MCU-FDTMF Second Year Section 1

From Dr. Garcia s Lecture

PERIOPERATIVE MANAGEMENT
6Ps
Proper Preoperative Preparation Prevents Post Operative Problems
Principle of PRIMUM NON NOCERE First Do no harm
PERIOPERATIVE MANAGEMENT
Care of a surgical patient before, during and after a surgical procedure
Divided into three phases
- PREOPERATIVE
- INTRAOPERATIVE
- POSTOPERATIVE
END GOALS
Patient Safety
Limited/Acceptable Morbidity/Mortality
Life with quality
Palliative and Rehabilitative
Classifications of Surgery
Minor Surgery
o Small superficial lesions
o Under local anesthesia
Major Surgery
o Under Regional/Spinal or General Anesthesia
o Procedure done in cavity lesions
o Higher morbidity and mortality risk
Elective Surgery
o Can be scheduled
o Procedure can be delayed without further complications
Emergency Surgery
o Mortality or debilitating complications may arise from a delay of the procedure
PREOPERATIVE PHASE
Questions to be asked:
Is surgery necessary?
Is patient safe for surgery?
o Low
o Intermediate
o High
How to cut?
When to cut?
Complete History and physical examination is very vital for predicting patients fitness for surgery. 96%
Exemption is during emergency cases when rapid or immediate action is needed.
PREOPERATIVE ASSESSMENT
Complete Hx & PE
Confirm Diagnosis
ABCDE
Lab Work Ups
Risks
o >35 YO requires internist CP clearance prior to surgery
Systems Assessment:
1. CNS
a. BMP (Basal Metabolic Panel)

Transcribed by: Raymond De Gula

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MCU-FDTMF Second Year Section 1

From Dr. Garcia s Lecture

b.
2.

i. Electrolytes
1. Na hyponatremia may cause seizures
2. K arrhythmia
3. Ca tetany
ii. Glucose - hypoglycemia
iii. BUN renal function
iv. Creatinine renal function
CXR, CBC, ECG minimum requirements for patients older than the cut off

CVS

a. Most common cause of morbidity and mortality among elective surgeries

b. Delay surgery as much as possible (for MI patients 6months before elective surgery)
3. Pulmonary
a. High CO2 higher risk for respiratory failure (CXR, ABG, PFT)
b. Upper abdominal surgery or thoracic surgery may impair PF
i. Cholecystectomy
ii. Splenectomy
c. Stop smoking 8 weeks prior to surgery
d. Bronchodilators or steroids (USN/Nebulization)
e. Control infection
f. Lung expansion maneuvers
i. Deep breathing exercises
4. GI
a. Liver surgery limiting organ
i. Cirrhosis or tumor high risk
1. Infection
2. Hemorrhage
3. Wound complications
This is because the livers function is very important in developing enzymes necessary
Serum Albumin indicator of nutrition
PTPA
INR
PT
Childs Pugh Classification
DM if with complication increases the risk
Malnutrition
5. Renal
a. Electrolyte disturbance
b. Anesthetic complications
6. Hematologic/Oncologic
a. Anemia Transfuse blood
i. 7g/dl acceptable Hgb for surgery
ii. 50,000 acceptable platelet level
b. Metastatic Work Up (Staging)
i. Surgery is still the best option
ii. Later stages are for palliative instead of curative
iii. Neoadjuvant chemotherapy decreases size of tumor before surgery
7. Medications
i. Anticoagulants
ii. Diuretics
8. Social Hx
a. Smoking and alcohol
i. For healthy smokers, top smoking at least 7 days prior to surgery
Antimicrobial therapy
Prophylactic treatments - protective
Therapeutic 7days for definite infection

Transcribed by: Raymond De Gula

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MCU-FDTMF Second Year Section 1

From Dr. Garcia s Lecture
Empiric
- Skin and soft tissues G(+) 1st gen cephalosphorins
- GI tract 2nd gen G(-)
- Immunocompromised 3rd and 4th gen, quinolones G(+)(-)
- ICU patients- at risk for sepsis imipenem
Instrumentation:
CVP line has greater risk for congestion due to its direct connection in the central circulation.
Foley Catheter risk for infection
Monitor UO 30ml/hr minimum
0.5ml/kg
Conditions before surgery
Asepsis instrumental and environmental preparation
Antisepsis
- What you do on the operative site to minimize infections
o Gloves, drapes, cleansing solution and prep solution
Surgical Time Out
- Vital to identify and prevent problems
Surgical Team
Informed Consent - written and oral, rapport must be built to minimize legal issues
INTRAOPERATIVE PHASE
Skills
Decision Making most important
Gentle handling of tissues
Hemostasis
Drainage Jackson Pratt
POST OPERATIVE PHASE
- PACU/RR ICU
- Monitor VS I&O
- Spinal anesthesia flat on bed for 8 hrs to prevent spinal headache
- K = 1meq/Kg
- Complications
o Fever 1st day (atelectasis) no antibiotic must be given, instruct movement and deep breathing
exercises
2nd day urinary tract infection remove catheter immediately if not contraindicated
o Wound complications
Dehiscence most common in abdominal surgeries, exposure of visceral organs
Causes:
o Technical
o Malnutrition
o Increased abdominal pressure
Disruption up to the subQ only
o Hypotension
1st few hrs bleeding or anesthesia
Continuity maybe sepsis or cardiac problem
Kinds of Wounds
1. Clean wounds surgically incised wound
2. Clean contaminated there was a break In asepsis on the incised wound
3. Contaminated wound incisions involving cavities such as respiratory tract and gastrointestinal tract
4. Dirty Wound dirty lesions such as abscess and debridement with purulent discharges.
PCS Philippine College of Surgeons recommends:
Ruptured AP 7 day antibiotic prophylaxis and therapy before, during and after procedure
o If patient recovered immediately, just give for another 2 days instead of completing the 7 day

Transcribed by: Raymond De Gula

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