Download LESSON 2

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 patient
2. Describe the post-operative preparation of a
surgical patien
3. Describe the intra-operative preparation of a
patient
4. List some medical diseases which may adversely
affect surgical patients
Outline of Pre Op Prepation
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Medical/Surgical History
Physical Examination
Informed consent for operation
Relevant investigations
Analysis of risk factors
Appropriate management of the risk factors if any
Note any precautions
Specific procedural preparation
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 HISTORY
A 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 healthy
5. 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 factors
2. Patient risk factors
Procedure 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.g
Large gut procedures an operation
Transplant 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 xray 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.
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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 Evaluation
Preoperative preparation
Postoperative evaluation
Postoperative care
Medical diseases that may affect
surgical patient
5/4/2017