Perioperative Management Overview

Perioperative Management

• Perioperative management encompasses the preparation, surgical procedures, and recovery phases of patient care.
• Preoperative preparation involves assessing patient risk factors, optimizing patient status, and managing expectations.
• A thorough preoperative evaluation identifies comorbid conditions impacting surgical outcomes.
• Preoperative evaluation considers patient history, physical assessment, and relevant laboratory and radiology results.
• The American Society of Anesthesiologists (ASA) classification and the American Heart Association/American College of Cardiology (AHA/ACC) guidelines for surgical risk assist in assessing surgical risk.
• Preoperative patient assessment should include but is not limited to cognitive evaluations, tests for depression, alcohol and substance abuse, functional status, and fall risk.
• The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides standardized clinical data on risk factors and postoperative complications from multiple hospitals.
• A universal surgical risk calculator, based on ACS NSQIP data, determines 30-day postoperative outcomes utilizing 21 patient predictors and surgical procedure specifics.
• Perioperative decision-making considers timing, surgical site, anesthesia type, and preoperative preparation to optimize outcome.

Principles of Preoperative and Operative Surgery

• Surgical techniques optimize surgical outcome and wound healing.
• Well-planned procedures are integral for successful outcomes.
• A well-structured surgical training program fosters repetitive observation and performance of procedures.
• Surgical decisions may be made in an initial evaluation, but further tests or treatment plans may be considered.
• Informed consent is crucial for patients to comprehend potential risks and benefits of the surgical procedure.
• Perioperative factors influence patient risk, including intraoperative, postoperative (first 48 hours), and later postoperative (up to 30 days) periods.
• The aim of preoperative evaluation of risk is not simply to screen for disease, but to identify and analyze comorbidities to optimize surgical outcomes.

Optimal Preoperative Assessment of Geriatric Surgical Patients

• Assessment is critical due to the increasing numbers of geriatric surgical patients.
• Geriatric patients have significantly higher rates of inpatient and outpatient surgery compared to other age groups.
• Risk assessment and strategies are vital to ensure quality care, including strategies to address functional deficits, cognitive impairment, and dementia.
• Cognitive assessment (like the Mini-Cog) is strongly recommended.
• Comprehensive preoperative evaluation includes patient history, cognitive assessment, and risk factors for postoperative delirium.
• Patients at risk for postoperative delirium should avoid benzodiazepines and antihistamines (where possible).

Additional Preoperative Considerations

• Complete medication history includes over-the-counter medications, vitamins, and herbal supplements.
• Management of specific considerations such as risk factors for preoperative complications, including cardiac, pulmonary, renal, and hepatic issues, should be addressed with patient.
• All patients should be thoroughly evaluated for their ability to perform daily tasks (functional status).
• Patients at risk for postoperative complications should have a review of their pulmonary function tests.
• Patients with diagnosed or suspected cognitive conditions should be assessed before surgery.
• Nutritional status should be ascertained preoperatively, and supplementation should be considered for significant nutritional deficiencies.
• Patients with a history of steroid use may need preoperative steroid supplementation.
• Patients on anti-coagulant medication should have their medications adjusted or stopped before surgery.
• A preoperative time-out protocol should be followed for all surgical procedures.

Surgical Devices and Energy Sources

• Electrosurgery and electrocautery use high-frequency currents for cutting and coagulating tissues.
• Unipolar devices use a grounding pad for current return, whereas bipolar devices use a closed circuit between the instrument tips.
• Lasers use photons that excite chromophore molecules.
• Ultrasound can be used for cutting, coagulating, and other surgical procedures.
• Microwave ablation uses microwave energy to induce heat for tissue ablation.