Care of the patient in the

perioperative period
 The perioperative period is a time of increased risk for
every patient undergoing an operation. This risk is caused
by the effects of anaesthesia, the operation itself and its
complications, and the stress response to surgery.
 Perioperative care includes:
Preoperative care
1. History
2. Examination
3. Investigations
4. Preoperative problems
Postoperative care
1. Postoperative complications
2. Wounds care
3. Drains care
4. Discharge letter
Preoperative plan for the best patient
outcomes
 Collect all relevant information
 Optimize patient condition
 Choose surgery that offers minimal risk .
 Anticipate and plan for adverse events
 Inform everyone concerned

Principles of history taking

Listen: What is the problem? (Open questions)
Clarify: What does the patient expect? (Closed questions)
Narrow: Differential diagnosis (Focused questions)
Fitness: Comorbidities (Fixed questions)
Key topics in past medical history.
 Cardiovascular
 Ischaemic heart disease
 Respiratory
 Chronic obstructive pulmonary disease
 Gastrointestinal
 Peptic ulcer disease
 Urinary tract
 Urinary tract infection
 Neurological
 Epilepsy
 Endocrine/metabolic
 Diabetes
 Locomotor system
 rheumatoid arthritis
 Other
 Hepatitis
 Malignancy
 Allergy
 Previous surgery Problems
 Family history of problems with anaesthesia
Examination
 General: Positive findings should be explored
 Surgery related: Type and site of surgery.
 Systemic: Comorbidities and their severity
General
Anaemia, jaundice, cyanosis, nutritional status,
Cardiovascular Pulse, blood pressure, heart sounds, bruits,
peripheral oedema
Respiratory
Respiratory rate and effort, chest expansion and percussion
note, breath sounds, oxygen saturation
Gastrointestinal
Abdominal masses, ascites, bowel sounds, hernia, genitalia
Neurological
Consciousness level, cognitive function, sensation, muscle
power, tone and reflexes
Airway assessment
Investigations:
 Full blood count. (FBC) is needed for major operations, in the
elderly and in those with anaemia or pathology with ongoing blood
loss.
 Urea and electrolytes. (U&E) are needed before all major
operations, in most patients over 60 years of age
 Electrocardiography. (ECG) is required for those patients aged over
60 years, cardiovascular, renal and cerebrovascular involvement.
 Clotting screen. If a patient has a history suggestive of bleeding
tendency, liver disease, or has a family history of bleeding disorder.
 chest x-ray : is not required unless the patient has a significant
cardiac history, or respiratory problems.
 Urinalysis. should be performed on all patients to detect urinary
infection, glucose in urine.
 Blood glucose and HbA1c. These should be performed in patients
with diabetes mellitus.
 Arterial blood gases. This test allows detailed assessment of severe
respiratory conditions and acid–base disturbances.
 Liver function tests. indicated in patients with jaundice, known or
suspected hepatitis, cirrhosis, malignancy .
 Other investigations. Further investigations should be undertaken
to assess capacity of specific organ system.
SPECIFIC PREOPERATIVE PROBLEMS
 Cardiovascular disease
 The patient is known to have poor left ventricular function or
cardiomegaly.
 Ischemic changes can be seen on ECG even if patient is not
symptomatic (silent MI).
 There is an abnormal rhythm on the ECG, arrhythmias.
 Hypertension.
 Valvular heart disease.
 Anemia and blood transfusion
 Chronic anaemia is well tolerated in the perioperative period.
 If the patient is undergoing a major procedure, preoperative
transfusion may be considered below a haemoglobin level of 8
g/dL.
 If excessive bleeding is expected, then a preoperative ‘group
and save’ should be performed and an appropriate number of
units of blood cross matched.
 Respiratory disease
Stopping smoking reduces carbon monoxide levels and the patient
is better able to clear sputum.
Asthma, patients should continue to use their regular inhalers until
the start of anesthesia.
Chronic obstructive pulmonary disease, patients need to be
referred to the respiratory physicians.
Infection, Elective surgery should be postponed if the patient has a
chest infection. It should be treated with antibiotics and
physiotherapy.
 Gastrointestinal disease
Nil by mouth, Patients are advised not to take solids within
6 hours and clear fluids within 2 hours before anesthesia to
avoid the risk of acid aspiration.
Regurgitation risk patients, give antacids, H2-receptor
blockers or proton pump inhibitors.
Liver diseases, Elective surgery should be postponed until
any acute episode has settled.
 Genitourinary disease
Renal diseases
Urinary tract infections
 Endocrine and metabolic disorders
DM
 Patients with diabetes should be first on the operating list
and if they are operated on in the morning advised to
omit the morning dose of medication and breakfast.
 the patient’s blood sugar levels should be checked every 2
hours.
 An intravenous insulin sliding scale should be started for
type 1 diabetes mellitus undergoing major surgery or if
blood sugar is difficult to control.
 Those with type 2 diabetes should stop oral
hypoglycaemic agents on the day of operation.
Malnutrition
Obesity
 Coagulation disorders
High-risk patients with a history of recurrent DVT,
pulmonary embolism (PE) and arterial thrombosis will be
on warfarin. This should be stopped 3-4 days before
surgery and replaced by low molecular weight heparin.
Antiplatelets should be stopped 1 week before operation
time.
 Musculoskeletal and other disorders
 Rheumatoid arthritis can lead to unstable cervical spine with the
possibility of spinal cord injury during intubation.
 Neurological and psychiatric
disorders
 In patients with a history of stroke, pre-existing neurological
deficit should be recorded.
 Postoperative period
General principles
 All anaesthetised patients should be recovered in a
recovery room.
 All vital parameters should be monitored and
documented.
 Treat pain and nausea/vomiting.
 Watch for complications.
The patient can be discharged from the recovery room
when they fulfil the following criteria:
• Patient is fully conscious.
• Respiration and oxygenation are satisfactory.
• Patient is normothermic, not in pain.
• Cardiovascular parameters are stable.
• Oxygen, fluids and analgesics have been prescribed.
• There are no concerns related to the surgical procedure.
 POSTOPERATIVE COMPLICATIONS:
 Respiratory complications
Obese, smokers and those with chronic lung conditions
are more likely to have respiratory complications.
Post operative Hypoxia
1. Upper airway obstruction
2. Laryngeal oedema
3. recurrent laryngeal nerve palsy after thyroid surgery.
4. Hypoventilation related to anaesthesia.
5. Atelectasis and pneumonia.
6. Pulmonary oedema
7. Pulmonary embolism.
 Cardiovascular complications
• Hypotension in the postoperative period can be
multifactorial.
• Arrhythmias can be prevented and corrected by treating
hypotension and electrolyte imbalance.
• Myocardial ischemia/infarction will need management
with the help of cardiologists.
 Renal and urinary complications
• Postoperative renal failure is associated with high
mortality.
• Urinary retention and infection are a common problem.
 Postoperative bleeding
• The patient’s blood pressure, pulse, urine output,
dressings and drains should be checked regularly in
the first 24 hours after surgery.
• If bleeding has occurred, then pressure should be
applied to the site and blood samples should be
sent for blood count, coagulation profile and
crossmatch.
• Fluid resuscitation and oxygenation should also be
started.
• The patient may be taken back to the operating
theatre.
• Blood or blood products given if the haemoglobin
concentration is less than 8 g/dL.
• Prothrombin time (PT) greater than 1.5 times
normal levels indicate the need for fresh frozen
plasma.
• The platelet count should be maintained above 75 ×
109/L.
Fever
 About 40 per cent of patients develop pyrexia after major surgery.
 In most cases no cause is found.
 The causes of a raised temperature postoperatively include:
• days 2–5: atelectasis of the lung;
• days 3–5: superficial and deep wound infection;
• day 5: chest infection, urinary tract infection and
thrombophlebitis;
• >5 days: wound infection, anastomotic leakage, collections and
abscesses;
• DVTs, transfusion reactions, wound hematomas, atelectasis and
drug reactions, may also cause pyrexia of non-infective origin.
 Wound dehiscence
 Wound dehiscence is disruption of any or all of the layers in a
wound.
 Wound dehiscence most commonly occurs from the 5th to the 8th
postoperative day when the strength of the wound is at its
weakest.
 Most patients will need to return to the operating theatre for
resuturing. In some patients, it may be appropriate to leave the
wound open and treat with dressings.
 Pressure sores
Preventing pressure sores
• Recognize patients at risk
• Address nutritional status
• Keep patients mobile or regularly turned if bed-bound
 Pain
Inadequate pain control can slow recovery and contribute
to many post operative complications e.g delayed
ambulation.
 Nausea and vomiting
 Fluid and electrolytes imbalance
 Deep vein thrombosis
 Hypothermia
 Confusion
Wound care
 Within hours of the wound being closed, the dead
space fills up with an inflammatory exudate. Within
48 hours of closure, a layer of epidermal cells from
the wound edge bridges the gap. So, sterile dressings
applied in theatre should not be removed before this
time.
 Wounds should be inspected only if there is any
concern about their condition or the dressing needs
changing.
 If the wound looks inflamed, a wound swab may need
to be taken and sent for Gram staining and culture.
 Infected wounds and hematoma need treatment with
antibiotics or even a wound washout.
 Skin sutures or clips are usually removed between 6
and 10 days after surgery.
 If the wound is healing satisfactorily, then the patient
may be allowed to shower one week after surgery.
Drains
 Drains are used to prevent accumulation of blood,
serosanguinous or purulent fluid or to allow the early
diagnosis of a leaking surgical anastomosis.
 They can result in complications, such as trauma to
surrounding tissues, and act as a conduit for infection.
 The lost fluid should be replaced with additional intravenous
fluids with the same electrolyte contents.
 Drains should be removed as soon as possible and once the
drainage has stopped or become less than 25 mL/day.
Discharge letter should include:
 Diagnosis
 Treatment
 Laboratory results
 Complications
 Discharge plan
 Support needed
 Follow up