Perioperative Care Notes

Concept of Perioperative Care

The perioperative period is a term used to describe the three distinct phases of any surgical procedure, which include the preoperative phase, the intraoperative phase, and the postoperative phase.

Preoperative Care

Every patient presenting for surgery must be optimally prepared before surgery to ensure best possible outcome of surgery. Optimisation is done based on the urgency of surgery, nature of the disease and presence of other comorbidities.

Read And Learn More: Basic Principles Of Surgery Notes

Preoperative Care Elective Surgery

• There is sufficient time available for evaluation and preparation of patients presenting for elective surgery. Preoperative evaluation will consist of detailed history, physical examination, and investigations based on the findings.
• There is no ‘routine’ investigation. All investigations must be tailored to the patient and the surgery. A patient with no other comorbidity and minimum change in his homeostasis may require no further preparation, whereas some will require considerable preparation.

Elective Surgery Examples:

• A patient may have pre-existing conditions unrelated to surgery such as asthma, chronic obstructive pulmonary disease, hypertension, or diabetes.
• They must be thoroughly evaluated and their condition optimized prior to surgery. Smoking should be stopped at least 4 weeks before surgery.
• Patients with respiratory conditions and those presenting for major thoracic or abdominal surgery may be advised incentive spirometry and respiratory exercises to improve their breathing ability.
• A patient with thyrotoxicosis must be made euthyroid before thyroidectomy, a patient with phaeochromocytoma must have the hypertension well under control before surgery.

Nutrition: Nutritional support may be considered for patients who are severely malnourished.

• Examples may be carcinoma esophagus, achalasia cardia, or a few cases of intestinal fistulae. These patients should receive seven or more days of enteral or parenteral nutrition prior to surgery.
• Enteral nutrition has a number of advantages such as preservation of gut mucosa, decreased leakage of gut bacterial antigens, reduction of inflammation, maintenance of immune function, and decreased hyperglycemia. Healing after surgery is improved with better nutrition.
• Patients with coagulopathies or bleeding disorders may be at increased risk for bleeding. They may require perioperative transfusion of blood products.
• Anti-platelet drugs should be stopped 7 days before the procedure unless they need to be continued. Low dose aspirin, however, is usually continued.

 Elective Surgery:

1. Optimise pre-existing conditions: Control of diabetes, hypertension, bronchial asthma
2. Functional status to be normal while operating on thyroid and adrenals
3. Nutritional support
4. Tailor investigations to the patient’s condition and surgery

Preoperative Care Emergency Surgery

These surgeries can be broadly classified further into surgeries for trauma and non-trauma.

 Emergency Surgery Urgent surgery:

• There is usually some time available for optimization of these patients, say a few hours, before surgery. For example, acute appendicitis, intestinal obstruction, obstructed hernia, blunt abdominal trauma.
• This time is utilized to treat them with intravenous fluids to optimize blood volume, correct electrolyte imbalance, administer antibiotics, bronchodilators if asthmatic, and to obtain investigations done such as echocardiogram.
• Most abdominal emergency cases need to have a nasogastric tube inserted and urinary bladder catheterized.

Emergency surgery:

• Occasionally, some surgeries are absolutely emergent and no time should be wasted to optimize these patients. In these patients, evaluation, resuscitation, surgery, and optimization happen simultaneously.
• Examples: Life-threatening conditions such as a patient with uncontrolled bleeding after polytrauma, limb-threatening conditions such as vascular injury.

Patient Preparation

• Preoperative care also includes preparing the part for surgery, marking the site and side, and obtaining informed consent (Follow WHO checklist).
• Consent is taken after explaining to the patient, the nature of surgery, anticipated outcome, possible complications, and postoperative course, possible need of postoperative intensive care, and even mortality (as applicable in those cases) in his own language.
• A witness to the process of obtaining consent must also sign this document along with the patient and the surgeon.
• In addition, the patient must be referred to the anaesthetist (pre-anaesthesia checkup) who will once again evaluate the patient from his/her perspective, obtain additional investigations as necessary, and take informed consent.
• All patients are kept fasting for solids and milk for at least 6 hours and to clear fluids for at least two hours prior to surgery. This is done to minimize the risk of

Preparation of the Patient:

1. Informed consent and signature
2. Clipping of the hair just before surgery
3. Mark the site—especially small lumps in the breast, hernias, benign lumps
4. Nil per oral 6 hours for solids, and 2 hours for liquids
5. Follow anaesthesia orders. Give drugs prescribed by,anaesthetist

vomiting and pulmonary aspiration of regurgitated gastric contents during anesthesia which can lead to aspiration pneumonia.

• Instructions regarding premedication, investigations (as required on the morning of surgery), and other regular medications as prescribed by the anaesthetist must be followed.

Intraoperative Care

• The intraoperative period is the most stressful part of surgery and is the combined responsibility of the surgeon, the anesthetist, nurses, and the entire surgical team.
• On the day of surgery, the patient is wheeled into the operation theatre, where his identity, surgery, site, and side, availability of blood products (as necessary), fasting status and consent are once again checked before beginning anesthesia.
• Antibiotics are given within 30 minutes to an hour before commencement of surgery. Once anaesthesia has been given, the anaesthetist monitors the vitals of the patient while the surgeon concentrates on the surgery.
• The maintenance of depth of anaesthesia, administration of intravenous fluids, blood products, analgesics, and maintenance of physiology of the patient is the responsibility of the anaesthetist.
• The surgeon undertakes the surgery with aseptic precautions, with an effort to minimize blood loss, tissue damage and in a reasonable period of time.
• Once surgery is done, the incision is closed after careful count of the gauzes and instruments (done by the nurse) so that nothing is left behind unintentionally inside the patient’s body.
• Upon completion of surgery and emergence from anaesthesia, the patient is shifted to the postanesthetic care unit for further observation.
• The patient can then be shifted to the ward after fulfilling discharge criteria (hemodynamically stable with adequate oxygenation, fully conscious, able to void if not catheterized and is pain free).
• The patients are shifted to high dependency units, if they have undergone major surgery but are stable postoperatively.
• If the patient needs postoperative mechanical ventilation or is hemodynamically unstable, then he is shifted to the intensive care unit for further management.

Postoperative Care

Upon arrival in the recovery area, the surgeon and the anaesthetist explain to the recovery nurse in charge of the patient about the surgery, intraoperative events and give instructions for postoperative care.

Postoperative Care:

1. Vitals: Airway, breathing, circulation and disposition
2. Analgesia
3. Fluid and electrolyte balance: Intake/output chart
4. Thromboprophylaxis—mobilisation of legs
5. Nutrition
6. Antibiotics

1. Postoperative Care ABCD:

• Monitoring and restoration to normal physiology and function of organs [(A—airway, B— breathing, C—circulation, and D—disposition (consciousness)].
• The patients are monitored closely and appropriate management done till their vitals are normal.

2. Postoperative Care Pain Relief:

Adequate analgesia is important in the postoperative period. This may include intravenous paracetamol, opioids, nonsteroidal anti-inflammatory drugs, or regional analgesia depending on the nature of the pain and severity.

3. Postoperative Care Fluid and electrolyte balance:

• The patients are monitored closely postoperatively to ensure their fluid and electrolyte status is normal. An intakeoutput chart is maintained for all patients who have undergone major surgery.
• Their fluid input (including blood products) is matched with output (urine, blood loss, and any other excessive secretions).
• In the early postoperative period, one must remember that antidiuretic hormone (ADH) is released which results in conserving of water. Aldosterone secretion increases leading to reabsorption of sodium and potassium secretion.

4. Postoperative Care Bowel movements:

Patients who undergo laparotomy have paralytic ileus, so it is common not to have bowel movement for 2 to 3 days. Once bowel sounds are heard, the patient is given sips of water followed by soft diet.

5. Postoperative Care Leg movements:

Both passive and active are done, to minimize thromboembolic complications. They are also prescribed thromboprophylaxis depending upon the nature of the surgery.

6. Postoperative Care Nutrition:

• Patients who undergo gastrectomy, esophageal surgeries and surgeries on intestines, may require parenteral nutrition for a few days. Enteral nutrition is resumed as early as possible.

7. Postoperative Care Preventing infection:

• In all contaminated and dirty cases, antibiotics have to be continued for a period of 5 to 7 days. In cases of sepsis and septic shock, they have to be continued for 14 days.
• Once the patients are stable, they are discharged home with instructions for home care and follow-up.