Surgery

PRINCIPLES OF PREOPERATIVE PREPARATION OF SURGICAL PATIENTS Dr. Ponadon  CONSENT: Patient must agree first to the procedure that is to be done before he/she signs the consent form.  EXPLAIN: Thus, take time to explain the procedure to be done. o Be honest enough. o Don’t be pessimistic but don’t try to promise. o If patient is not knowledgeable, explain to relatives. Why is the need for Preoperative Preparation for Surgery?  Optimize the patient: Avoid complications and decrease the risk from: 1. Surgery 2. Anesthesia  Thus: Decrease morbidity and mortality Preoperative preparation: -Preparation depends on the type of surgery. 1) Elective operation  A planned, non-emergency surgical procedure  May be either medically required (e.g., cataract surgery) or optional (e.g., breast augmentation or implant).  Have all the time to prepare the patient  If there’s a need to delay to prepare more, do so. 2) Emergency operation  Short period of time to prepare  No matter how urgent, take time to partially correct the deficits; not unless the patient has massive bleeding – direct to OR  No correction of deficits – death (due to hypovolemia, vomiting, etc)  Some cases like cardiac tamponade: do initial operation on ER then complete it in OR  Most important: fluid resuscitation  Best gage besides vital sign: Urine output  Death in appendectomy: usually due to anesthetic issues In preoperative preparation we: 1. Assess operative risk  Relative rewards and risks of treatment  Sometimes, no need to operate  Acidotic patient (7.2-7.3) – dies when insist on operation  Timing of the operation vary on the situation, depends on how you assess the patient on its capability to survive the surgery  Considerations that influence operative risk: a. Cardiovascular disease b. Respiratory disease c. Renal disease d. Gastrointestinal disease

 As part of the operative risk assessment include: a. Personal and family history of bleeding tendencies b. Allergic response c. Current medication  Basic factors affecting operative risk: a. Age over 70 years b. Overall physical status c. Elective versus emergency operation d. Physiologic extent of procedure e. Number of associated diseases 2. Develop a genuine bond of communication and personal responsibility with the patient  It’s better to talk before surgery than after surgery!  But for other surgeons: less talk, the better...  The patient has the right to know everything but try to balance it especially when there is conflict w/ the relatives  Increase patient confidence  Decrease legal actions 3. General preparation of the patient:  Consider the type of surgery: o Elective o Emergency Type of Surgery Determines:  Rapidity of preoperative preparation  Completeness of preoperative preparation A. Psychologic Preparation:  Frank but optimistic discussion of possibilities  Avoid undue fear  No matter how poor the prognosis, the condition should not be presented as hopeless B. Physiologic Preparation: 1) Blood volume considerations o 10 gmHgb, minimum for general anesthesia 2) Fluid and electrolytes o start prior to surgery and continue during the operation 3) Nutrition o Enteral or parenteral 4) Prevention of infection o Protection from infected patients o Operative site preparation (washing, shaving, or not at all)  Early shaving predisposes to wound infection  Abrades skin  Shave at least an hour before surgery o Antibiotic prophylaxis

Factors Influencing Likelihood of Infection after Operation: 1. Definite Host Resistance:  Increasing age  Obesity  Malnutrition  Diabetic ketoacidosis  Acute, chronic steroid therapy  Immunosuppressive drugs  Remote synchronous infections 2. Possible Decreased Host Resistance:  Cancer  Radiation therapy  Adrenocortical deficiency  Percutaneous foreign bodies  Early shaving of operative site 3. No Effect on Host Resistance:  Patient’s gender  Patient’s race  Controlled diabetes mellitus  Acute nutritional deprivation Operations Benefitting From Systemic Antibiotic Prophylaxis 1. Head and neck which open aerodigestive tract 2. Esophagus excluding hiatal hernia 3. GIT 4. Biliary tract  70 years old  Acute cholecystitis  Choledochostomy 5. Gangrenous perforated appendix 6. Hysterectomy 7. Prosthetic graft operation  General guideline: Operation on hollow viscus benefit from systemic antibiotic prophylaxis  Have an idea of the microbial flora in the organ you’re operating on  In hollow viscus: Gram (-) anaerobes; thus, give antibiotic w/c will have coverage on Gram (-)  Given 1-2 hrs before surgery. Some give upon incision so that it peaks during surgery. Operative Techniques to Minimize Infection: 1. Eliminate hair if indicated just prior to incision time 2. Effective skin preparation 3. Gentle tissue handling 4. Effective hemostasis  Make sure there’s no bleeding at closure site!  Don’t depend too much on drains

5. Eradicate dead space  Problems are more likely to develop if dead space is not eliminated 6. Operation lasting less than 2 hours  Shorter operations (about 2 hrs), the better  If more than 2-3 hrs, give prophylactic antibiotic intra-operatively 7. Closed suction drainage a distance from incision  Make another hole to place your drain 5) Specific Organ/System Preparation: a. Cardiovascular: Preoperative Factors Associated with Postoperative Cardiac Complications in Order of Discovery Significance: 1. Jugular vein distention or S2 gallop 2. Myocardial infarction in previous 6 months 3. PAC or Rhythm other than sinus on ECG 4. 3 to 5 PVC’s/min 5. Age over 70 6. Significant aortic valvular stenosis 7. Poor general medical condition  PaO2< 60mmHg  PacCO2> 50mmHg  K < 0.3meq/L  HCO3< 20meq/L  BUN > 50mg/100mL  Crea> 3.0mg/100mL  Elevated transaminases  Chronic liver disease  Bed ridden from non-cardiac cause     

#1-7 more likely to develop CV complications In cases of complications, you have to ask others to help, joint treatment. Joint management with cardiologist Don’t economize too much. If patients need assistance, do so. Cut off for CP clearance: 35 yrs old & above; some at 40 yrs old

Capacity to Increase Cardiac Output from Intra- and Post-op Challenge  Most fundamental determinant of survival from complex operation Patients at Risk for Thromboembolism Requiring Anticoagulation: 1. Clear history of clinical signs of prior thrombosis or embolism 2. Prolonged operations which temporarily interfere with lower extremities blood flow  Aortic reconstruction  Perineal operations with stirrups 3. Reconstructive operations on the hip

b. Respiratory: 2 Major Groups Developing Respiratory Complications: 1. Development of respiratory abnormalities secondary to anesthetic agents and operations in patients with grossly normal lungs 2. Patients with overt chronic lung disease who require operations Pulmonary Function Tests:  Differentiates obstructive and non-obstructive pulmonary emphysema In General: Patients below 40 with no pulmonary signs and symptoms do not require special pulmonary function tests. Patients older and with pre-existing diseases needs pulmonary function tests specially operations of upper abdomen and chest. Simple Test for Pulmonary Function: Brisk walk up a flight of stairs: Observe tolerance Risk Factors for Post-operative Pulmonary Complications: 1. Thoracic and upper abdominal surgery 2. Preoperative history of COPD 3. Preoperative purulent productive cough 4. Anesthesia time > 3 hours 5. History of cigarette smoking 6. Age greater than 60 years 7. Obesity 8. Poor preoperative state of nutrition 9. Symptoms of respiratory disease 10. Abnormal findings on P.E. 11. Abnormal Chest film findings Perioperative Prophylactic Pulmonary Maneuvers 1. Cessation of smoking 2. Bronchodilators 3. Chest physiotherapy and postural drainage 4. Preoperative education and postoperative use of incentive spirometer and deep breathing exercises 5. Preoperative antibiotics if sputum is purulent 6. Early post operative ambulation  Pre-operative purulent productive cough (subject to elective operation) should be treated prior to surgery or else complications like pneumonia may develop.  Stop smoking 1 week before surgery  W/ COPD, start treatment before surgery  Post-operative early ambulation: c. Renal  BUN, Creatinine, Urinalysis

 BUN: may be misleading, rely on creatinine  Renal disease not as frequent as cardiovascular and respiratory in asymptomatic population Hypovolemia: most common cause of oliguria in surgical patients and not renal disease Prostatic Hypertrophy: catheter drainage and elimination of infection prior to elective surgery  Urine output- for renal function  Pediatrics: very particular in H&PE d. Hepatic  Abnormalities as a result of Hepatic disease (malnutrition, decreased PT) should be corrected. If not completely then marginally.  If liver problems can not be corrected completely, partial correction is accepted e. Neurologic  Maintenance of cerebral function via appropriate oxygenation and circulation  Careful history  Best determinant of whether CVD causes a real or imagined risk  Special concerns: occult CVD in elderly  CNS entails more attention  W/ stroke – elective surgery after 6 months Special Problems Demanding Preoperative Correction: 1. Incomplete alimentary tract cleaning 2. Pulmonary Aspiration 3. Evacuation of stomach  Trauma patients: place NGT, urine catheter, intravenous line  Intra-abdominal operation: Place NGT to evacuate the stomach ROUTINE NGT: decompress and prevent pneumonia NGT: may lead to vomiting or regurgitation Preoperative Physical Status Classification of Patients According to the ASA: Class Definition 1 Normal Healthy Patient Mild systemic disease 2 No functional limitation Moderate to severe systemic disease 3 Some functional limitation Severe systemic disease 4 Constant threat to life Functionally incapacitated Moribund 5 Not expected to survive with or without surgery

Brain dead Whose organs are being harvested If procedure is emergency E Physical status is followed by an “E” #4- usually not operative since they die/end up in vegetable state 6

Preoperative Principles: 1. Patient / Relatives fully informed 2. Consent for surgery 3. Preoperative antibiotics Operative Principles: 1. Strict Aseptic/Antiseptic technique  Hand scrubbing  Gowning / Gloving  Skin preparation  Drapes  Avoid contamination!  Aseptic involves gloving, gowning, scrubbing, etc  Antiseptic involves preparation of the operative site  Back to back sa OR!   Use of drapes: eye sheet for minor surgeries  Thyroidectomy infection is difficult to control  Clean wounds usually don’t develop complications  Do not use infected instruments to tohers 2. Incision Dependent on:  Emergency / Elective  Cosmetic Considerations  Extensibility  Exposure  Strength  Emergency operation: make an incision that can be done rapidly and can be extended to have adequate exposure (Vertical incision)  Elective: Medically acceptable; incision that favors extensibility & rapidity of closure  Strength of the wound: - Transverse incisions: stronger than vertical incisions - The strength of the wound lies in the number of fascias sutured (fascial repair) - 2 fascias: Stronger > Midline: 1 fascial layer > Paramedian and transverse: 2 3. Minimal tissue damage / manipulation  Avoid too much electrocautery 4. Adequate lavage / washing

* Peritoneal cavity: 10 liters: Gauge that it is adequately washed - Before you close, should have adequate hemostasis - Used drain as indicated: choice of drain - You should have the idea of what sutures and needles to be used  Non absorbable sutures: not continuous, should be interrupted  Why? If it gets infected, you have to remove the entire suture. If it is continuous, more risk of bleeding and infection * Ligatures: non absorbable * Needles: atraumatic needles below the skin * Cutting needles: for the skin - If you are rushing: use continuous non absorbable - For instances that you don’t close the wound: put towel drapes - Remove the instruments placed inside the patient’s body, to avoid legal suits 5. Hemostasis / Drain 6. Choice of sutures/materials / needles 7. Type of suturing 8. Eliminate Dead Space 9. Skin Closure  Subcuticular  Interrupted  Staples 10. Dressing Bulk dressings: much drainage Pressure dressings: fluid oozing