Surgery EOR: Preoperative/Postoperative Care

When can a patient eat prior to a major surgery?

NPO after midnight or at least 8 hours

What risks should be discussed with all patients and documented on the consent form for a surgical procedure?

Risk: Bleeding, infection, anesthesia, scars

If a patient is on anti-HTN meds should the patient take them on the day of the procedure?

Yes

Should a patient who smokes cigarettes stop before an operation?

Yes - improvement is seen in just 2-4 weeks of smoking cessation

What lab test must all women of childbearing age have before entering the OR?

B-Hcg and CBC

What is a preop colon surgery "bowel prep"?

Bowel prep with a colon cathartic (GoLYTELY), oral abx (neomycin, erythromycin), IV antibiotic before incidsion

What must you always order preoperatively for you patient undergoing a major surgery?

1. NPO/IVF

2. Preop abx

3. Type and cross blood (PRBCs)

What electrolyte must you check preoperatively if a patient is on hemodialysis?

Potassium

Who gets a preop EKG?

Patients over 40 or undergoing cardiac procedure

What is the most important preoperative eval performed by the surgical team?

H&P - no documentation exists linking a reduction in mortality and morbidity to routine lab testing in otherwise healthy patients undergoing elective procedures

Detailed H&P prior to surgery including special attention to...

Hx of CVA, heart dz, pulm dz, renal dz, liver dz, GI d/o, DM, prior surgeries, bleeding problems, clotting problems, difficulty w/ anesthesia, nutrition, etoh, illicit drugs

What is an ASA score?

American Society of Anesthesiologists (ASA) classification system which stratifies the degree of perioperative risk for patients

Describe the ASA classification system

ASA 1: Normal healthy patient

ASA 2: Patient with mild systemic disease

ASA 3: Patient with severe systemic disease

ASA 4: Patient with severe systemic disease with a constant threat to life

ASA 5: Moribound patient who are not expected to survive without an operation

ASA 6: Brain dead patient

Mouth PE important to note

Teeth - if loose worry about intubation

Tongue - think sleep apnea if large

Jaw - TMJ could be difficult intubation

Mallampati score

Airway concerns with surgery

Tracheal deviation - can be issue for maintaining airway during surgery

Neck concerns with surgery

If >17in there is concern for sleep apnea, masses, deformities, ROM

Mallampati score

Classifies how open the airway is

1 - Can see the uvula, no prob w/ intubation

IV- No uvula, hard intubation

Routine preop labs/tests for patients with cardiac disease/vascular disease?

CBC

EKG

What are major cardiac risk factors for surgery?

Unstable coronary syndromes

Recent MI

Severe valvular disease

Ventricular arrhythmias

What are minor cardiac risk factors for surgery?

Hx of CVA

Uncontrolled HTN

What is the Goldman Criteria for Cardiac Risk?

Assesses risk of perioperative fatal and nonfatal cardiac events. Another used is Detsky's

What are moderate cardiac risk factors for surgery?

Asymptomatic MI

DM

Compensated CHF

What is Lee's revised cardiac risk index?

Validated way to predict risk in patients who undergo elective noncardiac procedures. There are 6 predictors (each get one point):

History of ischemic heart disease

CHF

Hx of CVA

High-risk operation

Preoperative treatment with insulin

Preoperative SCr >2.0 mg/dL

Goldman criteria points

0-5 = Class I

6-12 = Class 2

13-25 = Class 3

>25 = Class 4

Preop lab assessment for cardiac disease?

Resting LV function

Ambulatory EKG monitoring

Exercise stress test or nuclear stress test

Stress echo

Patients with an EF <___% are at greatest risk for complications during surgery

<35%

What are indications for preop coronary angiography?

Patients with suspected left main disease, triple vessel coronary occlusive disease, or unstable coronary syndromes (high risk patients)

What is appropriate medical therapy for CAD prior to surgery?

BB, CCBs, nitrates to ensure myocardial oxygen demand does not exceed supply

What do patients with a history of rheumatic heart disease require prior to surgery?

Prophylactic antibiotics to prevent endocarditis

What should you do if you find your patient to have carotid artery disease?

Endorterectomy prior to surgery - wait 6 months before operation if possible

What are the 2 big things to worry about in surgery w/ a cardiac patient

1. Catecholamine surge which causes an increase in myocardial o2 demand

2. Suppression in the fibrinolytic system which leads to thrombosis

What kind of murmurs are usually benign?

Short, soft, systolic murmurs that are asymptomatic often don't require further investigation

What are risk factors for postop pulmonary complications (PPC)?

Advanced age

Elevated ASA class

CHF

Functional dependence

COPD

Sleep apnea

Smoking status

Low arterial O2 sat

Anemia

Upper abdominal/thoracic operations

Duration of operations over 2 hours

Emergency surgery

Routine preop labs/tests for pulmonary disease?

CBC

EKG

CXR

CXR screening guidelines

All >60

Patients with cardiac/lung disease

Patients undergoing thoracic procedure

Patient education to reduce risk of PPC?

Use of incentive spirometry

Deep inspiration

Coughing

Smoking cessation

Early mobilization

Oral hygiene

Use of CPAP/BiPAP

Clinical features of thrombophlebitis/DVT?

Dull pain

Erythema

Tenderness

Induration of involved vein

Swelling of involved area with heat and redness

Homan's sign (unreliable)

What is Virchow's triad?

Used to identify patients at risk for VTE

Risk factors for DVT?

Prolonged bed rest/immobility

Ortho surgery (total hip replacement)

Long air travel

Malignancy

Nephrotic syndrome

Use of OCPs/HRT

Hypercoagulable state (Pregnancy, Factor V Leiden)

Where does a DVT most commonly occur?

Lower extremities (Long saphenous vein)

Pelvis

Diagnostic test for DVT?

Duplex ultrasound <---preferred study

Venography <--- most accurate study, rarely done

D-dimer (neg is <500)

Spiral CT if PE is suspected (or VQ scan if there is renal impairment)

Treatment for thrombophlebitis/DVT?

Superficial thrombophlebitis is treated with bed rest, local heat, elevation of extremity, NSAIDs

Antibiotics

Surgical intervention if serious

When should DVT prophylaxis be started?

Preoperatively because it is thought that thrombosis starts as early as at the induction of anesthesia

What is the Caprini score?

Elaborate risk factor index for DVT

What is Wells Criteria?

Predicts risk for PE

What are VTE prophylaxis options?

Unfractionated heparin

Enoxaparin (low molecular weight heparin)

Warfarin

Fondaparinux

SCDs

Greenfield filter insertion

Dextran

How is unfractionated heparin dosed for DVT prophylaxis?

5000 units given SQ every 8 or 12 hours until patient is fully ambulatory

How is LMWH dosed for DVT prophylaxis?

40mg SQ daily started 12 hours before or soon after the procedure and continued till patient is fully ambulatory or up to 14 days post op

What is the preferred DVT prophylaxis method for trauma patients or those with abdominal or pelvic cancer?

Lovenox

How is Warfarin dosed for DVT prophylaxis?

Will vary from patient to patient. Goal INR is 2-3. Primarily used in ortho patients

How is fondaparinux dosed for DVT prophylaxis?

2.5mg given SQ dialy starting 6 hours post op. Adjustment is needed in patients with renal insufficiency

What should not be used as DVT prophylaxis?

Nonfitted thromboembolic stockings - they can actually promote a tourniquet effect so only fitted stockings should be used (if at all)

Recommended DVT prophylaxis for surgery with Caprini score of 0 (low risk)?

None

Recommended DVT prophylaxis for surgery with Caprini score of 1-2 (low risk)?

LMWH

LDUH (low dose unfractionated heparin)

MP (mechanical prophylaxis)

Recommended DVT prophylaxis for surgery with Caprini score of 3-4 (moderate risk)?

MP

Recommended DVT prophylaxis for surgery with Caprini score of >5 (high risk) and low risk of bleeding?

LMWH

LDUH

MP

Recommended DVT prophylaxis for surgery with Caprini score of >5 (high risk) and high risk of bleeding?

MP

Recommended DVT prophylaxis for surgery with Caprini score of >5 (high risk) and low risk of bleeding but LMWH/LDUH is contraindicated?

Low dose ASA

Fondaparinux

MP

Recommended DVT prophylaxis for abdominal/pelvic surgery for cancer with Caprini score of >5

LMWH for 4 weeks

What is the pathophysiology of hyperglycemia in the post op patient?

Surgical incisions cause increased stress hormones (catecholamines, growth hormone, glucagon, ACTH, and cortisol) and relative insulin deficiency and resistance.

How does hyperglycemia lead to decreased wound healing/increased infection?

Causes decreased neutrophil function

Routine preop labs/tests for patients with DM?

BMP

EKG

Elevated postop blood glucose levels (>140) in diabetic patients are associated with what complications?

Surgical site infections (SSIs)

Prolonged hospital stays

Death

What are current recommendations for glucose ranges in critically ill patients?

120-180

If a patient is on an oral hypoglycemic agent (OHA), should the patient take it on the day of surgery?

Not if the patient is to be NPO on day of surgery

If a patient is taking insulin should they take it on the day of surgery?

In general take only half of a long acting insulin and start D5 NS IV. Check glucose levels pre-op, operatively, and post-op q 6hrs

When should diabetics be scheduled for surgery?

As first case of the day because they will not be eating which will simplify glucose control

How does long term use of steroids cause complications during surgery?

Prolonged use of steroids for any inflammatory disorder can cause suppression of CRH/ACTH so if steroids are stopped suddenly this will lead to decreased production of cortisol and an Addinsonian crisis

How should patients on long term steroids be managed during surgery?

IV drip of hydrocortisone at 10mg/hr or 100-mg q8hr provides adequate replacement

In general when do you consider giving a blood transfusion?

Hemoglobin <7

Why is it important to ask about tobacco, alcohol, and illicit drug use/substance abuse?

It heightens awareness about the possibility of postoperative withdrawal. In general, patients should be advised to refrain from taking illicit drugs for at least a couple of weeks before an operation

What are signs of a wound infection?

Systemic manifestations: fever, chills, malaise/fatigue, tachycardia, tachypnea

Local manifestations: erythema, discharge. heat, pain

Wound dehiscence

What are risk factors for wound infection?

Malnutrition

Advanced age

Immunosuppressive drugs

Prolonged hospitalization

Recent abx use

Obesity

Catheters

Poor tissue perfusion

Steroids

Radiation

What are the 4 classes of wounds?

Clean

Clean contaminated

Contaminated

Dirty

What are examples of clean wounds?

Breast biopsy

Inguinal hernia repair

What are examples of clean-contaminated wounds?

GI, GU, GYN organs entered but no gross contamination

What are examples of contaminated wounds?

Perforated appy

Colectomy for diverticulitis

Perforated bowel/ulcer

Penetrating GI trauma

What are dirty wounds?

Traumatic wounds

Burns older than 72 hours

Free colon perforation

When should antibiotics be administered before incision?

Within 1 hour before incision

What antibiotic is recommended for surgical prophylaxis for the majority of clean surgical procedures? What is an alternative to this?

Cefazolin (Ancef) - can use Vancomycin if there is an allergy to cephalosporins

Which antibiotic should be administered to cover bacteroides?

Metronidazole

Which antibiotics are used for class 1 wounds? Class 2? 3?

1 - 1st gen cephalosporin

2 - 1st, 2nd, 3rd gen cephalosporin depending on procedure

3 - 2nd gen cephalosporin or Zosyn + metronidazole

What are some adjuvant prophylaxis measures besides antibiotics to prevent SSI?

Use of warming blankets to enhance tissue perfusion

Chlorhexidine soap showers

Sterile technique

Removal of hair

What is necrotizing fasciitis?

Life threatening infection that involves different facial layers of the body.

Clinical features of necrotizing fasciitis?

Characterized by discoloration/cyanosis around an incisional site with numbness of the area

MC caused by strep but often polymicrobial

Those at risk are diabetics, immunocompromised, and those with PVD.

How do you treat necrotizing fasciitis?

Debride tissue

Broad spectrum abx (Zosyn+Clinda+Cipro)

IVF

What % of our body is water?

Total body mass is 45%-60% water. The percentage in any individual is influenced by age and lean body mass.

What % of body water is intracellular? Extracelluar?

Two-thirds of total body water (TBW), is intracellular

One-third is extracellular

What % of extracellular fluid is interstitial? Intravascular?

80% is interstitial

20% is intravascular

What is the main intracellular cation? Extracellular?

Intracellular - K

Extracellular - Na

What is the 2nd most plentiful intracellular cation?

Mg

What is the main intracellular anion?

Phosphate

What ions balance K? Na?

K is balanced by PO4

Na is balanced by Cl

What is the main protein in intravascular fluid?

Albumin - it is the main cause of the high colloid osmotic pressure of serum which regulates fluid distribution between two extracellular compartments

What regulates the body's volume status and electrolyte composition? How?

The kidneys - by modulating how much free water and Na+ is reabsorbed from the renal filtrate. Antidiuretic hormone (ADH), also known as arginine vasopressin, is the chief regulator of osmolality.

What hormone regulates Na levels?

Aldosterone - increased levels causes increased retention of Na

What causes hypovolemia in the surgical patient?

Loss of isotonic fluids in the setting of hemorrhage, gastrointestinal losses (eg, gastric suctioning, emesis, and diarrhea), sequestration of fluids in the gut lumen (eg, bowel obstruction, ileus, and enteric fistulas), burns, and excessive diuretic therapy

What are some assessments to determine volume status? What is the #1 assessment?

Blood pressure - #1

Pulse

Edema

Skin turgor - (less useful in elderly)

Mucous membranes - (less useful in elderly)

Hematocrit

Fractional excretion of Na

BNP

BUN/Cr ratio (>20)

How do patients clinically present with hypovolemia?

Thirsty

Decreased urinary output

Tachycardia

Fatigue

Muscle cramps

Dizziness

Hypotension

If severe: ischemia, shock, lethargy, AMS

What labs confirm hypovolemia? (4)

Hct - will be high

Serum albumin - high

Urinary Na - decreased

Urea - increased