CHAPTER 5 Preoperative and postoperative care
Preoperative preparation
Assessment
2. Examination: directed not only at the presenting complaint but also including a thorough examination of all systems, especially the cardiovascular and respiratory.
4. Radiographs: CXR should be obtained in all patients with cancer, and cardiac, respiratory and renal disease. A routine preoperative CXR is unnecessary in young patients unless there are abnormalities on auscultation.
Principles of preoperative preparation
2. Obtain informed consent. Explain all forms of possible treatment available for the condition. Explain the likely outcome without surgery. Explain the nature of the operation and the risks. Obtain the signature of the patient, parent or legal guardian. There is a special consent form for Jehovah’s Witnesses.
7. DVT prophylaxis, e.g. graded compression stockings (thromboembolic deterrent – TED), subcutaneous low molecular weight heparin, e.g. Clexane.
Postoperative care
1. Detailed operation note including intraoperative drugs; postoperative instructions should accompany the patient to the ward.
2. Monitoring of vital signs. Monitor BP, pulse and respiratory rate every 15 min until the patient is stable and thereafter hourly for 24 h. Monitor CVP after major surgery in the elderly and those with cardiac disease. Continuous ECG monitoring is advisable in those with cardiac disease or elderly patients undergoing major surgery.
3. Early mobilization. Patients requiring prolonged bed rest should be turned regularly from side to side to avoid pressure sores. Nurse on airbed. Protect sacrum and heels, especially in diabetics.
4. Diet. Nasogastric tubes are used in a number of abdominal operations. However, increasingly, these are taken out at the earliest opportunity to allow the patient to eat. If the patient is at high risk of ileus, then they may be retained for 24–48 h. In operations not involving the GI tract, the patient may drink when fully awake after a GA.
5. Intravenous fluids. Administer according to requirements – monitored by clinical examination, urine output and CVP.
7. Urinary output. If the patient is catheterized, monitoring is easy. If the urine output falls below 30 mL/h action is required. If the patient is not catheterized, inform the surgeon if urine has not been passed within 8 h postoperatively.
9. Laboratory tests. After major procedures, the Hb, FBC and U&Es should be checked 24 h postoperatively and thereafter according to indications.
10. Radiographs and ECG. Carry out according to indications and not as routine. CXR may be necessary if pyrexia continues after 24 h postoperatively, if there is sputum production or chest signs.
Conditions affecting surgical risk
Medical problems in surgical patients
Cardiovascular
Respiratory disease
Renal disease
Hepatic disease
Obstructive jaundice
There is usually a clear history. Surgery will usually have been necessary to deal with the problem.
Haematological disease
Endocrine disease
Diabetes
This poses numerous risks and affects many systems. Complications include:
• Vasculopathy: heart – increased risk of MI; peripheral vascular disease (PVD) – risk of lower limb ischaemia with ulcers and gangrene; risk of stroke
• Neuropathy – peripheral neuropathy with risk of pressure ulcers on heels and autonomic neuropathy with risk of cardiac arrest and gastric stasis with aspiration
• Retinopathy leading to blindness – problems with management of blind patient in unfamiliar surroundings; anticoagulation, if needed, may make retinal haemorrhage worse
Thyroid disease
Hyperthyroidism
Patients should be euthyroid prior to elective surgery (→ Ch. 11). Hyperthyroidism is associated with arrhythmias and hypertension. A thyroid crisis is associated with oversecretion and may be triggered by infection. This presents as hyperthermia, arrhythmias, cardiorespiratory failure and coma.
American society of anesthesiologists’ classification of physical status (ASA grading)
The ASA grading system for quantifying anaesthetic risk is as follows:
II. A patient with mild to moderate systemic disease process caused either by the condition to be treated surgically or by other pathological process which does not limit the patient’s activity in any way, e.g. mild diabetic, treated hypertensive.
III. A patient with a severe systemic disturbance from any cause and which imposes a definite functional limitation on the patient, e.g. severely limiting organic heart disease, severe diabetes with vascular complications, severe COPD.
IV. A patient with severe systemic disease which is a constant threat to life, e.g. severe unstable angina, advanced liver failure.
Postoperative complications
All operations carry a risk of complications (a Classification is shown in Table 5.1). Complications may be divided as:
Haemorrhage | Early postoperative Secondary haemorrhage |
Wound | Infection Bleeding Haematoma Seroma Suture sinus Breakdown: |
Cardiovascular | Cardiac arrest MI Pulmonary oedema Arrhythmias DVT |
Lung | Atelectasis Aspiration Pneumonia PE Pulmonary oedema Pneumothorax ARDS |
Cerebral | Confusion:Stay updated, free articles. Join our Telegram channelFull access? Get Clinical TreeGet Clinical Tree app for offline access |