Perioperative Management PDF

SECTION II Perioperative Management 201 www.medicalebookpdf.com 10 CHAPTER Principles of Preoperative and Operative Surgery Leigh Neumayer, Nasrin Ghalyaie OUTLINE Preoperative Preparation of the Patient Additional Preoperat...

SECTION II Perioperative Management 201 www.medicalebookpdf.com 10 CHAPTER Principles of Preoperative and Operative Surgery Leigh Neumayer, Nasrin Ghalyaie OUTLINE Preoperative Preparation of the Patient Additional Preoperative Considerations Principles of and Preparation for Preoperative Checklist Surgery Potential Causes of Intraoperative Optimal Preoperative Assessment of Instability Geriatric Surgical Patients Operating Room Systems Approach to Preoperative Surgical Devices and Energy Sources Evaluation Outpatient Surgery PREOPERATIVE PREPARATION OF THE PATIENT be largely directed toward confirmation of relevant physical find­ ings and review of the clinical history and laboratory and inves­ The modern preparation of a patient for surgery is epitomized tigative tests that support the diagnosis. A recommendation by the convergence of the art and science of the surgical discipline. regarding the need for operative intervention can be made by the The context in which preoperative preparation is conducted surgeon and discussed with the patient and family members. A ranges from an outpatient office visit to hospital inpatient con­ decision to perform additional investigative tests or consideration sultation to emergency department evaluation of a patient. of alternative therapeutic options may postpone the decision for Approaches to preoperative evaluation differ significantly depend­ surgical intervention from this initial encounter to a later time. It ing on the nature of the presenting complaint and the proposed is important for the surgeon to explain the context of the illness surgical intervention, the patient’s general health and assessment and the benefit of different surgical interventions, further inves­ of risk factors, and results of directed investigation and interven­ tigation, possible nonsurgical alternatives when appropriate, and tions to optimize the patient’s overall status and readiness for what would happen if no intervention were undertaken. surgery. This chapter reviews the components of risk assessment The surgeon’s approach to the patient and family during the applicable to the evaluation of any patient for surgery and pro­ initial encounter should foster a bond of trust and open a line of vides basic algorithms to aid in the preparation of patients for communication among all participants. A professional and unhur­ surgery. ried approach is mandatory, with time taken to listen to concerns and answer questions posed by the patient and family members. The surgeon’s initial encounter with a patient should result in the PRINCIPLES OF AND PREPARATION FOR SURGERY patient being able to express a basic understanding of the disease process and the need for further investigation and possible surgical Proper operative technique is of paramount importance for opti­ management. A well-articulated follow-up plan is essential. mizing outcome and enhancing the wound-healing process. There is no substitute for a well-planned and conducted operation to Perioperative Decision Making provide the best possible surgical outcome. One of the most reli­ During the decision-making process, numerous considerations able means of ensuring that surgeons provide quality care in the must be addressed regarding the timing and site of surgery, type operating room is through participation in high-quality surgical of anesthesia, and preoperative preparation necessary to under­ training programs that provide opportunities for repetitive stand the patient’s risk and to optimize the outcome. These com­ observation and performance of surgical procedures in a well- ponents of risk assessment take into account the perioperative structured environment. With their participation, young surgeons (intraoperative period through 48 hours postoperatively) and later in training can progressively develop the technical skills necessary postoperative (up to 30 days) period and seek to identify factors to perform the most demanding and complex operative that may contribute to patient morbidity during these periods. procedures. Preoperative Evaluation Determining the Need for Surgery The aim of preoperative evaluation is not to screen broadly for Patients are often referred to surgeons with a suspected surgical undiagnosed disease but to identify and quantify any comorbidity diagnosis and the results of supporting investigations in hand. In that may affect the operative outcome. This evaluation is driven this context, the surgeon’s initial encounter with the patient may by findings on the history and physical examination suggestive of 202 www.medicalebookpdf.com  CHAPTER 10 Principles of Preoperative and Operative Surgery 203 organ system dysfunction or by epidemiologic data suggesting the has been used to develop predictive models for postoperative benefit of evaluation based on age, sex, or patterns of disease morbidity and mortality, and several factors have consistently progression. The goal is to uncover problem areas that may require been found to be independent predictors of postoperative events. further investigation or be amenable to preoperative optimization The ACS NSQIP has been validated as an excellent quality (Table 10-1).1 Routine preoperative testing is not cost-effective improvement tool by accounting for the influence of patient risk and, even in older adults, is less predictive of perioperative mor­ on outcomes from surgery and allowing hospitals to compare their bidity than the American Society of Anesthesiologists (ASA) status outcomes with the outcomes of their peers. Understanding the or American Heart Association (AHA)/American College of Car­ risks of surgery is important for patients and surgeons in the diology (ACC) guidelines for surgical risk. shared decision-making process. Informed consent requires that The preoperative evaluation is determined in light of the risk patients have a thorough understanding of the potential risks of of the planned procedure (low, medium, or high), planned anes­ surgery. However, predicting postoperative risks and identifying thetic technique, and postoperative disposition of the patient patients at a higher risk of adverse events have traditionally been (outpatient or inpatient, ward bed, or intensive care). In addition, based on individual surgeon experience and augmented by pub­ the preoperative evaluation is used to identify patient risk factors lished rates in the literature from single-institution studies or for postoperative morbidity and mortality. Along with being a clinical trials. generally accepted program for risk adjustment to monitor and The ACS NSQIP collects high-quality, standardized clinical improve surgical outcomes, the American College of Surgeons data on preoperative risk factors and postoperative complications National Surgical Quality Improvement Program (ACS NSQIP) from more than 500 hospitals in the United States. These data are TABLE 10-1 Suggestions for Adult Preoperative Testing BASIC: MINOR Additive Surgical and Medical Factors SURGERY IN HEALTHY PATIENT SURGICAL PROCEDURES CLINICALLY SIGNIFICANT AND CHANGING DISORDERS AND/OR MEDICATIONS (SHADED = WITHIN 90 TEST (WITHIN 90 DAYS) (WITHIN 90 DAYS) DAYS; LIGHT = TEST FOR DISORDER PROBABLY SHOULD BE PERFORMED WITHIN 30 DAYS) Healthy Adult 70 y/o Cardiac/Thoracic Vascular Major Intraperitoneal/Abdominal Anticipated >2 U EBL Intracranial Orthopedic Prosthesis TURP, Hysterostomy Hypertension Smoking Morbid Obesity h/o Stroke Cancer (?Metastatic) Seizure Medications Cardiovascular Respiratory Diabetes Hepatic Renal Fluid or Electrolyte Loss Autoimmune/Lupus EtOH/Drug Abuse Steroids/Cushing’s Syndrome HIV Parathyroid Unstable Thyroid Anticoagulant/Bleeding Suspected Pregnancy ECG M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ± Y Y Y Y Y Y CBC + platelets Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Electrolytes Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y BUN/creatinine Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Glucose Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y LFTs ± Y Y Y Y Y Calcium Y PT/PTT Y Y Y Y Y Y Y Y U/A, culture S CXR Y S Y S Hormone levels Y Bleeding time S ± Pregnancy Y* Drug levels S S ± Tumor markers S Clot Depends primarily on extensiveness of proposed surgery, as per Blood Bank MSBOS guidelines Adapted from Halaszynski TM, Juda R, Silverman DG: Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med 32:S76–S86, 2004. NOTE: (1) Times and test listings are suggestions; they are not absolute and should not preclude other testing in given settings or prevent a case from proceeding if the anesthesiologist and surgeon deem it to be appropriate. (2) Testing for a given disorder depends on the severity of the disorder in the context of the planned surgery; that is, are the tests likely to generate potentially clinically significant information and provide information that would be an important component of the history and physical examination? Shaded area indicates timing of test is not typically critical; results from 90 days (and possibly 180 days) may be acceptable. Unshaded area indicates it is typically best to obtain test within 30 days of surgery. BUN, blood urea nitrogen; CXR, chest x-ray; EBL, estimated blood loss; EtOH, ethanol; h/o, history of; LFTs, liver function tests; M, usually indicated for male patient; MSBOS, maximum surgical blood order schedule; PT/PTT, prothrombin time/partial thromboplastin time; S, may be requested (and reviewed) by the surgeon as part of surgical workup; TURP, transurethral resection of the prostate; U/A, urinalysis; Y, usually indicated; ±, if situation acute or severe. *At a minimum, a urine pregnancy test should be performed on the morning of surgery in any woman of childbearing age, unless the uterus or ovaries are surgically absent. www.medicalebookpdf.com 204 SECTION II Perioperative Management used to provide hospitals with risk-adjusted 30-day outcomes cardiac arrest, myocardial infarction (MI), proximal deep comparisons. The intended use would be to counsel patients and venous thrombosis (DVT), systemic sepsis facilitate decision making for elective surgery in an office-based Serious complication—death, cardiac arrest, MI, pneumonia, setting or to discuss risks for more emergent or urgent surgery in progressive renal insufficiency, acute renal failure, PE, DVT, the inpatient setting. return to the operating room, deep incisional SSI, organ space SSI, systemic sepsis, unplanned intubation, urinary tract infec­ Universal Surgical Risk Calculator tion, wound disruption The ACS NSQIP surgical risk calculator is a decision-support tool Pneumonia based on reliable multi-institutional clinical data, which can be Cardiac event (cardiac arrest or MI) used to estimate the risks of most operations.2 The goal of the SSI ACS NSQIP risk calculator is to provide accurate, patient-specific Urinary tract infection risk information to guide surgical decision making and informed Venous thromboembolism (VTE) consent. The risk calculator uses 21 patient predictors (e.g., age, Renal failure (progressive renal insufficiency or acute renal ASA class, body mass index [BMI], hypertension) and the planned failure) procedure (Current Procedural Terminology code) to predict the The risk calculator was built using data collected from more chance that patients will have any of nine different outcomes than 1.4 million operations from 393 hospitals participating in within 30 days after surgery (Table 10-2). The outcomes include the ACS NSQIP during the period 2009-2012. Entering the most the following: complete and accurate patient information provides the most Death precise risk information. However, the estimates can still be cal­ Any complication—superficial incisional surgical site infection culated if some of the patient information is unknown. (SSI), deep incisional SSI, organ space SSI, wound disruption, If preoperative evaluation uncovers significant comorbidity or pneumonia, unplanned intubation, pulmonary embolism evidence of poor control of an underlying disease process, consul­ (PE), ventilator use for more than 48 hours, progressive renal tation with an internist or medical subspecialist may be required insufficiency, acute renal failure, urinary tract infection, stroke, to facilitate the workup and direct management. In this process, TABLE 10-2 ACS NSQIP Variables Used in the Prior Colon-Specific and the New Universal Surgical Risk Calculators VARIABLE CATEGORIES COLON-SPECIFIC UNIVERSAL Age group, yr 55 15.3 >40 30.5 From Arozullah AM, Khuri SF, Henderson WG, et al: Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 135:847–857, 2001; and Arozullah AM, Daley J, Henderson WG, et al: Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg 232:242–253, 2000. Acute hepatitis Patient with liver Obstructive disease facing surgery jaundice 1. Perioperative fluid management Chronic hepatitis to prevent renal dysfunction Postpone elective surgery at least until 2. No dopamine or mannitol liver function tests 3. Lactulose may be helpful have normalized 4. Antibiotic prophylaxis Surgery is generally 5. No routine preoperative biliary considered safe in drainage these patients 6. Check for abnormal coagulation parameters Cirrhosis Child’s A and B: Treat ascites, coagulopathy and proceed to surgery Child’s C: Postpone until the patient’s Child’s class could be improved or cancel surgery for conservative management Encephalopathy Coagulopathy 1. Treat with lactulose Target PT—no more than 2 sec above normal 2. Prevent by treating 1. Vitamin K—10 mg SQ precipitating conditions 2. FFP if no improvement with Vit K such as GI bleeding, 3. Give cryoprecipitate as needed alkalosis, uremia, avoidance of sedatives Ascites 1. Fluid restriction 2. Diuretics—furosemide and/or spironolactone 3. Paracentesis—may be diagnostic or therapeutic with simultaneous administration of albumin FIGURE 10-2 Approach to a patient with liver disease. FFP, fresh-frozen plasma; GI, gastrointestinal; PT, prothrombin time; SQ, subcutaneous. (From Rizvon MK, Chou CL: Surgery in the patient with liver disease. Med Clin North Am 87:211–227, 2003.) greater than 2. Laboratory evidence of chronic hepatitis or clinical and elevated transaminase levels is managed nonoperatively, when findings consistent with cirrhosis is investigated with tests of feasible, until several weeks after normalization of laboratory hepatic synthetic function, notably serum albumin, prothrombin, values. Urgent or emergency procedures in these patients are and fibrinogen levels. Patients with evidence of impaired hepatic associated with increased morbidity and mortality. A patient with synthetic function also have a CBC and serum electrolyte analysis. evidence of chronic hepatitis may often safely undergo surgery. A Type and screen are indicated for any procedure in which blood patient with cirrhosis may be assessed with the Child-Pugh clas­ loss could be more than minimal. sification, which stratifies operative risk according to a score based In the event of an emergency situation requiring surgery, such on abnormal albumin and bilirubin levels, prolongation of the an investigation may be impossible. A patient with acute hepatitis prothrombin time, and degree of ascites and encephalopathy www.medicalebookpdf.com 216 SECTION II Perioperative Management TABLE 10-10 Child-Pugh Scoring System TABLE 10-11 Insulin Types POINTS ONSET OF PEAK DURATION PARAMETER 1 2 3 TYPE OF INSULIN ACTION EFFECT OF ACTION Encephalopathy None Stage I or II Stage III or IV Rapid-acting (lispro, 10-30 min 30-90 min 3-4 hr Ascites Absent Slight (controlled Moderate despite NovoLog, Apidra) with diuretics) diuretic treatment Short-acting (regular, 30-60 min 2-5 hr 6-10 hr Bilirubin (mg/dL) 3 Humulin, Novolin) Albumin (g/liter) >3.5 2.8-3.5 160 mm Hg) Microwave coagulation is achieved by using a generator to trans­ History of congestive heart failure mit microwave energy at a frequency of 2450 MHz via a probe Respiratory placed under image guidance within target organs or tissue. A Asthma, chronic obstructive pulmonary disease requiring long-term medica- rapidly alternating electrical field is created in the target tissue to tion or with acute exacerbation and progression within past 6 mo induce motion of polar molecules in the tissue, such as water. History of major airway surgery or unusual airway anatomy Kinetic energy is dissipated as heat, which causes coagulation Upper or lower airway tumor or obstruction necrosis. It was initially used for lesions in the liver; however, its History of chronic respiratory distress requiring home ventilator assistance or applications have been expanded to treatment of cardiac rhythm monitoring disturbances, prostatic hyperplasia, endometrial bleeding, steril­ ization of bony margins, and partial nephrectomy. The major Endocrine limiting factor is that the area that can be ablated with the current Insulin-dependent diabetes mellitus equipment is very small, necessitating multiple insertions of the Adrenal disorders microwave probe to treat a single lesion.37 Active thyroid disease The premier tool in radiosurgery is the Gamma Knife; its principal area of use is in neurosurgery. This tool allows more than Neuromuscular 200 separate sources of high-energy gamma radiation, arranged History of seizure disorder or other significant central nervous system disease in a circular fashion, to be focused stereotactically onto a minute (e.g., multiple sclerosis) area in the brain. Avoiding injury to normal brain tissue requires History of myopathy or other muscle disorder that the head be held motionless by an external fixation device. This ability to destroy finite areas within the brain has been Hepatic applied to the treatment of benign and malignant brain neo­ Any active hepatobiliary disease or compromise plasms, arteriovenous malformations, and epilepsy. Musculoskeletal Kyphosis or scoliosis causing functional compromise Temporomandibular joint disorder OUTPATIENT SURGERY Cervical or thoracic spine injury Over the past 25 years, outpatient surgery has become more com­ Oncology monplace. It is estimated that 75% of elective surgical procedures Patients receiving chemotherapy are now performed in an outpatient setting, which means that Other oncology process with significant physiologic residual or compromise patients do not experience an overnight stay around the time of the procedure. Even patients who will need a postoperative inpa­ Gastrointestinal tient stay after the procedure are usually admitted to the hospital Massive obesity (