The document discusses various aspects of pre-operative, operative, and post-operative surgical care including evaluating patient medical history and risk factors, optimizing medical conditions, obtaining informed consent, monitoring vital signs and drainage after surgery, and emphasizing the importance of proper preparation, timing, and follow-up to minimize risks and optimize surgical outcomes. Key factors discussed include cardiac, pulmonary, renal, hepatic, diabetic, nutritional status as well as use of prophylactic antibiotics and measures to prevent thromboembolic events.

1. DR. elias arteen

2. SURGERY
“ One of the most challenging aspect of surgical
practice is not just making the decision to
perform a surgical procedure on a patient, but
deciding on the proper timingthe proper timing when a surgical
procedure can be done.”

3. SURGERY
“ Thus, appropriate pre-operative preparation and post-
operative monitoring is absolutely mandatory and
essential to minimize the risks, reducing
complications and optimize outcome of a patient even
with the best technically performed operative
procedure.”

4. Phases of Surgery at Glance
Preoperative phase.
Operative phase.
Post operative phase

5. Surgery
Management
Disease
Patient

6. SURGERY
Disease Factor:
Natural History
Prognosis
Management Factor:
Classical and Advances in Surgical and Medical
Techniques (Management Options)
Anesthesia Methods and Medications
Patient Factor:
General Health (Optimization)
Co-morbid Conditions (Identify and Manage)
Psychological Preparation

7. Management of Diseases
 Medical (Conservative)
- Chest infection, UTI, Hypertension, DM,
IHD, PUD, IBD…..etc
Surgical ( operative)
- Management of complications i.e.
Empyeama, PUD, IBD.
- Emergency, surgical pathology

8. Surgical Management
Emergency:
- Trauma: (Bleeding, perforated viscus …etc)
- Acute abdomen: (Appendicitis, intestinal
obstruction…etc)
Elective
- Hernia repair, cholecystectomy,
mastectomy,...etc

9. Surgical Management & Procedures
Minimally invasive
- Endoscopic, laparoscopic, percutaneous
procedures.
Formal Surgery (open surgery)
- Minor: Biopsies, Hernia repair, scrotal,
and Anal
surgeries….etc
- Major: Cholecystectomy, Mastectomy,
Thyroidectomy, and Bowel surgery … etc

10. Surgical Management & Procedures
Day Care Surgery
- Minor surgical procedures.
- Endoscopic procedures.
- Some laparoscopic procedures.

11. General Aspects of Pre-op Care
Establish and confirm the diagnosis.
Review medical history.
Determine the physical status.
Identifies associated risk factors.
Determine the current medications.
Determine the nature of treatment required.
Discuss all information with patient and take
consent for surgery.
Patient Preparation
Prophylactic measures

12. Emergency History
AMPLE History:
A Allergies
M Medications
P Past Medical History
L last meal
E Events Preceding Surgery

13. Review Medical History
Control chronic current diseases.
HT, DM, BA, CHF, IHD
Review and improve medical care systems
Elective/Emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

14. Pre-operative Medical Care
Elective/Emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

15. Myocardial Infarction
Pt without risks: 0.5% chance of MI
Pt with risks: 5 % chance of perioperative MI
Perioperative MI has 17-41% mortality.
CAD causes MI.
Risk stratifications:
MI w/in 3 months of ORMI w/in 3 months of OR 27% reinfarction rate27% reinfarction rate
MI 3-6 months beforeMI 3-6 months before
OROR
10% reinfarction rate10% reinfarction rate
MI >6 months of ORMI >6 months of OR 5-8% reinfarction rate*5-8% reinfarction rate*

16. Criteria: Points
A. History:
Age >70 yr. 5
Myocardial infarction previous 6 months 10
B. Examination:
S3 gallop or jugular venous distention 11
Significant aortic valvular stenosis 3
C. Electrocardiogram:
Premature atrial contractions or other rhythm 7
>5 premature ventricular contractions/min. 7
D. General status:
Abnormal blood gases 3
K+/HCO3 abnormalities 3
Abnormal renal function 3
Liver disease or bedridden 3
E. Operation:
Emergency 4
Intraperitoneal, intrathoracic, aortic 3
Adaptedman, L., Caldera, D. L., Nussbaum, S. R., et al.: N.
Engl. J. Med., 1977; 297:845. Copyright 1977. Massachusetts Medical
Society. All rights reserved.

17. Goldman Classification
Class Point Total
I 0-5
II 6-12
III 13-25
IV > 26

18. Goldman Cardiac Risk in Non-cardiac SurgeryClass III & IV patient warrant routine
pre-operative cardiology consultation
Class IV – life saving procedure only
28 of the 53 points are potentially
correctible pre-operatively
Index correctly classified 81% of
cardiac outcomes

19. Pre-operative Medical Care
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

20. Pulmonary Disease
Patient History:
Unexplained dyspnea, cough, reduced exercise
tolerance.
Physical Exam:
Wheeze, rales, rhonchi, ↑ exp time, ↓ BS more likely
to develop pulmonary complications.*
Pre-operative CXR:
Mandatory in patients over 40 year.
ABG:
No role for routine use.
Result should not prohibit surgery.
* Lawrence et al Chest 110:744, 1996

21. Pulmonary Disease
Patient-related risks:
Chronic lung dz –
wheeze, productive
cough
Smoking
General health
Obesity
Age?
 separate from others?
Procedure related risks:
Type of anesthesia
 GETA alone ↓ FRC 11%
 inhibited coughing peri-op
Surgical site.
Duration of surgery

22. Modifiable Pulmonary Risks
Obesity Risks:
↓ lung capacity, FRC, VC
Hypoxemia
Tobacco Risks:
Definition of “stopped
smoking”....
“When was your last
cigarette?”

23. Pre-operative Medical Care
Surgical
emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Dialysis dependent
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

24. Renal Dysfunction
Not all renal failure is oliguric
Check BUN/Cr
Assume DM have CRI
Volume status
Electrolytes
Drug metabolism

25. Pre-operative Medical Care
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished
Why does hepatic disease
cause coagulopathy?

26. Child-Pugh Criteria for Hepatic Reserve
MeasureMeasure 11 22 33
BilirubinBilirubin < 2.0< 2.0 2-32-3 >3.0>3.0
AlbuminAlbumin >3.5>3.5 2.8-3.52.8-3.5 <2.8<2.8
INRINR >1.7>1.7 1.7-2.31.7-2.3 < 2.3< 2.3
AscitesAscites NoneNone SlightSlight ModerateModerate
NeuroNeuro NoneNone MinimalMinimal ““Coma”Coma”

27. Child-Pugh Criteria for Hepatic Reserve
Class A 5-6 points one year survival 100%
Class B 7-9 points one year survival 81%
Class C 10-15 points one year survival 45%
Predictor of perioperative mortality:
Class A: 0 - 5%
Class B: 10 – 15%
Class C: > 25%
Correct what you can → vitamin K, FFP, Albumin,
etc.
Anticipate bleeding, complicationsTownsend, Textbook of Surgery, 16th ed.

28. Perioperative Medical Care
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

29. Patients with Diabetes
Has higher risk of
Coronary Artery Disease
Neuropathy
Diabetic Nephropathy
Infection
Others
Treatment:
Control of hyperglycemia pre-operatively

30. Pre-operative Medical Care
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Iatrogenic
Inherited
Malnourished
Reasons patients are placed
on anticoagulants:
−Atrial fibrillation
−Prosthetic heart valve
−DVT or PE
−CVA or TIA
−Hypercoagulable state
REVIEW: Merritt J Thrombosis and Thrombolysis 13(2), 97-103, 2002

31. Evaluation of Hemostatic Disorders
History:
 Easy bruising, epistaxis.
Cut when shaving
Heavy menstrual bleeding
 Family history of bleeding disorders
 ASA / NSAID’s.
 Renal disease.
 Hepatic disease (Et OH)
Physical:
Ecchymosis
Hepato -splenomegaly
Excessive mobility of joints or excess skin laxity
Stigmata of renal or hepatic disease

32. Patients on Anticoagulants
Aspirin (ASA)
Coumadin (Warfarin)
Heparin
Low molecular weight heparin (Clexane)
1
Ridker et al Ann Intern Med 114:835-839, 1991.

33. Perioperative medical care
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

34. Patients who are malnourished
Proteins are essential for healing and regenerating
tissue
Malnourished patients have
Higher wound complications (dehiscence) and
greater anastomotic leak rate.
More postoperative muscle weakness (diaphragm)
Longer time in rehabilitation

35. Treating malnourishment
“If the gut works, use it.”
TPN vs. enteral feeds
Preoperative “bulking up”
Gastric and esophageal
cancers
 Why are they malnourished?
How do you build someone up?

36. General Aspects of Pre-op Care
Establish and confirm the diagnosis
Review medical history.
Determine the physical status.
Identifies associated risk factors.
Determine the current medications.
Determine the nature of treatment required.
Discuss all information with patient and take
consent for surgery.
Patient Preparation
Prophylactic measures

37. Determine The Physical Status
American Society of Anesthesiologists’ (ASA)
ClassificationClassification
(Elective)(Elective)
ClassificationClassification
(Emergency)(Emergency)
DescriptionDescription
11 1E1E Normally healthyNormally healthy
22 2E2E With mild systemic diseaseWith mild systemic disease
33 3E3E With severe systemic disease thatWith severe systemic disease that
is not incapacitatingis not incapacitating
44 4E4E With incapacitating systemicWith incapacitating systemic
disease that is a constant threatdisease that is a constant threat
to lifeto life
55 5E5E Moribound patient not expectedMoribound patient not expected
to survive without operationto survive without operation
66 6E6E Comatose/Organ DonorComatose/Organ Donor

38. Identifies Associated Risk Factors
Age
Obesity
Smoking
MI
CVA
PE
Cortisone
Anti coagulant
Contraceptive pills

39. Determine The Current Medications
Aspirin
Hypertensive drugs
Oral hypoglycemic and insulin therapy
Oral anti-coagulant
Cortisone
Oral contraceptive pills
Thyroid therapy
Tricyclic antidepresent

40. Determine The Nature of Treatment
Required
Conservative
Surgical
- Minimally invasive
- Day car surgery
- Laparoscopy
- Formal open surgery

41. General Aspects of Pre-op Care
Establish and confirm the diagnosis
Review medical history.
Determine the physical status.
Identifies associated risk factors.
Determine the current medications.
Determine the nature of treatment required.
Discuss all information with patient and take
consent for surgery.
Patient Preparation
Prophylactic measures

42. Patients Consent for Surgery
Details of the disease
Details of a particular surgical procedure:
Procedure
Preparation (bowel preparation; NPO guidelines)
Benefit from the procedure
Risks and potential complications
Possible complications
Answer questions of patients and relatives:
To dispel fear and alleviate anxiety

43. Patient Preparation
Psychological:
Acceptance and positive outlook
Physical:
Skin preparation
Bowel preparation
Prophylactic antibiotics
Physiological:
Correcting associated co-morbid conditions
Patient optimization

44. Prophylactic Measures
Prophylactic Antibiotic.
Prophylactic measures against Thrombo-
embolic disease.
Prophylactic measures against Renal failure
(Hydration, Mannitol, Lasix)
Prophylactic measures against Bleeding
tendency in obstructive jaundice patients .
( IV vit K 72h prior to surgery, FFP).

45. Prophylactic measures against thrombo-
embolic disease
Correction of dehydration and infection
Low dose of heparin.
Low molecular weight heparin Clexane
Intermittent numatic compression of calf
muscles
TED stocking

46. Peri- and Post-operative Monitoring
Important aspects:
Physiologic Monitoring:
 Vital Signs
 Hemodynamic
 Respiratory
 Gastric Tonometry
 Renal
 Neurologic
 Metabolic/Nutritional

47. Traditional 4 Cardinal Vital Signs
Temperature:
Rectally or orally
Aural (Digital): measures core temperature
Heart Rate:
Cardiac rate
Pulse rate
Blood Pressure:
Standard BP apparatus
Respiratory Rate:
Breaths per minute

48. Principles of Post Operative Care
Hemodynamic stability (Fluid and electrolytes,
Hemostasis)
Treatment of infection (Emberically first, then
according to C&S)
Management of anurea
Early detection of signs of multiorgan
dysfunction syndrome ( MODS,MOF)
Determine indication of admission to surgical
ICU (Ventilation, Invasive monitoring, TPN)

49. Immediate Post-Op
Assessment and Interventions
Areas of ConcernAreas of Concern InterventionIntervention
Neurological StatusNeurological Status Assess LOC– response to nameAssess LOC– response to name
Return of swallow and gag reflexReturn of swallow and gag reflex
Fluid and ElectrolyteFluid and Electrolyte
BalanceBalance
Intake and OutputIntake and Output
IV FluidsIV Fluids
Dressing, Tubes,Dressing, Tubes,
DrainsDrains
Color, consistency and amount ofColor, consistency and amount of
drainagedrainage
PainPain May need 1/2 to 1/3 less analgesia inMay need 1/2 to 1/3 less analgesia in
recover roomrecover room
Safety and ComfortSafety and Comfort Side railsSide rails
WarmthWarmth
Aseptic TechniqueAseptic Technique

50. Immediate Post-Op
Assessment and Interventions
Areas ofAreas of
ConcernConcern
InterventionIntervention
RespiratoryRespiratory ASSESS !!!ASSESS !!!
Position on SidePosition on Side
Keep Airway inKeep Airway in
OxygenOxygen
CardiovascularCardiovascular ASSESS !!!ASSESS !!!
Watch for:Watch for:
Post-op hypotension; cardiac arrest;Post-op hypotension; cardiac arrest;
hemorrhagehemorrhage
Signs of Hemorrhage:Signs of Hemorrhage:
↑↑ pulse and respiratory rate; restlessness;pulse and respiratory rate; restlessness;
↓↓ blood pressureblood pressure;; cold, clammy skin;cold, clammy skin;
thirst; pallorthirst; pallor