Preoperative Care (PowerPoint)

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					Preoperative Care
  N. Kittisarapong PGY 1
                   Objectives
•   Surgical Indication
•   Informed Consent
•   Preoperative Evaluation
•   Preoperative Preparations
• Postoperative Concerns and Complications
                  Surgical Indication
• Explore pt. reproductive tract/pelvic complaints, acquire
  good history and physical exam, examination of lab and
  radiographic data already done on pt., ordering further
  studies to confirm pt. diagnosis if needed

• Explain to pt. her dysfunction/disorder, how it can affect
  physiologically, physically, and even emotionally based on
  how it affects her daily life in language comparable to her
  educational level

• Medical and noninvasive interventions should be
  considered first, if failed or there is mutual agreement to
  bypass, then surgical intervention is discussed, the
  indication, benefits/risks of both medical and surgical
  options, alternatives to both, and expected disease course
  without intervention should be discussed
• Make sure that pt. can explain in her own words her
  disease process and the options that were explained to
  her

• Use illustrative drawings, pamphlets, videos, and
  appropriate language level when explaining to the
  patient and her family her condition, her medical and
  surgical options, benefits, and risks

• Most stressful time for patient, discussions should be
  done in a private setting, allowing for two-way
  communication, have good eye contact, caring touch,
  unhurried approach
                Informed Consent

• Should explain indication for surgery, the actual
  procedure, risks, benefits, alternatives and
  disease course w/o intervention

• Pt. should be able to describe in her own words
  the procedure and what she thinks are the risks/
  benefits/ alternatives

• Should include discussion of complications
  (infection, bleeding, discussion of death and/or
  permanent disability, injury to bladder, ureter,
  fistula formation, injury to bowel, prolonged
  catherization, possible removal of bowel,
  obstruction, breakdown of repair)
                  Informed Consent

• Be reassuring and discuss strategies used to prevent
  complications/risks (Prophylaxis, IS, etc.) and discuss
  possible involvement of consults if necessary

• Be cognizant of educational level and language

• Encourage pt. to write down questions and should be
  flexible to encompass more than one session with patient
  prior to surgery

• Discuss possibility of unexpected findings and
  possibility of intraoperative modifications due to the
  nature of pt. disease-include in informed consent list of
  procedures phrase “…and any anticipated/indicated
  procedures required in judgment of surgeon”
                  Informed Consent
• Discuss the team of personnel that will be involved in the
  surgery

• Document day and time, topics discussed,
  questions/answers, pt. understanding, agreement and if
  refusal the reason for refusal in pt. chart

• If pt. refuses, document day/time and the discussion
  regarding the need, the consequences/risks of declining the
  procedure and the reason for pt. refusal

• Understand that there is the possibility of modifications to
  the surgery secondary to patient’s desires/wishes
           Preoperative Preparation

• Timing and site of surgery
• Correction of anemia, risk stratification, medical
  stabilization of co morbid conditions, and consultation
  with other subspecialties for pt. co morbidities
• Review current medications and preop medication
  management
• Discuss with pt. what she is to expect on day of
  surgery, during her hospitalization, how long she may
  need to stay, recovery, and return to regular activities
• Bowel Preparation
• Antibiotic prophylaxis and sterile prep for infection
  prevention
• DVT prophylaxis
• Selection of anesthesia
      Clinical Evaluation, Risk Assessment
               and Risk Reduction
• 79% of surgical mortality is attributed to patient’s existing medical
  conditions

• Explore the patient’s complete hx including medical, family,
  ob/gyn, social, and surgical hx to seek out all physical, medical,
  psychological co morbidities that can be reduced prior to the
  surgery. Note allergies, medications, current physicians involved
  w/ pt. care. This evaluation should guide what subsequent testing
  pt. will require

• Goal of Preoperative lab testing is the reduction of risks associated
  w/ procedure and to uncover problems associated w/ current co
  morbid diseases of pt. that are amendable to optimization before
  surgery w/ help of medical subspecialty/internist

• Systems Based Evaluation, risk stratification, and optimization
        Cardiovascular Assessment and Risk
                   Stratification
• Nearly 50,000 perioperative MI occur yearly, 20,000 are fatal

• Majority of inhaled anesthetics depress cardiac function, modify neural
  tone, are arrhythmogenic

• Must assess risk, refine the assessment w/ non invasive testing, then
  reduce the cardiac risk

• Risk stratification helps determine which pts. require further noninvasive
  testing and therapeutic management to help minimize intraoperative,
  peri- and post-operative complications

• Perioperative intervention can center around coronary revascularization
  (CABG, PCTA) or modification of anesthesia choice or use of invasive
  intraoperative management
Step-wise approach to Preoperative Cardiac Risk Assessment
(Adapted from Sabiston’s Textbook of Surgery)
       Clinical Predictors of Increased Perioperative
                    Cardiovascular Risk

• Major:
-Unstable coronary syndrome- acute/recent MI w/ evidence of ischemic risk by
    symptoms or noninvasive study, unstable/angina angina
-decompensated HF NYHA class IV, worsening or new onset HF
-significant arrhythmias: high grade block, Symptomatic ventricular arrhythmias in
    presence of underlying heart disease, Supraventricular arrhythmias w/uncontrolled
    ventricular rate
-severe valvular disease: aortic stenosis, symptomatic mitral stenosis

• Intermediate:
-mild angina pectoris
-previous MI or pathological Q waves
-compensated/prior HF
-DM
-renal insufficiency

• Minor :
-advanced age, low functional capacity
-abnormal EKG (LVH, LBBB, ST abnormalities), rhythm other than sinus
-hx of CVA
-uncontrolled HTN
Risk Stratification of Non Cardiac Sx Procedures
              ACC/AHA Guidelines
• High Risk (Cardiac Death/nonfatal MI Often)
   -Aortic and other major vascular sx
   -Peripheral arterial sx
• Intermediate Risk (Cardiac Death/Nonfatal MI 1-5%)
   -carotid endardarectomy
   -head/neck sx
   -intraperitoneal/intrathoracic sx
   -orthopedic sx
   -prostate sx
• Low Risk (Cardiac Death/Nonfatal MI < 1%)
   -ambulatory sx
   -endoscopic procedures
   -cataract sx
   -breast sx
      Assessment of Functional Capacity
Helps to determine cardiopulmonary functional status

Metabolic Equivalents
1 Taking care of yourself, eat, dress, shower, walk 2.5 mph,
   play golf
4 light housework, sexual intercourse, walking 4 mph on
   level ground, climbing 1 flight of stairs, walking 2 blocks
5 walking up hill
7 carry 24 lbs. up 8 steps, shovel snow, do outdoor work,
   walk/jog 5 mph, recreational sports
10 strenuous sports
          Comparison of 3 Methods Assessing Cardiovascular
                             Disability
CLASS     NY Heart Association Functional Classification       Canadian Cardio Society         Specific Activity Scale
                                                               Functional Classification

I         cardiac disease w/o resulting limitations of         ordinary physical activity      pt. can perform to
          physical activity (no fatigue, palpitations,         not cause angina BUT there      completion any activity
          dyspnea, angina)                                     is angina w/ strenuous,         requiring >/ 7 METS
                                                               rapid, prolonged exertion at
                                                               work/recreation


II        cardiac disease resulting in slight limitation of    slight limitation of ordinary   Pt. can perform to
          physical activity. Comfortable at rest but           activities (4METS) walking      completion activity
          ordinary physical activity causes fatigue,           uphill, climbing more than      requiring </ 5 METS, but
          dyspnea, palpitation, angina                         one flight of stairs, walking   not activities requiring >/
                                                               2 blocks                        7METS


III       cardiac disease resulting in marked limitation       marked limitation of            pt. can perform to
          of physical activity. Comfortable at rest but less   ordinary physical activity-     completion activities
          than ordinary activity causes fatigue,               walking 2 blocks, climbing      requiring </ 2 METS
          palpitation, dyspnea, angina                         1 flight of stairs in normal
                                                               conditions


IV        cardiac disease resulting in inability to carry on   inability to carry on           pt. can't perform to
          any physical activity w/o discomfort. Cardiac        physical activity w/o           completion activities
          insufficiency or anginal syndrome symptoms           discomfort-anginal              requiring > 2 METS
          may be present at rest and if physical activity is   syndrome symptoms
          undertaken, discomfort increases                     present at rest



adapted from Up-to-Date-Estimation Of Cardiac risk prior to Non-Cardiac Surgery
                            Cardiac Risk Indices

• Revised Goldman Cardiac Risk Index
Six independent predictors of major cardiac complications (1 point each)
High risk surgery
Hx of ischemic heart dz (MI, + stress test, CP/abnormal EKG due to myocardial ischemia,
    nitrate therapy, coronary revascularization)
Hx of HF
Hx of CVA
IDDM
Perioperative serum CR > 2 mg/dl
Rate of cardiac death, nonfatal MI, nonfatal cardiac arrest according to number of predictors
No risk factors 0.4 %
One risk factor 1%
Two risk factors 2.4%
Three or greater risk factors 5.4%
Risk factors of cardiac death, MI, cardiac arrest, pulm edema, heart block due to predictors
    and use/non use of Beta Blockers
No Risk factors 0.4-1%, < 1% w/ BBlocker
One to two risk factors 2.2-6.6%, 0.8-1.6% w/ BBlocker
Three or more risk factors > 9%, 3% w/BBlocker
History
                                                                         Goldman
Age > 70                                    5
Preop MI w/in 6 months                      10                           Cardiac Risk
PE
S3 gallop or increased JVP > 12 cm H2O      11                           Index
Significant Aortic Stenosis                 3

EKG                                                                      Total possible points = 53
Rhythm other than sinus                     7
VPBs > 5/min at any time                    7                            Can underestimate pt. true
General Medical Status w/ one or more of:   3                            risk

PO2< 60 or PCO2 > 50
Serum K < 3 or HCO3 < 20
BUN > 50 or CR > 3 mg/dl
Chronic Liver disease or debilitation

Operation                                   3
Intraperitoneal, intrathoracic, aortic      4
Emergent                                                                 Adapted from Goldman, L.
                                                                         et al NEJM 1997; 297:845
Class I                                     0-5 = 1% complication risk
        Non Invasive Testing and Recommendations
• Cardiac Stress Testing
-High (-) predictive value and low (+) predictive value for postop cardio events (better for reducing risk
     than identifying pt at high risk)
-Good for High risk pt. (>3 RCRI) and w/ poor functional capacity (< 4 METS) scheduled for vascualr sx if
     management will change
-Not good for pt. undergoing intermediate risk noncardiac surgery with no risk factors or low risk non
     cardiac surgeries
-Pt who can exercise to target HR can have exercise stress test w/ concurrent imaging to better identify
     hihg risk features requiring further work-up w/ angiography
-Pt. unable to ambulate sufficiently to target can undergo pharmacological stress test w/ thallium or
     dobutamine echocardiography

• Echocardiography
-pt. w/murmur (AS causes poor postoperative cardiac outcome w/ 10% cardiac morbidity)
-evaluating for MS which needs HR control to decrease HF risk or if severe-balloon valvuloplasty)
-AR evaluation (needs volume control, afterload reduction, and bradycardia avoidance to reduce HF risk)
-MR, severe MVP require LVEF monitoring, low R valve causes backflow and pulm edema/PA P elev.
-evaluation for PHTN
- r/o HOCM
-evaluation of LV function in poorly controlled HF/dyspnea w/ unknown cause

• Angiography
-used to determine exact anatomical location of lesion contributing to ischemia

• EKG
-pt. w/ one or no clinical risk factor requiring vascular procedures
-pt. w/atherosclerotic dz or w/ one risk factor undergoing intermediate risk procedures
• CABG recommended for pt. w/significant abnormal testing w/LCA stenosis, 3
  vessel CAD w/ LV dysfunction, 2 vessel dz involving severe proximal LAD
  obstruction, intractable ischemia despite medical intervention, pt. should have
  viable amount of myocardium

• CABG NOT for pt. undergoing low risk noncardiac procedures w/less severe
  lesions

• Pt. who have had PCTA w/ stenting, recent ( 7-30 days) or acute (w/in 7 days)
  MI should wait 4-6 wks for elective non pelvic surgery or 2-4 wks for elective
  pelvic sx to decrease risk of stent thrombosis , BUT > 6-8 wks allows for
  restenosis of vessels

• Start Beta Blocker therapy in hemodynamically stable medium to high risk pt.
  undergoing major to intermediate risk surgery, titrating to HR of 60 bpm
  minimizes ischemia and MI risk

• Surgical delay in Pt. w/ Stage I/II HTN not necessary, elevated pressures for pt.
  w/ Stage III (180/110) need to be controlled prior to sx to avoid ischemic
  complications

• Evaluate ICD’s before and after sx, if rate responsive mode-inactivate during sx
  and turned back on after sx

• Pacemakers that have dependent-pacing threshold needs to be evaluated

• Continue BBlocker,CCB,clonidine, statins day of sx but d/c diuretics/ACEI,ARBS
                  Pulmonary Assessment and
                      Risk Stratification
• Definite Risk Factors Associated w/ Postoperative complications
Upper abdominal incisions
Surgery > 3 hours
Poor health status (high ASA class), low albumin
COPD/increased sputum production
Smoking hx w/in past 8 weeks
Comorbid conditions
Use of pancuronium NM blockade

• Probable Risk Factors
Use of general anesthesia
Emergent Sx
PaCO2 > 45 mm Hg

• Possible Risk Factors
URI/pneumonia/OSA
Abnormal CXR
Age > 70 y/o
Obesity
• Extremity, neurological, lower abdominal sx procedures
  have less affect on pulmonary function than upper
  thoracic and abdominal sx
• Pulmonary Assessment determines factors that increase
  risk and potential targets for risk reduction to prevent
  complications like atelectasis, ARDS
• Pulmonary function tests are Necessary for pt
  w/uncharacterized dyspnea, exercise intolerance, COPD,
  asthma pt. who don’t clinically show optimal airflow
  obstruction reduction:

-FEV1 (if <0.8 L/sec (80%) or 30% of predicted=higher risk
  for complications)
   use systemic corticosteroids

-DLCO (Diffusion capacity of CO)
• Recommendations for preoperative
  reduction of postop complications:
-smoking cessation > 2 months prior to sx

-bronchodilator therapy for COPD and asthma pt

-antibx tx for preexisting infection

-symptomatic asthmatics need systemic corticosteroids
   perioperatively

-educate pt. about lung expansion maneuvers

-limit sx to < 3 hrs., use laparoscopic sx, use spinal or epidural
   anesthesia, avoid pancuronium
  -administer Beta agonist/anticholinergics/LT morning of sx

  -hold theophylline day of sx

  -pt receiving > 20 mg. prednisone for > 3 wks. in the last 6
  months prior to sx are assumed to have HPA axis
  suppression, need their usual dose of steroid + continuous 10
  mg infusion hydrocortisone during induction of anesthesia ,
  this dose ½ day after sx, and maintenance dose resumed on
  POD #2

-postop - early ambulation, use of IS, intermittent deep
  breathing
                                     Renal
• 5 % of the population has some degree of renal dysfunction that can affect other
  organ systems and is one of most important

•   CR >/ 2 mg/dl is an independent risk factor for cardiac complication and
    renal dysfunction usually has concomittent cardiovascular, metabolic,
    hematologic, circulatory derailments, check UA, urine studies, BUN/CR if:
     -pt. > 50 y/o undergoing intermediate/high risk sx
     -young pt. w/ suspected renal dz and hypotension is likely during sx or if
           there will be nephrotoxic drugs used during sx

• Advance/d Renal Failure:
    -CBC to explore for anemia and PLT count, correct for it w/ help of nephrologist
    using erythropoietin/Aranesp and inform anesthesiologist regarding PLT
    improving agents
    -check lytes, CA, Mg, PO4 for hypocalemia, hyperphosphatemia, hyperkalemia,
    hypermagnesemia, metabolic acidosis, hyponatremia and tx
    -AVOID NEPHROTOXIC DRUGS, NSAIDS, ACEI,ARBS
    -MINIMIZE LV DYSFUNCTION
• ESRD:
   -can dialyze day before and day after surgery to help prevent fluid
   overload
   -maintain adequate intravascular volume
   -watch for increased K+ b/c operative manipulation and transfusion
   -do lytes,Ca,Mg,PO4 prior to sx and tx derailments with calcium
   supplements, PTH antagonists, phosphate binders, fluid restriction,etc.
   -Be aware of peritoneal dialysis/HD catheters and possible dislodgement

• Important to watch postoperative renal function for postopertive
  postrenal azotemia especially after difficult dissection, pelvic organ
  prolapse, tx of malignancy
• Use renal u/s to r/o ureteral injury/ligation
Hepatobiliary
• Assess degree of functional impairment-acquire hx of exposure to blood
  products, hepatitis, exposure to hepatotoxic drugs, check PT/INR/PTT,
  LFT’s, Bilirubin, albumin, monitor nutritional status
• Be aware and careful of dosing medications metabolized in the liver i.e
  benzo’s and narcotics)
• Assess mortality of a pt. with cirrhosis with Child Pugh Score




                       MORTALITY Class A 10% Class B 31% Class C 76%
         Endocrine Considerations
• Diabetes Mellitus
  -Should monitor and control blood glucose b/c it promotes good wound
  healing and decreased infection rates pre/postoperatively
  -preop check of lytes, BUN/CR, UA for protein, HgA1C, glucose check pre
  and postprandial to determine insulin/oral medication needs, check EKG
  -maintain glucose btwn 8-150 mg/dl and hydrate pt well

  -NIDDM: d/c long acting solfonylureas and metformin (can cause
  hypoglycemia and lactic acidosis if RF) day of surgery, resume once diet is
  resumed. Control glucose w/ short acting insulin (Aspart/Lispro/regular
  insulin) during NPO

  -IDDM: schedule for early morning sx, hold long acting (ultralente) on day
  of sx, take 2/3 normal amount of long acting/intermediate acting insulin the
  night before sx, take ½ dose of intermediate insulin (NPH/Lente) the
  morning of sx, D5 will be initiated morning of sx w/ insulin drip during sx,
  monitor glucose every hour during sx, beware of sudden glucose shifts

  -Post operatively: use BID dosing of intermediate acting insulin w/ short
  acting ISS coverage based q 2-4 hr. BGC until pt. resumes oral diet
• Thyroid Considerations:
  -pt. w/clinically suspected dz/know dz need TSH,T4,T3, lytes, EKG, +/-
  CXR
  -Defer sx until euthyroid state is attained w/tx
  -Hyperthyroidism: continue PTU/methimazole, BBlocker, digoxin
  -Hypothyroidism: Pt. on chronic T4 therapy but NPO don’t need T4
  IV/IM unless can’t take oral medication for > 5-7 days, if needed do 80%
  oral dose

• OCP: stop 4-6 weeks prior to moderate/high risk sx associated w/DVT,
  check BHCG prior to sx and use other forms of contraception, resume 1
  month postop
• Estrogen/SERM: taper dosage down 4-6 wks. Prior to sx and resume 1
  month postop

• Assess HPA response w/low dose ACTH stimulation test if pt. is on
  chronic steroid
NO HPA Axis Suppression             HPA Axis Suppression              HPA Axis Suppression
                                           Uncertain
<5 mg. prednisone/day,           20 mg. prednisone/day for        5-20 mg. prednisone/day > 3
every other day short acting     > 3 wks. , Cushingnoid,          wks. :
steroid, use < 3 wks:            failed ACTH stimulation:

                                                                  1. Minor procedure:
1. Give usual PO dose            1. Minor procedure:              Give usual PO dose w/o
perioperatively                  give usual PO steroid w/o        supplementation
                                 extra supplementation            2. moderate/major stress:
                                 2. Moderate sx stress: 50        check ACTH stimul. Test or
                                 mg. hydrocortisone IV            give supplemental steroids
                                 before anesthesia, then 25       as if HPA suppressed
                                 mg. hydrocortisone q 8 hrs.
                                 X 24-48 hrs, then resume PO
                                 dose
                                 3. Major sx stress: 100 mg.
                                 before anesthesia, then 50
                                 of Surgery and 48-72 hrs.,
Adapted from Sabiston’s Textbook mg. q 8 hrs. x Schiff,RL: Perioperative Eval. and Management of
Pt. w/Endocrine dysfunction, Med Clin North Am 87;175-192, 2003
                                 then resume PO dose
                           Neurological
• Antiepileptic, TCA, Lithium can be continued pre and
  perioperatively unless there are EKG effects (if so, dose adjustments
  per psych/neuro), check thyroid/electrolytes/fluids in lithium users

• MAOI: continue if anesthesiologist is comfortable or if consulting
  psychiatrist thinks that mood disorder will be exascerbated/
  precipitated w/ withdrawal. If continued, postop diet should
  exclude foods high in tyramine. If not, should d/c 2 weeks prior to
  sx

• Antiparkinsonian drugs: d/c the evening before b/c can cause
  hypotension

• Benzo’s: continue b/c w/drawal will cause seizures, HTN, delirium
  (sympathetic response)

• ADHD medications: d/c night before sx

• Chronic Opiod users: continue pre/perioperatively but MONITOR
                                 Hematologic
• Anemia:
  -symptomatic pt. need CBC w/diff, iron, ferritin, transferrin, B12, folate, reticulocyte count,
  coagulation profile, pelvic, rectal exam
  -Most healthy pt can tolerate Hgb 6-8 g/dl, if tachycardic, hypotensive, O2<50%, >30%
  volume loss, Hgb < 8 then transfuse, be aware of pt cardiac condition (CHF, LVEF) as they
  may need Lasix in addition to transfusion to avoid volumne overload

• Risk Stratification for VTE:

  Low risk: < 40 y/o undergoing surgery lasting < 30 minutes, with no additional
  risk factors.

  Moderate risk: pt. undergoing surgery lasting < 30 minutes, with additional risk
  factors; 40 to 60 y/o pts. with no additional risk factors who are undergoing
  surgery lasting < 30 minutes; or those undergoing major surgery who are < 40
  y/o, with no additional risk factors.

  High risk : surgery lasting < 30 minutes in patients > 60 y/o or who have
  additional risk factors, or major surgery in patients > 40 y/o or who have
  additional risk factors

  Highest risk: pt. > 60 y/o undergoing major surgery who have risk factors of a
  previous VTE, neoplasm, or hypercoagulable state.
                         Risk Factors for Venous Thrombosis

           Inherited Thombophilia                      Acquired Disorders
  Factor V Leiden                         Malignancy
  Prothrombin Gene Mutation G2010A        Central venous cath
  Protein S deficiency                    Surgery
  Protein C deficiency                    Trauma
  Antithrombin deficiency                 Pregnancy
  Dyfibrinogenemia                        Oral contraceptives
  Homocysteinemia                         Hormone replacement
  thrombophilia                           Tamoxifen,lenalidomide, thalidomide
                                          Immobilization
                                          Congestive HF
                                          Antiphospholipid syndrome
                                          Myeloproliferative disorders
                                          Paroxysmal noctural hemoglobinuria
                                          IBS
                                          coagulation labs,
Pt. w/ hx of clotting/PE/DVT or fhx = needNephrotic sydrome factor V, protein
deficiency, antiphospholipid, homocysteine, antithrombin, prothrombin labs drawn
                                          Smoking
• DVT prophylaxis and Anticoagulant Therapy

-ASA isn’t recommended
-MODIFY SX TECHNIQUE:
  position ankles higher than the knees and knees higher than the
  hips to allow drainage and prevent pooling, don’t excessively flex
  hips and watch amount of extremity compression against OR
  table/stirrups, use Trendelenburg, avoid placing laparatomy packs
  against pelvic veins and operating near pelvic veins

MECHANICAL: (continued until pt is ambulatory)
Intermittent Pneumatic Compression Boots (IPC)
Graduated Compression Stockings (GCS) – thigh high

PHARMACOLOGICAL:
-LDUH 5000 units SQ administered 2 hours before sx and then every 8-
   12 hrs. til pt. is d/c
-LMWH enoxaparin 40 mg SQ or dalteparin 1200 units administered
   12 hours before sx then daily pt. d/c
     American College of Physician Recommendations for
      Thrombophylaxis undergoing Gynecological Surgery:
   -Low risk (minor sx in mobile pt.) = entirely laparoscopic procedure w/ no DVT
   risk factors = don’t require phrophylaxis but pt. should have early and frequent
   ambulation

   -Moderate Risk Sx = GCS or IPC started before surgery and continued until the
   patient is fully ambulatory and SQ LDUH 5000 U started 2 hours before surgery
   and given every 12 hours after surgery til pt. d/c or SQ LMWH (dalteparin 2500
   antifactor-Xa units or enoxaparin 40 mg) given 12 hours before surgery and once
   on each postoperative day til d/c

   -High risk Pt. = IPC initiated before surgery and continued til d/c and SQ LDUH
   5000 U, beginning 2 hours before surgery and continuing every 8 hours after
   surgery or SQ LMWH (dalteparin 5000 antifactor-Xa units or enoxaparin 40 mg),
   given 12 hours before surgery and once on each postoperative day til d/c

   -Highest risk Pt. = Combination prophylaxis (pneumatic compression devices
   plus either LDUH or LMWH, Prophylaxis with LMWH may be continued as an
   outpatient for up to 28 days after surgery

• If LMWH cannot be started 12 hours before surgery, the first dose may be given
  6 to 12 hours after surgery.
• Monitor PLT count for HIT and ITP X 15 days, monitor PT/INR/PTT
• Don’t use LMWH < 12 hrs. after using regional anesthesia or < 2 hrs. after
  epidural cath removal
                 Patients on Anticoagulant Therapy
•   Pt. with recent DVT/PE should have surgery delayed for 1 month, recurrence of DVT is
    1%/day and reduces significantly after 2-3 months
•   If Surgery is necessary, stop warfarin 5 days before and use pre and post op IV heparin or
    SQ LMWH
•   If VTE occurred in 2 weeks and risk of bleeding with bridging anticoagulation is high = put
    in IVC filter
•   Cessation of anticoagulation depends on extent of bleeding risk of sx
•   Elective Sx should be delayed in pts. who recently had stents placed and are on
    thienopyridine and ASA therapy (1 month for bare metal stents, 12 months for drug
    eluding stents) b/c of stent thrombosis risk
•   Check their PT/INR/PTT

•   Half Lives and When to d/c prior to Surgery:
    -Warfarin: 20-60 hours, stop 3-4 days prior to sx, there is a period of subtherapeutic INR 2
    days before and 2 days after surgery
    -LDUH: 45 minutes, stop 5 half lives or 4-6 hrs. before sx
    -LMWH: 4-6 hours, stop 5 half lifes or 24 hrs. before sx and b/c of residual anticoagulation
    effect, last dose prior to cessation should be ½ dose
    -Clopidogrel: 8 hours, d/c 5-10 days prior
    -Dipyridamole: 10 hours, d/c 2 days prior to sx
    -Aggrenox/ASA : 15 hours, d/c 7-10 days prior to sx

•   Resuming anticoagulation:
    -Low risk Surgery: resume 24 hours after sx
    -High Risk Surgery: resume 48-72 hours after hemostasis secured
• MORE ON WARFARIN…….
• Fully elective surgery: hold warfarin 3-4 days prior to allow INR of 1.5-
  2.0. Hold for 5 days if INR should be 1-1.5 if bleeding risk of sx is high
• Semi Urgent Sx: anticoagulation needs to be reduced in 1-2 days, hold
  warfarin and 1-2 mg. of IV Vitamin K should be administered
• Urgent Sx: anticoagulation reversal needed in 1 day, hold warfarin and
  2.5-5 mg of Vitamin K IV should be administered
• Extremely Urgent Sx: reversal w/in minutes to hours, hold warfarin,
  give 10 mg Vitamin K IV over 20-60 minutes (slow infusion) with FFP 2-
  3 units or if extremely urgent prothrombin complex concentrate or
  recombinant factor VII

• For low-risk (NO prior thromboembolism, mitral stenosis, mechanical
  prosthetic valve, intracardiac thrombus and preserved left ventricular
  systolic function) patients with AF = discontinue 3-4 days prior to the
  procedure and resume warfarin on the evening of the procedure, use
  LMWH or LDUH as bridge if interruption will exceed 2 weeks

• For High Risk Pt. (Prior VTE,MS, prosthetic mechanical valve, LV
  dysfunction) w/ AF = administer 5000 U LDUH 4-6 hrs prior to surgery
  and then continue after hemostasis has been established after sx to PTT
  of 2 times the normal
                             Antibiotic and Skin Prep
• Preventing Surgical Site Infections
No elective sx if pt has infection
Achieve maximal SQ concentration of perioperative antibiotics
Maintain Prophylactic antibiotics for only a few hrs. after closing incision
High Risk C-Sections get prophylactic antibiotics ASAP after umbilical cord is
   clamped
Use clippers, NOT shaving to remove hair preop
Control Glucose levels
Have pt. shower/bath in antiseptic agent one night before sx
Don’t use vanco as prophylaxis unless other agents not work
Use appropriate sx/sterile technique
No surgical staff w/ draining lesions to participate
Apply sterile dressing to incision for 24-48 hrs. post op and wash hands prior to
   contact w/ sx site
Use appropriate topical microbicides during sx

Adapted from CDC Guidelines for Surgical Site Infection Prevention on CDC website
             Antibiotic Prophylaxis Recommended For:
  • Hysterectomy
  • Urogynecology procedures, including with mesh
  • Hysterosalpingogram or chromopertubation ( if hx of PID or procedure shows
    dilated fallopian tubes)
  • Surgical abortion

       Operation                    Pathogen                            Antibiotics
Vaginal, abdominal,         GBS, enteric Gram (–)         Cefotetan/cefoxitin/cefazolin 1-2 g. IV
                            bacilli, enterrococcus        Ampicillin-sulbactam 3 g. IV
laparoscopic hysterectomy
Cesarean section            GBS, enteric Gram (–)         Cefazolin 1-2 g. IV post umbilical cord
                            bacilli, enterrococcus        clamping



Abortion                    GBS, enteric Gram (–)         1st trimester: PEN G 2 million units IV or
                            bacilli, enterrococcus        Doxycycline 300 mg. PO
                                                          2nd trimester: cefazolin 1-2 g. IV

Genitourinary               enteric Gram (–) bacilli,     Cipro 500 mg. PO or 400 mg. IV
                            enterrococcus

Incisions through oral or   Anaerobes, enteric gram (-)   Clindamycin 600-900 mg. IV PLUS
                            bacilli, Staph aureus         gentamycin 1.5 mg/kg IV OR
pharyngeal mucosa
• Antibiotics given as a single IV dose 30 min. prior to incision ands
  repeated if procedure goes beyond 4 hrs. or if blood loss > 1.5 L.
• Clinda/metronidazole monotherapy not recommended for perioperative
  prophylaxis


• Pt. with Beta Lactam allergy:
-Clindamycin 600-900 mg. + gentamycin 1.5 mg/kg
-Clindamycin 600-900 mg. + Fluoroquinolones
   (cipro 400 mg., levofloxacin 750 mg., moxifloxacin 400 mg.)
-Clindamycin 600-900 mg. + aztreonam 1-2 g.
-Metronidazole 1 g. + gent/fluoroquinolones
                             Bowel Prep
• Indications:
  removing fecal material, lowers bacterial load, reduces possibility of
  injury to bowel, improves intraoperative handling, reduces
  spillage/contamination intraoperatively, lessens the possibility of
  mechanical disruption, facilitates intraoperative palpation, allows
  intraoperative colonoscopy,aids laparoscopic handling

• Contraindications:
  -complete bowel obstruction, perforation, ileus, severe colitis,
  neurological impairment preventing proper swallowing, gastric
  retention

   -no evidence exists recommending its routine use for the prevention of
   infection or bowel injury, small/underpowered studies showed no
   difference in infection rates and randomized studies have shown that
   suboptimal prep actually increases the risk of contamination
   -2009 Study of 83 women in Arch of Gyn/Obstetrics showed a low fiber
   diet preoperatively had equivalent efficacy and more compliance than
   mechanical bowel prep
                      TYPES of PREP
• Senna/Biscodyl/Castor Oil (stimulants) - increase peristalsis,
  promote fluid secretion into intestinal lumen – HARSH, NOT VERY
  EFFECTIVE
• Lactulose (hyperosmotic laxatives) - draw H2O into the intestine
  causing bowel distention/stimulation of evacuation BUT not for
  electrosurgical procedures b/c of hydrogen gas made by bacteria
  causing risk of explosions
• Saline laxatives/Sodium Phosphate (FLEETS/Visocol) – Mg and
  PO4 in the prep are not absorbed well and cause hyperosmotic
  effect in small intestine and H2O retention = stretch receptor
  stimulation and increases peristalsis, NOT recommended for pt. w/
  renal impairment b/c causes electrolyte abnormalities and seizures
  from imbalances since they have Mg and PO4. Take 3 pills every 15
  minutes w/ 8 oz. of water
• PEG (GoLytely)/Sulfate Free PEG – recommended in pt. w/ CHF,
  ascites,cirrhosis, renal impairment, has good cleansing
  efficacy/tolerance/non damaging to colon mucosa, better in 2 doses -
  2 L given @ 6 pm night before with ducolax @ 8 pm and a liquid
  dinner diet, then 2 L of Golytely in the morning atleast 2 hrs. before
  sx
Clear Liquid Diet:
  -24 hrs. before sx and up to 5 hrs. before
  -water,broth, coffee/tea w/o milk, ices, juices/gelatin, (non red)

Inadequate Prep:
  -use 2 days of liquid diet
  -no fat rich diet for 1 week
  -schedule morning procedure

Poor Tolerance:
  -disrupt regimen 1-2 hrs. and slow rate of consumption
  -give compazine/zofran
  -chilling solution
  -tell pt. to suck on lemon slices
  -add crystal light or lemon juice to diminish taste
                   Anesthesia
• Almost all organ systems affected, associated with
  duration of surgery
• 20% reduction in resting heat production and
  increased body surface heat loss = increased
  hypothermia = increased adverse cardiac event risk,
  altered pulmonary oxygenation, impairs coagulation,
  decreases wound healing
• Decreased renal blood supply, suppression of immune
  system, increased risk of ileus and gastric ulcers
• Goal of anesthesia: is maintenance of physiological
  homeostasis
• Mallampati rules for gauging airway:
Class I: soft palate, uvula, fauces, and pillars visible
Class II: soft palate, uvula, fauces visible
Class III: soft palate and base of uvula present
Class IV: only hard palate visible
ASA Risk Stratification
I -Normal Healthy Pt.
II - Pt. w/ mild systemic disease
III - Pt with severe systemic dz limiting physical activity but
    NOT incapacitating
IV - Pt w/ incapacitating dz that is a constant threat to life
V - Moribund Pt not expected to survive 24 hrs. with or w/o
    operation

                                     MALAMPATI GRADING
                                     FOR AIRWAY PATENCY




                                       What Grade is this?
• Preoperative Testing

• General Anesthesia:
   <40, 40-50 y/o – H&H, preg. test
   50-64 y/o - H&H, EKG, preg. Test, EKG
   65-74 y/o – H&H, EKG, BUN/CR
   >74 y/o - H&H, EKG, BUN/CR, glucose, CXR

• MAC, Regional Anesthesia:
   <40, 40-50 y/o – none needed
   50-64 y/o - H&H
   65-74 y/o – H&H, EKG
   >74 y/o - H&H, EKG, BUN/CR, glucose

5 P’s of RSI :
Plan
Prepare to Entubate
Preoxygenate for 5 minutes
Pretreat with Lido/Opiate/ anticholinergic (atropine), defasiculating agent
Put to Sleep
• General Anesthesia :
Upper abdominal and thoracic surgeries
-causes reversible state of unconsciousness and composed of 3 phases: induction,
    maintenance, emergence
-4 components of general anesthesia (amnesia, analgesia, inhibition of noxious
    reflexes, and skeletal muscle relaxation) achieved by combination of IV
    anesthetics and analgesics, inhalational anesthetics, and muscle relaxants
-preferred for pt. w/hx of arrythmia, cyanotic congenitaql heart disease, mechanical
    valve, intrabdominal/pelvic congential abnormalities

COMPLICATIONS:
Bradycardia
Hypotension
Nausea/vomitting
Damage to teeth
Larygospasm/larygoedema
Hypotension
Malignant hyperthermia
                             Types of Inducing Agents
Agent        Dose      Onset and             Side Effects           Indications       Caution
             (mg/kg)   duration
Thiopental   2-5       30-60 sec. onset      Hypotension            Increasede ICP    Hypovolemia
                       10-30 min. duration                                            LV dysfunction
                                                                                      asthma

Ketamine     1-2       30-60 sec. onset      Hypertension           For asthmatics,   ICP
                       Duration 10-15 min    Tachycardia            pt in shock,      Ischemic heart
                                                                    hypotensive,
                                             N/V, nystagmus,
                                                                    bronchospasm
                                             larygospasm in
                                             severe asthmatics,
                                             apnea

Propofol     1-2       20-40 s. onset        Hypotension            Less N/V          CAD
                       10-20 min. duration   Trismus/spasm          postop            Hypovolemia
                                                                    Decrease ICP      (IVF before
                                                                    anticonvulsant    admin. Helps)

Etimodate    0.1-0.3   < 60 sec onset        Adrenal suppression,   Rapid             Addison’s dz
                       Duration 6-10 min.    decreased ICP,         induction ,       supplement
                                             V/hiccups, pain on     older pt.,        steroids
                                             injection, apnea       hypotensive,
Routine Monitors

• Pulse oximetry
• Measure blood oxygen saturation
• Heart rate
• Blood pressure
• Electrocardiography
• Capnography
• Intratracheal placement of endotracheal tube
• Ventilator pressure monitor
• Monitoring of airway pressure
• Temperature monitoring
• Urine output (Foley catheter)
• Arterial catheter
• Central venous catheter- Continuous measurement of central venous pressure
• Measurement of pulmonary artery pressure- Measurement of left ventricular
  pressure, Measurement of cardiac output, Measurement of mixed venous
  oxygenation
• Precordial Doppler Detection of air embolism- Esophageal Doppler Assessment
• Esophageal and precordial stethoscope
• Auscultation of breathing and heart sounds
• NEURAXIAL ANESTHESIA:
  -Lower extremities and abdomen
  -preferred for pt. w/ airway abnormalities, impaired cardiac contractility
• Spinal anesthesia:

  -urologic, lower abdominal, perineal, and lower extremity surgery
  -induced by the injection of local anesthetic, with or without opiates, into the
  subarachnoid space. Provides excellent sensory and motor blockade below the
  level of the block. Relatively rapid and predictable onset
  -Advantages: avoiding manipulation of the airway, complication of tracheal
  intubation, side effects of nausea, vomiting, and prolonged emergence or
  drowsiness
  -Intrathecal opiate administration can provide high-quality postoperative
  analgesia for patients undergoing abdominal, lower extremity, urologic, and
  gynecologic procedures
• Usually administered as a single bolus injection = limited duration, not suitable
  for prolonged procedures
• continuous spinal anesthesia with the use of small-bore catheters abandoned
  because of neurologic complications associated with local anesthetic toxicity
• continuous spinal anesthesia with relatively large-bore epidural catheters can
  provide incremental titration and ability to administer additional doses in
  selected elderly patients BUT has high likelihood of inducing a post–dural
  puncture headache in young patients
• EPIDURAL:
   -catheter is inserted into epidural space. Local anesthetic can be added in
   a controlled fashion so that the time to onset of the block can be well
   controlled and the catheter can be use for repeated dosing so that
   anesthesia can be provided for the duration of lengthy procedures. Local
   anesthetics or opiates can be administered for several days to provide
   postoperative analgesia

COMPLICATIONS:

Spinal hematoma
Epidural abscess
Dural puncture
Numbness
Nerve damage
Headache
Infection/swelling
             THANK YOU FOR YOUR
                ATTENTION!!!




Resources:
1. Sabiston’s Textbook of Surgery
2. Danforth’s Obstetrics and Gynecology
3. Up to Date: Preoperative Assessment in the Gyn. Pt, Medication
   management in perioperative period, Anticoaguant management in
   perioperative period, Bowel Preparation, Preoperative Assessement in the
   Healthy Pt., Preoperative Period

				
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