LESSON 2

General care of the surgical Patient

Pre-op preparation and Post-op care, medical conditions that may affect surgical patients

OBJECTIVES

By the end of this lesson, you should be able to:1.Describe the pre-operative preparation of a surgical

patient2.Describe the post-operative preparation of a

surgical patien3.Describe the intra-operative preparation of a

patient4.List some medical diseases which may adversely

affect surgical patients

Outline of Pre Op Prepation

1. Medical/Surgical History2. Physical Examination3. Informed consent for operation4. Relevant investigations5. Analysis of risk factors6. Appropriate management of the risk factors if any7. Note any precautions8. Specific procedural preparation9. Premedication if any

Ensure the following is done• Explain procedure and prepare relatives• Explain preparation procedure and

investigations• Describe theatre, theatre personnel an

recovery room• Starve patient if indicate & set an IV line• Remove all jewellery, glasses, rings, dentures

and make-ups• Advice on bathing• Site preparation• Monitor vital signs

PRE-OPERATIVE EVALUATION• If an emergency procedure is required,

preoperative evaluation must be rapid and is thus limited.

• In other cases, the surgical team may consult an physicians to obtain a formal preoperative evaluation, which helps minimize risk by identifying correctable abnormalities and by determining whether additional monitoring is needed or whether a procedure should be delayed so that an underlying disorder can be controlled optimally.

Routine Preoperative evaluation

Routine preoperative evaluation varies substantially from patient to patient, depending on the patient's age, general health, and risks of the procedure.

SURGICAL HISTORYA relevant preoperative history includes information about all of the

following: • Current symptoms suggesting an active cardiopulmonary disorder

(eg, cough, chest pain, dyspnea on exertion, ankle swelling) or infection (eg, fever, dysuria)

• Risk factors for thromboembolism (e.g. DVT), excessive bleeding (bleeding disorders, anticoagulants), or infection

• Known disorders that increase risk of complications, particularly hypertension, heart disease, kidney disease, liver disease, diabetes, asthma, COPD, and bleeding disorders

• Previous surgery, anesthesia, or both, particularly their complications

• Allergies• Tobacco and alcohol use• Current prescription and nonprescription drug and supplement

use• If an indwelling catheter may be needed, patients should be asked

about prior urinary retention or prostate surgery.

Physical examination• Physical examination should include not only areas

affected by the surgical procedure but also the cardiopulmonary system and a search for any signs of ongoing infection (eg, upper respiratory tract or skin).

• When spinal anesthesia is likely, patients should be evaluated for scoliosis and other anatomic abnormalities that may complicate lumbar puncture.

• Any cognitive dysfunction, especially in elderly patients who will be given a general anesthetic, should be noted.

• Preexisting dysfunction may become more apparent postoperatively and, if undetected beforehand, may be misinterpreted as a surgical complication.

Investigations

No preoperative tests are required in healthy patients undergoing operations with very low risk of significant bleeding or other complications

In symptomatic patients or in patients undergoing operations with a higher risk of significant bleeding or other complications, laboratory evaluation may include the following tests: -

Preoperative Investigations 1.Full Blood Count (Haemogram)2.Urinalysis (glucose, protein, and cells)3.Renal Function Tests - Serum urea ,electrolytes and

creatinine (U/E/C)4.Plasma glucose (RBS) are measured unless patients

are extremely healthy5.Liver Function tests - if abnormalities are suspected

based on the patient's history or examination.6.Coagulation studies (INR) and bleeding time are

done only if patients have a history of bleeding diathesis or a disorder associated with bleeding.

Preoperative Investigations cont…

1. ECG is done for patients at risk of coronary artery disease, including all men > 45 and women > 55.

2. CXR – for patients with suspected chest or heart diseases undergoing GA

3. Pulmonary function testing may be done if patients have a known chronic pulmonary disorder or symptoms or signs of pulmonary disease.

Surgical Risk Factors

The following should be considered:1. Procedure risk factors2. Patient risk factorsProcedure Risk factors• Dependent of magnitude, complexity, organ being

manipulated, duration of surgery• Highest risk in – Heart & lung, major orthopaedic, prostate

and neurosurgical operations• Patients undergoing elective surgery that has a significant risk

of hemorrhage should consider autologous transfusion• Autologous transfusion decreases the risks of infection and

transfusion reactions.

Patient risk factors• They are stratified using published criteria Cardiac

Risk Index in Noncardiac Surgery. • Older age is associated with decreased physiologic

reserve and greater morbidity if a complication occurs.

• However, chronic disorders are more closely associated with increased postoperative morbidity and mortality than is age alone.

• Older age is not an absolute contraindication to surgery.

• Emergency surgery also has a higher risk of morbidity and mortality.

Cardiac risk factors

• Cardiac risk factors dramatically increase surgical risk.

• Among the most serious are the following cardiac disease disease: –Unstable angina–Recent Myocardial Infarction–Poorly controlled heart failure

Incidental infections

• Incidental infections (e.g, UTIs) should be treated with antibiotics but should not delay surgery unless prosthetic material is being implanted, in which case incidental infections should be controlled or eliminated before surgery if possible.

Fluid and electrolyte imbalance

• Fluid and electrolyte imbalance should be corrected before surgery if possible.

• Dehydration should be treated with IV normal saline because BP tends to fall when anesthesia is induced.

• K deficiencies should be corrected to reduce risk of arrhythmias.

Undernutrition

• Undernutrition increases surgical risk. For example, serum albumin < 2.8 g/dL is associated with increased morbidity and mortality.

• If surgery can be delayed for several weeks, sometimes nutritional deficiencies are correctable.

• Usually, the patient's calorie and protein intake should be increased during the perioperative period.

• Obesity is unlikely to be correctable in the time available

Specific procedural preparations

Several operative procedures have specific preparations which need to be done.

e.gLarge gut procedures an operationTransplant surgery

Postoperative Care • Postoperative care begins in the recovery room and

continues throughout the recovery period.• Critical concerns are airway clearance, pain control,

mental status, and wound healing. • Other important concerns are preventing urinary

retention, constipation, deep venous thrombosis, and BP variability (high or low).

• For patients with diabetes, plasma glucose levels are monitored closely by finger-stick testing every 1 to 4 h until patients are awake and eating, because better glycemic control improves outcome.

Airway• Most patients are extubated before leaving the

operating room and soon become able to clear secretions from their airway.

• Patients should not leave the recovery room until they can clear and protect their airway (unless they are going to an ICU).

• After intubation, patients with normal lungs and trachea may have a mild cough for 24 h after extubation; for smokers and patients with a history of bronchitis, postextubation coughing lasts longer.

• Most patients who have been intubated, especially smokers and patients with a lung disorder, benefit from an inspirometer.

Post operative dyspnoea• Postoperative dyspnea may be caused by pain secondary to

chest or abdominal incisions (nonhypoxic dyspnea) or by hypoxemia (hypoxic hypoxemia secondary to pulmonary dysfunction is usually accompanied by dyspnea, tachypnea, or both

• Thus, sedated patients should be monitored with pulse oximetry.

• Hypoxic dyspnea may result from atelectasis or, especially in patients with a history of heart failure or chronic kidney disease, fluid overload.

• Whether dyspnea is hypoxic or nonhypoxic must be determined by pulse oximetry and sometimes BGAs; chest x-ray can help differentiate fluid overload from atelectasis.

• Hypoxic dyspnea is treated with oxygen. Nonhypoxic dyspnea may be treated with anxiolytics or analgesics.

Take care of the following

• Pain management: Pain control may be necessary as soon as patients are conscious

• Mental status: All patients are briefly confused when they come out of anesthesia. The elderly, especially those with dementia, are at risk of postoperative delirium, which can delay discharge and increase risk of death

• Wound care: The surgeon must individualize care of each wound, but the sterile dressing placed in the operating room is generally left intact for at least 24 h unless signs of infection (eg, increasing pain, erythema, drainage) develop

Fever: A common cause of fever is a high metabolic rate that occurs with the stress of an operation.

Other causes include pneumonia, UTIs, and wound infections.

Spirometry and periodic coughing can help decrease risk of pneumonia

Other issues• Certain types of surgery require additional

precautions. For example, hip surgery requires that patients be moved and positioned so that the hip does not dislocate.

• Other operations require special positions• Any physician moving such patients for any

reason, including auscultating the lungs, must know the positioning protocol to avoid doing harm; often, a nurse is the best instructor

• Ensure adequate fluid intake

Urinary retention and constipation• Urinary retention and constipation are common

after surgery. • Causes include use of some drugs, immobility, and

decreased oral intake. • Patients must be monitored for urinary retention.• Straight catheterization is typically necessary for

patients who have a distended bladder and are uncomfortable or who have not urinated for 6 to 8 hrs after surgery

Loss of muscle mass (sarcopenia)• Loss of muscle mass and strength occur in all

patients in whom bed rest is prolonged. • With complete bed rest, young adults lose about

1% of muscle mass/day, but the elderly lose up to 5%/day because growth hormone levels decrease with aging.

• To avoid sarcopenia patients should sit up in bed, transfer to a chair, stand, and exercise as much as and as soon as is safe for their surgical and medical condition.

• Nutritional deficiencies also may contribute to sarcopenia. Thus, nutritional intake of patients on complete bed rest should be optimized.

Medical diseases that may affect surgical patients

• Diabetes mellitus, • Hypertension• Heart (cardiac diseases) – CCF, MI, HHD• Chronic obstructive airway disease (COLD) e.g.

Bronchial asthma• HIV• Tuberculosis• Haematological diseases e.g Leukaemia, bleeding

disorders• Infections• Renal failure• Liver failure

Conclusion

Preoperative EvaluationPreoperative preparationPostoperative evaluationPostoperative careMedical diseases that may affect

surgical patient

04/20/23