Perioperative Care

Roys A. Pangayoman, dr., SpB

Maranatha Christian University

Immanuel Hospital
Bandung 2008
Assessment of fitness for surgery

ASA Grading

Risk scoring systems

Laboratory testing & imaging

Preoperative investigation

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1. ASA Grading
 Medical co-morbidity increases the risk
associated with anaesthesia and surgery
 American Society of Anesthesiologists
(ASA) grade is the most commonly used
grading system
 ASA accurately predicts morbidity and
mortality
 50% of patients presenting for elective
surgery are ASA grade 1
 Operative mortality for these patients is
less than 1 in 10,000.
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ASA Grading
ASA
Grade Definition Mortality (%)

I Normal healthy individual 0.05

II Mild systemic disease that does not 0.4
limit activity

III Severe systemic disease that limits 4.5

activity but is not incapacitating

IV Incapacitating systemic disease which 25

is constantly life-threatening

V Moribund, not expected to survive 24 50

hours with or without surgery

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2. Risk scoring systems
 Differ in many respects including:
 Age
 Previous health status
 Reason for admission
 Severity of illness
 All factors influence the prognosis of the patient
 Scoring systems can be used for
 Audit
 Research
 Clinical management
 Scoring systems can be generic or specific
 Limitations and errors associated with their use include
 Missing data
 Observer error
 Inter-observer variability
 Lead time bias

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APACHE II score
A general measure of disease severity
based on
Current physiologic measurements
Age
Previous health condition.
 Scores range from 0-71
 Increasing score associated with an
increasing risk of hospital death.
 APACHE II score = (acute physiology
score) + (age points) + (chronic
health points)

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APACHE II

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POSSUM system
 Outcome of surgery depends on several factors
including:
Physiological status of the patient
Disease process that requires surgical intervention
Nature of operation
Pre and perioperative support
 Raw morbidity and mortality data can provided a
biased picture
 POSSUM = Physiological and operative severity score
for the enumeration of mortality and morbidity
 Allows risk-adjusted assessment of surgical quality
 Accurately predicts 30-day morbidity and mortality
 Two-part scoring system including:
Physiological assessment
Operative severity

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3. Laboratory testing and imaging
 Most important:

Respiratory function

Cardiac function

Renal function

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Respiratory function
 Lung function tests should be able to predict
the type and severity of lung disease
 Can predict risk of complications and
postoperative mortality
 Tests fall in to three categories
Lung mechanics
Gas exchange
Control of breathing
 Useful radiological investigations include
chest x-ray and high-resolution thoracic CT
 Arterial blood gases may be invaluable

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Lung function tests
 Allows assessment of :

Lung volumes

Airway calibre

Gas transfer

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Lung volumes
 assessedwith spirometry
 Volumes measured include:
IC = Inspiratory capacity
IRV = Inspiratory reserve volume
TV = Tidal volume
VC = Vital capacity
FRC = Functional residual capacity
RV = Residual volume
ERV = Expiratory reserve volume
TLC = Total lung capacity

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Spirometry

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Airway calibre
 assessed with peak flow measurements
 Requires co-operation and maximum voluntary effort of the
patient
 Flow rates measured include
 FVC = Forced vital capacity
 FEV1 = Forced expiratory volume in one second
 Absolute values depend on height, weight, age, sex and
race
 FEV1 / FVC ratio is important
 Lung function can be classified as:
 Normal
 Restrictive
 Obstructive
 In restrictive lung disease FVC is reduced but FEV1/FVC is
normal
 In obstructive lung disease FVC is normal or reduced and
FEV1/FVC is reduced

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Peak Flow

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Gas Transfer
 Arterial blood gases are best measure
available of gas transfer
 Also allow assessment of
ventilation/perfusion mismatch
 Important parameters to measure are:
pH
Partial pressure of oxygen
Partial pressure of carbon dioxide
 Pulse oximetry gives an indirect estimate of
gas transfer
 Technique is unreliable in the presence of
other medical problems (e.g. anaemia)
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Cardiac Function
 Simple non-invasive and more
complicated invasive tests of cardiac
function exist
 Non-invasive
Chest x-ray
ECG
Exercise test
Echocardiography
 Invasive
Coronary angiography
Thallium scanning

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Chest X-ray
 Routine chest x-ray is not recommended
 It is indicated in the presence of
cardiorespiratory symptoms or signs
 Important signs associated with increased
cardiac morbidity are:
Cardiomegaly
Pulmonary oedema
Change in the cardiac outline characteristic of
specific diseases

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ECG
 Resting ECG is normal in 25-50% of
patients with ischaemic heart disease
 Characteristic features of ischaemia or
previous infarction may be present
 Exercise ECG provides a good indication of
the degree of cardiac reserve
 24-hour monitoring is useful in the
detection and assessment of arrhythmias

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Echocardiography
 Can be performed percutaneously or
transoesophageal
 Two-dimensional echocardiography allows
assessment of
Muscle mass
Ventricular function / ejection fraction
End-diastolic and end-systolic volumes
Valvular function
Segmental defects
 Doppler ultrasound allows assessment of
valvular flow and pressure gradients

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Nuclear Medicine
 Myocardial scintigraphy allows assessment of
myocardial perfusion
 Radiolabelled thallium is the commonest
isotope used
 Areas of ischaemia or infarction appear as
'cold' spots
 Vasodilators can be used to evaluate
reversibility of ischaemia
 Radiolabelled albumin or red cells can be
used to assess ejection fraction
 Such dynamic studies are performed 'gated'
to the ECG

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Renal function
 Glomerular filtration rate is the gold standard
test of renal function
 Can be calculated by measuring creatinine
clearance rate
 Requires 24-hour urine collection
 Serum creatinine allows a good estimate of
renal function
 Use of serum creatinine may be inaccurate in
patients with:
Obesity
Oedema
Pregnancy
Ascites

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4. Preoperative Investigation
Investigation Indication
Full blood count All adult women
Men over the age of 60 years
Cardiovascular or haematological disease
Urea & electrolytes All patients over 60 years
Cardiovascular and renal disease
Diabetics
Patients on steroids, diuretics, ACE inhibitors
ECG Men over 40 years
Women over 50 years
Cardiovascular disease
Diabetics
Chest X-ray Cardiovascular and respiratory disease
Malignancy
Major thoracic and upper abdominal surgery

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Preoperative Investigation
 Pre-operative investigations rarely
uncover unsuspected medical conditions
 Inefficient as a means of screening for
asymptomatic disease
 5% of patients have abnormalities on
investigations not predicted by a clinical
assessment
 0.1% of these investigations ever change
the patients management
 70% of pre-operative investigations could
be eliminated without adverse effect
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PREPARATION FOR SURGERY

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1. Pre-operative assessment
 Aims:
 Reduce morbidity and mortality associated
with surgery
 Prevent unnecessary cancellations
 Reduce hospital stay
 Planning:
 Inform patient of the proposed procedure
 Obtain informed consent for the procedure
 Assess pre-existing medical conditions
 Plan pre and postoperative management of
these conditions

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Issues that should be discussed
 Time of admission and starving instructions
 Management of usual medication
 Any specific pre-operative preparation that may
be required
 Transport to theatre
 Any specific anaesthetic issues
 Anticipated duration of surgery
 Likely recovery period
 Need for drains, catheters
 Likely discharge date
 Need for dressing change
 Follow up requirements
 Likely date of return to work or full activity

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2. Informed Consent
 Duties of a doctor
 Make the care of your patient your first concern
 Treat every patient politely and considerately
 Respect patients' dignity and privacy
 Listen to patients and respect their views
 Give patients information in a way that they can understand
 Respect the rights of patients to be fully involved in decisions
about their care
 Keep your professional knowledge and skills up to date
 Recognise the limits of your own professional confidence
 Be honest and trustworthy
 Respect and protect confidential information
 Make sure that your personal beliefs do not prejudice your patients
care
 Act quickly to protect patients from risk if you have good concerns
to believe that you or a colleague may not be fit to practice
 Avoid abusing your position as a doctor
 Work with colleagues in the ways that best serve patients interests

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Informed consent
 Patients autonomy must be respected at all times
 Patients can determine what treatment that they
are or are not willing to receive
 They have the right to decide not to undergo a
treatment
 This could adversely affect outcome or result in
their death
 Patients must be given sufficient information to
make these decisions
 Obtaining informed consent is not an isolated
event
 It involves a continuing dialogue between doctor
and patient

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Information required for valid consent
 Details of diagnosis and prognosis with and
without treatment
 Uncertainties about the diagnosis
 Options available for treatment
 The purpose of a proposed investigation or
treatment
 The likely benefits and probability of success
 Any possible side effects
 A reminder that the patient can change his or
her mind at any stage
 A reminder that the patient has the right to a
second opinion

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3. Pre-medication
 Is the administration of drugs prior to an anaesthetic
 Has three potentially useful effects:
Anxiolysis
Reduced bronchial secretions
Analgesia
 Anxiolysis if needed can be achieved with either
benzodiazepines or phenothiazines
 Opiate analgesics also have useful sedative properties
 Reduction of sections is not as important today with
modern inhalational agents
 Ether was notorious for stimulating bronchial
secretions
 If required secretions can be reduced with hyoscine
 Also reduce salivation and prevents bradycardia
 Analgesia best achieved with strong opiates

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Principles of premedication
 Anxiolysis
 Analgesia
 Amnesia
 Antiemetic
 Antacid
 Anti-autonomic
 Adjuncts

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4. Risk Assessment
 We all take risks in everyday life
 The degree of risk taken depends on the
perceived benefit
 Most decisions are made on previous
experiences
 Risk assessment forms an integral part of
patient care
 An assessment needs to be made of the risks
vs. benefits for an procedure performed
 These will then influence decisions made by
the surgeon or the patient

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Risk assessment models
 Assessment of risk in surgery depends on
many factors
 These involve knowledge of the:
Patient
Disease
Comorbidities
Proposed surgery
Physiological status

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Risk assessment tools
 Decision making is rarely simple and
straight forward
 Risk assessment tool in common use
include
Goldman Cardiac Risk Index
Parsonnet Score
POSSUM
Injury Severity Score
Revised Trauma score
APACHE I, II and III

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Induction
 Induction agents are usually administered
intravenously
 Distributed to organs with a high blood
flow (e.g. brain)
 Highly lipid soluble and rapidly cross blood
brain barrier
 With falling blood levels they are rapidly
redistributed from brain
 Have rapid onset and without
maintenance would have rapid recovery

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References
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References
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