1. Perioperative Management

2. Perioperative period Definition not well established Importance
directly related to the outcome of surgery
itself
Composition
preoperative preparation & postoperative
management

3. Preoperative Preparation
The principle
Different preparation for different operation
The classification of operations according to
the characteristics of operations
1. Elective surgery
2. Restrictive surgery
3. Emergent surgery

4. Preoperative Assessment
To confirm the diagnosis
To assess the risk of operation
To assess the general condition and function
of important organs
To evaluate the patients endurance to
the operation and risk of operation

5. Essential steps in preoperative assessment and preparation
History taking
Physical examination
Collating pre-admission information about diagnosis
Arranging any further diagnostic investigation
Making special preparations for the particular operation
Investigating any intercurrent or occult illness suggested by medical clerking

6. Essential steps in preoperative assessment and preparation
Discussing the operation with the patient and his family and obtaining signed consent
Marking the operation site
Making arrangements for the operation with the operating theatre staff
Arranging and informing the anaesthetist
Prescribing medication prophylactic antibiotics etc.
Planning rehabilitation and convalescence

7. General Preparation Psychological preparation
talk frankly and appropriately to patients
Physiological preparation
Adaptive exercise
Transfusion
Prevention of infection
Gastro-intestinal tract preparation
Maintenance of fluid, electrolyte and nutrition

8. Specific Preparation Malnutrition and dysfunction of immune system
Malnutrition dramatically increases
the morbidity and mortality
Preoperative nutritional support is more
valuable

9. Hypertension Mild-to-moderate essential hypertension
systolic pressure ＜ 180mmHg
diastolic pressure ＜ 110mmHg
At minimal risk
of cardiac complication
Antihypertensive drugs should be used
all time
Sudden withdrawal of drugs is dangerous

10. Severe or poorly controlled
hypertension
At high risk of perioperative cardiac failure
or stroke. This type of patients should not
undergo general anaesthesia and surgery
until adequately treated.
The blood pressure should be reasonably
controlled under 160/100 mmHg.

11. Cardiovascular disease
Ischaemic heart disease
Cardiac failure
Arrhythmias
Valvular heart disease
Cerebrovascular disease

12. Angina Previous infarction Stable angina poses little increased risk
during operation but unstable angina is as
dangerous as recent myocardial infarction
Previous infarction
The risk of reinfarction is about 30% if an
operation is performed during the first 3 months
At 6 months the risk is about 10 ~ 15% which
may be acceptable for important elective surgery

13. Adequate preparation for
heart disease
To correct the fluid and electrolyte imbalance.
To correct anaemia through several blood
transfusion with small amount.
To control the cardiac arrhythmias.
(Atrial fibrillation, Tachycardia, Bradycardia)

14. Respiratory dysfunction
Respiratory complications occur in up to 15% of surgical patients and are the leading cause of postoperative mortality in the elderly.

15. respiratory complication
Risk factors for
respiratory complication
Chronic obstructive pulmonary or airways disease
(Chronic bronchitis, emphysema, bronchiectasis,
pneumoconiosis, pulmonary tuberculoses)
Cigarette smoking
Current respiratory infections
Asthma

16. Preoperative investigation of
respiratory disease
A chest X-ray, CT scan if necessary
EKG
Spirometer
Blood gas measurement

17. Perioperative management of respiratory disease and high risk patients
1. Preoperative physiotherapy
teaching the patient breathing exercises and
correct posture
2. Drug therapy
Theophyllines
Prophylactic antibiotics
Preoperative bronchodilator
Adequate hydration

18. 3. Encourage to stop smoking from the time
of book for elective surgery
4. Alternation methods of anaesthesia
Local, regional or spiral anaesthesia should be
considered
5. Early postoperative physiotherapy
to enhance deep breathing, coughing and general
mobility

19. Liver disorder The tolerance to operation depends upon
the severity of liver function impairment.
The liver function could be estimated by Child
staging.
Malnutrition, ascites and jaundice are contraindications
except for emergency surgery.

20. Preoperative assessment
and management
Serological test for HBV and HCV, full blood
count, clotting screen and platelet count, plasma
urea and electrolytes, bilirubin, transaminases,
calcium, phosphate, gamma glutaryl transferase
and albumin.
When prothrombin time is prolonged, vitamin K
should be given for several days before operation.

21. Renal disorders Preoperative assessment
plasma urea, electrolytes, creatinine
and Bicarbonate should be checked
Mild chronic renal failure
Drugs should be given in smaller doses
Fluid and electrolyte homeostasis
Moderate-to-severe chronic renal failure
Operations should be performed under haemodialysis

22. Disorders of Adrenal Function
Adrenal Insufficiency
The most common cause of adrenal insufficiency
is hypothalamo-pituitary-adrenal suppression by
long-term corticosteroid therapy.
The lack of adrenal response in these patients may
cause acute post-operative cardiovascular collapse with
hypotension and shock.
For any steroid-dependent patient, a doctor should
write clearly in the note “Treat any unexplained collapse
with hydrocortisone”.

23. Diabetes Mellitus At special risk from general anaesthesia and surgery
Patients with diabetes fall into three groups
1. Insulin dependent
2. Taking oral hypoglycaemic medication
3. Diet-controlled

24. Perioperative management
Attempt to maintain blood glucose level
between 4 and 10 mmol/L, avoid
hypoglycemia in particular.
Blood glucose level ＞13 mmol/L, an
unreceptible risk of ketoacidosis or a
hyperosmolar non-ketotic state.

25. The general principle of perioperative management
Establish good diabetic control before operation
Given insulin as a continuous intravenous infusion during the operative period
Given an infusion of dextrose throughout the operative period to balance the insulin given and to make up for lack of dietary intake

26. The general principle of perioperative management
Add potassium to the dextrose infusion
Monitor blood glucose and electrolytes frequently throughout the operative and early postoperative period

27. Post-operative Management
Recovery room is necessary
ICU is optimal if possible
Monitoring
Closely monitor the life signs as a routine
CVP monitoring is necessary if hemodynamic
unstable during operation
Other items monitored accordingly
Fluid balance

28. Position and getting up
Supine position for spiral anaesthesia
Semireclining position for neck and chest
operation.
Lateral position for obesity patients.
Get up as early as possible and make
movements as much as possible

29. Diet and transfusion Period of fast depends upon the type of
operation.
Enteral and parenteral nutrition should be
taken into consideration.
Fluid and electrolytes homeostasis should
be maintained.

30. Management of Drainage
Different drainage for different purpose
(infection focus, leakage prevention and
massive exudation)
Nasal-gastric tube
Urinary catheter

31. Wound healing and suture removing
Classification of incision
clean incision
contaminated incision
infected incision
Type of healing
Type A perfect healing
B some inflammation
C infected

32. Management of postoperative complaint
1. Postoperative pain
any motions increasing tensions will increase pain
Analgesia is obligatory
2. Pyrexia
common postoperative observation
a search be made for a focus of infection
non-infective causes of pyrexia

33. Nausea and Vomiting Drugs (opiates, erythromycin, metronidazole)
Bowel obstruction
mechanical obstruction
Adynamic bowel
Hypokalaemia
faecal impaction
Systemic disorders
electrolyte disturbances
Uraemia
raised intracranial pressure

34. Abdominal distension Hiccup More common after abdominal surgery
Diaphragm irritation or central nervous
system stimulated
Subphrenic infection should be
suspected for continuous hiccup

35. Retention of urine There is a palpable suprapubic mass
with dull to percussion.
Urinary catheter is indicated when
diagnosed.

36. The main postoperative complications:
Atelectasis
Chest infection
Aspiration pneumonitis
Pneumonia

37. Management of postoperative complications
Postoperative Haemorrhage
Causes
inadequate operative haemostasis
a technical mishap as slipped ligature
Management
re-operation to stop bleeding
some preparation is necessary

38. Wound Dehiscence (Burst Abdomen)
Causes
blood supply is poor
excess suture tension
long-term steroid therapy
immunosuppressive therapy
malnutrition
infection
coughing or abdominal distension
Management
re-suturing with tension sutures the
whole thickness of the abdominal wall

39. Wound Infection Minor wound infections
localized pain, redness and a slight
discharge
Wound Cellulitis and Abscess
cellulitis treated by antibiotics
abscess treated by surgical drainage

40. Atelectasis Prevention and treatment
Airway become obstructed and air is absorbed from
the air spaces distal to the obstruction
Bronchial secretions are the main cause of this
obstruction
Prevention and treatment
perioperative physiotherapy is the best way for
prevention
deep breathing exercises
regular adjustments of posture
vigorous coughing
flexible bronchoscopy to aspirate occluding
mucus plugs

41. Urinary Tract Infections
Causes
reduced urinary output
reducing “flushing” of bladder
incomplete bladder emptying
inadequate perineal hygiene
Treatment
ensuring adequate fluid input
appropriate antibiotics

42. Deep vein thrombosis Causes bed bound after operation venous stasis
plasma concentrated due dehydration
viscosity increased
Manifestations
swelling of the leg
tenderness of the calf muscle
increased warmth of the leg
calf pain on passive dorsiflexion of the
foot

43. Treatment
Anticoagulation:
Systemic thrombolytic therapy:
streptokinase
Local thrombolytic drugs is more promising
intravenous heparin
subcutaneous heparin
oral warfarin therapy

44. Prevention
postoperative mobilization
adequate hydration
avoiding calf pressure
for high risk cases
low dose subcutaneous heparin
calf compression devices
graded-compression ‘anti-embolism’
stockings
Intravenous dextran
Warfarin anticoagulation

45. Thank you