1
Perioperative Care of the Surgery Patient
Rocco G. Ciocca
Objectives
1. To describe features of a patient’s clinical history that influence surgical decision making. Consider known diseases, risk factors, urgency of opera- tion, medications, etc.
2. To discuss tools that may assist in preoperative risk assessment. Consider laboratory studies, imaging studies, etc. Include the following:
• Pulmonary (example: exercise tolerance, pul- monary function testing)
• Cardiovascular (ASA classification, Goldman criteria, echocardiography, thallium studies, Doppler)
• Renal (blood urea nitrogen, creatinine dialysis history)
• Metabolic (nutritional assessment, thyroid function).
Case
An 87-year-old man is seen in the emergency room. He is complaining of vague abdominal pain over the past few months. He has had a markedly diminished appetite with associated weight loss. During a rather cursory initial physical examination, the emergency room physi- cian palpates a firm, slightly tender mass in the patient’s right upper quadrant. A surgical consult is requested.
Introduction
One might wonder what is unique in the surgical assessment of a patient that differentiates it from any other medical evaluation. The answer is nothing and everything.
3
A good medical evaluation and a good surgical evaluation really should contain many of the same components. A surgical evaluation should include a thorough history and physical exam. Close attention to the patient’s underlying medical conditions is critical and comes into play when the surgeon is trying to assess the risks for a given patient of a particular operation. This is particularly pertinent when evaluat- ing the 87-year-old patient in the case presented here.
The main differences between the two types of evaluations are acuity and the need to frequently make a difficult decision with limited data in the surgical scenario. The decisions made by a surgeon frequently involve subjecting patients to a procedure that may either save their life or hasten their demise. (These decisions are not unique to surgeons but also are often experienced by interventionalists.) The question is: How can one maximize the former while minimizing the latter?
A great deal can be said for experience and time, and few would argue that the more experience one has the better one’s judgment becomes. Education begets experience to some degree, and therefore it is incumbent on the budding physician to read and absorb as much material as possible. (Later chapters in this text will help you do that.) It is extremely important to correlate the material that one has read to clinical cases. Therefore, the art of medicine is a constant learning and rereading of given topics.
Since patients’ presentations can be confusing, it is necessary for the physician to develop a systematic evaluation of a patient. This sys- tematic organized approach, in fact, forms the essence of the surgical approach. The organization of preoperative preparation forms the basis of this chapter. What does it take to safely and properly prepare a patient for an operation?
As a surgical resident frequently called to the emergency room or clinic to evaluate a patient with a “surgical” problem, always approach the patient with the following questions in mind: (1) Does the patient need to be operated on? If the answer is no, then the problem is not sur- gical and appropriate medical therapy or consultation can be set up. If the answer is yes, then the question is: When? Emergently, urgently, or can the operation be done electively? This leads to the next question: (2) Does the patient need to be admitted to the hospital? If the answer is yes, then the appropriate therapy needs to be started (intravenous fluid, antibiotics, standard preoperative testing) (See Algorithm 1.1.).
History and Physical Examination
The foundation of both medicine and surgery begins with a
thorough history and physical examination. Often, they are the only
necessary diagnostic evaluations prior to surgery. We have become
dependent on myriad diagnostic studies that, while at times helpful,
are sometimes unnecessary, expensive, overutilized, time-consuming,
and, occasionally, dangerous. A well-performed history and a physical
exam have none of these disadvantages.
While specifics of the history and physical exam differ depending on the specific complaint of the patient and are discussed in greater detail in the ensuing chapters, there are a few constants to keep in mind. The first constant is to take some time to listen to the patient. As simple and as seemingly easy as this is to do, it is something that all physi- cians, on occasion, fail to do. It can be time-consuming, since patients do not always clearly and concisely articulate their problem. It is important, however, to let patients explain their problem. Based on the chief complaint or complaints, the physician then can ask more directed questions to illuminate the problem further. Very often, the physician needs to act like a good newspaper reporter, concisely obtaining the What, Where, When, and How of a problem: What is the problem?
Where does it hurt? When did it start? How does it make you feel?
How bad is it? How did it happen? The answers to these questions are important and frequently diagnostic.
Another critically important component of the patients’ history includes a listing of their past medical history, usually starting with whether or not they have ever experienced earlier episodes of their current problem. If they have, then a description of the type and success of the therapy may be helpful. One should inquire, in a systematic manner, about any history of major medical illnesses. Particular at- tention to any history of previous surgery is of obvious import. The patient’s past medical history in the case presented at the beginning of this chapter is critically important.
Family history may be important and pertinent to patients’ presen- tation. The patients’ social history also may provide insight into their problem. This certainly will give the examiner a clearer understanding of what the patient does and what sort of familial or social support the patient may have. Always inquire, in as nonjudgmental manner as pos- sible, about social habits such as smoking, alcohol intake, illegal drug
History and Physical Exam
Nonsurgical Problem
Appropriate medical referral Does not need hospital admit
Surgical Problem
Needs hospital admit
Outpatient—
referred to surgeon for workup
Needs emergent
surgery Needs nonemergent
surgery Minimal diagnostic
Tests and workup O.R Risk assessment for cardiopulmonary disease, nutrition, hematologic, etc.
O.R.
Algorithm 1.1. Patient presents with complaint.
use, and sexual practices. As delicate and uncomfortable as these ques- tions may be to both the patient and examiner, the answers are clini- cally and at times critically important.
Patients sometimes lack insight regarding their health. A thorough listing, including dosages, of medications is necessary and frequently provides insight into the patient’s underlying medical conditions.
Inclusion of any adverse reactions or allergies to medications is of obvious import.
The physical exam should begin with an overall observation of the patient. Does he/she appear robust and healthy or frail and chroni- cally ill? This so-called “eyeball” test, while difficult to scientifically validate, can be helpful, particularly when the patient’s presenting problem requires urgent or emergent surgical intervention. The exam should be thorough and systematic. It is helpful to examine the patient in a head-to-toe manner. This makes intuitive sense, and, if one performs the examination in the same order each time, the likelihood of missing an important physical finding decreases. Avoid the tendency to examine first, and sometimes only, the body area for which the patient has a complaint. The specifics of the physical exam will be dealt with more thoroughly in later chapters.
Risk Assessment
Cardiac
It is estimated that more than 3 million patients with coronary artery disease undergo surgery every year in the United States. Of these patients, approximately 50,000 patients sustain a perioperative myo- cardial infarction (MI). The mortality of a perioperative MI is high, roughly 40%. The challenge is proper assessment of an individual for coronary artery disease and whether preoperative intervention actu- ally improves the patient’s final outcome or merely shifts morbidity and mortality to another procedure or healthcare professional. This is one area where evidence-based medicine has made an attempt to provide healthcare professionals/surgeons with guidelines (Tables 1.1, 1.2, 1.3, and 1.4).
The above-cited data and tables are helpful. Elective surgery should be avoided or postponed in patients who have suffered a recent MI or who have unstable angina. These patients are at greatest risk of having an MI perioperatively within the first 30 days of their initial MI (27%). This risk decreases over the ensuing weeks and drops to about 5% after 6 months. Shorter delays may be acceptable for patients who must be operated upon sooner than 6 months after an MI. For these patients, full hemodynamic monitoring may be beneficial.
One cannot emphasize enough the need to optimize the patient’s
underlying cardiac conditions prior to surgery. Congestive heart
failure should be controlled, blood pressure optimized, cardiac rhythm
stabilized, and medications fine-tuned. Frequently, the surgeon must
handle these issues, but a cardiologist or primary care physician can be
extremely helpful in achieving these goals.
T able 1.1. Risk stratification parameters and criteria for cardiac events following noncardiac surgery . Parameter Low risk Intermediate risk High risk Clinical characteristic Advanced age Mild angina Myocardial infarction within previous 7–30 days Abnormal ECG (L VH, LBBB, Prior myocardial infarction Unstable or severe angina ST -T abnormalities) Atrial fibrillation or other Previous or compensated nonsinus rhythm congestive heart failure Low functional capacity (climb Diabetes mellitus
<1 flight stairs with bag of groceries)
Hypertension History of stroke T ype of operation Endoscopic procedures Carotid endarterectomy Emergent major surgery (partial list) Skin or skin structure operation Head and neck procedure Aortic and other major vascular Low: <1% cardiac risk; (i.e., groin hernia, breast procedures, including High: >5% cardiac risk. procedure) peripheral procedures Cataract excision Intraabdominal procedures Long procedures/major fluid shifts or blood loss Intrathoracic procedures Orthopedic surgery Prostate surgery Characteristics of ECG No ischemia Ischemia at moderate-level Ischemia at low-level stress test (i.e., treadmill) Ischemia only at high-level exercise (heart rate 100–130) exercise (heart rate <100 exercise (heart rate >130) ST depression >0.1 mV ST depression >0.1 mV ST depression >0.1 mV T ypical angina T ypical angina T ypical angina One or two abnormal leads Three or four abnormal Five or more abnormal leads leads Persistent ischemia Persistent ischemia 1–3 min after exercise >3 min after exercise Sour ce: Reprinted fr om Barie PS. Perioperative management. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Sur gery: Basic Science an d Clinical Evidence. New Y ork: Springer -V erlag, 2001, with permission.
The amount of testing that goes on in the name of cardiac risk assess- ment is staggering. The American College of Cardiology/American Heart Association Guideline Algorithm for Perioperative Cardiovas- cular Evaluation of Noncardiac Surgery provides useful and reason- able recommendations, which, if followed, may avoid unnecessary and expensive studies.
Pulmonary
In patients with a history of pulmonary disease or for those who will require lung resection surgery, preoperative assessment of pul- monary function is of value. Postoperative respiratory complications are leading causes of postoperative morbidity and mortality, ranking second only to cardiac complications as immediate causes of death.
History and physical exam can be helpful in assessing a patient’s risk of pulmonary problems, and, frequently, these are all that are necessary. Routine chest x-rays are of little value in a patient with a Table 1.2. Cardiac risk index system (CRIS).
Factors Points
History
Age >70 years 5
Myocardial infarction <6 months ago 10
Aortic stenosis 3
Physical examination
S
3gallop, jugular venous distention, 11
or congestive heart failure
Bedridden 3
Laboratory
P
O2<60mmHg 3
P
CO2>50mmHg 3
Potassium <3mEq/dL 3
Blood urine nitrogen >50mg/dL 3
Creatinine >3mg/dL 3
Operation
Emergency 4
Inrathoracic 3
Intraabdominal 3
Aortic 3
Approximate cardiac risk (percent incidence of major complications):
Class
aBaseline I II III IV
Minor surgery 1 0.3 1 3 19
Major noncardiac surgery, 4 1 4 12 48
age >40 years
Abdominal aortic surgery, or age 10 3 10 30 75
>40 with other characteristics
a
CRIS class I, 0–5 points; class II, 6–12 points; class III, 13–25 points; class IV, ≥26 points.
Source: Adapted from Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845–850.
Reprinted from Barie PS. Perioperative management. In: Norton JA, Bollinger RR, Chang
AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag,
2001, with permission.
normal physical exam and at low risk based on history. Certainly, a chest x-ray (posteroanterior and lateral) may be helpful in a patient with a history of chronic obstructive pulmonary disease (COPD), short- ness of breath (SOB), and physical findings consistent with congestive heart failure (CHF) or upper respiratory infections or as screening for metastatic disease.
Preoperative laboratory testing is generally not predictive of peri- operative pulmonary problems. Studies often confirm what a careful physician already has deciphered from a history and physical exam.
Table 1.3. Evaluation steps corresponding to American College of Cardiology/American Heart Association (ACC/AHA) guideline algo- rithms for perioperative cardiovascular evaluation of noncardiac surgery.
Step 1. What is the urgency of the proposed surgery? If emergent, detailed risk assessment must be deferred to the postoperative period.
Step 2. Has the patient had myocardial revascularization within the past 5 years? If so, further testing is generally unnecessary if the patient is stable/asymptomatic.
Step 3. Has the patient had a cardiologic evaluation within the past 2 years? If so, further testing is generally unnecessary if the patient is stable/asymptomatic.
Step 4. Does the patient have unstable symptoms or a major predictor of risk? Unstable chest pain, decompensated congestive heart failure, symptomatic arrhythmias, and severe valvular heart disease require evaluation and treatment before elective surgery.
Step 5. Does the patient have intermediate clinical predictors of risk, such as prior myocardial infarction, angina pectoris, prior or compensated heart failure, or diabetes? Consideration of the patient’s capacity to function and the level of risk inherent in the proposed surgery can help identify patients who will benefit most from perioperative noninvasive testing.
Step 6. Patients with intermediate risk and good-to-excellent functional capacity can undergo intermediate-risk surgery with very little risk. Consider additional testing for patients with multiple predictors about to undergo higher-risk surgery.
Step 7. Further testing can be performed on patients with poor functional capacity in the absence of clinical predictors of risk, especially if vascular surgery is being planned.
Step 8. For high-risk patients about to go to high-risk surgery, coronary angiography or even cardiac surgery may be less than the noncardiac operation. Clinical, surgery-specific, and functional parameters are taken into account to make the decision.
Indications for coronary revascularization are identical whether or not considered in preparation for noncardiac surgery.
Source: Adapted from Eagle KA, Brundage BH, Chaitman BR, et al. ACC/AHA guide- lines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 1996;27:910–948. Copyright 1996 The American College of Cardiology Foundation and American Heart Association Inc. Permission for one time use. Further reproduction is not permitted without the permission of the ACC/AHA.
Reprinted from Barie PS. Perioperative management. In: Norton JA, Bollinger RR, Chang
AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag,
2001, with permission.
An elevated serum bicarbonate concentration suggests chronic respi- ratory acidosis, while polycythemia may suggest chronic hypoxemia.
A room air blood gas may provide useful baseline information so that one is not surprised that the postoperative arterial blood gas findings are so abnormal. A room air arterial oxygen tension (Pao
2) less than 60 mm Hg correlates with pulmonary hypertension, whereas a Paco
2greater than 45 mm Hg is associated with increased perioperative mor- bidity. Spirometry before and after bronchodilators is simple and easy Table 1.4. Guidelines to perioperative cardiovascular evaluation of noncardiac surgery.
Indications for assessment of left ventricular function at rest (radionuclide angiography, echocardiography, contrast ventriculography)
Level I: Patients with current or poorly controlled congestive (helpful) heart failure
Level II: Patients with prior congestive heart failure or (possibly dyspnea of unknown etiology
helpful)
Level III: Routine testing of ventricular function in patients (not helpful) without prior congestive heart failure
Indications for cardiac catheterization
Level I: High-risk results during noninvasive testing Unstable chest pain syndrome
Nondiagnostic or equivocal noninvasive testing result in high-risk patient before high-risk procedure
Level II: Intermediate results from noninvasive testing Nondiagnostic or equivocal noninvasive testing
result in low-risk patient before high-risk procedure
Urgent noncardiac surgery after a recent acute myocardial infarction
Perioperative myocardial infarction
Level III: Low-risk noninvasive testing result in patient with known coronary artery disease, before a low-risk procedure
Screening before a noninvasive test
Asymptomatic patient with normal exercise tolerance after coronary revascularization
Normal coronary angiography in previous 5 years Revascularization impossible, contraindicated, or
refused a priori
Source: Adapted from Eagle KA, Brundage BH, Chaitman BR, et al. ACC/AHA guide- lines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 1996;27:910–948. Copyright 1996 The American College of Cardiology Foundation and American Heart Association Inc. Permission for one time use. Further reproduction is not permitted without permission of the ACC/AHA.
Reprinted from Barie PS. Perioperative Management. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery: Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.
Summary of evidence-based recommendations for supplemental evaluation of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines, Committee on Perioperative Cardiovascular Evaluation for Noncardiac
Surgery, 1996.
to obtain. Analysis of forced expiratory volume in 1 second (FEV
1) and forced vital capacity (FVC) usually provides enough information for clinical decision making. Dyspnea is assumed to occur when FEV
1is less than 2 L, whereas an FEV
1less than 50% of the predicted value correlates with exertional dyspnea. In patients with COPD, the FVC decreases less than the FEV
1, resulting in an FEV
1/FVC ratio less than 0.8. Spirometry correlates with the development of postoperative atelectasis and pneumonia, particularly if FEV
1is less than 1.2 L or less than 70% of predicted, or FEV
1/FVC is less than 0.65. If spirometric parameters improve by 15% or more after bronchodilator therapy, such therapy should be continued. If pulmonary resection is planned, then split-lung function can be obtained. An FEV
1of approximately 800 mL from the contralateral lung is required to proceed with pneumonec- tomy. For abdominal surgery, there is no indication for evaluation beyond spirometry and arterial blood gas analysis.
Patients may be well served by a preoperative discussion with their surgeon or respiratory therapist regarding the role of post- operative incentive spirometry and pulmonary toilet procedures. The patients need to be informed of the need for their active involvement postoperatively if they are to avoid pulmonary complications such as atelectasis and pneumonia. They also should be reassured that, while they will have some postoperative discomfort, measures will be taken to assure that they will have adequate pain relief.
Perhaps the most useful intervention is for the smoking patient to cease smoking prior to surgery. Cessation of cigarette smoking is very important for those who smoke more than 10 cigarettes per day. Short- term abstinence (48 hours) decreases the carboxyhemoglobin to that of a nonsmoker, abolishes the effects of nicotine on the cardiovascu- lar system, and improves mucosal ciliary function. Sputum volume decreases after 1 to 2 weeks of abstinence, and spirometry improves after about 6 weeks of abstinence.
Prophylaxis for venous thromboembolism is covered in Chapter 29.
Nutritional
There is a strong inverse correlation between the body’s protein status and postoperative complications in populations of patients undergoing elective major gastrointestinal surgery and, to a lesser extent, other forms of surgery. With this in mind, it would seem useful to assess the nutritional status of a patient prior to surgery and possibly intervene preoperatively if a deficit is unmasked. While this makes intuitive sense, there in not much evidence to support improved clinical outcome via aggressive nutritional supportive measures.
While there are many clinical and laboratory measures that can help
assess a patient’s nutritional status, there is no “gold standard.” Param-
eters such as weight loss, albumin, prealbumin, and immune compe-
tence (measured by delayed cutaneous hypersensitivity or total
lymphocyte count) have been used to classify patients into states of
mild, moderate, and severe malnutrition, but, by themselves, individ-
ual markers may not accurately represent the nutritional status of the patient. Preoperative weight loss is an important historical factor to obtain, if possible. In general, a weight loss of 5% to 10% over a month or 10% to 20% over 6 months is associated with increased complica- tions from an operation. A more thorough history of weight loss in the patient in the case presented at the beginning of this chapter will be important.
While no one marker is predictive of surgical outcome, combinations of measurements have been used to quantify the risk for subsequent complications. The prognostic nutrition index (PNI) correlates with poor outcome in the following equation:
PNI (%) = 158 - 16.6 (ALB) - 0.78 (TSF) - 0.20 (TFN) - 5.8 (DH) where PNI is the risk of complication occurring in an individual patient, ALB is the serum albumin (g/dL), TSF is the triceps skin fold thickness (mm), TFN is serum transferring (mg/dL), and DH is delayed hypersensitivity reaction to one of three recall antigens (0, nonreactive; 1, <5-mm indurations; 2, >5-mm indurations). Because delayed hypersensitivity is uncommon in clinical practice, the equation has been simplified by substituting the lymphocyte score, using a scale of 0 to 2, where 0 is less than 1000 total lymphocytes/mm
3, 1 is 1000 to 2000 total lymphocytes/mm
3, and a score of 2 is more than 2000 total lymphocytes/mm
3. The higher the score using either of these equa- tions, the greater the risk of postoperative complications.
Nutritional issues are discussed in greater detail in Chapter 3. It is important to take the patient’s nutritional state into consideration after surgery. In the majority of well-nourished patients, little needs to be done other than to ensure that they resume a normal diet as soon as possible after surgery, preferably within 5 to 10 days. In patients who are severely malnourished, aggressive nutritional support may be of some benefit, with most of the benefit occurring in the early postoperative period.
Hematologic
An obvious concern for a surgeon who is about to induce iatrogenic injury to a patient is that of bleeding and the patient’s inherent ability to form clots. The patient’s ability to form clots is always a double-edged concern. On the one hand, the surgeon depends on it so that the patient does not exsanguinate from the intervention (fortu- nately, an exceedingly rare event). Conversely, a patient in a hyper- coaguable state may suffer from a thromboemblic event that could be life threatening. In addition, a growing number of patients requiring surgical intervention are chronically anticoagulated for a number of reasons, e.g., Afib, previous valve replacement, history of hyper- coaguablity, etc., and the surgeon needs to have a strategy to deal with these patients.
The best test for clotting problems is a thorough history and phys-
ical. Historical information of importance includes whether the patient
or a family member has had a prior episode of bleeding or a throm-
boembolic event, and whether the patient has a history of prior
transfusions, prior surgery, heavy menstrual bleeding, easy bruising, frequent nosebleeds, or gum bleeding after brushing teeth. Informa- tion on the coexistence of kidney or liver disease, poor dietary habits, excessive ingestion of alcohol, and use of aspirin, other nonsteroidal antiinflammatory drugs (NSAIDs), lipid lowering drugs, or anticoag- ulants must be ascertained. If the history is negative and the patient has not had a previous significant hemostatic challenge, then the like- lihood of a bleeding or thrombotic event is exceedingly rare and the value of preoperative coagulation testing is low.
The standard “coags” routinely ordered as screening test—the pro- thrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count—identify abnormalities of importance in only 0.2% of patients. This underscores the importance of adopting a rea- sonable strategy of ordering only those diagnostic tests indicated by the patient’s history. If a clinically important coagulopathy is identi- fied, therapeutic strategies for management of various coagulation dis- orders in preparation for surgery are listed in Table 1.5.
Caring for patients who are taking anticoagulants requires careful planning. A good deal of the planning hinges upon how urgently the surgery needs to be performed and the indication for the anticoagula- tion. Most patients who take warfarin and who are to undergo ambu- latory or same-day admission elective surgery can be managed simply by having them discontinue their warfarin for several days prior to surgery. If there is concern that the patient should not be without anticoagulation, the patient can be systemically anticoagulated with unfractionated intravenous heparin. The heparin infusion is discon- tinued approximately 4 hours prior to surgery (the half-life of heparin is about 90 minutes), and surgery proceeds with good hemostasis.
There is growing interest in the use of low molecular weight heparin (LMWH) as a bridge for surgery, and it is an attractive option, yet data are currently insufficient to provide a definitive recommendation for its use.
Antibiotic Prophylaxis
This topic is discussed in greater detail in future chapters. Suffice it to say that surgery is an insult to the body’s immune system and infection is frequently an unwanted side affect. Antibiotic therapy may help decrease the incidence of postoperative infection.
Antibiotic therapy must be used judiciously so as to avoid overuse and selection of resistant strains of bacteria. Table 1.6 sum- marizes the evidence-based guidelines for prevention of surgical site infections.
Lab Studies
The studies that are generally performed include a complete blood
count, serum electrolytes, PT, and aPTT. A type and screen or type
and crossmatch should be requested for operations where blood
transfusions are likely (Table 1.7).
Diagnosis Treatment Factor deficiencies
Hemophilia A: Mild, factor VIII >10% Desmopressin, 0.3mg/kg i.v. q 12–24h ¥ 5–7 days for
Severe minor surgery.
Factor VIII concentrate (level 50–75% for mild–
moderate injury, 75–100% for severe insults).
Dose: 1 U will increase F VIII level by 2% in a 70-kg patient; give one-half i.v. q 12 h or 1/24 dose i.v. q 1 h by infusion after the initial bolus.
Levels should be maintained for 5–7 (moderate injury) or 7–14 days (severe injury), as delayed bleeding is typical. Levels of 25–30% are adequate for a minor operation.
Hemophilia B: Mild Desmopressin, 0.3 mg/kg i.v. q 12–24 h.
Severe Factor IX concentrate (level 50–75% for mild–
moderate injury, 75–100% for severe insults).
Dose: 1 U will increase F IX level by 2% in a 70-kg patient; give one-half i.v. q 18–24 h after the initial bolus. Levels should be maintained for 5–7 (moderate injury) or 7–14 days (severe injury), as delayed bleeding is typical. Levels of 10–25% are adequate for a minor operation.
von Willebrand’s disease: Type 1 Desmopressin, 0.3 mg/kg i.v. q 12–24 h ¥ 5–7 days.
Tachyphylaxis can be restored by a 24-h drug holiday to allow repletion of endothelial stores.
Keep VIII: vWF 60% for 24–72 h for minor surgery 80% for 5–7 days for major surgery.
Type 2 Trial of desmopressin (unpredictable effect).
Cryoprecipitate (contains 80–100 units vWF/10 units).
Liver disease (multifactorial) Based on specific defect. Fresh-frozen plasma to keep PT/aPTT <1.3 ¥ control (difficult to correct factor VII deficiency).
Vitamin K, 10 mg i.m., if vitamin K deficiency suspected.
Platelet count >50,000–100,000.
Cryoprecipitate if low fibrinogen ( <100–150mg/dL), factor VIII.
Warfarin (vitamin K deficiency, factor II, VII, IX, X).
Fresh frozen plasma to keep PT <1.3 ¥ control.
Vitamin K, 10 mg i.m., if the patient does not require immediate correction ( <12–48h) or short- term anticoagulation.
Platelet abnormalities
Thrombocytopenia Transfuse platelets <50,000 if bleeding or invasive procedure is anticipated; <20,000 otherwise.
Idiopathic thrombocytopenic purpura Intravenous immunoglobulin, 2 g/kg over 2–4 days (VERY expensive).
Platelet infusion after ligation of the splenic artery during splenectomy if the response to immune globulin is poor.
Drug-induced Discontinue all noncritical medications.
Transfuse platelets only if surgery cannot be delayed to allow spontaneous recovery.
Uremia Aggressive hemodialysis?
Transfuse to hematocrit ~30% to allow improved adhesion?
Desmopressin, 0.3 mg/kg i.v. q 12–24 h (rapid effect of short duration).
Cryoprecipitate, 10 units (rapid effect but short duration).
Conjugated estrogens, 25 mg i.v./day for 3 days (slow onset of action but effective for up to 2 weeks).
Source: Reprinted from Kudsk KA, Jacobs DO. Nutrition. In: Norton JA, Bollinger RR, Chang AE, et al, eds. Surgery:
Basic Science and Clinical Evidence. New York: Springer-Verlag, 2001, with permission.
tion (wound infection).
Preparation of the patient
Level I: Identify and treat all infections remote to the surgical site before elective operations.
Postpone elective operations until the infection has resolved.
Do not remove hair preoperatively unless hair at or near the incision site will interfere with surgery. If hair is removed, it should be removed immediately beforehand, preferably with electric clippers.
Level II: Control the blood glucose concentration in all diabetic patients.
Encourage abstinence from tobacco for a minimum of 30 days before surgery.
Indicated blood transfusions should not be withheld as a means to prevent surgical site infection.
Patients should shower or bathe with an antiseptic agent at least the night before surgery.
Wash and clean the incision site before antiseptic skin preparation.
Hand/forearm antisepsis Level II: Keep nails short.
Scrub the hands and forearms up to the elbows for at least 2–5 min with an appropriate antiseptic.
Antimicrobial prophylaxis
Level I: Administer antibiotic prophylaxis only when indicated.
Administer the initial dose intravenously, timed such that a bactericidal
concentration of the drug is established in serum and tissues when the incision is made. Maintain therapeutic levels of the agent in serum and tissues for the duration of the operation. Levels should be maintained only until, at most, a few hours after the incision is closed.
Before elective colon operations, additionally prepare the colon mechanically with enemas or cathartic agents. Administer nonabsorbable oral antimicrobial agents in divided doses on the day before surgery.
For high-risk cesarean section, administer the prophylactic antibiotic agent immediately after the umbilical cord is clamped.
Level II: Do not use vancomycin routinely for surgical prophylaxis.
Surgical attire and drapes
Level II: A surgical mask should be worn to cover fully the mouth and nose for the duration of the operation, or while sterile instruments are exposed.
A cap or hood should be worn to cover fully hair on the head and face.
Wear sterile gloves after donning a sterile gown.
Do not wear shoe covers for the prevention of surgical site infection.
Use surgical gowns and drapes that are effective barriers when wet.
Change scrub suits that are visibly soiled or contaminated by blood or other potentially infectious materials.
Asepsis and surgical technique
Level I: Adhere to principles of asepsis when placing intravascular devices or when dispensing or administering intravenous drugs.
Level II: Handle tissue gently, maintain hemostasis, minimize devitalized or charred tissue and foreign bodies, and eradicate dead space at the surgical site.
Use delayed primary skin closure or allow incisions to heal by secondary intention if the surgical site is contaminated or dirty.
Use closed suction drains when drainage is necessary, placing the drain through a separate incision distant from the operative incision. Remove drains as soon as possible.
Postoperative incision care
Level II: A sterile dressing should be kept for 24–48 h postoperatively on an incision closed primarily. No recommendation is made regarding keeping a dressing on the wound beyond 48 h.
Wash hands before and after dressing changes and any contact with the surgical site.
Use sterile technique to change dressings.
Educate the patient about surgical site infections, relevant symptoms and signs, and the need to report them if noted.
a
