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General Surgery
Preoperative and Postoperative Management
Built from Maingot's Abdominal Operations
What’s inside
12 sections · 203 slides
Overview
- Scope of perioperative management
- Systems assessed around abdominal surgery
- Systems assessed around abdominal surgery
Pain and delirium
The two commonest neuropsychiatric complications after abdominal surgery
- Consequences of uncontrolled pain and delirium
- Preoperative assessment of the pain plan
- Patient-controlled analgesia
- Evidence on patient-controlled analgesia
- Epidural analgesia
- Advantages of epidural analgesia
- Patient-controlled versus epidural analgesia
- Nonsteroidal anti-inflammatory drugs for pain
- Trial evidence for perioperative NSAIDs
- Postoperative delirium: definition and frequency
- Precipitants of perioperative delirium
- Causes of perioperative delirium
- Patient risk factors for delirium
- Procedural risk factors for delirium
- The vicious cycle of pain, hypoxia and sedation
- Prevention of postoperative delirium
- Bedside evaluation of new delirium
- Investigation of postoperative delirium
- Treatment of established delirium
- Non-drug measures and sedation choices
Cardiac evaluation
Finding the patient whose heart will not tolerate the operation
- 1 million
- Procedures and conditions that raise cardiac risk
- Limits of the risk guidelines in women
- Clinical predictors of increased perioperative cardiac risk
- Procedure-related cardiac risk
- Factors that increase the risk of perioperative cardiac complications
- Reading the odds ratios
- Who should be evaluated and by whom
- Functional capacity as a measure of cardiac reserve
- Intraoperative factors that stress the heart
- Perioperative hypertension
- Antihypertensive drugs through the perioperative period
- Baseline cardiac tests before surgery
- Echocardiography and chest radiography
- Exercise testing findings that signal severe disease
- Pharmacological stress testing
- Nuclear perfusion imaging and angiography
- ACC/AHA preoperative cardiac risk assessment algorithm
- First four steps of the cardiac assessment algorithm
- Predictor group, functional capacity and the next decision
- Mechanism of perioperative myocardial infarction
- Indications for revascularization before noncardiac surgery
- Evidence on preoperative coronary intervention
- Bypass grafting and stents before surgery
- Catecholamine surge and plaque rupture
- Perioperative beta-blockade: the early evidence
- Perioperative beta-blockade: the reversal
- Congestive heart failure before surgery
- Arrhythmias and conduction abnormalities
- Aortic stenosis
- Managing aortic stenosis around surgery
- Aortic and tricuspid regurgitation
- Tricuspid regurgitation and right heart strain
- Mitral stenosis and mitral regurgitation
- Examination and tests in valve disease
- Haemodynamics of mitral regurgitation
- Mitral valve prolapse
- Endocarditis risk after invasive procedures
- Cardiac conditions by endocarditis risk
- Mitral valve prolapse and antibiotic prophylaxis
- AHA endocarditis prophylaxis recommendations
- Timing and choice of prophylactic antibiotics
- Antibiotic choice by procedure site
Antithrombotic medication
Balancing bleeding during the operation against clotting while the drug is stopped
- Balancing bleeding risk against thromboembolic risk
- Indications for chronic anticoagulation
- Moderate risk and the CHADS2 score
- Bridging anticoagulation in venous thromboembolism
- Timing of anticoagulant interruption and restart
- Antiplatelet drugs and coronary stents
- Perioperative management of antithrombotic medications
Pulmonary evaluation
Why lungs fail after abdominal surgery, and who is most likely to suffer
- Postoperative pulmonary complications
- History and examination for pulmonary risk
- Value of preoperative pulmonary testing
- Blood gases, incision and anaesthetic technique
- Physiological changes after upper abdominal surgery
- Mechanism of postoperative alveolar collapse
- Airway injury and aspiration risk after surgery
- Predictors of postoperative pulmonary impairment
- Smoking cessation before surgery
- Optimising COPD and asthma before surgery
- Obesity and sleep-disordered breathing
- Diagnosing and assessing sleep-disordered breathing
- Postoperative pulmonary care
- Lung expansion measures after surgery
Gastrointestinal evaluation
Stress ulceration, postoperative ileus, and early bowel obstruction
- Stress ulceration: history and mechanism
- From mucosal ischaemia to bleeding
- Prophylaxis against stress gastritis
- When ulcer prophylaxis is not needed
- Postoperative ileus: definition and time course
- Mechanism of postoperative ileus
- Recognising and distinguishing ileus
- Prolonged ileus and the role of laparoscopy
- Mobilisation, tubes and feeding after abdominal surgery
- Preventing and shortening postoperative ileus
- Opioids and the duration of ileus
- Early postoperative bowel obstruction
- Adhesions as the dominant cause
- Internal hernia after abdominal surgery
- Why internal hernia needs early operation
- Distinguishing ileus from early obstruction
- Management of early postoperative obstruction
Renal evaluation and fluids
Kidney risk, postoperative fluid therapy, oliguria and electrolytes
- Preoperative electrolyte and urine screening
- Interpreting the preoperative urinalysis
- Renal insufficiency and its comorbidities
- Preoperative work-up in kidney disease
- Dialysis around the time of surgery
- Choice of postoperative fluid therapy
- Fluid sequestration and mobilisation
- Postoperative renal monitoring and replacement therapy
- Risk factors for postoperative renal failure
- Contrast-induced nephropathy
- Categories of acute renal failure
- Recognising postoperative renal failure
- Oliguria in the perioperative patient
- Initial management of oliguria
- Assessing volume status after surgery
- Fluid overload and hemodynamic optimisation
- Sodium disorders after surgery
- Potassium disorders after surgery
- Treatment of hyperkalaemia
Glycemic control
How tightly to control blood sugar after surgery
- Hyperglycemia and intensive insulin therapy
- Targets for perioperative glucose control
- <180 mg/dL
Hematological evaluation
Bleeding risk, transfusion, and the drugs that prevent clots
- History for bleeding disorders
- Routine coagulation testing before surgery
- Limitations of bleeding time and PTT
- Platelet function and antiplatelet drugs
- Glycoprotein IIb-IIIa inhibitors around surgery
- Indications for red blood cell transfusion
- Deciding when to transfuse
- Platelet transfusion
- Fresh frozen plasma and cryoprecipitate
- Venous thromboembolism risk and prevention
- Inferior vena cava filters
- Monitoring and reversing heparin
- Heparin dosing for prevention and treatment
- Heparin-induced thrombocytopenia
- Recognising and treating HIT
- Anticoagulation after HIT, and warfarin pharmacology
- Vitamin K, pregnancy and early warfarin effects
- Perioperative INR targets and the unprotected window
- Risk arithmetic of interrupting anticoagulation
- Weighing embolism against postoperative haemorrhage
- Timing anticoagulation around the operation
- Heparin infusion around the procedure
Infectious complications
Surgical site infection: who gets it, and what actually prevents it
- 2%
- Why surgical site infection matters
- Patient risk factors for surgical site infection
- CDC guidelines for basic surgical practice
- CDC category 1 recommendations for reduction of surgical site infections
- Principles of antibiotic prophylaxis
- Surgical wound classification
- Antibiotics in clean (class I) procedures
- Antibiotics in clean-contaminated (class II) procedures
- Antibiotics in contaminated and dirty wounds
- Class IV wounds and risk scoring systems
Nutritional evaluation
Finding malnutrition before surgery and feeding the patient afterwards
- Consequences of malnutrition in surgical patients
- Clinical assessment of nutritional risk
- The Nutritional Risk Index
- Classification of malnutrition
- Criteria for protein and calorie deficiency
- Grading mixed protein calorie malnutrition
- How the malnutrition criteria are applied
- Expected nutritional deficit after abdominal surgery
- Glycogen, gluconeogenesis and the glucose requirement
- Indications for nutritional support after surgery
- Postoperative causes of deficient nutritional intake
- Choosing the route of nutritional support
- Enteral nutritional support
- Planning feeding access and using the parenteral route
- Calculating calorie requirements
- Calorie and protein targets
- Essential nutrients in any feeding regimen
- Monitoring the response to nutritional support
- Serum markers of nutritional repletion
- Nitrogen balance
- Interpreting nitrogen balance
- Uncontrolled diabetes as a nutritional complication
Summary
What to carry away from perioperative management
- Key points on pain, delirium and the heart
- Key points on lungs, gut, kidneys and blood
- Key points on infection and nutrition
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- Maingot's Abdominal Operations, 12th Edition