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|| |
|Pregnancy test|| |
Preoperative tests should be ordered only if they are indicated.
|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
Preoperative nutritional assessment
Clinical indicators of severe protein energy malnutrition (> 2 of the following)
- Body mass index <18.5
- Recent weight loss
- Bedridden or otherwise significantly reduced functional capacity
- Obvious significant muscle wasting; loss of subcutaneous fat
- 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.
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|| |
|Antianginal drugs|| |
|Psychiatric drugs|| |
|Anticoagulant or antiplatelet drugs|| |
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.
- Discontinue certain medications (see above).
The preoperative fasting recommendations can be remembered with the “2, 4, 6, 8 rule”!
- Anesthesia (see and
Perioperative antibiotic prophylaxis
- Aim: to reduce the incidence of postoperative surgical site infections; (most commonly caused by S. aureus)
- Antibiotic of choice
- 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.
- Early mobilization
Surgical wound management
- Daily examination of the incision site and wound drainage
- Assess the wound healing process
- Assess for signs of wound-related complications (e.g., fever, severe tenderness, erythema, induration); possible causes include , n, , , and/or
- Regular wound dressings (every 24–48 hours) to facilitate healing
- Counsel patients to avoid maneuvers that increase tension on the surgical wound.
- Provide adequate analgesia with NSAIDs (e.g., acetaminophen).
|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 febrile drug reaction.
|Type of perioperative hemorrhage||Definition||Etiology|
|Primary hemorrhage|| || |
|Secondary hemorrhage||< 24 hours|
|> 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).
Infection arising within 30 days of a surgical procedure at the site of the surgical incision.
- 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|| || |
|Dirty or infected wounds|| || |
Classification and clinical features
|Type of SSI||Incisional SSI||Organ/space SSI|
|Superficial incisional SSI||Deep incisional SSI|
- Incisional SSI: wound swab for Gram stain and wound culture
- Organ/space SSI: imaging (e.g., CT, MRI)
- Surgical therapy
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 PLUS metronidazole, levofloxacin PLUS metronidazole, or carbapenem
- If group A Streptococcus or C. perfringens; infection is suspected: penicillin and clindamycin
- Targeted antibiotic therapy may be initiated once results of the bacterial culture are available.
- 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|
|Procedure or treatment related|| |
- < 1 week after surgery; : self-limiting gastric or intestinal atony; , or a more severe
- > 1 week after abdominal surgery; : early
- See also differential diagnoses of nausea and vomiting
- Reduction of baseline risk:
- Additional measures:
Treatment of PONV 
- Address any contributing factors (e.g., discontinue opioid analgesics, start bowel regimen).
- Use an antiemetic that was not used for prophylaxis (see antiemetics).
Acute management checklist for PONV
- Prolonged hospital stay
- Increased risk of
- Secondary hemorrhage due to retching
- Mallory Weiss syndrome
- Definition: failure to void > 4 hours after surgery
- 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-agonists or anticholinergics (e.g., atropine)
- 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
- If the patient is catheterized preoperatively
- Acute → postrenal cause of acute kidney injury
- Prolonged hospital stay → increased risk of hospital-acquired infections
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