Fluid and electrolytes management in post op patientsDr.Sonal Dixit
sonal dixit , mbbs , ms obg
After surgery modification in normal physiology of fluid and electrolytes balance.
- ACUTE STRESS leads to increased sympathetic stimuli- tachycardia, vasoconstriction & stress.
Increased ACTH stimulate adrenal gland which secretes large amount of hydrocortisone to fight acute stress and aldosterone which leads to Na retension and urinary loss of K.
Wound management has made rapid advances over the last 25 years. New innovations in dressing technology could have a huge impact on the greater wound care industry.
Principles of surgery. Day case surgery is a rapidly evolving surgical sub speciality that seeks to eliminate the need for prolonged admission in surgical patients and the attendant complications of prolonged immobilization. It is based on the documented evidence that most post op patients does not require specialised post op care and hence can be allowed to recover at home. This form of surgery appeals to patients and their families due to the fact that it allows only minimal interruption of patient's social life
Fluid and electrolytes management in post op patientsDr.Sonal Dixit
sonal dixit , mbbs , ms obg
After surgery modification in normal physiology of fluid and electrolytes balance.
- ACUTE STRESS leads to increased sympathetic stimuli- tachycardia, vasoconstriction & stress.
Increased ACTH stimulate adrenal gland which secretes large amount of hydrocortisone to fight acute stress and aldosterone which leads to Na retension and urinary loss of K.
Wound management has made rapid advances over the last 25 years. New innovations in dressing technology could have a huge impact on the greater wound care industry.
Principles of surgery. Day case surgery is a rapidly evolving surgical sub speciality that seeks to eliminate the need for prolonged admission in surgical patients and the attendant complications of prolonged immobilization. It is based on the documented evidence that most post op patients does not require specialised post op care and hence can be allowed to recover at home. This form of surgery appeals to patients and their families due to the fact that it allows only minimal interruption of patient's social life
Preanesthetic evaluation of patients in oral and maxillofacial surgeryPunam Nagargoje
The word is derived from the Greek words an, which means “without” and aithesia which means “feeling”
The use of medical anesthesia was first reported in 1846
The development of anesthesia has made today’s modern surgical techniques possible
• Basic Principles of Anesthesia
• “Triad of General Anesthesia”
need for unconsciousness
need for analgesia
need for muscle relaxation and loss of reflexes
• Preoperative Evaluation
• The preanesthetic evaluation has specific objectives including:
- Establishing a doctor-patient relationship,
- Becoming familiar with the surgical illness and
- coexisting medical conditions,
- Anticipating potential complication
Developing a management strategy for perioperative anesthetic care,
- Obtaining informed consent for the anesthetic plan.
The overall goals of the preoperative assessment are to reduce perioperative morbidity and mortality and to allay patient anxiety.
• Pre-operative
This applied both in evaluation & investigations
• General
This include the following:
1-General condition of the patient.
2-Psychological condition. ( Specially in major operations).
• Specific
This include the following:
1-Related to anaesthesia.
2-Related to the surgery.
• Medical History
1. Review the chart
2. Review previous records
3. Interview the patient
• Demographic Data
Height / weight
Vital signs
Diagnosis
History and Physical Exam
Note any abnormalities
Don’t assume that all problems are listed
• Steps of the preoperative visit :
• Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.
• Pre-op Testing Schema Example
• Preoperative Laboratory Testing:
• only if indicated from the preoperative history and physical examination.
• "Routine or standing" pre operative tests should be discouraged
• -CBC anticipated significant blood loss, suspected hematological disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy.
• -Electrolytes diuretics, chemotherapy, renal or adrenal disorders
• -ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease, DM, renal, thyroid or metabolic disease.
• -Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a change in respiratory symptoms in the past six months.
• -Urine analysis DM, renal disease or recent UTI.
• -tests for different systems according to history and examination
• Disease-based indications
Alcohol abuse
CBC, ECG, lytes, LFTs, PT
Anemia
CBC
Bleeding disorder
CBC, LFTs, PT, PTT
Cardiovascular
CBC, creatinine, CXR, ECG, lytes
• Disease-based indications
Cerebrovascular disease
Creatinine, glucose, ECG
Diabetes
Creatinine, electrolytes, glucose, ECG
Hepatic disease
CBC, creatinine, lytes, LFTs, PT
• Disease-based indications
Pregnancy (controversial)
Serum B-hCG- 7 days, Upreg 3 days
Pulmonary disease
CBC, ECG, CXR
Renal disease
CBC, Cr, lytes, ECG
RA
CBC, ECG, CX
BCC4: Michael Parr on ICU - Surviving Trauma GuidelinesSMACC Conference
Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.
perioperative preparations in obstetrics and Gynecology.pptxEkramNasher
This PowerPoint describe all preparations that doctors follow during preparation obstetrical and Gynecological cases for operations and the important instructions which should be taken
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
2. Outline
• Objectives
• Introduction
• Patient assessment
• Specific preop problems and management
• Preop assessment in emergency surgery
• Risk assessment and consent
• Arranging the theatre list
• References
2
3. Objectives
• Be able to organize preoperative care and the
operating list
• To understand Surgical, medical and anesthetic
aspects of assessment
• To understand How to optimize the patient’s
condition
• To understand How to take consent
3
5. Introduction
• Preoperative care is a comprehensive
approach which begins with the decision to
perform surgery and continues until the
patient enters the OR.
6. Components of preoperative care
• Preoperative assessment
Reviewing client’s health status(Hx&Px)
Investigating
• Optimization of pt condition
7. Patient assessment
• To look actively for risks and manage them so as
to enable surgery to go ahead safely.
• Done by the surgical, nursing team and/or
anesthetic team
• Includes history, physical examination and
investigations
• The aim of preoperative evaluation is not to
screen broadly for undiagnosed disease, but to
identify and quantify any co morbidity that may
affect the operative outcome.
7
8. Patient Assessment
• Goals:
Assess the Risk of surgical vs non-surgical Rx.
Assess the extent of known disease present.
Identify unknown or hidden diseases(risks ).
Develop an individualized anesthetic plan.
8
9. Risk Assessment
• Two major questions
1. Is the patient in optimal medical condition for
surgery?
2. Benefits of surgery vs associated risk balance.
Is it worthy?
9
10. I. Review the client’s health status
History
Hx of present illness and reason for surgery
Past medical Hx
Prior Hx of problem with anesthesia
Allergies and current medications
Substance use
Review of system
12. Airway evaluation
• Purpose is to predict and possibility of
intubation
• look for- neck mobility
short neck
protruding teeth
large tongue
Mallapati test
15. INVESTIGATIONS
• Rationale for preoperative testing
– To detect unsuspected abnormalities
– To establish a baseline value for a test
– For medico-legal reasons
• Routine preoperative testing
– Not cost-effective
– Less predictive of perioperative morbidity
– Should be individualized
15
16. Preoperative Ixs
Should be individualized
• CBC, BG and X- match
• S/electrolytes
• RFT
• U/A
• CXR
• ECG
• Other tests – coagulation studies, radiographic, TFT, RBS,
HbA1C PFT, LFT as necessary
18. CVS
• is the leading cause of death in the
industrialized world, and
• its contribution to perioperative mortality
during noncardiac surgery is significant
• All patients scheduled to undergo noncardiac
surgery should have an assessment of the risk
of a cardiovascular problems
18
19. Cardiovascular disease
• Contributes to perioperative mortality.
• The degree of risk can be assessed using the:
– Goldman Index
– Lee’s criteria(RCRI)
–MET
–NYHA
19
20. Goldman Index
Risk factor Score
Age > 70 years 5
MI within 6 months 10
Third heart sound /gallop rhythm 11
Aortic stenosis 3
Rhythm other than sinus 7
>5 Ventricular ectopics per min 7
Emergency surgery 5
Abdominal or thoracic operation 3
Poor general condition 3
Cardiac Complication Rate:
Class I ( 0-5)……0.9%
Class ii (6-12)……. 7.1%
Class iii (13-25)….. 16%
Class iv ( > 26) …….. 63.6 %
• above 26 has a mortality of
50% and only life- saving
operations should be
considered
20
21.
22. Metabolic equivalent of task (MET).
– 1 MET= 3.5 mL O2/kg per minute (oxygen
consumption by 40 year, 70 kg man at rest)
– 1 MET = eating and dressing
– 4 MET = climbing two flights of stairs
– 6 MET = short run
– >10 MET = able to participate in strenuous sport
NB Patients who can exercise at 4 METS or
above have lower risk of perioperative mortality
22
23. NYHA Functional Class
Class
I
No limitation of physical activity; ordinary
activity does not cause fatigue,
palpitations or syncope
Class
II
Slight limitation of physical activity;
ordinary activity results in fatigue,
palpitations or syncope
Class
III
Marked limitation of physical activity; less
than ordinary activity results in fatigue,
palpitations or syncope; comfortable at
rest
Class
IV
Inability to do any physical activity without
discomfort; symptoms at rest
23
24. Very high-risk patients need optimization
• Recent MI
• Unstable angina
• Decompensated heart failure
• High-grade arrhythmias
• Hemodynamically important VHD
• Uncontrolled Hypertension
25. Hypertension
• Most common medical reason for postponing
surgery
• Leads to many complications
• Poorly controlled hypertension
– DBP > 110 or SBP > 160 25
26. Cardiovascular disease…
• Elective surgery
– DBP >110mmHg should not undergo elective surgery
– CBC, RFT, ECG and CXR
– Bp should be controlled to near 160/90 mmHg
– If a new antihypertensive is introduced
• stabilisation for at least 2 weeks
26
27. Cardiovascular disease…
• Well-controlled hypertension
– continue medication up to, and including, the day of
surgery
• Premedication
– benzodiazepines
– two hours prior to surgery
• Emergency Surgery
– Bp may need to be controlled more rapidly
– but don’t drop Bp precipitously
28. Ischemic Heart Disease
• Dangerous risk factor
• Recent MI is strong contraindication for elective surgery
• At least 3-6 months should be lapsed after an attack
• Significant mortality from anesthesia within 3 mon.
• Elective surgery- should be delayed for 6 months.
• If urgent surgery needed
- aggressive therapy.
− meticulous optimization of O2 and fluid balance
throughout the perioperative period must be obtained
28
29. CVS …cont’d
Valvular heart disease:
– Cardiologist and anesthesiologist evaluation
– Warfarin should be stopped 5days before surgery
with INR of 1.5
– UFH infusion if INR is/falls below 1.5 until 2hrs
before surgery with aPTT goal of 1.5 times norma
– Continue postoperatively..
29
30. CVS …cont’d
• Dysrhythemia
o AF should be controlled before surgery.
o If Digoxin used- measure K reguraly
o 2nd & 3rd degree heart block – pacemaker.
• Anemia & Transfusion
o Preop HgB less than 6-7mg/dl
o Symptomatic
o Active bleeding 30
32. Respiratory disease
• Perioperative pulmonary physiology:
– Vital capacity (VC) is reduced by 50 to 60 percent
and may remain decreased for up to one week.
– Functional residual capacity (FRC) is reduced by
about 30 percent.
32
33. Respiratory disease … cont’d
Risk factors for pulmonary complications can
be grouped into patient-related and procedure-
related risk
1. Procedure-related risk factors
– Surgical site
– Duration of surgery (>3-4hrs)
– Type of anesthesia
– Type of neuromuscular blockade
2. Patient-related risk factors
33
34. Pulmonary Disease…
• Decrease postoperative pulmonary complications
– smoking cessation (>2 mos before the planned
procedure)
– bronchodilator therapy
– antibiotic therapy for preexisting infection
– pretreatment of asthmatic patients with steroids
– use of epidural anesthesia
– vigorous pulmonary toilet and rehabilitation
35. Pulmonary Disease…
COPD & ASTHMA
Management
– Preoperative bronchodilator
– Regional anesthesia is better
– Intra op stress dose steroid administration
Infection
• elective surgery should be postponed
• treat with antibiotics and physiotherapy
• operation rescheduled after 4–6 weeks
36. Respiratory disease … cont’d
Pulmonology referral :
– Severe disease deteriorating from usual
– Major surgery for resp. comorbidities
– Right side heart failure
– Young pt with COPD
36
37. Gastrointestinal disease
NPO and regular medications:
– Clear liquids- 2hrs
– Breast milk- 4hrs
– Cow milk, formula milk, light meal- 6hrs
– Fried or fatty food or meat – 8hrs
– Medications with sips of water
37
38. Gastrointestinal disease…cont’d
Regurgitation risk: hiatus hernia, obesity,
pregnancy and diabetes are at risk of regurgitation
even after NPO
– Rx with clear antiacids , H2 blocker/PPIs
Liver disease:
any evidence of clotting problems, renal involvement,
alcoholic hepatitis and encephalopathy, surgery should
be postponed at least 12wks/patient recover .
In chronic hepatitis surgery can be safely done
38
39. Genitourinary disease
Renal disease
– CKD: rx cxs like acidosis, hypocalcemia, and
hyperkalemia >6mmol/l If pt is on dialysis continue until
few hours before surgery and determine RFT, CBC and
serum electrolytes
– Anemia is usually well tolerated
– AKI with emergency surgery needs simultaneous surgical
and medical rx with critical care support as needed
UTI
– Should be treated 1st for elective surgery, but in case of
emergency rx started and surgery after good urine output
39
40. Endocrine and metabolic disorders
Malnutrition:
• Nutritional assessment : ABC
– Anthropometry and body weight
• BMI<18.5 nutritional impairment
• BMI<15 is associated with major hospital mortality
• Skin fold thickness
• MUAC
– Biochemical (laboratory studies)
• Serum albumin<30g/l indicator of poor prognosis
• Lymphocyte count and skin test for delayed hypersensitivity
– Clinical
• MUST- five step screening tool
40
41. 41
Nutritional support for a minimum of 2 weeks before surgery
is required to have any impact on subsequent morbidity
42. Endocrine and metabolic disorders…
cont’d
Obesity : morbid obesity BMI>35 is associated
with increased risk of postop cxs
– Perioperative sleep apnea
– DVT
– Aspiration
• Rx : prolong surgery if possible
– CPAP and cholesterol reducing agents
– Prophylaxis for aspiration and DVT
42
43. Endocrine and metabolic disorders…
cont’d
Diabetes mellitus
Strict glycemic control is needed b/c surgery and GA causes
neuroendocrine stress response
Assess for
• Type of DM
• Long term cxs
• Baseline glycemic control if >200mg/dl associated with deep
wound infection
• Hypoglycemia hx
• Hx of therapy
• Type of anesthesia and surgery
Ixs : ECG,RFT, RBS, and HgbA1c
43
44. Endocrine and metabolic disorders…
cont’d
Goals of glycemic control
General goal
Avoid hypoglycemia
Prevent DKA/Hyperosmolar state
Maintenance of fluid and electrolyte
Avoid marked hyperglycemia
Glycemic targets
110-180mg/dl in noncritical hospitalized pt
80- 180mg/dl in perioperative pt
44
45. Endocrine and metabolic disorders…
cont’d
• Perioperative phase:
– Pts should have surgery as early as possible in morning
– T2DM with diet rx alone
• Do not require rx perioperatively
• Correction insulin if RBS is above target
• Monitor RBS every 2hr for long surgery(>2hs)or
surgeries with expected high glucose level
– T2DM on oral hypoglycemic agent
• Continue routine medication until morning dose(hold)
• If HgbA1c <7.0% will not need insulin
• Determine RBS every 2hrs and put on sliding scale
every 6hrs if hyperglycemic 45
46. Endocrine and metabolic disorders…
cont’d
• T1DM or T2DM on insulin
– Pt undergoing morning procedure where breakfast and
lunch likely to be missed:
• Omit short acting insulin
• Reduce to 1/3 - 1/2 of dose on intermediate and long acting
• Pt on continuous infusion can continue
• Start on D5W at rate of 75-125 ml/hr to avoid metabolic
change of starvation
• RBS every hour or less if RBS is <100mg/dl
• Put on sliding scale if hyperglycemia develops
• Postoperative phase: perioperative rx regimen
maybe reinstated once pt is eating well
46
49. THROMBOSIS RISK
• Patients with increased risk of VTE balance with risk of bleeding
• AAOS risk factors for major bleeding
– bleeding disorders
– history of a recent gastrointestinal bleed
– history of a recent hemorrhagic stroke
• AAOS risk factors for pulmonary embolus
– hypercoagulable state
– previous documented pulmonary embolism
50. Neurological and psychiatric
disorders
• Hx of stroke , pre-existing neurologic deficit on
antiplatelet and anticoagulant
– If risk of cardiovascular thrombotic is low stop aspirin
7days and clopidogrel 10 days before surgery
– If risk is high continue aspirin only
• Anticonvulsant and anti parkinson medication is
continued perioperatively
• Lithium should be stopped 24 hours prior to
surgery
• Inform anesthetist about TCA , MAOIs as they
interact with anisthesia
50
51. Musculoskeletal and other disorders
• RA of cervical spine can lead to unstable cervical
spine with the possibility of spinal cord injury
during intubation
• In ankylosing spondylitis spinal/epidural
anesthesia are often challenging
• SLE may be associated with hypercoagulable
state along with airway difficulties
• NSAID- hold 3 days prior to surgery
• Methotrexate- continue up to including day of
surgery, in patient with renal insufficiency hold 2
weeks prior to surgery
51
52. Pre op Medication
• OCP/HRT—4-6 weeks
• Asprin—1 week??
• Warfarin -5-7 days
• NSAIDS –5-7 days
• ACEI
• Lasix
• Metformin
• Heparin
52
Discontinue Early
Discontinued on
Day of Surgery
54. Prophylactic antibiotics
• to prevent surgical site infection
• 30min to 2 hour before surgical incision
Indications
– clean surgery involving insertion of a prosthesis or
implant
– clean-contaminated surgery
– contaminated surgery
• should be discontinued within 24 hours of surgery
55. Antimicrobial prophylaxis Orthopedic
surgery
• Antimicrobial prophylaxis is warranted for spinal
procedures, repair of hip and other closed
fractures, implantation of internal fixation device
(screws, nails, plates, and pins), and total joint
replacement.
• Antimicrobial prophylaxis is not warranted for
clean orthopedic procedures; these include
arthroscopy and other procedures involving the
hand, knee, or foot with no implantation of
foreign materials.
55
56. Peri-operative Skin Preparation
56
• Whole body cleansing with chlorhexdine.
• The night before & morning.
• Clipping of hair is preferable .
• Hair should be removed as close as to the
surgery.
57. Preoperative assessment in
emergency surgery
• Start: Similar principles to that for elective
surgery
• Constraints: Time, facilities available
• Consent: May not be possible in life-saving
emergencies
• Organizational efforts: For example,
local/national algorithms for treatment of
multi-trauma patient
57
58. Risk assessment
• Risk after surgery is a complex interaction of
multiple factors :
1. Patient factors
History of severe cardiac disease:- IHD, MI, CHF
Severe respiratory disease :- COPD, respiratory failure
Aged >70 years with limited physiological reserve in
one or more vital organs
Metabolic disease :- renal failure, poorly controlled
diabetes
Morbid obesity
Late stage vascular disease
Poor nutrition 58
59. Risk assessment… cont’d
2. Surgical factors
– Prolonged duration of surgery (>1.5 hours)
– Extensive surgery (e.g. oesophagectomy, gastrectomy)
– Type of surgery (thoracic, abdominal, vascular)
– Emergency surgery (e.g. perforated viscus, gangrenous
bowel, gastrointestinal bleeding)
– Acute massive blood loss (>2.5 litres)
– Septicaemia (positive blood cultures or septic focus)
– Severe multiple trauma e.g. >3 organs or >2 systems
or ≥2 body cavities open
59
60. Risk assessment… cont’d
• Number of scoring systems have been developed
over the years with the aim of identifying high-
risk patients
• Risk scoring systems
– ASA is simple, but subject to user interpretation
– MET measures exercise tolerance related to daily
living
– RCRI used to predict cardiac risk for non-cardiac
surgery
– POSSUM can only be used postoperatively and better
for some types of surgery, e.g. colorectal, vascular
– CPET is non-invasive, objective and becoming
increasingly popular
60
63. Consent
• 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’
63
64. consent…
Steps in consent taking
• patient’s demographic details should be checked
• make sure that the patient understands
– who you are
– what your role is
• the planned operation should be outlined and confirmed
with the patient
• a brief explanation of the planned operation
– the risks and benefits involved
– alternatives
– the risks and benefits of doing nothing
65. consent…
• Discuss the type of anesthetic proposed
• Give the patient time and space to make the final decision
• Check that the patient understands and has no more
questions
• Record clearly and comprehensively what has been agreed
66. Preoperative Preparation Immediately Before
Surgery…
7/19/2023
• Consent
– if they want the consent process to be repeated
– any questions
– happy to proceed with surgery
– should be recorded in the notes
• Check that all relevant results and imaging are available
• The side or area to be operated on should be marked.
67. Preoperative Preparation Immediately Before
Surgery
7/19/2023
• The patient’s identity should be confirmed
• A check should be made
– no change in the patient’s condition
– for any sepsis (skin, teeth, urine and chest)
68. Arranging the theatre list
• Date, place and time of operation
• Appropriate equipment and instrument
• Operating list should be distributed to all staff
• Priorities for:
– Children
– Diabetic
– Limb and life threatening
– Cancer pts
68
69. References
Bailey & Love’s short practice of surgery, 27th
edition
Sabiston Textbook of Surgery 20th edition
Uptodate 2022
ASA classification system
• Apley and Solomon’s System of Orthopaedics and
Trauma
• Orthobullet
69
The perioperative period is a term used to describe the three distinct phases of any surgical procedure, which includes the preoperative phase, the intraoperative phase, and the postoperative phase.
the preoperative phase, begins with the decision to have surgery and ends when the patient is wheeled into surgery. This phase can be extremely brief, such as in the cases of acute trauma, or require a long period of preparation during which time a person may be required to fast, lose weight, undergo preoperative tests, or await the receipt of an organ for transplant.
The second phase, known as the intraoperative phase, involves the surgery itself. It starts when the patient is wheeled into the surgical suite and ends when the patient is wheeled to the post-anesthesia care unit (PACU).
The final phase, known as the postoperative phase, is the period immediately following surgery. As with the preoperative phase, the period can be brief, lasting a few hours, or require months of rehabilitation and recuperation.
Emotional state
Mind Competency
Coping strategies
Support system
Toassesstheris kofsurgeryvs.non-surgicia ltreatments
i nordertoallowachoiceoftreatment stobeofferedand
informe dconsentaboutagivenoperationtobeobtained
*Toassessth eextentofknowndiseasepresen ti nthe
patien ti nordert oallowappropriatetreatmen tt obe
employedpreoperativelyandpostoperatively
Toidentif yunknownorhiddendiseases(risks )i norder
t oallowprophylacti ctreatmen tthatmightreduc eth e
ris kandallo wplannin gfo rmanagementofpotential
Patientselectionistheoverallprocessofassessmentand
riskcomparisonthatallowsthesurgeontomakeadecisionregardingthesuitabilityofapatientforagivenoperation.Previously,therewasverylittleselectioninvolved
inthedecisiontooperate,particularlyinlife-threatening
Conditions.
Risk assessment
Morbidity and mortality — The American Society of Anesthesiologists (ASA) physical status classification system is a relatively simple system that has proven effective in stratifying overall perioperative risk of morbidity and mortality for patient-specific risk factors (table 2) [2]. Patients are classified according to the degree to which underlying medical problems produce functional limitations. A higher ASA physical status is associated with increased risk of complications, unexpected hospital admission after ambulatory surgery, postoperative admission to the intensive care unit (ICU), longer hospital length of stay, higher costs, and mortality due to patient-specific and surgery-specific factors
Assessment should be completed by classifying the patients
according to ASA physical status and grading of surgery so that
high risk patients with poor reserves will require consultation with
specialists to help optimize the physical status for surgery and
anaesthesia
Personal or family history of anesthetic complications — Malignant hyperthermia is a rare complication of anesthetic administration that is inherited in an autosomal dominant fashion. Due to the morbidity and potential mortality associated with this condition, the preoperative history should include questioning about either a personal or family history of complications from anesthesia.
For the first rationale, three actions are possible regarding an abnormal test result. First, clinicians may take action to correct the abnormality before surgery with the hope that correction will decrease the risk of perioperative complications. Second, a serious abnormality might result in the clinician recommending that the surgery be canceled or the nature of the surgery be modified to a less intensive procedure. Third, the abnormality simply may be ignored.
Of the 27 million patients undergoing surgery in the United States every year, 8 million, or nearly 30%, have significant coronary artery disease or other cardiac comorbid conditions.
The risk of life-threatening cardiac complications is only 1% with total score up to 5. The risk becomes 5% if the points total up to 12, increases to 11% with counts up to 25, and reaches 22% when the points >25.
1-4 METS-standard home activity, walk around house, walk 1-2 blocks on level ground at 3-5 km/h
5-9 METS- climb a flight of stairs, walk up a hill, walk on level ground at >6km/h, run short distance, moderate activities (dancing)
10 or above- strenuous activities like swimming, bicycle
An easy, inexpensive method to determine cardiopulmonary functional status for noncardiac surgery is the patient's ability or inability to climb two flights of stairs. Two flights of stairs is needed because it demands greater than 4 metabolic equivalents (METs). In a review of all studies of stair climbing as preoperative assessment, prospective studies have shown it to be a good predictor of mortality associated with thoracic surgery.[7] In major noncardiac surgery, an inability to climb two flights of stairs is an independent predictor of perioperative morbidity, but not mortality.
Severe untreated hypertension in the perioperative period
AMI, left ventricular failure
Cerebral hemorrhage, hypertensive encephalopathy
Renal failure
Marked swings in blood pressure
Bleed more during surgery
These results suggest that elective surgery in patients with hypertension does not need to be delayed as long as the diastolic blood pressure is less than 110 mmHg and intraoperative and postoperative blood pressures are carefully monitored to prevent hypertensive or hypotensive episodes. On the other hand, when hypertension has caused end-organ disease such as congestive heart failure and renal insufficiency, the probability of adverse cardiac outcome in the perioperative period increases significantly [12]. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
The impact of systolic hypertension on operative risk is less clear. One study of patients undergoing carotid endarterectomy found that a systolic pressure greater than 200 mmHg was associated with an increased risk of postoperative hypertension and neurologic deficits [13]. Patients with isolated systolic hypertension are at increased risk for cardiovascular morbidity after coronary artery bypass surgery
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
BLOOD PRESSURE RESPONSE DURING ANESTHESIA — Sympathetic activation during the induction of anesthesia can cause the blood pressure to rise by 20 to 30 mmHg and the heart rate to increase by 15 to 20 beats per minute in normotensive individuals [5]. These responses may be more pronounced in patients with untreated hypertension in whom the systolic blood pressure can increase by 90 mmHg and the heart rate by 40 beats per minute.
The mean arterial pressure tends to fall as the period of anesthesia progresses due to a variety of factors, including direct effects of the anesthetic, inhibition of the sympathetic nervous system, and loss of the baroreceptor reflex control of arterial pressure. These changes can result in episodes of intraoperative hypotension. Patients with preexisting hypertension are more likely to experience intraoperative blood pressure lability (either hypotension or hypertension) [6], which may lead to myocardial ischemia
Patients with well-controlled hypertension responded similarly to normotensive subjects. Other studies have found that a diastolic pressure over 110 mmHg immediately before surgery is associated with a number of complications including dysrhythmias, myocardial ischemia and infarction, neurologic complications, and renal failure
Severe hypertension — An early study found that patients with untreated severe hypertension (mean systolic and diastolic pressures of 211 and 105 mmHg, respectively) had exaggerated hypotensive responses to the induction of anesthesia and marked hypertensive responses to noxious stimuli
Significant or worsening angina needs investigation by a
cardiologist before elective surgery (Fig. 13.2). If urgent surgery is
required, aggressive medical therapy is indicated and meticulous
optimisation of oxygenation and fluid balance throughout the
perioperative period must be obtained
Postoperative MI is associated with hospital mortality rates of 15% to 25%; these patients also are at greater risk for cardiovascular death and nonfatal MI during the 6 months after surgery.
The optimal timing of a surgical procedure after MI depends on the duration of time since the event and assessment of the patient’s risk for ischemia by clinical symptoms or noninvasive study. Any patient can be evaluated as a surgical candidate after an acute MI (within 7 days of evaluation) or a recent MI (within 7 to 30 days of evaluation). The infarction event is considered a major clinical predictor in the context of ongoing risk for ischemia. General recommendations are to wait 4 to 6 weeks after MI to perform elective surgery
In patients with mechanical heart valves, warfarin needs to
be stopped for 5 days before surgery, and an infusion of unfrac-tionated heparin started when the INRfalls below 1.5. The acti-vated partial thromboplastin time (APTT) should be monitored
to keep it at 1.5 times normal and the infusion is then stopped
2 hours before surgery. Heparin and warfarin should be started
in the postoperative period and heparin is stopped when the full
effect of warfarin is realised
Cardiac output can increase by 15% if sinus rhythm is restored
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.
ardiac output can increase by 15% if sinus rhythm is restored. Warfarin in patients with atrial fibrillation (AF) should be stopped 5 days preoperatively to achieve an international normalised ratio (INR) of 1.5 or less, which is safe for most surgery
The newer anticoagulants such as dabigatran (direct thrombin inhibitor) or rivaroxaban, apixaban and edoxaban (direct factor Xa inhibitors) do not have antagonists and must be stopped preoperatively, generally for 2–3 days in patients with normal renal function and longer when renal function is impaired. Alternative anticoagulation is not required in the perioperative period unless the risk of stroke is high (high CHA2DS2- VACs score)
Prosthetic or leaking cardiac valves
Prophylactic antibiotic cover is usually necessary in these
patients, especially if turbulent flow is likely to occur or the surgery may produce a bacteraemia.
postoperative pulmonary complications are the most costly of major postoperative medical complications (including cardiac, thromboembolic, and infectious)
Type of neuromuscular blockade — Residual neuromuscular blockade can cause diaphragmatic dysfunction, impaired mucociliary clearance, and ultimately contribute to postoperative pulmonary complications. Pancuronium, a long-acting neuromuscular blocker, leads to a higher incidence of postoperative residual neuromuscular blockade compared with shorter acting agents [41]. Residual neuromuscular blockade is also an important risk factor for critical respiratory events in the immediate postoperative period
As there is no evidence of harm related to a short duration of cigarette abstinence, we advise all patients anticipating elective surgery to quit smoking as soon as possible, regardless of the anticipated date of surgery. When time allows, a longer duration (at least eight weeks) of cessation is optimal
stopped smoking < 2mon : stopped for > 2 mon ; 4:1(57% : 14.5%)
quit smoking > 6 months : never smoked ; 1:1 (11.9% : 11%)
Operative risk reduction has only been documented after 8 weeks of smoking cessation; however, there are physiologic benefits to stopping as little as 48 hours before surgery.
Despite the increased risk of postoperative pulmonary complications in patients with obstructive lung disease, there appears to be no prohibitive level of pulmonary function below which surgery is absolutely contraindicated
For patients who present with symptoms or signs suggestive of an exacerbation of COPD, elective surgery should be delayed pending treatment and a return to baseline pulmonary functionPatients who have received >20 mg of prednisone per day or its equivalent (eg, 16 mg/day of methylprednisolone, 2 mg/day of dexamethasone, or 80 mg/day of hydrocortisone) for more than three weeks during the previous six months are assumed to have suppression of hypothalamic-pituitary-adrenal function. We recommend empiric use of stress-dose glucocorticoids in these patients immediately before induction of anesthesia to avoid potential adrenal insufficiency
NB If the surgery is delayed, oral (until 2 hours of surgery) or
intravenous fluids should be started especially in the vulnerable
groups of patients, e.g. children, elderly and diabetics.
30 % of surgical patients with gastrointestinal disease and 60 % prolonged hospital stay because of postoperative complications
*If height, weight or weight loss cannot be established, use documented or recalled
values (if considered reliable). When measured or recalled height cannot be
obtained, use knee height as surrogate measure.
If neither can be calculated, obtain an overall impression of malnutrition risk
(low, medium, high) using the following:
(i) Clinical impression (very thin, thin, average, overweight);
(iia) Clothes and/or jewellery have become loose fitting;
(iib) History of decreased food intake, loss of appetite or dysphagia up to 3–6 months;
(iic) Disease (underlying cause) and psychosocial/physical disabilities likely to cause weight loss.
† Involves treatment of underlying condition, and help with food choice and eating
when necessary (also applies to other categories).
ACE inhibitors and angiotensin receptor blockersContinuation can result in hypotension.Discontinue night before surgery unless using for HF and baseline blood pressure is adequate.Discontinue on night before surgery unless using for HF and baseline blood pressure is not low. Use parenteral enalaprilat as needed in postoperative period.
Allay anxiety and fear.
Reduce secretions.
Enhance the hypotonic effect of anaesthetic agents.
Reduce postoperative nausea & vomiting.
Produce amnesia.
Reduce the volume & increase pH of gastric contents.
Reduce vagal reflexes.
Limitation of sympathoadrenal response
Alcohol is used as an antiseptic because of its rapid
antimicrobial action.
11
One systematic review of five
RTCs found that CHG-alcohol formulations were more
effective at preventing SSI than aqueous povidoneiodine solutions, and in other studies there was no
conclusive evidence that CHG-alcohol solutions were more effective than povidone-iodine products dissolved
in alcohol or aqueous solutions.
20
While we cannot
make a claim about the superiority of CHG over
iodine-based antiseptics, it is suggested that whichever
agent is chosen, it be dissolved in alcohol.
ASA, American Society of Anesthesiologists; CPET, cardiopulmonary exercise testing;
MET, metabolic equivalent of task; RCRI, revised cardiac risk index; POSSUM,
Physiologic and Operative Severity Score for the enUmeration of Mortality and
Morbidity
First, the patient’s demographic details should be checked with the patient.
Second, the planned operation should be outlined and confirmed with the patient.
All life- or limb-threatening complications and all minor complications with an incidence of 1% or more should be discussed.
Check details (correct patient)
All relevant results, investigations and imaging must be available.
Adequate preoperative planning should have been undertaken and preferably recorded in the notes.
A check should be made for any sepsis (skin, teeth, urine and chest).
Any neurovascular complications, the neurovascular status should also be recorded at this stage.
The side to be operated on should be marked with indelible pen
Informed consent remains valid for an indefinite period, allowing advance consent to be sought, providing that the patient's condition has not changed, and/or new information concerning the proposed intervention or alternative treatments have not come to light in the intervening period.3 It is good practice, if consent was obtained in advance, to confirm consent at the time of surgery
PREOPERATIVE PREPARATION
IMMEDIATELY BEFORE SURGERY
Patient preparation
Both the operating surgeon and the anaesthetist should see
the patient prior to surgery. The patient’s identity and the
proposed surgery should be confirmed. After explaining the
risks and benefits to the patient, valid consent for surgery
should be obtained. There should be an opportunity for questions,
and the patient should have adequate time to make their
decision (see LED TO REASON Table 16.6). Any changes
in the patient’s condition since listing for surgery should be
noted, and a check made for any contraindications to elective
surgery, e.g. intercurrent illness or remote site infection.
In procedures that may cause neurovascular complications,
the preoperative neurovascular status should be assessed and
documented. Check that all relevant results and imaging are
available, and that the side or area to be operated on is marked
with an arrow at or near to the incision site.
The patient’s identity should be confirmed
the patient should be asked to confirm what surgery is being carried out. The case notes should agree with this and with what is written on the operating schedule.
A check should be made that there has been no change in the patient’s condition since they were last seen and, if the patient’s condition has changed, this needs to be recorded.
Consent.
The patient should be asked if they want the consent process to be repeated and, even if not, they should be asked whether they have any questions and whether they are happy to proceed with surgery. This should be recorded in the notes