Chapter 50: Perioperative Care

Enhanced Recovery After Surgery

Evidence based care pathways implemented to minimize surgical stress, maintain fluid balance, prevent hypothermia, avoid tubes/drains, and promote early nutrition/ambulation

Risk Factors

Age, preexisting conditions, medications, lifestyle, type of wound, postop limitations, and home support

Preoperative Assessment

Verify identity/procedure, review history, meds, and allergies, assess airway, perfusion, and nutrition, identify early risks, and establish respiratory, circulatory, and pain baselines

Universal Protocol

Guidelines for preventing mistakes during surgery, implemented during any invasive procedure, includes preoperative document verification, marking operative site, and time out during surgery to verify right patient, site, and procedure

Intrinsic Risks

Patient’s tolerance to a pressure injury, includes altered nutrition, decreased mobility, old age, decreased mental status, infection, incontinence, and co morbidities

Extrinsic Risks

Variables that increase tissue susceptibility to sustain external pressure, includes temperature, friction, shearing, and moisture

Circulating Nurse

RN who manages overall or suite safety, coordinates handoffs, monitors sterile technique, manages positioning, warming, and IPC equipment, documents care, and leads counts, does not scrub in

Scrub Nurse

RN or certified surgical technologist (CST) who scrubs in, maintains sterile field and anticipates surgical instruments

RN First Assistant

Advanced RN role collaborating with the surgeon to handle/cut tissue, using surgical devices, providing exposure of surgical area, hemostasis, and suturing

General Anesthesia

Reversible state of unconsciousness, analgesia, muscle relaxation, and amnesia, may cause hypotension, changes in heart rate/rhythm, lowered body temp, respiratory depression, and emergence delirium

Regional Anesthesia

Loss of sensation in an area where sensory pathways are anesthetized, includes spinal, epidural, and peripheral nerve blocks

Local Anesthesia

Loss of sensation at desired site by inhibiting peripheral nerve conduction, may cause skin rash, allergic reaction, restlessness, bradycardia, hypotension, and ischemic necrosis at injection site

Moderate Sedation

Depressed LOC but with spontaneous ventilation, patent airway, and response to stimuli, may cause respiratory depression, bradycardia, hypotension, and nausea, also called conscious sedation

Immediate Postoperative Recovery

Phase 1 of postop, focuses on acute stabilization, airway patency, cardiovascular stability, pain/sedation monitoring, and fluid balance, usually in PACU

Postanesthetic Discharge Scoring System

Assessment that determines discharge home from ambulatory surgery, includes activity, ambulation, pain, nausea, and bleeding, a score of >9 indicates discharge

Recovery in Ambulatory Surgery

Phase II of postop, prepare ambulatory or stable inpatients for transfer to general unit or home, less intensity, family is allowed in room

Convalescent Care

Phase III postop, ongoing patient recovery directed toward preparing for self care and discharge

Multimodal Pain Control

Combining non-opioids, regional nerve blocks, and opioids to optimize pain relief while minimizing opioid side effects

Preoperative

Time from when decision for surgical intervention is made to when patient is transferred to operating room table, focus on support, teaching, and procedure prep

Intraoperative

Time from when patient is transferred from operating room table to when they are admitted to PACU, focus on safety, infection prevention, and comfort

Postoperative

Time from when patient is admitted to PACU and ends after follow up evaluation, focus on ABCs, safety, and pain management

High Risk Medications

Anticoagulants, diabetic therapies, sedatives, and opioids

Informed Consent Elements

Patient ID, procedure details, risk/complications, anesthesia info, alternatives, consequences of non-treatment, right to refuse, blood transfusion consent, and signature/date

Surgical Never Events

Wrong body part, wrong patient, wrong procedure, retention of foreign object, and death in a normal health patient during or immediately after surgery

Malignant Hyperthermia

Genetic condition causing unexplained rising CO2, tachycardia, rigidity, and eventual rise in temperature during anesthesia, emergency, give patient dantrolene

Anaphylaxis

Severe allergic reaction causing hypotension, bronchospasm, swelling, or skin changes

Local Anesthetic Toxicity

Life threatening conditions in which anesthetic drugs reach toxic levels in the bloodstream, causes neurologic changes or cardiovascular collapse

Aldrete Score

Scoring system for transfer out of PACU postop, includes activity, respiration, circulation, consciousness, and oxygen saturation, score should be > 9

Common Postop Complications

Airway obstruction, hemorrhage, DVT/PE, infection, and sepsis

NSAIDs

Aspirin, ibuprofen, naproxen, indomethacin, and ketorolac

Opioids

Hydrocodone, oxycodone, codeine, fentanyl, and methadone

Topical Anesthetics

Lidocaine, benzocaine, dibucaine, phenol, and pramoxine

Paralytic Ileus

Loss of function of intestine, causes abdominal distention

Postoperative Urinary Retention

Inability to void, occurs in 70% of postop patients, scan bladder if patient fails to void 4 to 8 hours post op and if volume is > 600 mL with catheter (POUR)

Major Surgery

Extensive reconstruction or alteration in body part, poses great risk to well being (CABG, colon resection, lung resection)

Minor Surgery

Minimal alteration in body parts, poses minimal risks (cataract extraction, facial plastic surgery, tooth extraction)

Elective Surgery

Performed on basis of patient choice, not essential or immediately necessary (bunionectomy, plastic surgery, elective hernia repair)

Urgent Surgery

Necessary for patient health to prevent additional problems (excision of cancerous tumor, cholecystectomy, vascular repair)

Emergency Surgery

Must be done immediately to save life or preserve body function (appendectomy, traumatic amputation)

Diagnostic Surgery

Surgical exploration performed to confirm diagnosis (exploratory laparotomy, breast mass biopsy)

Ablative Surgery

Excision/removal of diseased body part (amputation, appendectomy)

Palliative Surgery

Relieves/reduces intensity of disease symptoms, does not produce a cure (colostomy, nerve root resection)

Reconstructive/Restorative Surgery

Restores function/appearance to traumatized or malfunctioning tissues (fracture fixation, scar revision)

Constructive Surgery

Stores function lost/reduced as a result of congenital anomalies (cleft palate repair)

Cosmetic Surgery

Performed to improve personal physical appearance

ASA I

Physical status classification of a normal, healthy patient

ASA II

Physical status of a patient with mild systemic disease without substantive functional changes (current smoker, pregnancy, obesity, controlled diabetes)

ASA III

Physical status of a patient with severe systemic disease that causes substantive functional changes (poorly controlled diabetes, COPD, active hepatitis, alcohol dependence)

ASA IV

Physical status of a patient with severe systemic disease that is a constant threat to life and occurred in the last 3 months (MI, CVA, TIA, sepsis)

ASA V

Physical status of a moribund patient that is not expected to survive without intervention (ruptured aneurysm, massive trauma)

ASA VI

Physical status of a declared brain dead patient whose organs are being removed for donor purposes

Bleeding Disorders

Condition that increase risk of intraoperative and postoperative hemorrhage (thrombocytopenia, hemophilia)

Diabetes Mellitus

Condition that impairs wound healing and increases risk of infection due to altered glucose metabolism, surgical stress causes severe hyperglycemia

Heart Disease

Condition that increases risk of myocardial demand during surgical stress and depressed cardiac contractility from anesthesia

Hypertension

Condition that increases risk for CVA and tissue hypoperfusion

Hemoglobin

Value in CBC, should be 12-16 (female) or 14-18 (male)

Hematocrit

Value in CBC, should be 37-47% (female) or 42-52% (male), low values indicate fluid overload and blood loss while high values indicate dehydration and hemoconcentration

Platelet Count

Value in CBC, should be 150,000-400,000, low values decrease clotting while high values increase risk of thrombosis

White Blood Cells

Value in CBC, should be 5,000-10,000, low values indicate immunosuppression while high values indicate inflammation/infection

Complete Blood Count

Hemoglobin, hematocrit, platelet count, and WBCs

Blood Chemistry

Sodium, potassium, chloride, carbon dioxide, blood urea nitrogen (BUN), glucose, and creatinine

Sodium

Value in blood chemistry, should be 136-145, low values indicate fluid overload or hyponatremia and high values indicate dehydration or hypernatremia

Potassium

Value in blood chemistry, should be 3.5-5.0, low and high values indicate cardiac dysrhythmias

Chloride

Value in blood chemistry, should be 98-106, follows sodium shifts

Carbon Dioxide

Value in blood chemistry, should be 23-30, low and high values indicate acid base imbalance

Blood Urea Nitrogen

Value in blood chemistry, should be 10-20, low values indicate liver disease or fluid overload while high values indicate renal dysfunction or dehydration

Glucose

Value in blood chemistry, should be 74-106 (fasting), low values indicate insulin reaction or starvation while high values indicate diabetes or surgical stress

Creatinine

Value in blood chemistry, should be 0.5-1.1 (female) or 0.6-1.2 (male), low values indicate malnutrition or low muscle mass while high values indicate renal disease/failure

Coagulation Studies

INR, prothrombin time, and partial thromboplastin time (PTT)

Atelectasis

Alveolar collapse from retained mucus or shallow breathing, causes tachypnea, dyspnea, fever, and crackles

Pneumonia

Alveolar inflammation from retained/aspirated secretions, causes fever, chills, productive purulent cough, and chest pain

Hypoxemia

Low arterial PaO2 from respiratory depression or mucus plugs, causes restlessness, confusion, tachycardia, and cyanosis

Pulmonary Embolism

Dislodged DVT occluding pulmonary artery, causes sudden chest pain, dyspnea, cyanosis, tachycardia, and hypotension

Hemorrhage

Massive blood loss from dislodged clot/suture, causes hypotension, tachycardia, cool/clammy skin, and oliguria

Hypovolemic Shock

Severe cellular hypoperfusion secondary to uncorrected hemorrhage

Thrombophlebitis

Inflammation of vein with clot formation, causes localized leg swelling, tenderness, warmth, and hard, cordlike vein

Thrombus

Clot formation in deep veins from stasis/hypercoagulability, causes unilateral swelling, edema, and pain

Embolus

Dislodged, mobile clot traveling to heart, lungs, or brain

Hospital Acquired Deconditioning

Loss of muscle strength, mass, and functional capacity from prolonged post op bed rest

Abdominal Distention

Gas retention from slowed peristalsis or laprascopic air insufflation, pain radiates to shoulder

PONV

Postoperative nausea and vomiting, caused by gastric stasis, opioid stimulation, or anesthesia, puts patient at risk of aspiration or suture dehiscence

POUR

Postoperative urinary retention

Surgical Site Infection

Invasion of surgical incision by pathogens, causes periwound redness, warmth, purulent, odorous discharge, and fever

Dehiscence

Separation of wound layers, caused by strain, infection, or obesity

Evisceration

Protrusion of visceral organs through dehisced incision, emergency requiring sterile saline gauze covering

Intractable Pain

Severe pain unrelieved by standard analgesics, caused by wound, drains, positioning, or anxiety

Ambulatory Surgery

Operative procedures performed on same day basis where patients are admitted, undergo surgery, and are discharged on day of surgery

Bariatric

Branch of medicine dealing with causes, prevention, and treatment of obesity and its associated surgical risks

Laproscopy

Minimally invasive procedure using small abdominal incisions and a camera to inspect or operate on internal organs

Moribund

Patient at the point of death or not expected to survive without immediate intervention

Never Event

Particularly shocking, preventable medical error for which healthcare payers withhold reimbursement

Oxygen Desaturation

Sudden/progressive drop in SpO2 below 92%, detected via pulse ox