is planned in a patient with significant respiratory comorbidities - Right heart failure is present - Patient is young with COPD
  26. 26. O Smoking : provide information regarding perioperative risks associated with smoking O Asthma : establish severity of asthma, PEFR , precipitating causes, frequency of steroid and bronchodilator use and any previous intensive care unit admission. Use regular inhalers until the start of anaesthesia O COPD : Patients with significant COPD who are undergoing major surgery will need to be referred to physicians to optimise their condition. ABG also useful O Infections : elective surgery postponed if chest infection. Treated with antibiotics and operation rescheduled after 4-6 weeks.
  27. 27. GASTROINTESTINAL DISEASE Nil by mouth and regular medications - Not to take solids within 6 hours and fluids within 2 hours before anaesthetic - Infants allowed a clear drink up to 2 hours , mother’s milk up to 3 hours and cow or formula milk up to 6 hours before anaes - If surgery delayed, oral (until 2 hours of surgery) or IV fluids started in the vulnerable group of patients
  28. 28. Regurgitation risk - High risk of pulmonary aspiration if patients with hiatus hernia, obesity, pregnancy and diabetes - Antacids, H2-receptor blockers or PPI given Liver disease - Cause of the disease , clotting problems, renal involvement and encephalopathy should be known - LFT, coagulation , blood glucose, urea and electrolyte levels - Ascitis, hypoalbuminaemia, sodium and water retention should be noted
  29. 29. THANK YOU….. (but to be continue…)
  31. 31. Genitourinary disease 1) Renal disease - Diabetes mellitus, hypertension and ischemia heart disease should be stabilised ( leading to chronic renal failure ) - Apporiate measures to treat acidosis, hypocalcemia and hyperkalemia > 6mmol/L - Continue peritoneal or hemodialysis until a few hours before surgery - Blood sample sent for FBC and U & E ( after final dialysis before surgery ) - Chronic renal failure patients often suffer chronic microcytic anemia that is well tolerated - Acute renal failure can present with acute surgical problems ; eg bowel obstruction needing emergency surgery ( simultaneous medical , surgery treatments and critical care unit )
  32. 32. 2) Urinary tract infection - Uncomplicated urinary infections are common in female - Outflow uropathy with chronically infected urine is common in men - For elective surgery * infection should be treated because it carries dire consequences eg joint replacements - For emergency surgery * give antibiotics, ensure good urine output before, during and after surgery
  33. 33. Endocrine and metabolic disorders 1 ) Malnutrition - BMI < 18.5 kg/m2 ( nutritional impairment ) - BMI < 15 kg/m2 ( significant hospital mortality ) - Nutritional support for 2 weeks before surgery 2) Obesity - Advice on healthy eating and taking regular exercise - Use CPAP device for obstructive sleep apnea and cholesterol reducing agents - If possible, delay surgery until patients more active and lost weight. - Preventative measures for acid aspiration , DVT and associated risks explained prior to surgery
  34. 34. 3) Diabetes mellitus - Check HbA1c level - Start lipid lowering medication in high risk group of cardiovascular complications of diabetes - Morning operation { advice to omit morning dose medication and breakfast, tight control of blood sugar not needed }, check blood sugar for every 2 hrs - Afternoon operation { breakfast + half regular dose of insulin or full dose of oral anti – diabetics, check blood sugar for every 2 hrs - Intravenous insulin sliding for insulin dependent diabetes mellitus undergoing major surgery or if blood sugar difficult to control for other reason 4 ) Adrenocortical suppression - Ask oral adrenocortical steroid dose and duration to avoid Addisonian crisis
  35. 35. Coagulation disorders 1) Thrombophilia - Thrombophylaxis needed if present of risk factors Risk factors for thrombosis - Increasing age - Significant medical comorbidities (particularly malignancy) - Trauma or surgery (especially of the abdomen, pelvis and lower limbs) - Pregnancy/puerperium - Immobility (including a lower limb plaster) - Obesity - Family/personal history of thrombosis - Drugs (e.g. oestrogen, smoking)
  36. 36. - Hormone replacement therapy ( HRT ) should be stopped 6 weeks prior to surgery - Low risk patients can be given thromboembolism deterrent stockings - Give warfarin for patients with high risk patients with history of recurrent DVT, pulmonary embolism and arterial thrombosis - Stop warfarin before surgery and replaced with low molecular weight heparin or factor Xa inhibitor Neurological and psychiatry disorders - History of stroke, pre existing neurological deficit patients may be on antiplatelet or anticoagulants. - Low risk of cardiovascular thrombosis, antiplatelet withdrawn ( 7days for aspirin, 10 days for clopidogrel ) - High risk patients, use aspirin alone - Anticonvulsant and antiparkinson continued to help early mobilization - Stop lithium 24 hours prior to surgery, measure blood level to avoid toxicity - Inform anaesthetist if psychiatric medications such tricyclic antidepressants or monoamine oxidase inhibitors to avoid drug interactions.
  37. 37. Musculoskeletal and other disorders - Rheumoid arthritis , flexion and extension lateral cervical spine x ray should be taken. ( lead to unstable cervical spine with spinal cord injurt during intubation ) - Rheumatologist will advice on steroids and disease modifying drugs so as to balance immunosuppression against need to stabilise disease preoperatively - In ankylosing spondylitis, technique of spinal or epidural anaesthesia often challenging - Patients with systemic lupus erthematosis may exhibit hypercoagulable state along with airway difficult 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
  38. 38. - Patient’s mouth open and tongue protruding - Higher the grade, higher the risk in obtaining and securing airways - Look for loose teeth, obvious tumors, scars, infections, obesity, thickness of neck which will indicate difficulty in obtaining airway - Modified Mallampati class - Jaw protrusion, neck movement and thyromental distance
  39. 39. Preoperative assessment in emergency surgery - Start similar principle to that for elective surgery - Constraints : time, facilities available - Consent : may be not be possible in life saving emergencies - Organisational efforts : for example, local/ national algorithms for treatment of multi-trauma patients
  41. 41. PURPOSES To enable a successful and faster recovery of the patient post operatively. To reduce post operative mortality rate. To reduce the length of hospital stay of the patient. To provide quality care service. To reduce hospital and patient cost during post operative period.
  43. 43. WHAT IS NEEDED?  the immediate recovery and requires to detect early signs of complication.  Receive a complete patient record from the operating room which to plan post operative care. Patient’s name •Age •Surgical procedure •Existing medical problem •Allergies •Aneasthetic & analgesics given •Fluid replacement •Blood loss •Urine output •Any surgical/ anaesthetic problems encountered
  44. 44. Assessing the patient  Monitor vitals-pulse volume and regularity, depth and nature of respiration.  Assessment of patient’s O2 saturation.
  46. 46. • Check the level of consciousness. Ability to respond to commands.
  48. 48. PROTECT AIRWAY  By proper positioning of patient’s head.  By clearing airway.  Oxygen therapy.
  49. 49. Maintaining IV Stability Hypovolemic shock: can be avoided by timely administration of IV Fluids, blood and blood products and medication.  Replacement of fluids.[colloids and crystalloids]  Keep the patient warm.  Monitor intake and output balance.  Monitor the vitals continuously with the patient condition.
  50. 50. ASSESSMENT OF THE SURGICAL SITE  Haemorrhage It is a serious complication of surgery that resulting death.  It can occur in immediate post operatively or upto several days after surgery.  If left untreated,cardiac output decreases and blood pressure and Hb level will fall rapidly.
  51. 51. • Blood transfusion if necessary. • The surgical site+incision should always be inspected. • If bleeding,pressure dressing are placed. • If the bleeding is concealed,the patient is taken in OR for emergency exploration of concealed haemorrhage in body cavity.
  52. 52. RELIEVING PAIN +ANXIETY  Administer opioid analgesia as per Doctor’s order.  Epidural analgesia.  NSAIDS.  Psychological support to relieve fear+To give support.
  53. 53. CONTROLLING NAUSEA+VOMITTING These are common problem in post operative period. Medication can be administered as per doctor’s order. Example: Inj Metaclopramide Inj Ondansetron ( Emeset )
  54. 54. WHEN TO BE DISCHARGED FROM RR? • When patient fulfill following criterias,  Fully concious Respiration and oxygenation are satisfactory Not in pain or nausea CVS parameters are stable Oxygen, fluids and analgesics prescribed No conceren related to surgical procedure
  57. 57. • most common are  hypoxaemia  hypercapnia  aspiration • late complication  Pneumonia  pulmonary embolism
  58. 58. POSTOPERATIVE HYPOXIA • Present as shortness of breath, or agitated due to upper airway obstruction • Signs  Absence of air movements  Seesaw movement of chest  Suprasternal recession  cyanosis
  59. 59. Causes of hypoxia Upper airway obstruction due to residual effect of anaesthesia Laryngeal edema due to tracheal intubation or palsy hypoventillatio n Atelectasis or pneuomia Pulmonary edema of cardiac origin Pulmonary embolism with sudden chest pain
  60. 60. TREATMENT • Should be treated urgently • Administer oxygen at 15L/min using a non- rebreathing mask + head tilt, chin lift and jaw thrust • Suctioning of any blood or secretions • Tracheal intubation and manual ventillation • If pneumonia : antibiotics, chest physiotherapy and bronchodillators • If pulmonary edema : start on diuretics and cardiology opinion sought
  62. 62. • Hypotension is common due to inadequate fluid replacement, vasodilatation from anesthesia • Other causes  Surgical bleeding  Sepsis  Arrythmias  Myocardial infarction  Cardiac failure  Tension pneumothorax  Pulmonary embolism
  63. 63. • Signs  Cold clammy extremities  Tachycardia  Low urine output ( < 0.5 ml/kg )  Low CVP
  64. 64. MYOCARDIAL ISCHEMIA / INFARCTION • Patient with previous cardiac problems are at risk of ACS • Present with retrosternal pain radiating to jaw, neck or arms, may have nausea, dyspnoea or syncope • ST elevation seen in 2 continous leads on ECG and serum troponin level will be high in both conditions
  65. 65. TREATMENT • Start with oxygen, glyceryl trinitrate, morphine and aspirin • Beta blockers or calcium antagonist may be started • Cardiologist should be involved.
  66. 66. ARRYTHMIA • Cause hypotension and ischemia • Need continuous monitoring • Treated according to Resuscitation Council peri-arrest guideline, Correct the cause including acid-base and electrolyte imbalance, hypoxia, and hypercapnia
  68. 68. ACUTE RENAL FAILURE • Any perioperative events like sepsis, bleeding, hypovolaemia, rhabdomyolysis and abdominal compartment syndrome precipitates • Treatment,  If urine output < 0.5ml/kg for 6 hrs, check the catheter if its blocked  Correct hypovolaemia, metabolic and electrolyte disturbance and stop nephrotoxic dugs
  69. 69. URINARY RETENTION • Common in pelvic and perineal operations • Catheterisation should be performed if an ope expected to last more than 3 hours or longer or when large volumes are administered
  70. 70. URINARY INFECTION • Patient present with dysuria or pyrexia • Immunocompromised, diabetis and patient with h/o urinary retention are at higher risk • Treatments Adequate hydration Proper bladder drainage antibiotics
  71. 71. Complicatons Related to Specific Surgical Specialities Anna Alisha Mathew Simon
  72. 72. Abdominal Surgery • The abdomen should be examined for distension, tenderness, drainage • Sites/wounds : – Paralytic illeus • following surgery, bowel movements may reduce temporarily • adequate hydration and electrolytes – Localised infection – Anastomotic leakage
  73. 73. Orthopeadic Surgery • Neurovascular status of limbs must be checked regularly • External fixator-pin site should be checked • Compartment syndrome-remove circumferential dressings-fasciotomy
  74. 74. Neck Surgery • Accumulation of blood = asphyxia • Recurrent laryngeal nerve damage-pre and post op
  75. 75. Thoracic Surgery • Regular review of chest drain • Continous ECG monitoring • Bronchopleural fistula • Heamothorax • Pleural effusion
  76. 76. Neurosurgery • Raised intracranial pressure-monitored closely Vascular Surgery • Regular clinical assessment and Doppler ultrasound post op
  77. 77. Plastic Surgery • Viability of flaps and perfusion needs to be monitored regularly Urology • Catheter patency must be check regularly • TURP-continous bladder irrigation- pulmonary oedema
  79. 79. • Pain • Nausea and vomiting • Bleeding • Deep vein thrombosis • Hypothermia and shivering • Fever • Prophylaxis against infection • Confusional state • Drains • Wound care • Wound dehiscence • Enhanced recovery
  80. 80. Pain • Most feared problem among patients • More than 80% of patients experience post operative pain
  81. 81. Nausea & Vomiting • Postoperative nausea and vomiting (PONV) can precipitate bleeding and dehiscence of wounds by dislodging the clots and bursting suture lines. • In neurosurgical patients  raised intracranial pressure • Risk factors: – Women – Non smoker – Past h/o PONV, motion sickness, migraine – Use of volatile anesthetic agents, opioids & NO – Duration and type of surgery • Management – Adequate treatment for pain, anxiety, hypotension & dehydration – Antiemetic (eg. Ondansetron, dexamethasone)
  82. 82. Bleeding • Primary hemorrhage: – either starting during surgery or following postoperative increase in blood pressure - replace blood loss and may require return to theatre to re- explore the wound • Secondary hemorrhage: – often as a result of infection.
  83. 83. Deep Vein Thrombosis • Presentation: – Calf pain – Swelling – Warmth – Redness – Engorged veins • Venography or duplex Doppler ultrasound is used to assess flow and the presence of thromboses • Management : – Use of stockings, calf pumps – Low molecular weight warfarin
  84. 84. Stratification of risk of DVT Low Medium High Maxillofacial surgery Inguinal hernia repair Pelvic elective and trauma surgery Neurosurgery Abdominal surgery Total knee and hip replacement Cardiothoracic surgery Gynecological surgery Urological surgery
  85. 85. Hypothermia and shivering • Anesthesia induces loss of thermoregulatory control. • Exposure of skin and organs to a cold operating environment, volatile skin preparation, infusion of cold IV fluids • Leads to increased cardiac morbidity, a hypocoagulable state, shivering with imbalance of O2 supply and demand, immune function impairment with possibility of wound infection. • Management  active warming devices
  86. 86. Fever • Causes of a raised temperature postopertively include: – Day 2-5 : atelectesis of lung – Day 3-5 : superficial & deep wound infection – Day 5 : chest infection, UTI and thrombophlebitis – > 5 days : wound infection, anastomotic leakage, abscess • Management : treat possible causes
  87. 87. Prophylaxis against infection • Patients who had foreign material insertion : – Hip or knee prosthesis – Aortic valve • Bacteria can be incorporated into the biofilm that forms on the surface of the implant. • Management : – Prophylactic antibiotic should be administered, usually one dose 30 mins before ‘knife to skin’ and two postoperatively.
  88. 88. Confusional state • Acute confusional states occur on recovery from anesth or few days after surgery. • Higher in elderly with hip fractures & is associated with increased morbidity and mortality. • Present as : – Anxiety – Incoherent speech – Clouding of consciousness – Destructive behavior (eg. pulling off cannula)
  89. 89. Cause Renal  Renal failure  Hyponatraemia  UTI  Urinary retention Respiratory  Hypoxia  Atelectesis Cardiocvascular  Pulmonary embolism  Dehydration  Septic shock  Myocardial infarction  Chronic heart failure  Arrhythmia Drugs  Opiates  Hypnotics  Cocaine  Alcohol withdrawal  Hypoglycemia
  90. 90. Neurological  Epilepsy  Encephalopathy  Head injury  Cerebrovascular accident Idiopathic (rare)  Hypothyroidism  Hyperthyroidism  Addison’s disease
  91. 91. • Risk factors: – Pre-existing cognitive impairment – Use of narcotics, benzodiazepines, alcohol – Renal impairment – Depression • Precipitating factors – Physical restraints – Addition of new medications – Electrolyte & fluid abnormalities – Intraoperative blood loss – Admission to ICU • Management – Treat underlying medical problems – Involve relative, friends – Pain control
  92. 92. Drains • Used to prevent – Accumulation of blood, serosanguinous or purulent fluid – To allow the early diagnosis of a leaking surgical anastomosis • Quantity & character of drain fluid can be used to identify any abdominal complication such as fluid leakage (eg. bile or pancreatic fluid) or bleeding – Additional IV fluids with same electrolyte contents • Removed if drainage stopped or become less than 25 ml/day
  93. 93. Wound care • Within hours, dead space cells fills up with an inflammatory exudate. • Within 48 hours, a layer of epidermal cells from wound edge bridges the gap. • Inspect wound only if there is any concern or the dressing needs changing (under sterile condition) • Inflamed wound  swab and sent for Gram staining & culture • Infected wound & hematoma  treat with antibiotics • Contaminated/nonviable tissue remains  packed & return to theater every 24-48 hours for cleaning • Skin sutures/clips are usually removed between 6-10 days after surgery. • Delayed wound healing  patients who are malnourished, or have vitamin A & C deficiency • Causes of inhibition of wound healing : – Steroids – Diabetes (uncontrolled)
  94. 94. Wound dehiscence • Is a disruption of any or all of the layers in a wound • Commonly occurred from 5th to the 8th postoperative day when the strength of the wound is at the weakest. • It may herald an underlying abscess & usually presents with serosanguinous discharge. • Management  Return to theater & resuturing  Leave wound open & treat with dressings or vacuum assisted closure (VAC) pumps
  95. 95. Risk factors General Local Malnourishment Inadequate or poor closure of wound Diabetes Poor local wound healing Obesity Increased intra-abdominal pressure Renal failure Jaundice Sepsis
  96. 96. Enhanced recovery • An approach to the perioperative care of patients undergoing surgery. • Designed to speed clinical recovery of patient, reduce the cost and length of stay in the hospital. • Strategies include : – Early planned physiotherapy & mobilisation (reduce risks of DVT, urinary retention, pressure sores) – Early oral hydration & nourishment – Good pain control NSAIDs – Discharge planning (support from stoma care nurses, physiotherapists)
  98. 98. Discharge Letter • Do include: – Diagnosis – Treatment – Laboratory results – Complications – Discharge plan – Support needed (eg: physiotherapy) – Follow up
  99. 99. Follow Up in Clinic • Reviewed in clinic when a key decision on management needs to be made • Letter to patient’s GP: – Care plan agreed with patient – Advise on recognizing the onset of complications • Discharge patient from clinic