perioperative evaluation

peri-operative carePreoperative & Postoperative care

Shaikah A.O.B

Objective:

1. Outline type ,class and grade of surgery.

2. Define the perioperative .

3. Discuses the general preoperative care .

4. Overview the anesthetic status classification and airway evaluation .

5. Discuses the common medical problems affecting a patient’s fitness for

operation. ( specific pre- op Assessment )

6. Notes about inter- operative complication .

7. Discuses the post-operative care .

8. Minchin the postoperative possible complications .

Surgery

Clean Surgery.

Clean-Contaminated.

Contaminated.

Dirty.

PHASES OF SURGERY Pre-operative – from the time of px’s decision

for surgical intervention to the px’s tranference to the OR.

Intra-operative – px is received in the OR (with physical preparation) unto the admission in the RR.

Post-operative – px’s admission in the RR until the follow-up evaluation.

Effects of Surgery

Stress Response Activation (SRA)

Decreased resistance to infection

Alteration in the vascular and respiratory

function

Vital organ function (VOF) is altered

Psychologic effects (common fears r/t SRA)

Types of surgery 1- According to pt.A-In pt. surgery : pt. expected to remain in the hospital fore

more than 24 hrs.

B-0ut pt. surgery : ambulatory surgery –same day surgery pt. return to his home in the same day of surgery.

2- According to their urgency A-optional : at the request of pt. as cosmetic surgery .

B-Elective : planned the convenience of pt. as removal of cyst

C- required : should be done promptly as removal of cataract

d-Urgent : required promptly within 24-48 hrs as malignant tumor

E-Emergency : Immediately for survival as intestinal obstruction appendectomy 

Classification Clean

Clean Contaminated

Contaminated

Dirty

Grades of Surgery

Grade I (Minor) Excision of a skin lesion or drainage of abscess.

Grade II (Intermediate) Tonsillectomy, correction of nasal septum, arthroscopy…….

Grade III (Major) Thyroidectomy, total abdominal hysterectomy….

Grade IV (Major+) Radical neck dissection, joint replacement, lung

operations…

peri-operative care

Three Phases of peri-operative care Perioperative Period: Period of the time

that constitute the surgical experience, include :-

Pre-operative .

Inter- operative.

Post – operative .

Definition : Pre – operative care :

is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation

purpose of preoperative evaluation Establish baseline history and physical.

Identify previously undetected disease.

Assess operative risk. Should the patient proceed with

elective surgery? Provide high-quality and safe patient care . Improve patient satisfaction and set foundation

for optimum outcomes

Make specific recommendations regarding preoperative treatment that might lower the risk of surgery.

Give suggestions regarding intraoperative and postoperative care.

Pre-operative Care

Assessment (evaluation). History

Examination Investigations Pro-op preparation .

Psychological preparation Physical preparation

Physiological preparation Counseling. On going to theater.

History and Physical Examination Diagnosis of current condition Identifies associated risk factors:

Age of the patient (Extremes of age) Co-morbid conditions Previous surgery

Determines current medications Reviews past medical history Determines physical status:

American Society of Anesthesiologists’ (ASA) Physical Status Assessment

Key topics to review when taking the past medical history

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary tract

Neurological

Endocrine/metabolic

Locomotor system

Infectious diseases

Previous surgery ■ Types of anaesthetic and any problems encountereda ■ Have any members of the patient’s family had particular problems with anaesthesia?

Key topics in the general medical examination General ■ Anaemia, jaundice, cyanosis, nutritional status, teeth, feet, leg ulcers (sources of infection) Cardiovascular ■ Pulse, blood pressure, heart sounds, bruits, peripheral pulses, peripheral oedema Respiratory ■ Respiratory rate and effort, chest expansion and percussion note, breath sounds, oxygen saturation Gastrointestinal ■ Abdominal masses, ascites, bowel sounds, bruits, herniae, genitalia Neurological ■ Conscious level, any pre-existing cognitive impairment or confusion, deafness, neurological status of limbs

American Society of Anesthesiologists Patient Classification1 =A normal healthy patient

2 =A patient with a mild systemic disease

3 = A patient with a severe systemic disease that limits activity, but is not incapacitating

4 =A patient with an incapacitating systemic disease that is a constant threat to life

5 =A moribund patient not expected to survive 24 hours with or without operation

ASA 1 A normal, healthy patient. The pathological

process for which surgery is to be performed is localized and does not entail a systemic disease.

Example: An otherwise healthy patient scheduled for a cosmetic procedure.

ASA 2 A patient with systemic disease, caused

either by the condition to be treated or other pathophysiological process, but which does not result in limitation of activity.

Example: a patient with asthma, diabetes, or hypertension that is well controlled with medical therapy, and has no systemic sequelae

ASA 3 A patient with moderate or severe

systemic disease caused either by the condition to be treated surgically or other pathophysiological processes, which does limit activity.

Example: a patient with uncontrolled asthma that limits activity, or diabetes that has systemic sequelae such as retinopathy

ASA 4 A patient with severe systemic disease that is

a constant potential threat to life.

Example: a patient with heart failure, or a patient with renal failure requiring dialysis.

ASA 5 A patient who is at substantial risk of death

within 24 hours, and is submitted to the procedure in desperation.

Example: a patient with fixed and dilated pupils status post a head injury.

Emergency Status (E)

This is added to the ASA designation only if the patient is undergoing an emergency procedure.

Example: a healthy patient undergoing sedation for reduction of a displaced fracture would be an ASA1 E.

General Ix-: Full blood count (for example to test for anaemia) Haemostasis (to test how well the blood clots) Renal function Random blood glucose (to test for diabetes) Urine analysis (for example to test for urinary

infections or kidney problems) Plain chest X-ray (radiograph) Resting electrocardiogram (ECG) Blood gases (to test for cardiovascular or lung

problems) Lung function Pregnancy

Indications for preoperative investigations

Full blood count All adult women Men over the age of 60 years Cardiovascular or haematological disease

Urea & electrolytes All patients over 60 years Cardiovascular and renal disease Diabetics Patients on steroids, diuretics, ACE inhibitors

Chest X-ray Cardiovascular and respiratory disease Malignancy Major thoracic and upper abdominal surgery

ECG Indicated :-

Men > 45 y - Women > 55 y . Known cardiac disease . H&P suggesting possibility of cardiac disease . Electrolyte imbalance risk (ie diuretic use) . DM/HTN . Candidates for major surgeries .

NOTE – ECG: Low likelihood of changing management Recent MI important to detect Cardiac event risk increased by:

Non-sinus rhythm PACs - Premature atriale contractions  >5 PVCs - Premature ventricle contractions 

No risk increase with BBB

NOTE:Basic Factors Affecting Operative Risk : 1. Age over 70 years

2. Overall physical status3. Elective vs. emergency surgery 4. Physiologic extent of the tumor5. Associated illnesses as Jaundice, Bleeding tendency

6.Chronic drug medication as Oral contraceptive pills. Anticoagulants Tranquilizers (hypnotic as benzodiazepine) Antibiotics – aminoglycosides Diuretics Antihypertensives Long term steroid therapy

(P.S ) : Blood volume considerations:-a. anemia – chronic or acuteb. minimal requirement for anesthesia –

10 g/dl Hgb

NOTE: Problems in elderly:

Tolerate hypo tension, tachycardia, over and under-hydration poorly

Usually emphysema, they are used to a high level of PCO2 which leads to respiratory acidosis

Atherosclerosis makes their CVS very fragile – any sudden increase in B.P. can cause cerebral haemorrhage.

Sluggish peripheral circulation – higher chances of Thromboembolism and Pulmonary embolism

Poorly tolerate acid-base imbalance

Problems of children: They have a raised BMR – lot of carbohydrates preoperatively

and quick feeding postoperatively Very high incidence of Respiratory tract infection Poorly tolerate fever and cold

Airway evaluation

History of difficult intubation Head and neck examination for airway

evaluation Face Oral cavity : mouth opening

mandibular space tongue teeth Mallampati classification

Mallampati classification

Airway evaluation Mentothyroid distance : normal 6 cm. Mentosternal distance : normal 15 cm Mentohyoid distance : normal 3 FB Neck movement: flexion and extension of

neck, history of radiation Nasal cavity

Thyromental distance

Difficult intubation Mouth opening less than 3 cm. Limitation of neck movement Micrognatia Macroglossia Protusion of teeth Short neck Morbid obesity

Wilson Risk Test

specific pre- op Assessment

Specific Risks

Pulmonary Cardiac Hepatic Hematologic Endocrine Thromboembolism Prophylaxis

Pulmonary Risks

Complications Hypoventilation Pneumonia Atelectasis

Occur in about a third of patients Accounts for half of perioperative mortality

Who’s at Risk

Smokers COPD Obesity

lung capacity, FRC, VC ,Hypoxemia Age > 70 Procedure related risks:

Type of anesthesia GETA alone FRC 11% inhibited coughing peri-op

Surgical site

Thoracic surgery Upper abdominal surgery Duration of surgery > 2 hours

Pulmonary Assessment :

Patient History: unexplained dyspnea, cough, reduced exercise

tolerance Physical Exam:

wheeze, rhonchi, exp time, Birthing Sound Pre-operative CXR: Mandatory in patients over 40 yo B.N ABG: no role for routine use result should not prohibit surgery

Pulmonary Assessment : Pulmonary Function test N.B FEV1 > 2L, probably safe FEV1 between 1 and 2L, increased risk FEV1 <1L, high risk

Risk Management

Quit smoking Bronchodilator therapy PT ( physiotherapy ) . Early treatment of bronchitis Early mobilization

Smoking cessation

24 hr: decrease carboxyhemoglobin 2-3 day: increase ciliary function but increase secretion 1-2 wk: decrease secretion 4-8 wks: decrease postop pulmonary complication

NOTE

Cardiac Risks

Complications Myocardial Infarction CHF Hypertension

50% fatal, 60% silent Increased mortality post-op day 3

Who’s at Risk

Recent MI (Interval between MI time and surgery less than 6 mo is more likely with reinfarction)

Valvular heart disease CHF Unstable angina Diabetes

Cardiac Assessment

Resting echocardiogram function Exercise stress testing Pharmacologic stress testing Dipyridamole or adenosine thallium Dobutamine echo Coronary angiographyP.S: Goldman Cardiac Risk-Index for Noncardiac

Surgery American College of Cardiology Risk

Assessment

Goldman Criteria

PointsS3 gallop or jugular venous distention on preoperative 11 physical examinationTransmural or subendocardial myocardial infraction in the previous 6 months 10Premature ventricular beats, more than 5/min documented at any time 7Rhythm other than sinus or presence of premature atrial contractions on last preoperative electrocardiogram 7Age over 70 years 5Emergency operation 4Intrathoracic, intraperitoneal or aortic site of surgery

3Evidence of important valvular aortic stenosis 3Poor general medical condition 3

(K 3, HCO3 20, BUN > 50, Cr > 3, pO2 < 60, pCO2> 40 Abnormal liver (GOT), or bedridden)

Goldman ‘s risk of noncardiac surgery

Cardiac Morbidity Cardiac Death

Class I (0 to 5 points) 0.7% 0.2%

Class II (6 to 12 points) 5% 2%

Class III (12 to 25 points) 11% 2%

Class IV (26 or more) 22% 56%

-Predicted complication of class 4 well

-Low sensitivity for identifying high-risk patient in the intermediate risk groups

Lee's Revised Cardiac Risk Index

Clinical variable PointsHigh-risk surgery (i.e., intraperitoneal, intrathoracic, or suprainguinal vascular surgery)

1

Coronary artery disease 1*Congestive heart failure 1 History of CVD 1 Insulin for diabetes mellitus 1Preoperative SCr > 2.0 mg/dL 1

Total:__1__

Interpretation of Risk Score

Risk class Points Complication* risk

I. Very low 0 0.4%

II. Low 1 0.9% III. Moderate 2 6.6% IV. High 3 +11.0% *- MI, PE, VF, cardiac arrest, or complete heart

block.

Risk Management

Monitor for perioperative ischemia Repair severe aortic stenosis first Treat CHF aggresively preoperative Postpone non-emergent procedures for at

least 6 months after an MI Continue medication except anticoagulant or

antifibrinolytic: aspirin,warfarin,ticlopidine etc.

Digitalis : discontinue except in severe arrhythmia

Patient risk for MI postop

1. DM2. Peripheral vascular disease3. HT4. Tobacco used5. Hypercholesterolemia

Hepatic disease Assessment Liver is the seat of metabolism of most of the

anaesthetic drugs. in the pre-operative phase it requires plenty of

carbohydrates, Vitamin K and other clotting factors.

Liver function tests not only reveal the state of the liver but other organs as well as the Heart.

Serum Cholesterol, Triglyserides, Proteins and Albumin are routinely done.

If 1gm%. Protein is less in blood 900 grams is less in the body.

Child-Pugh Criteria for Hepatic Reserve

Measure A B C

Bilirubin <2.0 2-3 >3.0

Albumin >3.5 2.8-3.5 <2.8

Prothrombin Time (PT) increase

1-3 4-6 >6

Ascites None Slight Moderate

Neuro None Minimal “Coma”

Child-Pugh Criteria for Hepatic Reserve Predictor of perioperative mortality:

Class A: 0 - 5% Class B: 10 – 15% Class C: > 25%

Correct what you can vitamin K, FFP, Albumin, etc.

Anticipate bleeding, complications P.S Don’t operate Px with active hepatitis ,

Don’t Op. Px with hepatic encephalopathy.

Townsend, Textbook of Surgery, 16th ed.

Hypertension History of end organ damage: cardiac

ischemia, renal, neurological Elective surgery should be delayed ifDBP ≥ 110 mmHg with or without new onset of

headache but if no sign of end organ damage surgery

may be proceed In DM keep DBP < 90mmHg Aggressive treatment associated with

reduction in long term risk Continue medication until day of surgery: ACEI

and diuretic may be discontinue

Renal Risk Not all renal failure is oliguric CRF CRF patient risk of congestive heart failure,

hyper K, plt.dysfunction, anemia After dialysis pt at risk of hypovolumia

Assessment Urine analysis , creatinine , BUN dialysis, type of dialysis, last dialysis, serum K, Hct. and platelet function

Specific Factors affecting Operative Risk - Renal

Pre op. Baseline renal function studies: BUN Creatinine GFR

Avoid rise in BP b/c it will exacerbate RF. Assume DM have CRI

Volume status Electrolytes

Careful admin. Of drugs: NephrotoxicityP.S catheter drainage of an obstructed

urinary tract

How to manage patient with CRF

on dialysis previously.

OR

Not on dialysis previously

CRF Patient on dialysis previously: Dialysis 24 h before surgery to minimize risk

of : volume overload hyper K Excess bleeding.

Check U/E ,creatinine postdialysis. CXR to exclude pulm. Edema. Post op dialysis delayed 24h.

CRF Patient NOT on dialysis previously: IF: -Euvolemic -No electrolyte disturbances, bleeding

tendency. -responsive to diuretic .

P.S no need for dialysis before surgery.But if patient develops diuretic resistance with

progressive edema pre op. dialysis is considered

Endocrine Risks

Thyroid storm Diabetic complications

Risk Management

Good control of thyroid function for at least 3 months prior

Hold oral hypoglycemics Reduce insulin by half

The Rx goal of the preoperative management of diabetic patientsTo avoid :

Hypoglycemia Excessive hyperglycemia Electrolyte disturbance Protein catabolism

Principles of management of diabetes in pre operative period:

the patients are insulin dependent .

On oral hypoglycemic.

Or controlled by diet.

Insulin dependent: Admit 2 days preoperatively: CXR, ECG, FBS,

U&E, HbA1c.

Establish good diabetic control (glucose 4-10 mmol/L).

TTT : but them on Dextrose /insulin / K infusion

Insulin dependent Check glucose intra-operatively and U&E

postoperatively.

Monitor glucose regularly in early postoperative period.

Continue infusion until full oral diet is establish and then reinstitute normal insulin regime.

Oral hypoglycemic Review control.

Major surgery: convert to glucose /insulin / K infusion .

Minor surgery : omit oral hypoglycemic agent. Check blood sugar.

If greater than 13 mmol/l give small dose of subcutaneous insulin .

Diabetic control by diet alone Review control.

‘if preoperative control is adequate , no other measure required other than routine check of blood sugar pre- and postoperatively.

Evaluation of Hemostatic Disorders History:

Easy bruising, epistaxis Cut when shaving Heavy menstrual bleeding

Family history of bleeding disorders ASA / NSAID’s Renal disease Hepatic disease (EtOH)

Physical: Ecchymoses Hepatosplenomegaly Excessive mobility of joints or excess skin laxity Stigmata of renal or hepatic disease

Laboratory Tests of Bleeding Function

Prothrombin time (PT/INR international normalized ratio): Measures factor VII and common pathway

factors (factor X, prothrombin/thrombin, fibrinogen, and fibrin)

Partial thromboplastin time (PTT): Intrinsic pathway and common pathway

Platelet count: quantifies platelets

Bleeding time and Clotting time: estimates qualitative platelet function

Patients on Anticoagulants Aspirin (ASA) Coumadin (Warfarin) Heparin

Reasons patients are placed on anticoagulants:

− Atrial fibrillation

− Prosthetic heart valve

− DVT or PE

− CVA or TIA

− Hypercoagulable state

1Ridker et al Ann Intern Med 114:835-839, 1991.

Preoperative transfusion may:

Induce immunosuppression Increase risk of infection Increase risk of tumour recurrence

If transfusion is required it should be given at least 2 days preoperatively

Blood transfused immediately prior to operation has reduced O2 carrying capacity

Thrombembolic Prophylaxis Specific to surgery:

Acute spinal cord injury  Major trauma Major surgery including: 

  - general cancer or non-cancer surgery   - hip and knee arthroplasty   - open gynaecological surgery   - open urological surgery   - prolonged surgery

Increased risk Elderly Obesity Prolonged anesthesia Immobility

Risk factors for DVT

Age >40 years Obesity Varicose veins High oestrogen pill Previous DVT or PE Malignancy Infection Heart failure / recent infarction Polycythaemia /thrombophilia Immobility ( bed rest over 4 days) Major trauma Duration of surgery.

Patients who are malnourished

Proteins are essential for healing and regenerating tissue

Malnourished patients have Higher wound complications (dehiscence in which

a wound breaks open along surgical suture) and greater anastomotic leak rate

More postoperative muscle weakness (diaphragm)

Longer time in rehabilitation

Nutritional assessment Clinical assessment

Weight loss  10% =mild malnutrition   30% = severe malnutrition BMI

Anthropometric assessment Triceps skin fold thickness Mid arm circumference Hand grip strength

Blood indices Reduced serum albumin, prealbumin or transferrin Lymphocyte count

‘End-of-bedogram’ No index of nutritional assessment shown to be superior

to clinical assessment

Methods of nutritional support Use gastrointestinal tract if available Prolonged post-operative starvation is probably not required Early enteral nutrition reduced post-operative morbidity P.S. Indications for total parenteral nutrition

Absolute indications Enterocutaneous fistulae

Relative indications Moderate or severe malnutrition Acute pancreatitis Abdominal sepsis Prolonged ileus Major trauma and burns Severe inflammatory bowel disease

Patient Preparation Psychological:

Acceptance and positive outlook , decrease Anxiety . Physical:

Skin preparation Bowel preparation

Preaneasthetic medications Opiates Anticholinergics Barbiturates Prophylactic antibiotics

Physiological: Correcting associated co-morbid conditions Patient optimization

A.Blood Orders:1. Type and screen or type and cross for

number of units appropriate to the procedure

B. Skin Preparation: 1. Hair removal best performed on day of

surgery with an electric clipper 2. Pre-operative scrub or shower of the

operative site with a germicidal soap.

C. Pre-operative antibiotics: 1. Administer prophylactic antibiotics 30 min

prior to incision

D. Respiratory Care:

1. Pre-operative spirometry on the evening prior to surgery when indicated

2. Bronchodilators for moderate to severe COPD

E. Decompression of GI tract:

1. NPO after midnight

NPO Guideline

NPO 6-8 hr. before surgery Clear liquid diet for 2 hr.

ChildrenClear liquid 2 hrBreast milk 4 hr Infant formula 6 hrsolid diet 8 hr.Guideline used for patient with no problewith gastric emptying time

Liquids Clear

Solids Clear Age

2h 4 h <6 months

3 h 6 h 6 -36 month

2 h 6 h >36 month

5% Dextrose in Lactated Ringer's Injection (D5LR):Hypertonic (cells shrink), Uses: hypertonic hydration; provides some calories; replace electrolytes and ECF losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis), the dextrose minimizes glycogen depletion, Complications: Same as LR - not enough electrolytes for maintenance; patients with hepatic disease have trouble metabolizing the lactate; do not use if lactic acidosis is presen

F. Intravenous fluids:

1. Maintenance rate overnight (D5LR) 2. Plasma and extracellular fluid deficit- volume and

concentrationa. hourly urine outputb. urine concentrationc. mucous membranesd. skin turgor

G. Access and Monitoring lines:

1. At least one ga.18 IV needed for initiation of anesthesia

2. Arterial catheters and central or pulmonary artery catheters when indicated

H. Thromboembolic prophylaxis:1. When indicated (those predispose to deep venous thrombosis)

I. Pre-operative sedation:1. As ordered by the anesthesiologist

J. Special Consideration: 1. Maintenance medication

2. Pre-operative diabetic management 3. Other prophylactic medications 4. Peri-operative steroid coverage (if needed)

K. Skin Marking:1. For Plastic/Reconstructive Surgeries2. Marking of stoma sites

P. Pre-operative notes

Intraoperative

Intraoperative Care -Complication Hypoventilation

Oral Trauma - endotracheal intubation

Hypotension

Cardiac dysrhythmia

Hypothermia

Peripheral nerve damage

Malignant hyperthermia

Malignant hyperthermia - due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased muscle contraction.

Signs and Symptoms - high fever, tachycardia, muscle rigidity, heart failure, pseudotetany, and CNS damage.

Treatment of Malignant Hyperthermia

discontinue inhalent anesthetic, Give Dantrium, oxygen, dextrose 50%, diuretic, antiarrhythmics, sodium bicarbonate, and hypothermic measures-cooling blanket, iced IV saline or iced saline lavage of stomach,

bladder, rectum

Postoperative care

Definition:

is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery

Perioperative CareImmediate Anesthetic Care (PACU)

Respiratory Status - patent airway Cardiovascular - regular, strong heart rate and

stable BP (VS); peripheral pulses; Homan’s Sign

Neurological – level of consciousness; orientation, sensation

Fluid and Electrolyte, Acid Base Balance

Post operative note and orders

The patient should be discharged to the ward with comprehensive orders for the following:

• Vital signs • Pain control • Rate and type of intravenous fluid • Urine and gastrointestinal fluid output • Other medications • Laboratory investigations The patient’s progress should be monitored and should

include at least: • A comment on medical and nursing observations • A specific comment on the wound or operation site • Any complications • Any changes made in treatment

Aftercare: Prevention of complications

1• Encourage early mobilization: o Deep breathing and coughing o Active daily exercise o Joint range of motion o Muscular strengthening o Make walking aids such as canes, crutches and

walkers available and provide instructions for their use 2• Ensure adequate nutrition 3• Prevent skin breakdown and pressure sores: o Turn the patient frequently o Keep urine and faeces off skin 4• Provide adequate pain control

Discharge not On discharging the patient from the ward,

record in the notes: • Diagnosis on admission and discharge • Summary of course in hospital • Instructions about further management,

including drugs prescribed. Ensure that a copy of this information is given

to the patient, together with details of any follow-up appointment

Postoperative Management If the patient is restless, something is wrong.Look out for the following in recovery: • Airway obstruction • Hypoxia • Haemorrhage: internal or external • Hypotension and/or hypertension • Postoperative pain • Shivering, hypothermia • Vomiting, aspiration • Falling on the floor • Residual narcosi

Postoperative ManagementThe recovering patient is fit for the ward when: • Awake, opens eyes • Extubated • Blood pressure and pulse are satisfactory • Can lift head on command • Not hypoxic • Breathing quietly and comfortably • Appropriate analgesia has been prescribed

and is safely established

Post Operative Complications:

Immediate Primary haemorrhage: either starting during

surgery or following post-operative increase in blood pressure - replace blood loss and may require return to theatre to re-explore wound.

Basal atelectasis: minor lung collapse. Shock: blood loss, acute myocardial infarction

, pulmonary embolism or septicaemia. Low urine output: inadequate fluid

replacement intra- and post-operatively

Early Acute confusion: exclude dehydration and sepsis Nausea and vomiting: analgesia or anaesthetic-

related; paralytic ileus Fever Secondary haemorrhage: often as a result of infection Pneumonia Wound or anastomosis dehiscence Deep vein thrombosis (DVT) Acute urinary retention Urinary tract infection (UTI) Post-operative wound infection Bowel obstruction due to fibrinous adhesions Paralytic Ileus

Late Bowel obstruction due to fibrous adhesions Incisional hernia Persistent sinus Recurrence of reason for surgery, e.g.

malignancy

Post-operative fever Days 0 to 2: Mild fever (T <38 °C)

(Common) Tissue damage and

necrosis at operation site

Haematoma Persistent fever (T >38

°C) Atelectasis: the

collapsed lung may become secondarily infected

Specific infections related to the surgery, e.g. biliary infection post biliary surgery, UTI post-urological surgery

Blood transfusion or drug reaction

Days 3-5: Bronchopneumoni

a Sepsis Wound infection Drip site infection

or phlebitis Abscess formation,

e.g. subphrenic or pelvic, depending on the surgery involved

DVT

After 5 days: Specific

complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation

After the first week Wound infection Distant sites of

infection, e.g. UTI DVT, 

pulmonary embolus (PE)

Post Operative Complications: Days Local Systemic 0-1 day Haemorrhage (reactionary) Shock and Asphyxia Urine obstruction 2-21 days Paralytic ileas (day 1-3) Pulmonary complications (day 3) Infections (day 4-6) Deep vein thrombosis (day 7-10) in those Secondary haemorrhage (day 12-15) who are obese,

diabetic and cardiac cases Wound dehiscence (8-12 days) Fat embolism Flap loss (1-3 days) Pneumonias – pain, dependency Urinary tract infection > 21 days Incisional Hernia Inadequate reconstruction Adhesive intestinal obstruction Morbidity of loss of body part

Recurrence of diseasePressure sores ____________________________________________________________________________

PERIOPERATIVE CARESummary

Specific Nursing Duties for each phase: Preoperative, Intraoperative, Postoperative

Throughout Perioperative Care, the nurse will always: Monitor patient’s response to therapeutic regime,

prevent complications, patient education and promote optimum well-being