Perioperative Management




Surgical Care Improvement Project (SCIP)



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Overview



Initiative sponsored by several organizations to improve the surgical care and reduce preventable surgical complications (morbidity and mortality). Linked to pay-for-performance quality parameters.



Four major targets for prevention:




  • • Surgical site infections.
  • • Venous thromboembolism.
  • • Cardiac morbidity.
  • • Respiratory morbidity.




Prevention of Surgical Site Infection



Surgical site infection is responsible for 15% of all nosocomial infections: 2–5% of clean extra-abdominal cases and up to 20% of intra-abdominal cases.



Measures:




  • • Appropriate selection of prophylactic antibiotics: eg, cephalosporin + metronidazole, ertanpenem, fluorochinolone + metronidazole. Betalactam allergy: fluoroquinolone + metronidazole, clindamycin + fluoroquinolone, clindamycin + aztreonam, etc.
  • • Prophylactic antibiotics received within 1 hour before surgical incision.
  • • Prophylactic antibiotics limited to 24 hours (longer duration okay for therapeutic indication).
  • • Appropriate hair removal for surgical field preparation (clipper, no razor).
  • • Monitoring and correction of peri-postoperative glucose levels.
  • • Maintenance of peri-/postoperative normothermia.




Prevention of Venous Thromboembolism



Without appropriate prophylaxis, DVT is a complication in 20–50% of major operations → pulmonary embolism in 10–30%.



Measures:




  • • Recommended DVT prophylaxis ordered.
  • • Appropriate DVT prophylaxis initiated within 24 hours before surgery to 24 hours after surgery.




Prevention of Adverse Cardiac Events



Adverse cardiac events (eg, myocardial infarction, sudden cardiac death, congestive heart failure) complicate 2–5% of noncardiac surgeries overall, causing increased mortality rate, length of stay, cost.



Measures:




  • • Perioperative β-blocker administration if previously required (eg, for angina, hypertension, arrhythmias).




Prevention of Respiratory Complications



Patients on respirator with mechanical ventilation are at increased risk of ventilator-associated pneumonia (10–30%), stress ulcer disease, and GI bleeding.



Suggested (but not yet approved) measures:




  • • Elevation of head of bed.
  • • Provision of stress ulcer disease prophylaxis.
  • • Use of ventilator weaning protocols to reduce duration of mechanical ventilation.





General Perioperative Management—Abdominal



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Overview



Colorectal surgery encompasses an enormously broad spectrum of diseases and conditions through all age and risk groups. Treatment equally varies in a wide range of approaches and is delivered in several different settings (office, OR, endoscopy suite, outpatient/inpatient).



Hence, management is not “one-size-fits-all.” Nonetheless, a few principles have evolved that should be considered in the perioperative management of a patient undergoing an abdominal procedure.




Risk Assessment




  • • < 40 years, no risk factors/symptoms → no specific workup needed.
  • • > 40 years, no risk factors → ECG, chest x-ray, basic set of lab work.
  • • Any age, specific risk factors/symptoms → ECG, chest x-ray, basic set of lab work, followed by selective internal medicine or cardiology clearance.
  • • Pregnancy test in all women of childbearing age.




Bowel Cleansing




  • • Dependent on surgery and surgeon: see separate discussion in this chapter.
  • • If mechanical bowel cleansing → monitoring and supplementation of electrolytes and fluid status.




Site Selection (Marking) for Possible Ostomy



Potential need for permanent or temporary ostomy → discussion and preoperative marking of possible stoma sites (stoma nurse, verification through operating surgeon).




Antibiotic Prophylaxis



See separate discussion in this chapter.




Venous Thromboembolism Prophylaxis



See separate discussion in this chapter.




Management of Medications




  • • Antihypertensives/β-blockers: should be actively continued.
  • • Oral antidiabetics: discontinued the day before (fasting period).
  • • Insulin: reduced dose for fasting and surgery period, ideally titrating drip.
  • • Steroids: > 20 mg/day of prednisone → give same dose IV (as prednisolone which is 1.25 times more potent that prednisone), < 20 mg/day → dose (as prednisolone) + additional stress dose.
  • • Past steroids (< 6 months): perioperative steroid stress dose:

    • – Short boost: 100 mg hydrocortisone IV on call to OR, repeat one dose in evening and next morning, then stop (ie, total of three doses).
    • – Longer taper: 100 mg hydrocortisone IV twice daily on surgery day (= equivalent to 40 mg prednisone) → switch to oral prednisone and reduce by 10 mg every 5 days down to 20 mg/day, last 20 mg tapered in 5-mg steps every 5–7 days.




Blood Transfusion



Many abdominal colorectal operations do not need a blood transfusion due to bloodless surgical and anesthesiologic technique and a lowered range for blood levels that are still acceptable in a given patient. Minimal blood levels depend on patient age, comorbidities, expected ongoing blood loss, current hemodynamics:




  • • < 40 years, no risk factors: hematocrit ≥ 25 (or individually even less).
  • • > 40 years, no risk factors: hematocrit ≥ 28.
  • • Any age, specific risk factors: hematocrit ≥ 30.
  • • Preexisting chronic anemia (eg, IBD, renal failure): hematocrit down to 20 acceptable?



Preoperative planning:




  • • Baseline: type and screen.
  • • Preexisting anemia, expected blood loss: type and cross.
  • • Preexisting anemia, bleeding risk, expected high blood loss: type and cross, including fresh frozen plasma, platelets.



Jehovah’s witnesses:




  • • Determine the individual patient’s acceptance of cell saver, albumin, fibrin glue, erythropoietin, etc.
  • • Preexisting anemia: determine whether optimizing blood levels possible, or whether further delay would result in more severe blood loss (eg, active bleeding from tumor, colitis, etc).
  • • Intraoperative availability of sealing devices, nontraumatic surgical technique; in case of bleeding → rapid packing and damage control.




Pain Management



Crucial to allow for adequate respiratory excursions to avoid atelectasis, pneumonia.




  • • Epidural analgesia (EDA) at thoracic level (Th6–Th12).
  • • Patient-controlled anesthesia (PCA).
  • • On demand: oral analgesics, intramuscular analgesics.



Caveat: postoperative ileus and prerenal borderline kidney function (large fluid shifts) increase risks of ketorolac and other NSAIDs to cause peptic ulcer or acute renal failure.




Foley Catheter



Placement indicated for all abdominal procedures to adequately monitor urine output peri- and postoperatively.



Removal:




  • • Procedure with pelvic dissection: after 3–5 days.
  • • Any procedure with EDA in place: continued until 6 hours after discontinuation of EDA.
  • • Procedure without pelvic dissection, patient stable, no EDA: removal after 1 day or less.
  • • Procedure without pelvic dissection, but major procedure, comorbidities, or unstable patient: continue until patient stable (eg, large procedure, ICU setting).
  • • Bladder repair: removal after ~10–14 days (after prior cystogram?).




Ureteral Stents




  • • Previous history of colorectal or pelvic dissections, ongoing inflammatory process → placement of prophylactic ureteral stents to allow intraoperative identification and protection. Lighted stents for laparoscopy.
  • • Postoperative management: depending on extent of adjacent dissection or traumatization during surgery removal after 0–2 days.




Nasogastric Tube




  • • No routine placement.
  • • Only for symptomatic patient (eg, gastric retention, bowel obstruction) → low intermittent wall suction until output < 200–300 mL/24 hours; limited amount of oral clear fluid intake is okay for patient comfort.
  • • Removal of NGT: if < 200–300 mL/24 hours; if function is uncertain: transition by intermittent clamping of NGT and checking of residuals every 4–6 hours.




Nutrition




  • • Fast-track concept → no waiting for passage of gas or stool but feeding on POD1 or as soon as no nausea/vomiting (ie, recovery of upper GI tract function). Caveat: aspiration precautions!
  • • Inability to have oral intake despite working GI tract (eg, intubated patient) → enteral nutrition.
  • • > 5 days inability to tolerate enteral nutrition or preexisting malnutrition → TPN. Cycled TPN, if need continued as outpatient.




Mobilization




  • • Early patient mobilization important: improve lung function, reduce DVT, stimulate GI function, limit decubitus risk.
  • • Starting no later than first postoperative day, unless patient intubated.
  • • Bedridden patient: repeated positional changes, soft mattress, physical therapy for prevention of extremity contractures, etc.




Respiratory Care in Nonintubated Patients




  • • Early patient mobilization and/or frequent positional changes.
  • • Incentive spirometry.
  • • Adequate pain control.
  • • Chest physical therapy.
  • • Inhaler treatment (bronchodilators, inhaled steroids, acetylcysteine, etc).





General Perioperative Management—Anorectal



Listen




Overview



Colorectal surgery encompasses an enormously broad spectrum of diseases and conditions through all age and risk groups. Treatment equally varies in a wide range of approaches and is delivered in several different settings (office, OR, endoscopy suite, outpatient/inpatient). Hence, management is not “one-size-fits-all.” Nonetheless, a few principles have evolved that should be considered in the perioperative management of a patient undergoing an anorectal procedure.




Risk Assessment




  • • < 40 years, no risk factors/symptoms → no specific workup needed.
  • • > 40 years, no risk factors → ECG, chest x-ray, basic set of lab work.
  • • Any age, specific risk factors/symptoms → ECG, chest x-ray, basic set of lab work → selective internal medicine or cardiology clearance.
  • • Pregnancy test in all women of childbearing age.




Bowel Cleansing




  • • Two Fleet enemas are sufficient for most anorectal procedures.
  • • Full bowel cleansing for selected indications.
  • • If mechanical bowel cleansing → monitoring and supplementation of electrolytes and fluid status.




Antibiotic Prophylaxis



See separate discussion in this chapter.




Venous Thromboembolism Prophylaxis



Outpatient procedure: not indicated (except intraoperative intermittent pneumatic compression).



Inpatient procedure: see separate discussion in this chapter.




Management of Medications




  • • Antihypertensives/β-blockers: should be actively continued.
  • • Oral antidiabetics: discontinued the day before (fasting period)
  • • Insulin: reduced dose for fasting and surgery period, ideally titrating drip.
  • • Steroids: > 20 mg/day of prednisone → same dose IV (as prednisolone), < 20 mg/day → dose (as prednisolone) + additional stress dose.
  • • Past steroids (< 6 months): perioperative steroid stress dose:

    • – Short boost: 100 mg hydrocortisone IV on call to OR, repeat one dose in evening and next morning, then stop.
    • – Longer taper: 100 mg hydrocortisone IV twice daily on surgery day (= equivalent to 40 mg prednisone) → switch to oral prednisone and reduce by 10 mg every 5 days down to 20 mg/day, last 20 mg tapered in 5-mg steps every 5–7 days.




Blood Transfusion



Blood transfusion is very unlikely for anorectal surgery.




Pain Management



Combination of NSAID (eg, ketorolac) with opiate generally works well.



Addition of antibiotics (eg, metronidazole), topical nitroglycerine, or topical sucralfate of potential benefit but controversial data.




Foley Catheter




  • • Routine placement not needed for anorectal procedure as long as anesthesiologist adheres to perioperative fluid restriction (< 500 mL total IV fluids) to avoid bladder distention.
  • • Selective indications.




Nutrition



Resumption of regular diet as soon as anesthesia has worn off (> 6 hours after end of surgery).




Bowel Management




  • • Bowel confinement not indicated (except for selected cases).
  • • Fiber supplementation with adequate fluid intake, stool softener, milk of magnesia (as needed) → soft but formed stool.




Wound Care




  • • Internal wound (eg, stapled hemorrhoidectomy): no wound care.
  • • Closed wound: rinsing off after bowel movement, patting dry.
  • • Open wound: sitz baths 2–3 times, plus after each bowel movement.





Comorbidities—Cardiac Disease



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Overview



Cardiac diseases or surgeries may either precipitate colorectal problems (eg, ischemic colitis) or indirectly interfere with the management of unrelated colorectal diseases. Both the need for colorectal surgeries and the prevalence of cardiac diseases show a parallel increase with age. Adequate cardiac function is a prerequisite for any surgical management. Appropriate risk assessment in view of the urgency and the natural course of the colorectal disease and the cardiac prognosis are relevant in order to adjust the management.



History and background information (eg, risk factors, cardiopulmonary or vascular symptoms and events, previous cardiac evaluations and/or interventions, medications, patient compliance, etc), current physical performance capacity, physical examination, and baseline tests are the basis to assess the need for more thorough cardiac evaluation.




Problems




  • • Risk assessments reflect a statistical probability and may not predict the individual’s outcome.
  • • Routine placement of pre-/perioperative pulmonary artery catheter is not beneficial, causing potential harm.




Risk Assessment Parameters




  • • Urgency and extent of colorectal operation: elective vs emergency, abdominal vs anorectal.
  • • Severity and prognosis of colorectal disease.
  • • Coexisting morbidity: pulmonary disease, diabetes, peripheral vascular disease, stroke, renal or liver disease, hematologic disorders (anemia, thrombocytosis, etc).
  • • Nature of cardiac disease:

    • – Coronary artery disease (diabetic, nondiabetic).
    • – Valvular heart disease (primary vs secondary with biologic or mechanical valve).
    • – Arrhythmias and conduction defects.
    • – Cardiomyopathy.
    • – Post–heart transplantation.

  • • Assessment of severity and prognosis of cardiac disease and identification of those patients who require cardiologic evaluation:

    • – Goldman classification (Table 7–1), and newer modifications (eg, Detsky index).
    • – Cardiac risk categories (Table 7–2).
    • – Adapted risk stratification for colorectal procedures (Table 7–3).

  • • Cardiac evaluation and testing:

    • – Exercise stress testing: treadmill testing.
    • – Ambulatory 24- to 48-hour ECG monitoring.
    • – Echocardiography: evaluation of murmurs (diastolic vs systolic vs valvular, etc), congestive heart failure of unknown cause.
    • – Dobutamine stress echocardiography.
    • – Dipyridamole/adenosine thallium stress test: predictive of postoperative cardiac problems, indicated if functional status cannot be determined otherwise (eg, treadmill).
    • – Coronary angiogram with/without stenting.




Table 7–1. Goldman Cardiac Risk Index.
Jan 14, 2019 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Perioperative Management
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