Pre-operative Preparation Pre-operative Preparation and and Peri-, Post-operative Peri-, Post-operative Monitoring Monitoring of the of the Surgical Patient Surgical Patient Alfred D. Troncales, MD, DPBS Alfred D. Troncales, MD, DPBS Pamantasan ng Lungsod ng Pamantasan ng Lungsod ng Maynila Maynila College of Medicine College of Medicine
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Pre-operative Preparation Pre-operative Preparation and and
Alfred D. Troncales, MD, DPBSAlfred D. Troncales, MD, DPBSPamantasan ng Lungsod ng Pamantasan ng Lungsod ng
MaynilaMaynilaCollege of MedicineCollege of Medicine
SURGERYSURGERY
“ “ One of the most challenging aspect One of the most challenging aspect of surgical practice is not just of surgical practice is not just making the decision to perform a making the decision to perform a surgical procedure on a patient, but surgical procedure on a patient, but deciding on deciding on the proper timingthe proper timing when a surgical procedure can be when a surgical procedure can be done.” done.”
Management Factor:Management Factor: Classical and Advances in Surgical and Medical Classical and Advances in Surgical and Medical
Techniques (Management Options)Techniques (Management Options) Anesthesia Methods and MedicationsAnesthesia Methods and Medications
Patient Factor:Patient Factor: General Health (Optimization)General Health (Optimization) Co-morbid Conditions (Identify and Manage)Co-morbid Conditions (Identify and Manage) Psychological PreparationPsychological Preparation
SURGERYSURGERY
“ “ Thus, appropriate Thus, appropriate pre-operative pre-operative preparationpreparation andand post-operative post-operative monitoringmonitoring is absolutely mandatory is absolutely mandatory and essential to minimize the risks, and essential to minimize the risks, lessen complications and optimize lessen complications and optimize outcome of a patient even with the outcome of a patient even with the best technically performed operative best technically performed operative procedure.” procedure.”
Pre-operative CarePre-operative Care
Optimize efficiency and bed utilization preoperatively
Avoid delays and cancellations resulting in lost operating room time
Proactively coordinate patient care with other specialties
Provide high-quality and safe patient care
Improve patient satisfaction and set foundation for optimum outcomes
OBJECTIVES
General Aspects of Pre-General Aspects of Pre-op Careop Care
History and Physical ExaminationHistory and Physical Examination
History and Physical History and Physical ExaminationExamination
Diagnosis of current conditionDiagnosis of current condition Identifies associated risk factors:Identifies associated risk factors:
Age of the patient (Extremes of age)Age of the patient (Extremes of age) Co-morbid conditionsCo-morbid conditions Previous surgeryPrevious surgery
Determines current medicationsDetermines current medications Reviews past medical historyReviews past medical history Determines physical status:Determines physical status:
American Society of Anesthesiologists’ (ASA) American Society of Anesthesiologists’ (ASA) Physical Status Assessment Physical Status Assessment
Pre-operative Medical Pre-operative Medical CareCare
AMPLEAMPLE History:History: A A llergiesllergies M M edications edications P P ast Medical Historyast Medical History L L last meallast meal E E vents Preceding Surgeryvents Preceding Surgery
Pre-operative Medical Pre-operative Medical CareCare
Physiology of SurgeryPhysiology of Surgery:: myocardial oxygen demandmyocardial oxygen demand catecholamines: catecholamines: HR, HR, contractility, contractility, PVRPVR HR also causes decreased diastolic fillingHR also causes decreased diastolic filling
Coronary arteries fill in diastoleCoronary arteries fill in diastole Less blood flowing in coronaries: less myocardial Less blood flowing in coronaries: less myocardial
OO22 supply supply
Myocardial InfarctionMyocardial Infarction Pt without risks: Pt without risks: 0.5% chance of MI0.5% chance of MI Pt with risks:Pt with risks: 5% chance of perioperative MI5% chance of perioperative MI Perioperative MI has 17-41% mortalityPerioperative MI has 17-41% mortality CAD causes MICAD causes MI Risk stratifications:Risk stratifications:
MI w/in 3 months of MI w/in 3 months of OROR
27% reinfarction rate27% reinfarction rate
MI 3-6 months before MI 3-6 months before OROR
10% reinfarction rate10% reinfarction rate
MI >6 months of ORMI >6 months of OR 5-8% reinfarction 5-8% reinfarction rate*rate*
Criteria: Points
A. Historical: Age >70 yr. 5 Myocardial infarction previous 6 months 10
B. Examination: S3 gallop or jugular venous distention 11 Significant aortic valvular stenosis 3 C. Electrocardiogram: Premature atrial contractions or other rhythm 7 >5 premature ventricular contractions/min. 7
D. General status: Abnormal blood gases 3 K+/HCO3 abnormalities 3 Abnormal renal function 3 Liver disease or bedridden 3 E. Operation: Emergency 4 Intraperitoneal, intrathoracic, aortic 3 Total possible: 53
Adapted from Goldman, L., Caldera, D. L., Nussbaum, S. R., et al.: N.
Engl. J. Med., 1977; 297:845. Copyright 1977. Massachusetts Medical Society. All rights reserved.
Goldman IndexGoldman Index
Goldman Classification
Class Point Total
I 0-5
II 6-12
III 13-25
IV > 26
Goldman Cardiac Risk in Non-cardiac SurgeryClass III & IV patient warrant routine pre-operative cardiology
consultation
Class IV – life saving procedure only
28 of the 53 points are potentially correctible pre-operatively
Index correctly classified 81% of cardiac outcomes
Pre-operative Medical CarePre-operative Medical Care
Child-Pugh Criteria for Child-Pugh Criteria for Hepatic ReserveHepatic Reserve
Predictor of perioperative Predictor of perioperative mortality:mortality: Class A: Class A: 0 - 5% 0 - 5% Class B: Class B: 10 – 15%10 – 15% Class C: Class C: > 25%> 25%
Correct what you can Correct what you can vitamin K, vitamin K, FFP, Albumin, etc.FFP, Albumin, etc.
(dehiscence) and greater anastomotic (dehiscence) and greater anastomotic leak rateleak rate
More postoperative muscle weakness More postoperative muscle weakness (diaphragm)(diaphragm)
Longer time in rehabilitationLonger time in rehabilitation
Treating Treating malnourishmentmalnourishment
““If the gut works, use it.”If the gut works, use it.” TPN vs. enteral feedsTPN vs. enteral feeds Preoperative “bulking Preoperative “bulking
up”up” Gastric and esophageal Gastric and esophageal
cancerscancers Why are they malnourished?Why are they malnourished?
How do you build someone How do you build someone up?up?
American Society of American Society of Anesthesiologists’ (ASA) Physical Anesthesiologists’ (ASA) Physical
Status AssessmentStatus AssessmentClassification Classification
(Elective)(Elective)ClassificationClassification
(Emergency)(Emergency)DescriptionDescription
11 1E1E Normally healthyNormally healthy
22 2E2E With mild systemic With mild systemic diseasedisease
33 3E3E With severe systemic With severe systemic disease that is not disease that is not
incapacitating incapacitating
44 4E4E With incapacitating With incapacitating systemic disease that is a systemic disease that is a
constant threat to lifeconstant threat to life
55 5E5E Moribound patient not Moribound patient not expected to survive expected to survive without operationwithout operation
66 6E6E Comatose/Organ DonorComatose/Organ Donor
Surgical ConsentSurgical Consent
Details of a particular surgical procedure:Details of a particular surgical procedure: ProcedureProcedure Preparation (bowel preparation; NPO Preparation (bowel preparation; NPO
guidelines)guidelines) Benefit from the procedureBenefit from the procedure Risks and potential complicationsRisks and potential complications
Answer questions of patients and relatives:Answer questions of patients and relatives: To dispel fear and alleviate anxietyTo dispel fear and alleviate anxiety
Patient PreparationPatient Preparation
Psychological:Psychological: Acceptance and positive outlookAcceptance and positive outlook
Indications:Indications: Continuous monitoring of blood pressureContinuous monitoring of blood pressure Frequent sampling of arterial blood Frequent sampling of arterial blood
Contraindications:Contraindications: Severe occlusive arterial disease (distal Severe occlusive arterial disease (distal
ischemia)ischemia) Vascular prosthesis (graft)Vascular prosthesis (graft) Local infectionLocal infection Caution:Caution:
Sites of catheterization:Sites of catheterization: Radial/UlnarRadial/Ulnar AxillaryAxillary FemoralFemoral Dorsalis pedisDorsalis pedis Superficial temporalSuperficial temporal BrachialBrachial
Assess CirculationAssess Circulation Allen’s test (E.V. Allen, 1929):Allen’s test (E.V. Allen, 1929):
patient makes tight fist for 1 min.patient makes tight fist for 1 min. radial & ulnar arteries compressedradial & ulnar arteries compressed one artery releasedone artery released observe color return in handobserve color return in hand repeat with other arteryrepeat with other artery
Allen’s Test FindingsAllen’s Test Findings Color return:Color return:
Total ventilationTotal ventilation The total volume of air leaving the lung each The total volume of air leaving the lung each
minuteminute A product of Respiratory frequency ( A product of Respiratory frequency ( f f ) and Tidal ) and Tidal
Volume (Vt)Volume (Vt)
Dead Space:Dead Space: The portion of tidal volume not involved in gas The portion of tidal volume not involved in gas
exchangeexchange 2 components:2 components:
Anatomic dead space (within conducting airways)Anatomic dead space (within conducting airways) Alveolar dead space (within unperfused alveoli)Alveolar dead space (within unperfused alveoli)
Pulmonary MechanicsPulmonary Mechanics
Inspiratory Force:Inspiratory Force: Measured as the maximal pressure Measured as the maximal pressure
below atmospheric that a patient can below atmospheric that a patient can exert against an occluded airwayexert against an occluded airway
< -20 to -25 cmH2O (good recovery)< -20 to -25 cmH2O (good recovery) Compliance:Compliance:
Measure of the elastic properties of the Measure of the elastic properties of the lung and chest walllung and chest wall
60 to 100 ml/cmH2O (normal)60 to 100 ml/cmH2O (normal)
Evaluates compliance as well as impedance factorsEvaluates compliance as well as impedance factors Calculated by dividing the volume delivered by the Calculated by dividing the volume delivered by the
peak airway pressure minus the positive end peak airway pressure minus the positive end expiratory pressure (PEEP)expiratory pressure (PEEP)
50 to 80 ml/cmH20 (normal)50 to 80 ml/cmH20 (normal) Work of Breathing:Work of Breathing:
A measure of the process of overcoming the elastic A measure of the process of overcoming the elastic and frictional forces of the lung and chest walland frictional forces of the lung and chest wall
A product of the change in pressure and volumeA product of the change in pressure and volume 0.3 to 0.6 J/L (normal)0.3 to 0.6 J/L (normal)
Blood-Gas MonitoringBlood-Gas Monitoring
Advantages:Advantages: Efficiency of gas exchangeEfficiency of gas exchange Adequacy of alveolar ventilationAdequacy of alveolar ventilation Acid-base statusAcid-base status
Methods:Methods: Arterial blood gasArterial blood gas Mixed-venous blood gasMixed-venous blood gas CapnographyCapnography Pulse oximetryPulse oximetry
Pulse OximetryPulse Oximetry
Gastric TonometryGastric Tonometry
Purpose:Purpose: A reliable monitor in elective cardiac and A reliable monitor in elective cardiac and
major vascular surgerymajor vascular surgery A predictor of organ dysfunction and A predictor of organ dysfunction and
mortalitymortality Principle:Principle:
Noninvasive monitor of adequacy of aerobic Noninvasive monitor of adequacy of aerobic metabolism in organs whose superficial metabolism in organs whose superficial mucosal lining is vulnerable to low flow and mucosal lining is vulnerable to low flow and hypoxemia secondary to shock and SIRS hypoxemia secondary to shock and SIRS
Importance:Importance: Guides in the resuscitative managementGuides in the resuscitative management Provide a metabolic end point to Provide a metabolic end point to
Purpose:Purpose: Monitor adequacy of perfusion Monitor adequacy of perfusion Prevention of parenchymal injury/failurePrevention of parenchymal injury/failure Predict drug clearance (proper dose Predict drug clearance (proper dose
management)management) Methods:Methods:
Urine output (0.5 to 1 ml/kg/hr)*Urine output (0.5 to 1 ml/kg/hr)* Glomerular function testGlomerular function test Tubular function testTubular function test
Glomerular Function Glomerular Function Test Test
Blood urea nitrogen (BUN):Blood urea nitrogen (BUN): Dependent on GFR and Urea productionDependent on GFR and Urea production Urea (increased):Urea (increased):
Prolonged TPNProlonged TPN GI BleedingGI Bleeding Catabolic states (Trauma, Sepsis and Catabolic states (Trauma, Sepsis and
Not a reliable monitor of renal functionNot a reliable monitor of renal function
Glomerular Function Glomerular Function Test Test
Creatinine:Creatinine: Not influenced by protein metabolism and rate Not influenced by protein metabolism and rate
of fluid flow through renal tubulesof fluid flow through renal tubules
Serum creatinine:Serum creatinine: Directly proportional to creatinine production Directly proportional to creatinine production
(muscle mass and metabolism)(muscle mass and metabolism) Inversely proportional to GFR Inversely proportional to GFR
Takes 24 to 72 hrs before serum creatinine Takes 24 to 72 hrs before serum creatinine changes are reflectedchanges are reflected
Glomerular Function Glomerular Function Test Test
24-hour Creatinine clearance:24-hour Creatinine clearance: Most reliable method for clinically Most reliable method for clinically
assessing GFRassessing GFR Most sensitive test for predicting renal Most sensitive test for predicting renal
dysfunction dysfunction Traditionally uses a 24-hr collectionTraditionally uses a 24-hr collection Currently uses 2-hr collection:Currently uses 2-hr collection:
Reasonable accurate and easier to performReasonable accurate and easier to perform
Tubular Function TestsTubular Function Tests
Purpose:Purpose: Measures concentrating ability of renal tubulesMeasures concentrating ability of renal tubules To differentiate causes of oliguria (pre-renal and To differentiate causes of oliguria (pre-renal and
Carotid endarterectomyCarotid endarterectomy Cerebrovascular surgeryCerebrovascular surgery Epilepsy surgeryEpilepsy surgery Open heart surgery (Some)Open heart surgery (Some)