- Clinical science
Perioperative management consists of preoperative patient evaluation as well as intraoperative and postoperative patient monitoring and care. The operative risks are assessed prior to surgery by considering patient history, physically examining the patient, and conducting any tests deemed necessary. Preoperative adjustments are made based on the assessment findings (e.g., stopping, replacing, or temporarily administering certain drugs by another route). The specialist responsible is legally obliged to disclose all relevant information regarding the procedure to the patient. Perioperative antibiotic prophylaxis is recommended in many types of surgery in order to prevent postoperative wound infections. The main goals in the postoperative phase are early recovery and preventing complications or, if complications occur, diagnosing and treating them as early as possible.
- Obtain .
- Obtain a thorough medical history; and perform a physical examination.
- Specific diagnostics
- Laboratory tests if indicated (see table below)
- Preoperative nutritional status assessment
|Hemoglobin or hematocrit|
|Blood grouping and crossmatching|| |
|Random blood glucose|
|Electrolytes and creatinine|
|Coagulation studies|| |
|Urine analysis|| |
|Pregnancy test|| |
Preoperative tests should be ordered only if they are indicated!
|ASA physical status classification system (ASA = American Society of Anesthesiologists)|
|ASA I|| ||0.1%|
|ASA II|| ||1%|
|ASA III|| ||4%|
|ASA IV|| ||20%|
|ASA V|| ||90%|
|ASA VI|| || |
|Cardiac risk stratification|
|Preoperative cardiac evaluation||Indications|
|Stress test|| |
- Patients should be asked about their smoking history; and discontinue smoking 8 weeks prior to surgery.
|Assessment||Indication for preoperative assessment|
|Cardiopulmonary exercise test|
- Indications for preoperative LFTs
- Patients with acute hepatitis: Elective surgery is contraindicated until LFTs improve.
- Chronic liver disease
Clinical indicators of severe protein energy malnutrition (> 2 of the following)
- Body mass index <18.5
- Recent weight loss (> 2% in 1 week, > 5% in 1 month, or > 7.5% in 3 months)
- Bedridden or otherwise significantly reduced functional capacity
- Obvious significant muscle wasting; loss of subcutaneous fat
- Nutritional intake of < 50% of recommended intake for 2 weeks or more (as assessed by dietitian)
- Laboratory tests that can be used to assess nutritional status include:
- If a patient is found to be malnourished: (preferably ) is given prior to surgery to optimize nutritional status.
Malnutrition has been associated with poorer postoperative outcomes, including increased overall morbidity and mortality, longer hospital stays, increased risk of infection, delayed wound healing, and increased rate of ICU admissions!
All preoperative patients should have their nutritional status assessed, with those at greater risk or with signs of malnutrition receiving a formal nutritional assessment!
|Common long-term medications||Recommendations|
|Antidiabetic drugs|| |
|Antianginal drugs|| |
|Oral contraceptives|| |
|Psychiatric drugs|| |
|Anticoagulant or antiplatelet drugs|| |
|*During the preoperative period, necessary drugs can be administered orally up to 2 hours before anesthesia. For orally administered drugs that are to be continued intraoperatively and postoperatively, a parenteral preparation or an equivalent parenterally administered substitute is required until oral consumption can be resumed.|
Antianginal medications, antiepileptics, statins, most antihypertensive drugs (except ACE inhibitors, ARBs, and diuretics), and most neuroleptics (except lithium) should be continued on the day of surgery!
- Discontinue certain medications (see above).
The preoperative fasting recommendations can be remembered with the “2, 4, 6, 8 rule”!
Surgical site preparation
- Bowel preparation (for colorectal surgery or colonoscopy)
- Hair removal at the operation site less than 24 hours before surgery
- Mark the side to be operated on in surgery of paired structures
Fluid infusion (see “Parenteral fluid therapy”)
- Preoperatively: Correct any volume deficit and replace ongoing fluid loss, if applicable.
- Administer 500–1000 mL of normal saline during every hour of the surgical procedure.
- Consider blood transfusion in the case of severe blood loss.
- Replace any ongoing fluid loss (e.g., from surgical drains).
- Continue maintenance fluid therapy until the oral fluids can be administered.
- Sedatives (premedication)
- Preventative analgesia with NSAIDS, opioids, or epidural catheters
- Anesthesia (see and
Perioperative antibiotic prophylaxis
- Aim: to reduce the incidence of postoperative surgical site infections
Antibiotic of choice
- First-line: intravenous cefazolin
- Add intravenous metronidazole for:
- No perioperative antibiotic prophylaxis is recommended for the following elective procedures:
- Low-risk laparoscopic cholecystectomy
- Clean head and neck surgeries without prosthesis placement
- Clean surgeries of the hand, knee, or foot without implantation of foreign material
- Patient positioning
- Disinfection and sterile draping of the surgical site
Monitor blood pressure, pulse, oxygen saturation, temperature, urine output, and surgical drain output.
- If a patient has a urine output < 0.5 mL/kg/hour for > 6 hours: Check catheter patency.
- Supportive care in intubated patients
- Pain management according to
- Stress ulcer prophylaxis with proton pump inhibitors
- Thromboprophylaxis with low-dose LMWH or UFH before and after surgery, especially for immobile, bedridden patients
- Incentive spirometry and breathing exercises in order to prevent lung atelectasis
- Fluids: and
- Enteral nutrition; should be started as soon as possible to prevent villous atrophy.
- Daily examination of the surgical wound
- Early mobilization
|General postoperative problems||Postoperative cardiac complications||Postoperative pulmonary complications||Renal and urinary tract complications|
| || || |
- Temperature > 38°C in the postoperative period
|Onset of fever||Etiology|
|Immediate|| || || |
|Acute|| || |
|Subacute|| || || |
|Delayed|| || |
The most common infectious causes of postoperative fever are surgical site infections, pneumonia, catheter-related urinary tract infections, and primary bloodstream infections. The most common noninfectious cause is a febrile drug reaction.
|Type of perioperative hemorrhage||Definition||Etiology|
|Primary hemorrhage|| || |
|Secondary hemorrhage||< 24 hours|| |
|> 1 week|
While bleeding due to mechanical causes and surgical site infection usually occurs from or near the surgical wound, bleeding due to hemostatic disorders can also occur at sites other than the wound (e.g., bleeding from central lines)!
Definition: infection arising within 30 days of a surgical procedure at the the site of surgical intervention
- For the following procedures, any infection arising deeper than subcutaneous tissue within 90 days of surgery is considered a surgical site infection.
- 15–20% of all healthcare-associated infections
- Most common nosocomial infection among patients undergoing surgery
- Incidence: ∼ 5% of all surgical wounds
- Causative pathogens
- Risk factors
|Type of surgical wound||Definition||Incidence of SSI|
|Clean|| || |
|Clean-contaminated|| || |
|Contaminated|| || |
|Dirty or infected wounds|| || |
- Classification and clinical features
|Type of SSI||Incisional SSI||Organ/space SSI|
|Superficial incisional SSI||Deep incisional SSI|
|Definition|| || |
|Clinical features|| |
- Suture removal; , incision and drainage; , regular dressings, and daily wound inspection
- Debridement; is indicated when there is devitalized tissue.
- Delayed closure once the wound is no longer infected
Empirical antibiotic therapy
Antibiotic of choice
- SSI in a clean wound over the trunk, head and neck, or limb:
- SSI in a clean-contaminated wound; , or in a clean wound over the perineal region: cephalosporin and metronidazole, levofloxacin and metronidazole, or carbapenem
- If group A streptococci or C. perfringens; is suspected: penicillin and clindamycin
- Targeted antibiotic therapy may be initiated once results of the bacterial culture are available.
- Surgical therapy
- Optimize blood glucose levels.
- Stop smoking one month before surgery.
- Delay the elective procedure until all infections, even those remote from the surgical site, are treated.
- Skin antisepsis in the operating room
- 30–50% among postsurgical patients in the general population
- Up to 80% in high-risk groups
- Sex: ♀ > ♂
|PONV risk factors||Adults||Children|
|Patient-related|| || |
|Procedure or treatment related|| |
- < 1 week after surgery; : self-limiting gastric or intestinal atony; , or a more severe
- > 1 week after abdominal surgery; : early
- Reduction of baseline risk
- Additional measures
- Treatment: : Use an antiemetic that was not used for prophylaxis.
- Prolonged hospital stay
- Increased risk of
- Secondary hemorrhage due to retching
- Definition: failure to void > 4 hours after surgery
- Age > 50 years
- Male patient
- Pre-existing obstructive urinary tract; symptoms (e.g., )
- Neurological; disease (e.g., ; , diabetic neuropathy)
- Long duration of procedure
- Inguinal hernia repair, gynecological, anorectal surgery, joint arthroplasty
- Severe postoperative pain
- Excessive administration of intravenous fluids (> 750 mL)
- Spinal or epidural anesthesia
- Use of sedatives; and or opioid analgesics
- Perioperative administration of α-blockers or anticholinergics (e.g., atropine)
- Perioperative administration of prazosin in high-risk patients
- Pre-emptive catheterization if multiple risk factors are present
- Diagnostics: Bladder ultrasound; is not required but may be performed to assess the bladder volume.
- If the patient is catheterized preoperatively
- Check the catheter for kinking or blocks in the lumen.
- If no kinking is present, consider .
- If the patient is not catheterized preoperatively
- Trial of voiding
- Adequate analgesia with NSAIDs
- Second-line: intermittent catheterization or the placement of an indwelling catheter
- If the patient is catheterized preoperatively
- Acute → postrenal cause of acute kidney injury
- Prolonged hospital stay → increased risk of hospital-acquired infections
- Open surgery
- Excessive bowel handling during intra-abdominal surgery
- Electrolyte imbalances (e.g., hypokalemia)
- Use of opiates
- Physiologic postoperative ileus; : impaired gastrointestinal motility that occurs following surgery and resolves spontaneously within 2–3 days
- Prolonged postoperative ileus: impaired gastrointestinal motility for > 3–5 days
- Failure to pass flatus
- Nausea and vomiting may be present.
- Abdominal distention may be present.
- Absence of bowel sounds on auscultation
- Differential diagnosis: early
- Physiologic postoperative ileus
- Prolonged postoperative ileus
- See .