Professional Documents
Culture Documents
Shaikah A.O.B
peri-operative care
Objective :
1. 2.
3.
4.
5.
Notes about inter- operative complication . Discuses the post-operative care . Minchin the postoperative possible complications .
Surgery
Clean Surgery.
Clean-Contaminated.
Contaminated.
Dirty.
PHASES OF SURGERY
Pre-operative from the time of pxs decision for surgical intervention to the pxs tranference to the OR. Intra-operative px is received in the OR (with physical preparation) unto the admission in the RR. Post-operative pxs admission in the RR until the follow-up evaluation.
Effects of Surgery
Types of surgery
1- According to pt. A-In pt. surgery : pt. expected to remain in the hospital fore more
than 24 hrs.
B-0ut pt. surgery : ambulatory surgery same day surgery pt. return to
his home in the same day of surgery.
2- According to their urgency A-optional : at the request of pt. as cosmetic surgery . B-Elective : planned the convenience of pt. as removal of cyst C- required : should be done promptly as removal of cataract d-Urgent : required promptly within 24-48 hrs as malignant tumor E-Emergency : Immediately for survival as intestinal obstruction
appendectomy
Classification
Clean
Clean Contaminated
Contaminated Dirty
Grades of Surgery
Grade I (Minor) Excision of a skin lesion or drainage of abscess. Grade II (Intermediate) Tonsillectomy, correction of nasal septum, arthroscopy. Grade III (Major) Thyroidectomy, total abdominal hysterectomy. Grade IV (Major+) Radical neck dissection, joint replacement, lung operations
peri-operative care
Perioperative Period: Period of the time that constitute the surgical experience, include :Pre-operative .
Inter- operative.
Post operative .
is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation
Establish baseline history and physical. Identify previously undetected disease. Assess operative risk. Should the patient proceed with
elective surgery? Provide high-quality and safe patient care . Improve patient satisfaction and set foundation for optimum outcomes
Make specific recommendations regarding preoperative treatment that might lower the risk of surgery. Give suggestions regarding intraoperative and postoperative care.
Pre-operative Care
Assessment (evaluation).
Pro-op preparation .
Determines current medications Reviews past medical history Determines physical status:
Anaemia, jaundice, cyanosis, nutritional status, teeth, feet, leg ulcers (sources of infection) Cardiovascular Pulse, blood pressure, heart sounds, bruits, peripheral pulses, peripheral oedema Respiratory Respiratory rate and effort, chest expansion and percussion note, breath sounds, oxygen saturation Gastrointestinal Abdominal masses, ascites, bowel sounds, bruits, herniae, genitalia Neurological Conscious level, any pre-existing cognitive impairment or confusion, deafness, neurological status of limbs
ASA 1 A normal, healthy patient. The pathological process for which surgery is to be performed is localized and does not entail a systemic disease.
ASA 2 A patient with systemic disease, caused either by the condition to be treated or other pathophysiological process, but which does not result in limitation of activity. Example: a patient with asthma, diabetes, or hypertension that is well controlled with medical therapy, and has no systemic sequelae
ASA 3 A patient with moderate or severe systemic disease caused either by the condition to be treated surgically or other pathophysiological processes, which does limit activity. Example: a patient with uncontrolled asthma that limits activity, or diabetes that has systemic sequelae such as retinopathy
ASA 4 A patient with severe systemic disease that is a constant potential threat to life. Example: a patient with heart failure, or a patient with renal failure requiring dialysis.
ASA 5 A patient who is at substantial risk of death within 24 hours, and is submitted to the procedure in desperation.
Example: a patient with fixed and dilated pupils status post a head injury.
General Ix :
Full blood count (for example to test for anaemia) Haemostasis (to test how well the blood clots) Renal function Random blood glucose (to test for diabetes) Urine analysis (for example to test for urinary infections or kidney problems) Plain chest X-ray (radiograph) Resting electrocardiogram (ECG) Blood gases (to test for cardiovascular or lung problems) Lung function Pregnancy
Chest X-ray
Cardiovascular and respiratory disease
Malignancy Major thoracic and upper abdominal surgery
ECG
Indicated :
Men > 45 y - Women > 55 y . Known cardiac disease . H&P suggesting possibility of cardiac disease . Electrolyte imbalance risk (ie diuretic use) . DM/HTN . Candidates for major surgeries .
NOTE ECG :
Low likelihood of changing management Recent MI important to detect Cardiac event risk increased by:
Non-sinus rhythm PACs - Premature atriale contractions >5 PVCs - Premature ventricle contractions
NOTE:
Basic Factors Affecting Operative Risk : 1. Age over 70 years 2. Overall physical status 3. Elective vs. emergency surgery 4. Physiologic extent of the tumor 5. Associated illnesses as Jaundice, Bleeding tendency 6.Chronic drug medication as Oral contraceptive pills.
Anticoagulants Tranquilizers (hypnotic as benzodiazepine) Antibiotics aminoglycosides Diuretics Antiypertensives Long term steroid therapy
(P.S ) : Blood volume considerations:a. anemia chronic or acute b. minimal requirement for anesthesia 10 g/dl Hgb
NOTE:
Problems in elderly:
Tolerate hypo tension, tachycardia, over and under-hydration poorly Usually emphysema, they are used to a high level of PCO2 which leads to respiratory acidosis Atherosclerosis makes their CVS very fragile any sudden increase in B.P. can cause cerebral haemorrhage. Sluggish peripheral circulation higher chances of Thromboembolism and Pulmonary embolism Poorly tolerate acid-base imbalance
Problems of children:
They have a raised BMR lot of carbohydrates preoperatively and quick feeding postoperatively Very high incidence of Respiratory tract infection Poorly tolerate fever and cold
Airway evaluation
History of difficult intubation Head and neck examination for airway evaluation Face Oral cavity : mouth opening
mandibular space tongue teeth Mallampati classification
Mallampati classification
Airway evaluation
Mentothyroid distance : normal 6 cm. Mentosternal distance : normal 15 cm Mentohyoid distance : normal 3 FB Neck movement: flexion and extension of neck, history of radiation Nasal cavity
Thyromental distance
Difficult intubation
Mouth opening less than 3 cm. Limitation of neck movement Micrognatia Macroglossia Protusion of teeth Short neck Morbid obesity
Specific Risks
Pulmonary Risks
Complications
Whos at Risk
Smokers COPD Obesity lung capacity, FRC, VC ,Hypoxemia Age > 70 Procedure related risks: Type of anesthesia GETA alone FRC 11% inhibited coughing peri-op Surgical site Thoracic surgery Upper abdominal surgery Duration of surgery > 2 hours
Pulmonary Assessment :
Patient History: unexplained dyspnea, cough, reduced exercise tolerance Physical Exam: wheeze, rhonchi, exp time, Birthing Sound Pre-operative CXR: Mandatory in patients over 40 yo B.N ABG: no role for routine use result should not prohibit surgery
Pulmonary Assessment :
Pulmonary Function test N.B FEV1 > 2L, probably safe FEV1 between 1 and 2L, increased risk FEV1 <1L, high risk
Risk Management
Quit smoking Bronchodilator therapy PT ( physiotherapy ) . Early treatment of bronchitis Early mobilization
NOTE
Smoking cessation
24 hr: decrease carboxyhemoglobin 2-3 day: increase ciliary function but increase secretion 1-2 wk: decrease secretion 4-8 wks: decrease postop pulmonary complication
Cardiac Risks
Complications
Whos at Risk
Recent MI (Interval between MI time and surgery less than 6 mo is more likely with reinfarction) Valvular heart disease CHF Unstable angina Diabetes
Cardiac Assessment
Resting echocardiogram function Exercise stress testing Pharmacologic stress testing Dipyridamole or adenosine thallium Dobutamine echo Coronary angiography P.S: Goldman Cardiac Risk-Index for Noncardiac Surgery American College of Cardiology Risk Assessment
Goldman Criteria
S3 gallop or jugular venous distention on preoperative physical examination Transmural or subendocardial myocardial infraction in the previous 6 months Premature ventricular beats, more than 5/min documented at any time Rhythm other than sinus or presence of premature atrial contractions on last preoperative electrocardiogram Age over 70 years Emergency operation Intrathoracic, intraperitoneal or aortic site of surgery Evidence of important valvular aortic stenosis Poor general medical condition (K 3, HCO3 20, BUN > 50, Cr > 3, pO2 < 60, pCO2> 40 Abnormal liver (GOT), or bedridden)
Points 11
10
7
7 5 4
3 3 3
Class I (0 to 5 points)
Class II (6 to 12 points) Class III (12 to 25 points) 2% Class IV (26 or more)
0.7%
5% 11% 22%
0.2%
2%
56%
Risk class Complication* risk I. Very low 0.4% II. Low 1 III. Moderate 2 IV. High 3
Points 0
Risk Management
Monitor for perioperative ischemia Repair severe aortic stenosis first Treat CHF aggresively preoperative Postpone non-emergent procedures for at least 6 months after an MI Continue medication except anticoagulant or antifibrinolytic: aspirin,warfarin,ticlopidine etc. Digitalis : discontinue except in severe arrhythmia
Liver is the seat of metabolism of most of the anaesthetic drugs. in the pre-operative phase it requires plenty of carbohydrates, Vitamin K and other clotting factors. Liver function tests not only reveal the state of the liver but other organs as well as the Heart. Serum Cholesterol, Triglyserides, Proteins and Albumin are routinely done. If 1gm%. Protein is less in blood 900 grams is less in the body.
A
2-3
B
>3.0 <2.8 >6
2.8-3.5 4-6
Ascites
Neuro
None
None
Slight
Minimal
Moderate
Coma
Correct what you can vitamin K, FFP, Albumin, etc. Anticipate bleeding, complications P.S Dont operate Px with active hepatitis , Dont Op. Px with hepatic encephalopathy.
Hypertension
History of end organ damage: cardiac ischemia, renal, neurological Elective surgery should be delayed if DBP 110 mmHg with or without new onset of headache but if no sign of end organ damage surgery may be proceed In DM keep DBP < 90mmHg Aggressive treatment associated with reduction in long term risk Continue medication until day of surgery: ACEI and diuretic may be discontinue
Renal Risk
CRF CRF patient risk of congestive heart failure, hyper K, plt.dysfunction, anemia After dialysis pt at risk of hypovolumia
Assessment
Urine analysis , creatinine , BUN dialysis, type of dialysis, last dialysis, serum K, Hct. and platelet function
tract
on dialysis previously.
OR
Check U/E ,creatinine postdialysis. CXR to exclude pulm. Edema. Post op dialysis delayed 24h.
P.S no need for dialysis before surgery. But if patient develops diuretic resistance with progressive edema pre op. dialysis is considered
Endocrine Risks
Risk Management
Good control of thyroid function for at least 3 months prior Hold oral hypoglycemics Reduce insulin by half
Insulin dependent :
Admit 2 days preoperatively: CXR, ECG, FBS, U&E, HbA1c. Establish good diabetic control (glucose 4-10 mmol/L). TTT : but them on Dextrose /insulin / K infusion
Insulin dependent
Check glucose intra-operatively and U&E postoperatively. Monitor glucose regularly in early postoperative period. Continue infusion until full oral diet is establish and then reinstitute normal insulin regime.
Oral hypoglycemic
Review control.
Major surgery: convert to glucose /insulin / K infusion . Minor surgery : omit oral hypoglycemic agent. Check blood sugar. If greater than 13 mmol/l give small dose of subcutaneous insulin .
Review control.
if preoperative control is adequate , no other measure required other than routine check of blood sugar pre- and postoperatively.
History:
Family history of bleeding disorders ASA / NSAIDs Renal disease Hepatic disease (EtOH) Ecchymoses Hepatosplenomegaly Excessive mobility of joints or excess skin laxity Stigmata of renal or hepatic disease
Physical:
Measures factor VII and common pathway factors (factor X, prothrombin/thrombin, fibrinogen, and fibrin) Intrinsic pathway and common pathway
quantifies platelets estimates qualitative platelet function
Platelet count:
Patients on Anticoagulants
CVA or TIA
Hypercoagulable state
1Ridker
Induce immunosuppression Increase risk of infection Increase risk of tumour recurrence If transfusion is required it should be given at least 2 days preoperatively Blood transfused immediately prior to operation has reduced O2 carrying capacity
Thrombembolic Prophylaxis
Specific to surgery:
Acute spinal cord injury Major trauma Major surgery including: - general cancer or non-cancer surgery - hip and knee arthroplasty - open gynaecological surgery - open urological surgery - prolonged surgery
Increased risk
Age >40 years Obesity Varicose veins High oestrogen pill Previous DVT or PE Malignancy Infection Heart failure / recent infarction Polycythaemia /thrombophilia Immobility ( bed rest over 4 days) Major trauma Duration of surgery.
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
Nutritional assessment
Clinical assessment
Weight loss 10% =mild malnutrition 30% = severe malnutrition BMI Triceps skin fold thickness Mid arm circumference Hand grip strength Reduced serum albumin, prealbumin or transferrin Lymphocyte count
Anthropometric assessment
Blood indices
Use gastrointestinal tract if available Prolonged post-operative starvation is probably not required Early enteral nutrition reduced post-operative morbidity
Absolute indications
Enterocutaneous fistulae
Moderate or severe malnutrition Acute pancreatitis Abdominal sepsis Prolonged ileus Major trauma and burns Severe inflammatory bowel disease
Relative indications
Patient Preparation
Psychological:
Physical:
Preaneasthetic medications
Physiological:
A. Blood Orders: 1. Type and screen or type and cross for number of units appropriate to the procedure B. Skin Preparation: 1. Hair removal best performed on day of surgery with an electric clipper 2. Pre-operative scrub or shower of the operative site with a germicidal soap.
D. Respiratory Care: 1. Pre-operative spirometry on the evening prior to surgery when indicated 2. Bronchodilators for moderate to severe COPD
E. Decompression of GI tract:
1. NPO after midnight
NPO Guideline
NPO 6-8 hr. before surgery Clear liquid diet for 2 hr.
Age Solids Clear Liquids Clear 2h 3h 2h
Children
Clear
liquid 2 hr <6 months 4h Breast milk 4 hr 6- 36 month 6h Infant formula 6 hr > 36 month 6h solid diet 8 hr. Guideline used for patient with no proble with gastric emptying time
5% Dextrose in Lactated Ringer's Injection (D5LR):Hypertonic (cells shrink), Uses: hypertonic hydration; provides some calories; replace electrolytes and ECF losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis), the dextrose minimizes glycogen depletion, Complications: Same as LR - not enough electrolytes for maintenance; patients with hepatic disease have trouble metabolizing the lactate; do not use if lactic acidosis is presen
F. Intravenous fluids: 1. Maintenance rate overnight (D5LR) 2. Plasma and extracellular fluid deficit- volume and concentration a. hourly urine output b. urine concentration c. mucous membranes d. skin turgor G. Access and Monitoring lines: 1. At least one ga.18 IV needed for initiation of anesthesia 2. Arterial catheters and central or pulmonary artery catheters when indicated
J. Special Consideration: 1. Maintenance medication 2. Pre-operative diabetic management 3. Other prophylactic medications 4. Peri-operative steroid coverage (if needed) K. Skin Marking: 1. For Plastic/Reconstructive Surgeries 2. Marking of stoma sites P. Pre-operative notes
Intraoperative
Hypoventilation
Cardiac dysrhythmia
Hypothermia
Peripheral nerve damage Malignant hyperthermia
Malignant hyperthermia - due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased muscle contraction. Signs and Symptoms - high fever, tachycardia, muscle rigidity, heart failure, pseudotetany, and CNS damage.
discontinue inhalent anesthetic, Give Dantrium, oxygen, dextrose 50%, diuretic, antiarrhythmics, sodium bicarbonate, and hypothermic measures-cooling blanket, iced IV saline or iced saline lavage of stomach, bladder, rectum
Postoperative care
Definition :
is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery
Respiratory Status - patent airway Cardiovascular - regular, strong heart rate and stable BP (VS); peripheral pulses; Homans Sign Neurological level of consciousness; orientation, sensation Fluid and Electrolyte, Acid Base Balance
The patient should be discharged to the ward with comprehensive orders for the following: Vital signs Pain control Rate and type of intravenous fluid Urine and gastrointestinal fluid output Other medications Laboratory investigations The patients progress should be monitored and should include at least: A comment on medical and nursing observations A specific comment on the wound or operation site Any complications Any changes made in treatment
Discharge not
On discharging the patient from the ward, record in the notes: Diagnosis on admission and discharge Summary of course in hospital Instructions about further management, including drugs prescribed. Ensure that a copy of this information is given to the patient, together with details of any follow-up appointment
Postoperative Management
If the patient is restless, something is wrong. Look out for the following in recovery: Airway obstruction Hypoxia Haemorrhage: internal or external Hypotension and/or hypertension Postoperative pain Shivering, hypothermia Vomiting, aspiration Falling on the floor Residual narcosi
Postoperative Management
The recovering patient is fit for the ward when: Awake, opens eyes Extubated Blood pressure and pulse are satisfactory Can lift head on command Not hypoxic Breathing quietly and comfortably Appropriate analgesia has been prescribed and is safely established
Immediate
Primary haemorrhage: either starting during surgery or following post-operative increase in blood pressure - replace blood loss and may require return to theatre to re-explore wound. Basal atelectasis: minor lung collapse. Shock: blood loss, acute myocardial infarction, pulmonary embolism or septicaemia. Low urine output: inadequate fluid replacement intraand post-operatively
Early
Acute confusion: exclude dehydration and sepsis Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileus Fever Secondary haemorrhage: often as a result of infection Pneumonia Wound or anastomosis dehiscence Deep vein thrombosis (DVT) Acute urinary retention Urinary tract infection (UTI) Post-operative wound infection Bowel obstruction due to fibrinous adhesions Paralytic Ileus
Late
Bowel obstruction due to fibrous adhesions Incisional hernia Persistent sinus Recurrence of reason for surgery, e.g. malignancy
Post-operative fever
Days 0 to 2: Mild fever (T <38 C) (Common) Tissue damage and necrosis at operation site Haematoma Persistent fever (T >38 C) Atelectasis: the collapsed lung may become secondarily infected Specific infections related to the surgery, e.g. biliary infection post biliary surgery, UTI post-urological surgery Blood transfusion or drug reaction
After 5 days:
Wound infection
Drip site infection or phlebitis Abscess formation, e.g. subphrenic or pelvic, depending on the surgery involved DVT
Specific complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation After the first week
Wound infection Distant sites of infection, e.g. UTI DVT, pulmonary embolus (PE)
Local Haemorrhage (reactionary) Paralytic ileas (day 1-3) Infections (day 4-6) Secondary haemorrhage (day 12-15)
Systemic Shock and Asphyxia Urine obstruction Pulmonary complications Deep vein thrombosis (day 7-10) in who are obese, diabetic Fat embolism Pneumonias pain, dependency Urinary tract infection Inadequate reconstruction Morbidity of loss of body part
Wound dehiscence (8-12 days) Flap loss (1-3 days) > 21 days Incisional Hernia Adhesive intestinal obstruction
Monitor patients response to therapeutic regime, prevent complications, patient education and promote optimum well-being