أسئلة الثامنة جراحة ثالثة الدلتا

• Lecture covers preoperative and postoperative care in surgery
• Focuses on optimizing patient condition and managing potential complications

Preoperative Care

• Involves a surgeon's review until the operation
• Aims to optimize patient condition for surgical outcomes
• Requires multidisciplinary collaboration among surgeons, anesthesiologists, radiologists, internal medicine, nurses, etc.
• Surgeons balance disease risks with the risks of the operation itself

Preparation

• Includes history and examination, document review, investigations, and consultations

History & Examination

• This is the most crucial step
• Special attention is given to allergies, medications, habits (smoking, alcohol), medical diseases, and previous surgeries

Document Review

• Review previous radiology or laboratory results
• Review previous operative details and pathological reports

Investigations

• These are tailored for each patient
• Labs include CBC, coagulation profile, LFTs, RFTs, blood group, cross matching, glycemic control, urine analysis and virology
• Pregnancy tests are performed for women of child-bearing age
• Radiology includes ECG, chest X-ray, abdominal X-ray, CT or ultrasound

Consultations

• A multidisciplinary approach is beneficial
• Cardiologist optimizes cases of heart failure

ASA Classification System

• ASA 1 - Normal healthy patient
• ASA 2 - Patients with mild systemic disease (controlled hypertension/diabetes, smoker without COPD, mild obesity, pregnancy)
• ASA 3 - Patients with severe systemic disease, some functional limitation (controlled CHF, stable angina, former heart attack, morbid obesity, chronic renal failure)
• ASA 4 - Patients with severe systemic disease, constant threat to life (unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure)
• ASA 5 - Moribund patients not expected to survive without surgery (imminent risk of death, multiorgan failure)
• ASA 6 - Declared brain-dead patient whose organs are being removed for donation

Optimization

• Elective cases are sometimes delayed for management of glycemic, hypertensive, or cardiac control
• Some drugs are stopped or altered (Clopidogrel 5 days prior, Warfarin shifted to heparin)
• Ensure good nutritional status
• Smokers should stop 4 weeks before surgery
• Antibiotics given 1-hour pre-incision
• Fasting for 2 hours (fluids) and 8 hours (solid food)
• Emergency cases are more complex

Consent

• Informed consent is required before the operation
• Including type of operation, risks and complications, life-changing outcomes
• Consent is not always mandatory in lifesaving operations, especially for hemodynamically unstable/unconscious patients with no relatives

WHO Safety Checklist

• Includes sign-in, time out, and sign-out procedures

Sign In

• Before anesthesia ensuring confirmation of patient identity, procedure, site marked and allergies
• Confirm Anesthetic safety, airway plan, availability of antibiotics and blood

Time Out

• Before skin incision to confirm patient’s name, procedure, site/side, imaging and allergies
• Determines if there significant blood loss
• Make sure diathermy on antibiotics given, specimen plan, warming on, VTE prophylaxis on

Sign Out

• Before leaving OR by the whole theatre team
• Determines the procedure was recorded correctly, counts correct, specimens labeled, packs removed / labeled, lines flushed, equipment problems and Post op plan, VTE and antibiotic plan or Daycase?

Postoperative Care

• Assessment includes vital signs, general condition, pain, fluid balance (2000-2500 ml/d), medications (analgesic, PPI, anticoag.), Drain amount and color

Postoperative Period

• Immediate phase: First 24 hours post-op
• Early phase: Inpatient or within 30 days of procedure
• Late phase: After 30 days following procedure

Frequency of Assessment

• Every 4-6 hours in stable patients
• Continuous monitoring in ICU patients

Postoperative Complications

Immediate Complications (0-24 Hours)

• Basal atelectasis: minor lung collapse
• Oliguria or Anuria: inadequate fluid replacement/urinary retention

Early Complications (1-30 Days)

• Acute confusion: dehydration, electrolyte imbalance, sepsis
• Nausea and vomiting: paralytic ileus or adhesions
• Postoperative fever
• Secondary hemorrhage: often infection-related
• Pneumonia
• Wound or anastomosis dehiscence
• DVT
• Urinary tract infection (UTI)
• Postoperative wound infection

Late Complications (>30 Days)

• Bowel obstruction due to adhesions
• Incisional hernia - Fistula or sinus
• Recurrence of reason for surgery (malignancy)
• Keloid formation

Clavien Classification of Postoperative Complications

• Grade 0: No complication
• Grade 1: Deviation from normal course, allowed physical therapy/medications
• Grade 2: Requires pharmacological treatment beyond Grade 1
• Grade 3: Requires surgical, endoscopic or radiological intervention
• Grade 4: Life-threatening, requires intermediate/intensive care
• Grade 5: Death

(1) Postoperative Fever

• Incidence: 40% of patients post major surgery
• Clinical features: Rigors, sweats
• 5 W's of Postoperative Fever; wind, water, walk, wound and wonder about drugs
• Causes based on operative day:
  • Day 0: Body response to surgery
  • Day 1-2: Atelectasis, Pneumonia
  • Day 3-5: UTI, Catheter-related phlebitis
  • Day 5-7: DVT , anastomatic leakage, Wound Infection
  • Anytime: Drug reaction, Transfusion reaction
• Diagnosis: History, examination, investigations (C/P cough, dyspnea, chest pain) and chest X-ray
• Treatment: Antibiotics, Chest measures

(2) Wound Dehiscence

• Surgical wound breaks down exposing underlying structure in Full thickness (Burst or Evisceration or Partial thickness
• Predisposing factors: Malnutrition, Infection, Smoking, Immunosuppression/steroids, Malignancy, Technical factors
• Management:
  • Burst: Cover with saline dressing and emergency operation
  • Partial thickness: Conservative (incisional hernia later)

(3) Postoperative Bleeding

• Primary: During operation
• Reactionary: Within 24 hours (slipped ligature, increased blood pressure)
• Secondary: Late (10-14 days), infection-related erosion into blood vessel
• Clinical picture (Same as hemorrhagic shock):
  • Tachycardia (first sign)
  • Tachypnea
  • Hypotension
  • Low UOP (best indicator of shock)
  • Altered mental status Anxious then lethargy then coma Increased capillary refill time > 2 seconds
  • Pulse pressure decrease
• Management:
  • Anti-shock measures: IV fluids (1-2 liters), blood transfusion, oxygen, tranexamic acid
  • Investigations: CBC, cross matching, radiology (source detection)
  • Stop bleeding: Surgical exploration or Angioembolization by gelfoam

(4) Surgical Wound Infection (SSI)

• Infection after surgery in the wound
• Organism: Usually from patient's own flora
  • Staph aureus from skin
  • E.coli from bowel
• Clinical features: Pain, fever, discharge, tenderness, redness, heat
• Investigations: CBC, CRP, wound swab (culture/sensitivity), blood cultures (if sepsis)
• Management:
  • Anti-shock measures for sepsis fluids, oxygen and antibiotics
  • Broad spectrum against likely source then guided by results of cultures taken.
  • Drainage of pus by: Removing some stitches at edge of the wound,US guided aspiration then Re-exploration.

(5) Anastomotic Leak

• Failure of anastomosis between hollow organs (intraluminal contents escape)
• Same as wound dehiscence
• Diagnosis: Peritonitis, Fistula or Abscess formation
• Time: 5-7 days postoperative
• Fate: May stop spontaneously by conservative measures
• Surgical or stoma diversion

(6) Fistula

• Abnormal connection between epithelial surfaces (viscus to viscus, viscus to surface)
• Types (according to output):
  • Low output: <200 ml/day
  • Medium output: 200-500 ml/day
  • High output: >500 ml/day
• Examples:
  • GIT and skin (enterocutaneous)
  • GIT and Resp (tracheo-oesophageal)
  • GIT and Urinary system (colovesical)
  • artery and vein (arteriovenous)
• Fate: Most close spontaneously except (Friends)
  • Foreign body
  • Radiation
  • IBD (Crohn's disaease = fistulizing disease)
  • Epithelialization
  • Neoplasm
  • Distal obstruction
  • Specific pathology or steroids
• Management: Specific to each type (conservative or surgical approach)