Pre-operative Preparation and

Peri-, Post-operative Monitoring

of the
Surgical Patient
DR. KAMEL IBRAHIM HADY
DR. SAMY AB ALREHMAN
CONSULTANT ANAESTHESIA/ICU
K.K.M.H

SURGERY
One of the most challenging aspect of surgical
practice is not just making the decision to
perform a surgical procedure on a patient, but
deciding on the proper timing when a surgical
procedure can be done.

Surgical Management Decision

Disease

Surgery
Management

Patient

SURGERY

Disease Factor:

Management Factor:

Natural History
Prognosis

Classical and Advances in Surgical and Medical Techniques (Management

Options)
Anesthesia Methods and Medications

Patient Factor:

General Health (Optimization)

Co-morbid Conditions (Identify and Manage)
Psychological Preparation

SURGERY
Thus, appropriate pre-operative preparation
and post-operative monitoring is absolutely
mandatory and essential to minimize the risks,
lessen complications and optimize outcome of a
patient even with the best technically performed
operative procedure.

Pre-operative Care

OBJECTIVES
Optimize efficiency and bed utilization
preoperatively

Avoid delays and cancellations resulting in lost

operating room time
Proactively coordinate patient care with other
specialties
Provide high-quality and safe patient care
Improve patient satisfaction and set foundation
for optimum outcomes

General Aspects of Pre-op Care

History and Physical Examination

Surgical Consent

Patient Preparation:
Psychological preparation
Physical preparation
Physiological preparation

History and Physical Examination

Diagnosis of current condition

Identifies associated risk factors:

Age of the patient (Extremes of age)

Co-morbid conditions
Previous surgery

Determines current medications

Reviews past medical history
Determines physical status:

American Society of Anesthesiologists (ASA) Physical Status

Assessment

Pre-operative Medical Care

Elective/Emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

Surgical Emergency

AMPLE History:
A llergies
M edications
P ast Medical History
L last meal
E vents Preceding Surgery

Pre-operative Medical Care

Elective/Emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

Coronary Artery Disease

Definition of CAD....

Physiology of Surgery:
myocardial oxygen demand
catecholamines: HR, contractility, PVR
HR also causes decreased diastolic filling
Coronary arteries fill in diastole
Less blood flowing in coronaries: less myocardial O2 supply

Myocardial Infarction

Pt without risks: 0.5% chance of MI

Pt with risks:
5% chance of perioperative MI
Perioperative MI has 17-41% mortality
CAD causes MI
Risk stratifications:
MI w/in 3 months of OR

27% reinfarction rate

MI 3-6 months before OR

10% reinfarction rate

MI >6 months of OR

5-8% reinfarction rate*

Goldman Index
Criteria:

Points

A. Historical:
Age >70 yr.
5
Myocardial infarction previous 6 months
10
B. Examination:
S3 gallop or jugular venous distention
11
Significant aortic valvular stenosis
3
C. Electrocardiogram:
Premature atrial contractions or other rhythm
7
>5 premature ventricular contractions/min.
7
D. General status:
Abnormal blood gases
3
K+/HCO3 abnormalities
3
Abnormal renal function
3
Liver disease or bedridden
3
E. Operation:
Emergency
4
Intraperitoneal, intrathoracic, aortic
3
Adapted
from
Goldman,
L.,
Caldera,
D.
L.,
Nussbaum,
S.
R.,
et
al.:
N.
Total possible:
53
Engl. J. Med., 1977; 297:845. Copyright 1977. Massachusetts Medical
Society. All rights reserved.

Goldman Classification
Class
I

II

Point Total
0-5

6-12

III

13-25

IV

> 26

Goldman
Risk in Non-cardiac
Class
III &Cardiac
IV patient
warrant Surgery
routine
pre-operative cardiology consultation

Class IV life saving procedure only

28 of the 53 points are potentially

correctible pre-operatively
Index correctly classified 81% of cardiac
outcomes

Pre-operative Medical Care

Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

Pulmonary Disease

Patient History:
unexplained dyspnea, cough, reduced exercise tolerance
Physical Exam:
wheeze, rales, rhonchi, exp time, BS
5.8x more likely to develop pulmonary complications*
Pre-operative CXR:

Mandatory in patients over 40 yo

ABG:
no role for routine use
result should not prohibit surgery
* Lawrence et al Chest 110:744, 1996

Pulmonary Disease

Patient-related risks:

Chronic lung dz
wheeze, productive
cough
Smoking
General health
Obesity
Age?

separate from others?

Procedure related risks:

Type of anesthesia

GETA alone FRC 11%

inhibited coughing peri-op

Surgical site
Duration of surgery

Modifiable Pulmonary Risks

Obesity Risks:

lung capacity, FRC, VC

Hypoxemia

Tobacco Risks:

Definition of stopped
smoking....
When was your last cigarette?

Pre-operative Medical Care

Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction

Dialysis dependent

Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

Renal Dysfunction

Not all renal failure is oliguric

Check BUN/Cr

Assume DM have CRI

Volume status
Electrolytes

Drug metabolism

Renal Dysfunction

Dialyze preop to improve

electrolytes, volume status

No or limit K+ in MIVF

Very judicious MIVF while on

NPO

Consider:

Altered drug metabolism

Altered platelet fxn

Pre-operative Medical Care

Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

Why does hepatic disease

cause coagulopathy?

Child-Pugh Criteria for Hepatic Reserve

Measure

Bilirubin

<2.0

2-3

>3.0

Albumin

>3.5

2.8-3.5

<2.8

Prothrombin
Time (PT)
increase
Ascites

1-3

4-6

>6

None

Slight

Moderate

Neuro

None

Minimal

Coma

Child-Pugh Criteria for Hepatic Reserve

Predictor of perioperative mortality:

Class A:
Class B:
Class C:

0 - 5%
10 15%
> 25%

Correct what you can vitamin K,

FFP, Albumin, etc.
Anticipate bleeding, complications

Townsend, Textbook of Surgery, 16th ed.

Perioperative Medical Care

Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

Patients with Diabetes

Coronary Artery Disease

Neuropathy
Diabetic Nephropathy
Infection
Others
Treatment:

Control of hyperglycemia pre-operatively

Pre-operative Medical Care

Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders

Iatrogenic
Inherited

Reasons patients are placed on

anticoagulants:
Atrial fibrillation

Prosthetic heart valve

DVT or PE
CVA or TIA

Hypercoagulable state

Malnourished
REVIEW:

Merritt J Thrombosis and Thrombolysis 13(2), 97-103, 2002

Evaluation of Hemostatic Disorders

History:

Easy bruising, epistaxis

Family history of bleeding

disorders
ASA / NSAIDs
Renal disease
Hepatic disease (EtOH)
Physical:
Ecchymoses
Hepatosplenomegaly
Excessive mobility of joints or
excess skin laxity
Stigmata of renal or hepatic
disease

Cut when shaving

Heavy menstrual bleeding

Laboratory Tests of Bleeding Function

Prothrombin time (PT/INR):

Partial thromboplastin time (PTT):

Intrinsic pathway and common pathway

Platelet count:

Measures factor VII and common pathway factors (factor X,

prothrombin/thrombin, fibrinogen, and fibrin)

quantifies platelets

Bleeding time and Clotting time:

estimates qualitative platelet function

Patients on Anticoagulants

Aspirin (ASA)

Coumadin (Warfarin)

Heparin

1Ridker

et al Ann Intern Med 114:835-839, 1991.

Inherited Bleeding Disorders

Hemophilia A
Hemophilia B
(Christmas disease)
Protein deficiency
von Willebrands
disease
Factor V

Antithrombin III
deficiency
. . . Other factor
deficiencies (rare)

Perioperative medical care:

Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

Patients who are malnourished

Proteins are essential for healing and

regenerating tissue
Malnourished patients have
Higher wound complications (dehiscence) and
greater anastomotic leak rate
More postoperative muscle weakness
(diaphragm)
Longer time in rehabilitation

Treating malnourishment

If the gut works, use it.

TPN vs. enteral feeds
Preoperative bulking up

Gastric and esophageal cancers

Why are they malnourished?

How do you build someone up?

American Society of Anesthesiologists (ASA)

Physical Status Assessment
Classification
(Elective)

Classification
(Emergency)

Description

1E

Normally healthy

2E

With mild systemic disease

3E

With severe systemic disease that

is not incapacitating

4E

With incapacitating systemic

disease that is a constant threat
to life

5E

Moribound patient not expected

to survive without operation

6E

Comatose/Organ Donor

Surgical Consent

Details of a particular surgical procedure:

Procedure
Preparation (bowel preparation; NPO guidelines)
Benefit from the procedure
Risks and potential complications

Answer questions of patients and relatives:

To dispel fear and alleviate anxiety

Patient Preparation

Psychological:

Acceptance and positive outlook

Physical:
Skin preparation
Bowel preparation
Prophylactic antibiotics

Physiological:
Correcting associated co-morbid conditions
Patient optimization

A. Blood Orders:
1. Type and screen or type and cross for
number of units appropriate to the procedure
B. Skin Preparation:
1. Hair removal best performed on day of surgery
with an electric clipper
2. Pre-operative scrub or shower of the operative site with
a germicidal soap.
C. Pre-operative antibiotics:
1. Administer prophylactic antibiotics 30 min prior to
incision

D. Respiratory Care:
1. Pre-operative spirometry on the evening prior
to surgery when indicated
2. Bronchodilators for moderate to severe COPD

E. Decompression of GI tract:
1. NPO after midnight
F. Intravenous fluids:

1. Maintenance rate overnight (D5LR)

G. Access and Monitoring lines:
1. At least one ga.18 IV needed for initiation of
anesthesia
2. Arterial catheters and central or pulmonary
artery catheters when indicated

H. Thromboembolic prophylaxis:
1. When indicated (those predispose to deep venous
thrombosis)
I. Pre-operative sedation:
1. As ordered by the anesthesiologist
J. Special Consideration:
1. Maintenance medication
2. Pre-operative diabetic management
3. Other prophylactic medications
4. Peri-operative steroid coverage (if needed)
K. Skin Marking:
1. For Plastic/Reconstructive Surgeries
2. Marking of stoma sites
P. Pre-operative notes

Peri- and Post-operative Care

Reasons to Monitor
1.
2.
3.

4.
5.

Patient safety
Positive outcome
Intra-operative case
adjustments
Assess equipment function
Improve patient vigilance

Peri- and Post-operative Monitoring

Important aspects:

Physiologic Monitoring:
Vital Signs
Hemodynamic
Respiratory
Gastric Tonometry
Renal
Neurologic
Metabolic/Nutritional

Traditional 4 Cardinal Vital Signs

Temperature:

Heart Rate:

Cardiac rate
Pulse rate

Blood Pressure:

Rectally or orally
Aural (Digital): measures core temperature

Standard BP apparatus

Respiratory Rate:

Breaths per minute

Monitoring Temperature

Hemodynamic Monitoring

Purpose:

To monitor cardiovascular function/performance

Traditional tools unreliable (critically ill patients)

Methods:
Arterial Catheterization
Central Venous Catheterization
Pulmonary Artery Catheterization

Arterial Catheterization

Indications:

Continuous monitoring of blood pressure

Frequent sampling of arterial blood

Contraindications:

Severe occlusive arterial disease (distal ischemia)

Vascular prosthesis (graft)
Local infection
Caution:

Bleeding diathesis
Anticoagulant therapy

Arterial Catheterization

Clinical Utility:
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
Mean arterial pressure (MAP)
Pulse Rate

Arterial Catheterization

Sites of catheterization:
Radial/Ulnar
Axillary
Femoral
Dorsalis pedis
Superficial temporal
Brachial

Assess Circulation

Allens test (E.V. Allen, 1929):

patient makes tight fist for 1 min.
radial & ulnar arteries compressed
one artery released
observe color return in hand
repeat with other artery

Allens Test Findings

Color return:
< 5 seconds - normal
5 - 15 seconds - delayed
> 15 seconds - abnormal

Arterial Catheterization

Complications:
Failure
Hematoma
Bleeding
Occlusion and ischemia
Infection
Fistulas/Pseudoaneurysms
Thrombo-embolism

Central Venous Catheterization

Indications:

Secure access:

Central venous pressure (CVP) monitoring

Others:

Fluid therapy
Drug infusions
Parenteral nutritiona

Aspirate air emboli (neurosugery)

Cardiac pacemaker placement
Hemodialysis

Contraindications:

Vessel thrombosis
Infection
Bleeding diathesis/anti-coagulant therapy

Central Venous Catheterization

Clinical Utility:
Central venous pressure (CVP)
Indirectly:

Right atrial pressure

Right ventricular end-diastolic pressure

Relationship between intravascular volume and right

ventricular function

Central Venous Catheterization

Sites of cetheterization:
Subclavian
Internal jugular
External jugular
Femoral
Brachiocephalic

Central Venous Pressure

Central Venous Catheterization

Complications:
Pneumothorax (subclavian)
Arterial puncture (internal jugular and femoral)
Hematoma/bleeding
Injury (neurovascular)
Infection
Thrombo-embolism

Pulmonary Artery Catheterization

Indications:
Critically ill patients
Extensive surgical procedure (cardiac surgery)

Contraindications:
Vessel thrombosis
Infection
Bleeding diathesis/anti-coagulant therapy

Pulmonary Artery Pressure

Pulmonary Artery Catheterization

Clinical Utility:

Central venous pressure (CVP)

Pulmonary artery diastolic pressure (PADP)
Pulmonary artery systolic pressure (PASP)
Mean pulmonary artery pressure (MPAP)
Pulmonary artery occlusion wedge pressure (PAOP)
Cardiac output (CO)
Indirectly:

Left atrial pressure (LAP)

Left ventricular end-diastolic pressure (LVEDP)

Pulmonary Artery Catheterization

Sites of catheterization:
Subclavian
Internal jugular
Femoral

Pulmonary Artery Catheterization

Complications:
Dysrhythmias (most common)
Transient right bundle branch block (RBBB)
Coiling, looping, knotting of catheter
Aberrant catheter placement
Infection
Thrombo-embolism
Bleeding

Respiratory Monitoring

Purpose:

To monitor respiratory performance:

Ventilation/Perfusion
Gas exchange
Oxygen transport

To anticipate mechanical ventilatory support

Methods:
Ventilation monitoring
Blood-Gas monitoring

Ventilation Monitoring

Advantages:

Predict and monitor ventilatory function

Methods:

Lung volumes:

Tidal volume
Vital capacity
Minute volume
Dead space

Pulmonary mechanics:

Inspiratory force/pressure
Static compliance
Dynamic characteristic
Work of breathing

Lung Volumes

Tidal Volume:
The volume of air moved in or out of the lungs in a
single breath
Respiratory frequency (f) : Tidal volume (Vt) ratio

Vital Capacity:
The volume of maximal expiration following a
maximal inspiration
65 to 75 ml/kg (Normal)

Lung Volumes

Minute Volume:

Total ventilation
The total volume of air leaving the lung each minute
A product of Respiratory frequency ( f ) and Tidal Volume
(Vt)

Dead Space:

The portion of tidal volume not involved in gas exchange

2 components:

Anatomic dead space (within conducting airways)

Alveolar dead space (within unperfused alveoli)

Pulmonary Mechanics

Inspiratory Force:
Measured as the maximal pressure below
atmospheric that a patient can exert against an
occluded airway
< -20 to -25 cmH2O (good recovery)

Compliance:
Measure of the elastic properties of the lung and
chest wall
60 to 100 ml/cmH2O (normal)

Pulmonary Mechanics

Dynamic Characteristic:

Evaluates compliance as well as impedance factors

Calculated by dividing the volume delivered by the peak
airway pressure minus the positive end expiratory pressure
(PEEP)
50 to 80 ml/cmH20 (normal)

Work of Breathing:

A measure of the process of overcoming the elastic and

frictional forces of the lung and chest wall
A product of the change in pressure and volume
0.3 to 0.6 J/L (normal)

Blood-Gas Monitoring

Advantages:
Efficiency of gas exchange
Adequacy of alveolar ventilation
Acid-base status

Methods:
Arterial blood gas
Mixed-venous blood gas
Capnography
Pulse oximetry

Pulse Oximetry

Gastric Tonometry

Purpose:
A reliable monitor in elective cardiac and major
vascular surgery
A predictor of organ dysfunction and mortality

Principle:

Noninvasive monitor of adequacy of aerobic

metabolism in organs whose superficial mucosal
lining is vulnerable to low flow and hypoxemia
secondary to shock and SIRS

Gastric Tonometry

Values Derived:

Intramucosal pH

Importance:
Guides in the resuscitative management
Provide a metabolic end point to resuscitation
Patient prognostication

Renal Monitoring

Purpose:
Monitor adequacy of perfusion
Prevention of parenchymal injury/failure
Predict drug clearance (proper dose management)

Methods:
Urine output (0.5 to 1 ml/kg/hr)*
Glomerular function test
Tubular function test

Glomerular Function Test

Blood urea nitrogen (BUN):

Dependent on GFR and Urea production
Urea (increased):

Prolonged TPN
GI Bleeding
Catabolic states (Trauma, Sepsis and Steroids)

Urea (decreased):
Starvation
Liver Disease

Not a reliable monitor of renal function

Glomerular Function Test

Creatinine:

Not influenced by protein metabolism and rate of fluid flow

through renal tubules

Serum creatinine:

Directly proportional to creatinine production (muscle mass and

metabolism)
Inversely proportional to GFR

Takes 24 to 72 hrs before serum creatinine changes are

reflected

Glomerular Function Test

24-hour Creatinine clearance:

Most reliable method for clinically assessing GFR
Most sensitive test for predicting renal dysfunction
Traditionally uses a 24-hr collection
Currently uses 2-hr collection:

Reasonable accurate and easier to perform

Tubular Function Tests

Purpose:

Measures concentrating ability of renal tubules

To differentiate causes of oliguria (pre-renal and ATN)

Methods:

Fractional sodium excretion (most reliable)

Normal: 1-2%

BUN : Creatinine ratio

Urine : Plasma Creatinine ratio

Neurologic Monitoring

Purpose:
Early recognition of cerebral dysfunction
Facilitate early and prompt intervention

Methods:
Intracranial pressure monitoring
Electrophysiologic monitoring
Transcranial doppler ultrasonography
Jugular venous oximetry

Intracranial Pressure Monitoring

Methods:

Permits calculation of:

Intraventricular catheter
Subarachnoid bolt
Epidural bolts
Fiberoptic catheter
Cerebral perfusion pressure (CPP) = MAP - ICP

Complications:

Infection
Malfunction/Malposition
Hemorrhage
Obstruction

Electrophysiologic Monitoring

Electroencephalogram (EEG)
Indications:
Carotid endarterectomy
Cerebrovascular surgery
Epilepsy surgery
Open heart surgery (Some)

Transcranial Doppler Ultrasound

Advantages:
Noninvasive
Portable
Reproducible

Disadvantage:

Operator dependent (technical familiarity)

Jugular Venous Oximetry

Applications:
Carotid endarterectomy
Neurosurgical procedures
Cardio-pulmonary bypass

Metabolic/Nutritional

Purpose:

To determine the need to substitute artificial or

parenteral feeding during the recovery phase

Methods:

Assessment of Caloric Expenditure

Basal Energy Expenditure (BEE)

Harris-Benedict Equation

Assessment of Oxygen Consumption

Thank You
Pamantasan ng Lungsod ng Maynila
College of Medicine

Department of Surgery