Pre-operative Preparation

and
Peri-, Post-operative
Monitoring
of the
Surgical Patient
Alfred D. Troncales, MD, DPBS
Pamantasan ng Lungsod ng
Maynila
College of Medicine
 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
Disea
se

Surgery

Managem Patient
ent
 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 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 27% reinfarction rate
OR
MI 3-6 months before 10% reinfarction rate
OR
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
Adapted from Goldman, L., Caldera, D. L., Nussbaum, S. R., et al.: N.
E. Operation:
Emergency
Engl. 4
J. Med., 1977; 297:845. Copyright 1977. Massachusetts Medical
Intraperitoneal,
Society. intrathoracic, aortic
All rights reserved. 3
Goldman Classification

Class Point Total

I 0-5
II 6-12
III 13-25
IV > 26
Class III Cardiac
Goldman & IV patient warrant
Risk in Non-cardiac routine
Surgery
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  Procedure related
risks: risks:
 Chronic lung dz –  Type of anesthesia
wheeze,  GETA alone ↓ FRC
productive cough 11%
 Smoking  inhibited coughing
peri-op
 General health
 Surgical site
 Obesity
 Duration of surgery
 Age?
 separate from
others?
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

 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
Why does hepatic disease
 Surgical emergency cause coagulopathy?
 Cardiac disease
 Pulmonary disease
 Renal dysfunction
 Liver dysfunction
 Diabetics
 Bleeding disorders
 Malnourished
 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

Prothrombi 1-3 4-6 >6

n Time
(PT)
increase
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
 Pre-operative Medical
Care
 Surgical emergency
 Cardiac disease
Reasons patients are placed on
 Pulmonary disease anticoagulants:
 Renal dysfunction
−Atrial fibrillation
 Liver dysfunction
−Prosthetic heart valve
 Diabetics
−DVT or PE
 Bleeding disorders
 Iatrogenic −CVA or TIA
 Inherited −Hypercoagulable state
 Malnourished
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 bleeding
disorders
 ASA / NSAID’s
 Renal disease
 Hepatic disease (EtOH)

 Physical:
 Ecchymoses
 Hepatosplenomegaly
 Excessive mobility of joints
or excess skin laxity
 Stigmata of renal or
hepatic disease
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

1
Ridker et al Ann Intern Med 114:835-839, 1991.
 Inherited Bleeding
Disorders
 Hemophilia A  Antithrombin III
 Hemophilia B deficiency
(Christmas  . . . Other factor
disease) deficiencies (rare)
 Protein deficiency
 von Willebrand’s
disease
 Factor V
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
 American Society of
Anesthesiologists’ (ASA) Physical
Status Assessment
Classification Classification Description
(Elective) (Emergency)
1 1E Normally healthy

2 2E With mild systemic

disease
3 3E With severe systemic
disease that is not
4 4E incapacitating
With incapacitating
systemic disease that is a
constant threat to life
5 5E Moribound patient not
expected to survive
6 6E without operation
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:
 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)

IV. 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. Patient safety
2. Positive outcome
3. Intra-operative case
adjustments
4. Assess equipment
function
5. 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:
 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

 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
 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

 Arterial Catheterization
 Complications:
 Failure
 Hematoma

 Bleeding

 Occlusion and ischemia

 Infection

 Fistulas/Pseudoaneurysms

 Thrombo-embolism
 Central Venous
Catheterization
 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
 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:
 Intraventricular catheter
 Subarachnoid bolt
 Epidural bolts
 Fiberoptic catheter
 Permits calculation of:
 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