Perioperative Management

Affiliated Hospital of Jining Medical College

Dep. Mammary and Thyroid Surgery
Zhu Kunbing
朱坤
兵
 Operation is a dominant method in
surgery,but surgical operation can
result in some physiological influence
to the whole body.
Major operations create surgical
wounds and cause severe
stress,subjecting the patients to the
hazard of infection metabolic and
other derangements.
 Appropriate preoperative
preparation facilities wound healing
and systemic recovery by making
certain that the patients condition is
optimal.
We must understand some kind of
preoperative and postoperative
management to recover physiologic
function of the body .
Type of surgical operations
(According to the timing)
1)Selective surgery
(subtotal gastrectomy…)

2)Subselective surgery
(malignant tumors
resection…)

3)Emergency surgery
(spleen rupture…)
 Preoperative preparation

Content Postoperative management

Postoperative complication
First part
 Preoperative preparation

1.General Health Assessment

2.Special preparation
General Health Assessment
a complete history and physical examination
Complete blood counts
Serum electrolyte
The chest x-ray
Electrocardiogram ECG
The function of liver and kidney
General Health Assessment
Bleeding tendencies
Medications being taken:aspirin
Allergies and reactions to antibiotics
Phychiatric consultation
Neurologic examintion
Peripheral arterial pulses
General Health Assessment
 Rectal examination
 Pelivic examination
 Papanicolaou smear of cervix
 Sigmoidoscope of rectal or colonic
biospy
 Physiologic preparation
1)adapt to postoperative changes
2)Blood replacement preparation
3)prophylactic management
4)nutritional support
5)gastrointestinal preparation
6)protein, vitamin,energy preparation
7)others
 Special preparation

 Diabetes mellitus
 Nutritional system
 Hypertension
 Cardiac disease
 Respiratory system
 Kidney and liver function
 Immunological system
 Diabetes mellitus
 Blood glucose concentration
 A thorough physical examination

to discover occult Infection

ECG
a complete urinalysis
serum potassium
serum creatinine levels
 Diabetes mellitus

 the level of serum glucose

a ideal level:100-200mg/dl
a safe level :350-400mg/dl
 Stop to take the drugs:sulfonylureas etc.
 Use the regular insulin to controll glucose
 Type 2 diabetes mellitus

 Small doses of insulin

Measure the glucose level every 3-4h
 Type 1 diabetes mellitus
 Require insulin during surgery
subcutaneous mangement of long-
acting insulin
constant infusion of a mixture of
glu and RI
separate infusions of glu and
insulin
 Monitore the glu level every 2 h to aviod the
hypoglycemia (<60mg/dl)
hyperoglycemia(>250mg/dl)
 Nutritional states
Mulnutrition

blood volume protein deficiency severe sepsis

decreased
tissue edema septic shock
Endurance ability
of blood loss or shock wound healing
decreased delayed

Preparation : protein
blood transfusion
vitamin intake
others
 Hypertension

Hypertension

Brain vascular Congestive heart

accident failure

preparation : furosomide in a certain degree

hydrochlorothiazide
nifedipine not neccesary
catopril decreased to normal
 Cardiac disease
 ECG
 Echocardiography

LEF:ejection fraction>50%
 DCG:dynamic electrocardiogram

Arrhythmia
PVC:premature ventricualr contraction
 Cardiac disease

Mortality
Cardiac patients noncardiac patients
2.8times

Approximately 8 million surgeries in the United States

are performed on patients with known or suspected cardiac
disease. Preoperative evaluation can help stratify risk.
The Relation Between Cardiac Disease and Operation Endurance

Type of cardiac disease operation endurance

Acynotic congenital heart disease

Rheumatic heart disease good
Hypertension but no cardiac failure

Coronry artery disease poor

atrioventricular block full scale preparations
Easily result in cardiac arrest

Acute mycarditis very poor

acute mycardial infarction surgery delayed
cardiac failure (exept of lifesaving)
The Goldman index
Useful in predicting cardiac events in an
unselected, random group of patients.
The type and extent of surgery anticipated
needs to be taken into account when one is
interpreting the results of the Goldman index.
Functional status
If patient can walk up stairs while carrying a
load (functional status class I and II), has a low
Goldman index and no known cardiac disease,
there is a very low risk of cardiac
complications.
 ECG routine
Ischemia on a resting ECG is suggestive of a
worse outcome.
However, exercise tolerance appears to be more
important than ECG changes in predicting
outcomes.
Echocardiography

1.those with murmurs that have not been

previously evaluated

2.diastolic versus systolic versus valvular

 History of Mycardial infarction

<3 weeks 25% mortality urgent procedure only

At 3 months 10% mortality semivrgent procedures
At 6 months 5% mortality elective

At 1 year same risk as asymptomatic

patient with cardiac disease
 Hematologic diseases

A.Positive sickle cell screen. Needs Hb

electrophoresis. If majority is Hb S will need
partial exchange transfusion before surgical
procedure
B.Coagulation disorders May need evaluation,
treatment .
C.Anemia Ideally HCT >30%, with Hb >10
g/dl at surgery. No evidence that anemia
contributes to surgical morbidity in the well-
hydrated, hemodynamically stable patient
with a Hb >7.0 g/dl.
 Integument(skin) disorders

If possible, avoid operating when there are active skin

infections present.
Chronic skin disorders should be optimally controlled for
postoperative healing.
For those who form keloids, may need to consider
different closure techniques.
 Obesity

Weight loss to improve cardiopulmonary

status and decrease problems with healing.
liquescence
 Special medications
Patient’s routine medications
( IM or IV )
Increased steroids steroid dependent

Pain medications needed

as indicated for infection and

Antibiotics sepsis or prophylaxis of endocarditis,

Indwelling hardware or graft placement.

 Antibiotics

Preoperative antibiotics are most effective when

given within 2 hours before surgery.

Cefotaxime 1 g IV or cefoxitin 2 g IV

reduce infection rates for intra-abdominal surgery

 Antibiotics
There is no evidence that continuing "prophylactic"
antibiotics postoperatively is helpful. However, antibiotics
should be continued in underlying conditions:

1)active infection
2)contamination
3)artificial material
4)long time operations
5)gastrointestinal operation
6)cancer or vascular operations
Prep for surgery
bowel preps
antiseptic shower
hair clipping

Premedication by anesthesia to lower

anxiety, lower secretions, and interact with
narcotics for sedation.
Second part
A.postoperative orders

1)Admit to ward, ICU, or recovery room.

2)Diagnosis Operation
3)Vital signs:BP,P,R every 15-30minutes
4)Allergies
5)Activity
Bedrest until fully awake;
up walking that night or next morning
depending on surgery.
6)Diet
NPO(nil per os,nothing by mouth) until nausea
resolves or resumption of bowel activity as
determined by bowel sounds, passing gas, or
having bowel movement.
Patients undergoing thoracic or abdominal surgery
and critically ill patients should NPO until normal
gastrointestinal function returned .
In general,after 3 days:completely fluid ;after 6
days semifluid;after 9 days normal diet.
7)Pulmonary function.
Deep breathing
Incentive spirometry
8)Intake and output.
Record intake or output every shift or
more frequently
Potassium(K) is normally included in
replacement solutions but is excluded from
maintenance solutions until normal renal
function is established.

Colloids do not provide any survival

benefit and are expensive.
Different tube management
1)gastric suction tube
2)bladder catheter
3)CVP:central venous pressure
B.Monitoring

1.vital sign
2.CVP(Central Venous pressure)
3.renal and bladder function
4. fluid and electrolytes
5.drain tubes
C.Nursing.
Encourage turning
coughing
deep breathing
incentive spirometry
Dressing changes
Any uncofortablity
fever
hypertension
hypotension
tachycardia
bradycardia
bleeding
pain
D.Medications

1)antibiotics
2)sedatives
3)pain relief drugs.
Pain medications
PCA :patient-controlled analgesia
provides better analgesia, and patients
generally require less narcotic than with IM
treatment;

If cannot use PCA

1)morphine (2-5 mg IV/hr)
2)meperdine(50mg IM)
3)tramadol
Drug dose of PCA

Morphine: 0.05 to 0.1 mg/kg IM Q3-6h.

Meperidine: 0.5 to 1.0 mg/kg IM Q3-6h.
postanesthetic nausea

Cause:
hypotension
stress reactions
Management:
droperidol
Antibiotics

Routine medications

infection
Suture removal time
General guidelines for suture removal:

Face 3 to 5 days
Scalp 7 to 10 days
trunk 7 to 10 days
arms 7 to 10 days
legs 10 to 14 days
joints 14days
dorsal surface 14 days
Third part
Common Postoperative complication

1)postoperative bleeding
2)wound infection
3)wound dehiscence
4)Atelectasis
5)Urinary infection
6)fat embolism
Special postoperative complications
Wound complication
1)hematoma
2)seroma
3)postoperative wound infection
4)wound dehiscence
Respiratory complications
1)atelectasis
2)pulmonary aspirations
3)postoperative pneumonia
4)postoperative pleural effusion and
pneumothorax
Cardiac complications

1)Arrhythmias
2)Postoperative mycardial infarction
3)Postoperative cardiac failure
Urinary complications

1)postoperative urinary retention

2)urinary tract infection
3)postoperative oliguria,anuresis
prerenal reason blood loss
acute tubolar necrosis
postrenal reason obstruction
4)renal failure
Cerebral complication

postoperative cerebrovascular accidents

Postoperative hepatic dysfunction

1)prehepatic jaundice
2)hepatocellular insufficiency
3)benign postoperative intrahepatic cholestasis
4)extrahepatic obstruction
Postoperative Fevers
Respiratory resean of postoperative fever

Early fever secondary to aspiration

Fever at 24 to 48 hours atelectasis

(Do not ignore an emerging pneumonia)

After 48 hours pneumonia.

Wound infection reasons postoper fever

First 24 hours Clostridium

48 to 72 hours Streptococci
Enteric aerobes
4days Anaerobes
Staphylococci
vascular reason of postoper fever

Thrombophlebitis

Occurs intraoperatively, and fever usually begins

after 24 hours.
Urinary reason of postoper fever

Urinary tract infections

Usually related to instrumentation or indwelling

Foley catheter and occurs after 24 hours. Remove
Foley as soon as possible.
Less common causes of perioperative fever

1.Transfusion reaction Immediate

2.Malignant hyperthermia anesthetic drugs
3.Drug reaction
4.Endocrine such as thyroid storm
5.Thrombophlebitis from IV site
6.Intraabdominal abscess
Postoperative Ileus
reason:
operation

management:
Maintain NPO with NG suction
Check electrolytes including calcium
potassium

anticholinergic
Avoid narcotics
calcium channel
blockers.
B.If prolonged
Consider pancreatitis
peritonitis
Intra-abdominal abscess
pneumonia
Free blood in the peritoneum