4928104-Pre-and-Postoperative-Monitoring-of-Patients, REVISED.ppt

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Pre-operative Preparation andPeri-, Post-operative Monitoring

of the

Surgical Patient

DR. KAMEL IBRAHIM HADYDR. 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, butdeciding on the proper timing when a surgicalprocedure can be done.”



Surgical Management Decision

Surgery

Management

Disease

Patient



SURGERY

Disease Factor: Natural History

Prognosis

Management Factor: 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 apatient even with the best technically performedoperative procedure.”



Pre-operative Care



Optimize efficiency and bed utilization

preoperatively

Avoid delays and cancellations resulting in lostoperating room time

Proactively coordinate patient care with otherspecialties

Provide high-quality and safe patient care

Improve patient satisfaction and set foundation

for optimum outcomes

OBJECTIVES



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




Elective/Emergency

Cardiac disease

Pulmonary disease

Renal dysfunction

Liver dysfunction

Diabetics




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*



Criteria: Points A. Historical:

Age >70 yr. 5Myocardial infarction previous 6 months 10

B. Examination:S3 gallop or jugular venous distention 11

Significant aortic valvular stenosis 3C. Electrocardiogram:

Premature atrial contractions or other rhythm 7>5 premature ventricular contractions/min. 7

D. General status: Abnormal blood gases 3K+/HCO3 abnormalities 3

Abnormal renal function 3Liver disease or bedridden 3

E. Operation:Emergency 4Intraperitoneal, intrathoracic, aortic 3

Total possible: 53 Adapted from Goldman, L., Caldera, D. L., Nussbaum, S. R., et al.: N.Engl. J. Med., 1977; 297:845. Copyright 1977. Massachusetts Medical

Society. All rights reserved.

Goldman Index



Goldman Classification

Class Point Total

I 0-5II 6-12

III 13-25

IV > 26



Goldman Cardiac Risk in Non-cardiac SurgeryClass III & IV patient warrant routinepre-operative cardiology consultation

Class IV – life saving procedure only

28 of the 53 points are potentiallycorrectible pre-operatively

Index correctly classified 81% of cardiacoutcomes




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, productivecough

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?”





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 improveelectrolytes, volume status

No or limit K + in MIVF

Very judicious MIVF while onNPO

Consider: Altered drug metabolism

Altered platelet fxn





Pulmonary disease

Renal dysfunction Liver dysfunction

Diabetics

Bleeding disorders

Malnourished

Why does hepatic disease

cause coagulopathy?



Child-Pugh Criteria for Hepatic Reserve

Measure A B C

Bilirubin <2.0 2-3 >3.0

Albumin >3.5 2.8-3.5 <2.8

Prothrombin

Time (PT)

increase

1-3 4-6 >6

Ascites None Slight Moderate

Neuro None Minimal “Coma”



Child-Pugh Criteria for Hepatic Reserve

Predictor of perioperative mortality: Class A: 0 - 5%

Class B: 10 – 15%

Class C: > 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





Pulmonary disease

Renal dysfunction

Liver dysfunction

Diabetics

Bleeding disorders

Iatrogenic Inherited

Malnourished

Reasons patients are placed on

anticoagulants:

−Atrial fibrillation

−Prosthetic heart valve

−DVT or PE

−CVA or TIA

−Hypercoagulable state

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



Evaluation of Hemostatic Disorders

History :

Easy bruising, epistaxis Cut when shaving

Heavy menstrual bleeding

Family history of bleedingdisorders

ASA / NSAID’s

Renal disease

Hepatic disease (EtOH)

Physical:

Ecchymoses

Hepatosplenomegaly

Excessive mobility of joints orexcess skin laxity

Stigmata of renal or hepaticdisease



Laboratory Tests of Bleeding Function

Prothrombin time (PT/INR): Measures factor VII and common pathway factors (factor X,

prothrombin/thrombin, fibrinogen, and fibrin)

Partial thromboplastin time (PTT):

Intrinsic pathway and common pathway

Platelet count:

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.



Perioperative medical care:

Surgical emergency

Cardiac disease

Pulmonary disease

Renal dysfunction

Liver dysfunction

Diabetics




Patients who are malnourished

Proteins are essential for healing andregenerating tissue

Malnourished patients have

Higher wound complications (dehiscence) andgreater 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

1 1E Normally healthy

2 2E With mild systemic disease

3 3E With severe systemic disease thatis not incapacitating

4 4E With incapacitating systemic

disease that is a constant threatto life

5 5E Moribound patient not expectedto survive without operation

6 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 fornumber of units appropriate to the procedure

B. Skin Preparation:1. Hair removal best performed on day of surgery

with an electric clipper2. Pre-operative scrub or shower of the operative site witha 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 priorto 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 ofanesthesia

2. Arterial catheters and central or pulmonaryartery 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 medication2. Pre-operative diabetic management3. Other prophylactic medications4. Peri-operative steroid coverage (if needed)

K. Skin Marking:1. For Plastic/Reconstructive Surgeries2. Marking of stoma sites

P. Pre-operative notes



Peri- and Post-operative Care



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: Rectally or orally

Aural (Digital): measures core temperature

Heart Rate: Cardiac rate

Pulse rate

Blood Pressure:

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




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




Clinical Utility:

Systolic blood pressure (SBP)

Diastolic blood pressure (DBP)

Mean arterial pressure (MAP)

Pulse Rate




Sites of catheterization:

Radial/Ulnar

Axillary

Femoral

Dorsalis pedis

Superficial temporal

Brachial



Assess Circulation

Allen’s 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



Allen’s Test Findings

Color return:

< 5 seconds - normal

5 - 15 seconds - delayed

> 15 seconds - abnormal




Complications:

Failure

Hematoma

Bleeding

Occlusion and ischemia

Infection

Fistulas/Pseudoaneurysms

Thrombo-embolism




Indications: Secure access:

Fluid therapy Drug infusions Parenteral nutritiona

Central venous pressure (CVP) monitoring Others:

Aspirate air emboli (neurosugery) Cardiac pacemaker placement Hemodialysis

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




Clinical Utility:

Central venous pressure (CVP)

Indirectly:

Right atrial pressure

Right ventricular end-diastolic pressure

Relationship between intravascular volume and right

ventricular function




Sites of cetheterization:

Subclavian

Internal jugular

External jugular

Femoral

Brachiocephalic



Central Venous Pressure




Complications:

Pneumothorax (subclavian)

Arterial puncture (internal jugular and femoral)

Hematoma/bleeding

Injury (neurovascular)

Infection

Thrombo-embolism




Indications:

Critically ill patients

Extensive surgical procedure (cardiac surgery)

Contraindications:

Vessel thrombosis

Infection

Bleeding diathesis/anti-coagulant therapy



Pulmonary Artery Pressure




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)




Sites of catheterization:

Subclavian

Internal jugular

Femoral




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 belowatmospheric that a patient can exert against an

occluded airway < -20 to -25 cmH2O (good recovery)

Compliance:

Measure of the elastic properties of the lung andchest 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 peakairway 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



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 mucosallining is vulnerable to low flow and hypoxemiasecondary 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



Gl l F i T



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

Gl l F i T




Creatinine: Not influenced by protein metabolism and rate of fluid flow

through renal tubules

Serum creatinine:

Directly proportional to creatinine production (muscle mass andmetabolism)

Inversely proportional to GFR

Takes 24 to 72 hrs before serum creatinine changes arereflected

Gl l F i T




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

T b l F i T



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

N l i M i i



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

I i l P M i i



Intracranial Pressure Monitoring

Methods: Intraventricular catheter

Subarachnoid bolt

Epidural bolts

Fiberoptic catheter

Permits calculation of: Cerebral perfusion pressure (CPP) = MAP - ICP

Complications: Infection

Malfunction/Malposition Hemorrhage

Obstruction

El h i l i M i i



Electrophysiologic Monitoring

Electroencephalogram (EEG)

Indications:

Carotid endarterectomy

Cerebrovascular surgery

Epilepsy surgery

Open heart surgery (Some)

T i l D l Ul d



Transcranial Doppler Ultrasound

Advantages: Noninvasive

Portable

Reproducible

Disadvantage:

Operator dependent (technical familiarity)

J l V O i



Jugular Venous Oximetry

Applications: Carotid endarterectomy

Neurosurgical procedures

Cardio-pulmonary bypass



Thank You

Pamantasan ng Lungsod ng Maynila

College of MedicineDepartment of Surgery

4928104-Pre-and-Postoperative-Monitoring-of-Patients, REVISED.ppt

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