Professional Documents
Culture Documents
and
Peri-, Post-operative
Monitoring
of the
Surgical Patient
Alfred D. Troncales, MD, DPBS
Pamantasan ng Lungsod ng
Maynila
College of Medicine
SURGERY
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
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
L last meal
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
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
Electrolytes
Drug metabolism
Renal Dysfunction
Dialyze preop to
improve electrolytes,
volume status
No or limit K+ in MIVF
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
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
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)
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
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
Bleeding
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
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
Infection
Thrombo-embolism
Bleeding
Respiratory Monitoring
Purpose:
To monitor respiratory performance:
Ventilation/Perfusion
Gas exchange
Oxygen transport
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
Serum creatinine:
Directly proportional to creatinine production (muscle
mass and metabolism)
Inversely proportional to GFR
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
Epilepsy surgery
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