• Clinical science
  • Clinician

Perioperative management

Summary

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.

General preoperative assessment

  1. Obtain surgical consent.
  2. Obtain a thorough medical history; and perform a physical examination.
  3. Specific diagnostics
    • Laboratory tests if indicated (see table below)
    • Preoperative cardiac assessment
    • Preoperative pulmonary assessment
    • Preoperative nutritional status assessment
Laboratory test Indication
Hemoglobin or hematocrit
  • Liver disease
  • Procedures in which severe blood loss is anticipated
  • Extremes of age
  • Clinical features of anemia
  • Clinical features or history of bleeding and/or hematopoietic disorders
Blood grouping and crossmatching
  • Procedures in which severe blood loss is anticipated
Random blood glucose
Electrolytes and creatinine
Coagulation studies
Urine analysis
  • Implantation of foreign bodies during surgery (e.g., metal implants, artificial heart valves)
  • Invasive urological surgery
  • Clinical features of urinary tract disease
Pregnancy test
  • Women of childbearing age if pregnancy would potentially alter management

Preoperative tests should be ordered only if they are indicated.

Preoperative cardiac assessment

Cardiac risk stratification
Preoperative cardiac evaluation Indications
ECG
Echocardiography
  • Exacerbation or new onset of cardiac symptoms (e.g., dyspnea, chest pain, syncope)
  • Patients with moderate or severe valvular regurgitation or stenosis who have not had an echocardiogram in the past year
Stress test
  • 0–1 RCRI risk factorlow-risk procedures → no stress test is required
  • > 1 RCRI risk factorelevated risk of a perioperative event

Preoperative pulmonary assessment

  • Patients should be asked about their smoking history; and discontinue smoking 8 weeks prior to surgery.
Assessment Indication for preoperative assessment
Chest x-ray
Pulmonary function tests
Cardiopulmonary exercise test

References:[1][2]

Preoperative hepatic assessment

  • Indications for preoperative LFTs
  • Risk assessment
    • Patients with acute hepatitis: Elective surgery is contraindicated until LFTs improve.
    • Chronic liver disease
      • Child class B and A, or a MELD score < 15: Surgery may be performed after treating encephalopathy, coagulopathy, and ascites.
      • Child class C or MELD score > 15: Elective surgery is contraindicated until the Child or MELD score improves.

Preoperative nutritional assessment

All preoperative patients should have their nutritional status assessed, with those at greater risk or with signs of malnutrition receiving a formal nutritional assessment.

Malnutrition has been associated with a greater risk of postoperative complications, including increased overall morbidity and mortality, longer hospital stays, increased risk of infection, delayed wound healing, and increased rate of ICU admissions!

Discontinuation of medication prior to surgery

Common long-term medications Recommendations
Antidiabetic drugs
  • Oral hypoglycemics
    • Metformin: discontinue 2 days before and after surgery
    • Discontinue other oral hypoglycemics on the day of surgery and postoperatively until the patient is no longer NPO.
  • Insulin
    1. Discontinue insulin on the day of surgery but administer IV intraoperatively.
    2. Continue insulin therapy postoperatively until glucose levels are stable and oral hypoglycemics can be resumed.
Antihypertensive drugs
Antianginal drugs
  • Continue
Statins
  • Continue
Oral contraceptives
  • Discontinue 4 weeks before surgery in patients with high risk of VTE
  • Continue oral contaceptives and give perioperative antithrombotic agents in patients with low to moderate risk of VTE
Psychiatric drugs
Antiepileptics
  • Continue
Anticoagulant or antiplatelet drugs
Thyroxine
  • Discontinue intraoperatively and resume postoperatively.
NSAIDs
  • Short-acting NSAIDs: discontinue 2–3 days before procedure
  • Long-acting NSAIDs: discontinue one week before procedure

Antianginal medications, antiepileptics, statins, antihypertensive drugs (except ACE inhibitors, ARBs, and diuretics), and most neuroleptics (except lithium) should be continued on the day of surgery.
References:[3][4][5][6]

Preoperative preparation

  • Discontinue certain medications (see discontinuation of medication prior to surgery above).
  • Fasting
    • 8 hours before surgery: no meat or fried, fatty food
    • 6 hours before surgery: no milk or solid food
    • 2 hours before surgery: nil per os (NPO)

The preoperative fasting recommendations can be remembered with the “2, 4, 6, 8 rule”!

References:[7][8]

Postoperative management

Postoperative complications

Wound-related complications
General postoperative problems Postoperative cardiac complications Postoperative pulmonary complications Renal and urinary tract complications

References:[9]

Postoperative fever

  • Temperature > 38°C in the postoperative period
  • Etiology
Onset of fever Etiology
Infectious Non-infectious
Immediate
  • Intraoperatively or within a few hours of surgery
  • Infection acquired prior to surgery
Acute
  • Within one week of surgery
Subacute
  • > 1 week but < 1 month after surgery
Delayed
  • > 1 month after surgery

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 febrile drug reaction.

  • Diagnostics
    • Only performed to diagnose a specific cause, based on the clinical presentation and time of onset
    • Chest x-ray, blood cultures, urine cultures, and wound cultures are indicated if nosocomial infections are suspected.
  • Treatment
    • Discontinue all unnecessary medications; and remove or change urinary catheters and peripheral venous lines.
    • Acetaminophen
    • Patients who are hemodynamically unstable: broad-spectrum antibiotic therapy

References:[11]

Perioperative hemorrhage

Type of perioperative hemorrhage Definition Etiology
Primary hemorrhage
  • Intraoperative hemorrhage
Secondary hemorrhage < 24 hours

1–7 days

> 1 week

While postoperative bleeding from the surgical wound is common (due to, e.g., infection or mechanical stress on the incision), it is important to remember that bleeding may also occur at other sites than the wound in patients with hemostatic disorders (e.g., due to central line insertion).

Surgical site infection

  • Definition: infection arising within 30 days of a surgical procedure at the the site of surgical intervention
  • Epidemiology
    • 15–20% of all healthcare-associated infections
    • Most common nosocomial infection among patients undergoing surgery
    • Incidence: ∼ 5% of all surgical wounds
  • Etiology
Type of surgical wound Definition Incidence of SSI
Clean
  • All of the following:
    • Noninflamed operative wound
    • The respiratory, alimentary, genital, and urinary tracts have not been entered during surgery.
    • Wound is closed primarily with or without a drain
  • 1.5%
Clean-contaminated
  • Noninflamed operative wound
  • The respiratory, alimentary, genital, and/or urinary tracts have been entered.
  • 8%
Contaminated
  • Fresh, open, accidental wounds
  • Inflamed operative wound without purulent drainage
  • Clean or clean-contaminated wounds with a break in sterile technique during surgery
  • 15%
Dirty or infected wounds
  • Old traumatic wounds
  • Inflamed operative wound with purulent drainage
  • 40%
  • Classification and clinical features
Type of SSI Incisional SSI Organ/space SSI
Superficial incisional SSI Deep incisional SSI
Definition
  • SSI involving fascia and muscle layers at the site of the incision
  • SSI involving any part of the body that is deeper than the fascia or muscle layers, and was opened or manipulated during surgery
Clinical features

References:[12][13][14][15][16]

Postoperative nausea and vomiting

Epidemiology

  • Incidence
    • 30–50% among postsurgical patients in the general population
    • Up to 80% in high-risk groups
  • Sex: >
PONV risk factors Adults Children
Patient-related
  • Female sex
  • Past history of PONV
  • History of motion sickness
  • Non-smoker
  • Age < 50 years
Procedure or treatment related

Differential diagnosis

PONV prophylaxis

Treatment of PONV [17][18]

Acute management checklist for PONV

  • Identify and treat acute abdomen.
  • Rule out alternative etiologies (see differential diagnoses for nausea and vomiting).
  • Address any contributing factors
  • Small, frequent meals
  • IV fluids
  • Start antiemetic therapy.

Complications

References:[17]

Postoperative urinary retention

Check the catheter for kinks or blockage if a catheterized patient develops signs of urinary retention (e.g., lower abdominal pain, bladder fullness).

Postoperative ileus

  • Risk factors
    • Open surgery
    • Excessive bowel handling during intra-abdominal surgery
    • Electrolyte imbalances (e.g., hypokalemia)
    • Use of opiates
  • Pathophysiology
    • 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
  • Clinical features
    • Failure to pass flatus
    • Nausea and vomiting may be present.
    • Abdominal distention may be present.
    • Absence of bowel sounds on auscultation
  • Differential diagnosis: early mechanical bowel obstruction
  • Management

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