This document outlines preoperative, intraoperative, and postoperative care. Preoperative care includes assessing risk factors, obtaining consent, and optimizing patient health. Intraoperative care focuses on monitoring vital signs and maintaining homeostasis. Postoperative care goals are a quick and safe recovery, including monitoring in recovery and treating any complications across body systems.

1. P R E A N D P O S T
O P E R AT I V E C A R
E
TO: DR.BINIYAM.
BY: BINIAM.M

2. O U T L I N E
Introduction
Preoperative preparation
 Perioperative management of the high-risk surgical
patient
Nutrition and fluid therapy
Intraoperative care
Postoperative care

3. I N T R O D U C T I O N
Surgery is an important treatment option for a wide range of acute
and chronic diseases. Around 10 million patients undergo a surgical
procedure each year and this number will continue to rise.
For most patients surgery is a success, both in terms of the
procedure itself and the care before and afterwards.
However, the population is changing and so must our
services. There are over 250,000 patients at higher risk from
surgery and this number is set to rise. So with increasing demand
and the increasing complexity of surgical procedures, come new
challenges that we must address.

4. P R E O P E R AT I V
E C A R E

5. C O N T. . .
Preoperative care refers to health care provided before a surgical
operation. The aim of preoperative care is to do whatever is right to
increase the success of the surgery.
At some point before the operation the health care provider will
assess the fitness of the person to have surgery. This assessment
should include whatever tests are indicated, but not
include screening for conditions without an indication.

6. B E N E F I T O F P R E O P E R AT I V E C A R E
To screen for and properly manage comorbid conditions.
To assess the risk of anesthesia and surgery and lower it.
To educate patients and families about the objectives and risks of
anesthesia and the anaesthesiologist's role in perioperative care.
To obtain informed consent.

7. S E R V I C E I N P R E O P E R AT I V E C A R E
History taking
physical examination
Investigation
risk assessment
 general and system-specific evaluations.

8. H I S T O R Y TA K I N G
The history of past surgery and anaesthesia can reveal problems
that may present during current hospitalisation (e.g. intraabdominal
adhesions and suxamethonium apnoea).
The use of recreational drugs and alcohol consumption should be
noted as they are known to be associated with adverse outcomes.
Check for allergies and risk factors for deep vein thrombosis (DVT).
 Social history, ability to communicate and mobility are important in
planning rehabilitation after surgery

9. P H Y S I C A L E X A M I N AT I O N
Patients should be treated with respect and dignity, receive a clear
explanation of the examination undertaken and kept as comfortable
as possible
A pre-operative physical examination is generally performed upon
the request of a surgeon to ensure that a patient is healthy
enough to safely undergo anesthesia and surgery.
This evaluation usually includes a physical examination, cardiac
evaluation, lung function assessment, abdominal assessment...etc

10. I N V E S T I G AT I O N S

11. I N V E S T I G AT I O N S
Routine lab tests before are admitted to the hospital or before
certain outpatient procedures.
The tests help find possible problems that might complicate surgery
if not found and treated early.

12. C O N T.
Full blood count. A full blood count (FBC) is needed for major
operations, in the elderly and in those with anaemia or pathology
with ongoing blood loss.
Urea and electrolytes. Urea and electrolytes (U&E) are needed
before all major operations, in most patients over 60 years of age
especially with cardiovascular, renal and endocrine disease or if
significant blood loss is anticipated

13. C O N T.
It is also needed in those on medications which affect electrolyte
levels, e.g. steroids, diuretics, digoxin, NSAIDs (non-steroidal anti-
inflammatory drugs), intravenous fluid or nutrition therapy.
Electrocardiography. Electrocardiography (ECG) is required for
those patients aged over 60 years, cardiovascular, renal and
cerebrovascular involvement, diabetes and in those with severe
respiratory problems.

14. C O N T. . .
Chest radiography. A chest x-ray is not required unless the patient
has a significant cardiac history, cardiac failure, severe chronic
obstructive pulmonary disease (COPD), acute respiratory
symptoms, pulmonary cancer, metastasis or effusions, or is at risk
of tuberculosis.
Urinalysis. Dipstick testing of urine should be performed on all
patients to detect urinary infection, biliuria, glycosuria and
inappropriate osmolality.

15. C O N T. . .
Human chorionic gonadotrophin. Pregnancy needs to be ruled
out in all women of childbearing age
Blood glucose and HbA1c. These should be performed in patients
with diabetes mellitus and endocrine problems. HbA1c indicates
how well diabetes has been controlled over a longer duration.

16. q C A R D I O VA S C U L A R S Y S T E M / C A R D I A C
P R O B L E M S
Patients with heart disease should be considered high-risk surgical
candidates and must be fully evaluated.
At preoperative assessment, it is important to identify the patients
who have a high perioperative risk of myocardial infarction (MI) and
make appropriate arrangements to reduce this risk.

17. C O N T. . .
These patients include those who have suffered coronary artery
disease, congestive cardiac failure, arrhythmias, severe peripheral
vascular disease, cerebrovascular disease or renal failure,
especially if they are undergoing intra-abdominal or intrathoracic
surgery.
In patients with ischaemic heart disease (IHD), the left ventricular
status can be evaluated using a stress test

18. C O N T. . .
For patients with symptomatic valvular heart disease or poor left
ventricular function, an echocardiography should be performed.
 Pressure gradients across the valves, dimensions of the chambers
and contractility can be determined using echocardiography; an
ejection fraction of less than 30 per cent is associated with poor
patient outcomes.

19. H Y P E R T E N S I O N
Prior to elective surgery, blood pressure should be controlled to
near 160/90 mmHg. If a new antihypertensive is introduced, a
stabilisation period of at least 2 weeks should be allowed.
Elective surgery should be postponed for three to six months after a
proven myocardial infarct to reduce the risk of perioperative
reinfarction

20. S M O K I N G
Information should be provided to indicate perioperative risks
associated with smoking. Stopping smoking reduces carbon
monoxide levels and the patient is better able to clear sputum.
Asthma It is important to establish the severity of the asthma,
precipitating causes, frequency of bronchodilator and steroid use,
PEFR (peak expiratory flow rate) and any previous intensive care
unit admissions.

21. C H R O N I C O B S T R U C T I V E P U L M O N A R Y
D I S E A S E ( C O P D )
Patients on steroid treatment, or oxygen therapy, or who have a
forced expiratory volume in the first second (FEV1) less than 30 per
cent of predicted value (for age, weight and height) have severe
disease and may have respiratory failure in the postoperative period

22. C O N T. . .
Preoperative chest x-ray or scans are useful in patients with
known emphysematous bullae, pulmonary cancer, metastasis or
effusions.
Patients with significant COPD who are undergoing major surgery
will need to be referred to the respiratory physicians for optimisation
of their condition.
An arterial blood gas analysis may also be useful as it can give an
indication of carbon dioxide retention. This is associated with an
increased risk of perioperative respiratory complications

23. L I V E R D I S E A S E
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 which need to be
performed are liver function tests, coagulation, blood glucose, urea
and electrolyte levels.

24. U R I N A R Y T R A C T I N F E C T I O N
Urinary tract infection Uncomplicated urinary infections are
common in women, while outflow uropathy with chronically infected
urine is common in men.
These infections should be treated before embarking on elective
surgery where infection carries dire consequences,
e.g. joint replacement. For emergency procedures, antibiotics
should be started and care taken to ensure that the patient maintains
a good urine output before, during and after surgery

25. P R E O P E R AT I V E A S S E S S M E N T I N
E M E R G E N C Y S U R G E R Y
In urgent or emergency surgery, the principles of preoperative
assessment should be the same as in elective surgery, except that
the opportunity to optimise the condition is limited by time
constraints.
 Medical assessment and treatments should be started (e.g.
according to the Advanced Trauma Life Support (ATLS) guidelines)
even if there is no time to complete those before the surgical
procedure is started.
Some risks may be reduced, but some may persist and whenever
possible these need to be explained to the patient

26. C O N T. . .
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 multi-trauma patient

27. R I S K A S S E S S M E N T A N D C O N S E N T
All life- or limb-threatening complications and all complications with
an incidence of 1 per cent or more should be discussed with the
patient
The risk of death doubles with every seven years of adult life lived.
The presence of peripheral vascular disease, stroke, heart failure,
myocardial infarction or renal failure each independently increases
the risk of death by

28. C O N T. . .
-About 1.5 times the baseline. The risks of the surgical procedure
itself are then to be added on separately.
 Valid consent implies that it is given voluntarily by a competent and
informed person who is not under duress
 In emergency situations or in an unconscious patient, consent may
not be obtained and the procedure carried out ‘in the best interests
of the patient’.

29. C O N T. . .
Adults are presumed to have capacity to consent unless there is
contrary evidence. For adults who are not deemed competent to
give consent, treatment can still proceed in their best interests by
filling in an inability to consent form.
Those under 16 years who demonstrate the ability to appreciate the
risks and benefits fully are deemed competent. This is known as
Gillick competence

30. R I S K A S S E S S M E N T A N D C O N S E N T
Risks: Related to the comorbidities, anaesthesia and surgery
■ Explain: Advantages, side effects, prognosis
■ Language: Simple, use daily life comparisons to explain risks
■ Consents: Valid consent is necessary except in life-saving
circumstances

31. N U T R I T I O N A N D F L U I D T H E R A P Y
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. Malnutrition is
common in hospital patients.

32. C O N T. . .
The success or otherwise of nutritional support should be
determined by tolerance to nutrients provided and nutritional end
points, such as weight.
It is unrealistic to expect nutritional support to alter the natural
history of disease.
It is imperative that nutrition-related morbidity is kept to a This
necessitates the appropriate selection of feeding method, careful
assessment of fluid, energy and protein requirements, which are
regularly monitored, and the avoidance of overfeeding.

33. I N T R A O P E R AT I V E
C A R E

34. D E F I N I T I O N
The term "intraoperative" refers to the time during surgery.
Intraoperative care is patient care during an operation and ancillary
to that operation.
Activities such as monitoring the patient's vital
signs , blood oxygenation levels, fluid therapy, medication
transfusion, anesthesia, radiography, and retrieving samples for
laboratory tests, are examples of intraoperative care.

35. C O N T. . .
The purpose of intraoperative care is to maintain patient safety and
comfort during surgical procedures.
Some of the goals of intraoperative care include maintaining
homeostasis during the procedure, maintaining strict sterile
techniques to decrease the chance of cross-infection, ensuring that
the patient is secure on the operating table, and taking measures to
prevent hematomas from safety strips or from positioning.

36. C O M P L I C AT I O N S
Intraoperative complications are surgery related, anesthesia
related, or position related. One complication occurring during the
intraoperative period that is not common but can be life threatening
is an anaphylactic (allergic) reaction to anesthesia.
The intraoperative staff is trained extensively in the treatment of
such a reaction, and emergency equipment should always be
available in the event it is needed for this purpose.

37. C O N T. . .
Another anesthesia-related complication is called "awareness
under anesthesia." This occurs when the patient receives sufficient
muscle relaxant (paralytic agent) to prohibit voluntary motor function
but insufficient sedation and analgesia to block pain and the sense
of hearing . Patients are aware

38. POST OPERATIVE
CARE

39. C O N T. . .
The aim of postoperative care is to provide the patient with as
quick, painless and safe recovery from surgery as possible.
Trainees should acquire knowledge and skills to manage surgical,
as well as medical, postoperative problems.

40. G E N E R A L M A N A G E M E N T
Patient’s vital parameters, consciousness, pain and hydration
status are monitored in the recovery room and supportive treatment
is given .
 Specific monitoring, such as Doppler flow for a free flap,
observations like neurological evaluation and laboratory tests such
as blood gas analysis may also be requested where necessary

41. C O N T. . .
The patient can be discharged from the recovery room when they
fulfil the following criteria:
 Patient is fully conscious.
 Respiration and oxygenation are satisfactory.
 Patient is normothermic, not in pain nor nauseous.
 Cardiovascular parameters are stable.

42. S Y S T E M - S P E C I F I C P O S T O P E R AT I V E
C O M P L I C AT I O N S
The presentation of complications may be similar for more than one
underlying condition.
Shortness of breath can be due to respiratory or cardiac problems,
abdominal pain can be due to surgical causes or sepsis, while chest
pain may be present in cardiac, respiratory and even in
gastrointestinal problems.

43. R E S P I R AT O R Y C O M P L I C AT I O N S
The most common respiratory complications in the recovery room are
hypoxaemia, hypercapnia and aspiration. Pneumonia and pulmonary
embolism tend to appear later in the postoperative period.

44. C A R D I O VA S C U L A R C O M P L I C AT I O N S
Hypotension in the immediate postoperative period may be due to
inadequate fluid replacement, vasodilatation from subarachnoid and
epidural anaesthesia or rewarming of the patient.
However, other causes of hypotension such as surgical bleeding,
sepsis, arrhythmias, myocardial infarction, cardiac failure, tension
pneumothorax, pulmonary embolism, pericardial tamponade and
anaphylaxis should be also sought

45. C O N T. . .
Patients with hypotension are likely to have cold clammy
extremities, tachycardia and a low urine output ≤0.5 mL/kg per hour
and low CVP.
Hypovolaemia should be corrected with intravenous crystalloid or
colloid infusions (see below under Bleeding).

46. U R I N A R Y R E T E N T I O N
Inability to void after surgery is common with pelvic and perineal
operations or after procedures performed under spinal anaesthesia.
Pain, fluid deficiency, problems in accessing urinals and bed pans,
and 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.

47. U R I N A R Y I N F E C T I O N
Urinary infection is one of the most commonly acquired infections in
the postoperative period.
Patients may present with dysuria and/or pyrexia.
Immunocompromised patients, diabetics and those patients with a
history of urinary retention are known to be at higher risk.
Treatment involves adequate hydration, proper bladder drainage
and antibiotics depending on the sensitivity of the microorganisms.

48. G E N E R A L P O S T O P E R AT I V E P R O B L E M S
A N D M A N A G E M E N T
Hypothermia and shivering Anaesthesia induces loss of
thermoregulatory control. Exposure of skin and organs to a cold
operating environment, volatile skin preparation (which cool by
evaporation), and the infusion of cold i.v. fluids all lead to
hypothermia.
.

49. F E V E R
About 40 per cent of patients develop pyrexia after major surgery;
however, in most cases no cause is found.
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.

50. C O N T. . .
Patients with a persistent pyrexia need a thorough review. Relevant
investigations include full blood count, urine culture, sputum
microscopy and blood cultures

51. E N H A N C E D R E C O V E R Y
Enhanced recovery is an approach to the perioperative care of
patients undergoing surgery. It is designed to speed clinical
recovery of the patient, and reduce 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
and then delivering evidence-based best care in the perioperative
period.

52. C O N T. . .
Postoperative strategies for enhanced recovery include:
Early planned physiotherapy and mobilisation.
Early oral hydration and nourishment.
 Good pain control using regular paracetamol with nonsteroidal
anti-inflammatory drugs (NSAIDs). Epidurals and nerve blocks are
managed by acute pain teams.

53. C O N T. . .
Discharge planning is started before the patient is even admitted to
hospital and involves support from stoma care nurses,
physiotherapists and other community care workers

54. C O N T. . .
Early mobilisation is encouraged to reduce the risks of DVT, urinary
retention, atelectasis, pressure sores and faecal impaction.
Telephone follow up is carried out to make sure that the patient is
recovering well once discharged.

55. R E F E R E N C E
Bailey and Loves: Short practice of Surgery, 26ed.
Hardy’s Textbook of Surgery

56. THANK YOU