PRE AND 

POST
O P E R AT I V E   C A R E  

TO: DR.BINIYAM.G
BY: BINIAM.M
OUTLINE 

Introduction
Preoperative preparation 
 Perioperative management of the high-risk surgical patient 
Nutrition and fluid therapy
Intraoperative care  
Postoperative care  
INTRODUCTION

Surgery is an important treatment option for a wide range of acute and chronic
diseases. Around 10 million patients undergo a surgical procedure each year
and this number will continue to rise. 
For most patients surgery is a success, both in terms of the procedure itself and
the care before and afterwards. 
However, There are over 300,000 patients at higher risk from surgery and this
number is set to rise. So with increasing demand and the increasing complexity
of surgical procedures, come new challenges that we must address.
P R E O P E R AT I V E
CARE 
C O N T. . .

Preoperative care refers to health care provided before a 

surgical operation. The aim of preoperative care is to do whatever is right
to increase the success of the surgery.
At some point before the operation the health care provider will assess the
fitness of the person to have surgery. This assessment should include
whatever tests are indicated, but not include screening for conditions
without an indication.
B E N E F I T O F P R E O P E R AT I V E C A R E    

To screen for and properly manage comorbid conditions.

To assess the risk of anesthesia and surgery and lower it.
To educate patients and families about the objectives and risks of
anesthesia and the anaesthesiologist's role in perioperative care.
To obtain informed consent.
S E RV I C E I N P R E O P E R AT I V E C A R E  

History taking 
physical examination
Investigation 
risk assessment
 general and system-specific evaluations.
H I S T O R Y TA K I N G  

The history of past surgery and anaesthesia can reveal problems that may
present during current hospitalisation (e.g. intraabdominal adhesions). 
 Adhesions occur after abdominal surgery and can cause tissues to stick together, when normally
they would just move around freely.

The use of recreational drugs and alcohol consumption should be noted as

they are known to be associated with adverse outcomes. Check for
allergies and risk factors for deep vein thrombosis (DVT).
 Social history, ability to communicate and mobility are important in
planning rehabilitation after surgery 
P H Y S I C A L E X A M I N AT I O N

Patients should be treated with respect and dignity, receive a clear

explanation of the examination undertaken and kept as comfortable as
possible
A pre-operative physical examination is generally performed upon the
request of a surgeon to ensure that a patient is healthy enough to safely
undergo anesthesia and surgery. 
This evaluation usually includes a physical examination, cardiac
evaluation, lung function assessment, abdominal assessment...etc 
I N V E S T I G AT I O N S
I N V E S T I G AT I O N S

Routine lab tests before are admitted to the hospital or before certain
outpatient procedures.
The tests help find possible problems that might complicate surgery if not
found and treated early. 
C O N T.

Full blood count. A full blood count (FBC) is needed for major
operations, in the elderly and in those with anaemia or pathology with
ongoing blood loss.
Urea and electrolytes. Urea and electrolytes (U&E) are needed before all
major operations, in most patients over 60 years of age especially with
cardiovascular, renal and endocrine disease or if significant blood loss is
anticipated
C O N T.

It is also needed in those on medications which affect electrolyte levels, e.g.

steroids, diuretics, digoxin, NSAIDs (non-steroidal anti-inflammatory
drugs), intravenous fluid or nutrition therapy.
Electrocardiography. Electrocardiography (ECG) is required for those
patients aged over 60 years, cardiovascular, renal and cerebrovascular
involvement, diabetes and in those with severe respiratory problems.
C O N T. . .

Chest radiography. A chest x-ray is not required unless the patient has a
significant cardiac history, cardiac failure, severe chronic obstructive
pulmonary disease (COPD), acute respiratory symptoms, pulmonary
cancer, metastasis or effusions, or is at risk of tuberculosis.
Urinalysis. Dipstick testing of urine should be performed on all patients to
detect urinary infection, biliuria, glycosuria and inappropriate osmolality.
C O N T. . .

Human chorionic gonadotrophin. Pregnancy needs to be ruled out in all

women of childbearing age
Blood glucose and HbA1c. These should be performed in patients with
diabetes mellitus and endocrine problems. HbA1c indicates how well
diabetes has been controlled over a longer duration.
qC A R D I O VA S C U L A R S Y S T E M / C A R D I A C
PROBLEMS

Patients with heart disease should be considered high-risk surgical

candidates and must be fully evaluated. 
At preoperative assessment, it is important to identify the patients who
have a high perioperative risk of myocardial infarction (MI) and make
appropriate arrangements to reduce this risk. 
C O N T. . .

These patients include those who have suffered coronary artery disease,
congestive cardiac failure, arrhythmias, severe peripheral vascular disease,
cerebrovascular disease or renal failure, especially if they are undergoing
intra-abdominal or intrathoracic surgery.
In patients with ischaemic heart disease (IHD), the left ventricular status
can be evaluated using a stress test
C O N T. . .

For patients with symptomatic valvular heart disease or poor left

ventricular function, an echocardiography should be performed.
 Pressure gradients across the valves, dimensions of the chambers and
contractility can be determined using echocardiography
H Y P E RT E N S I O N

Prior to elective surgery, blood pressure should be controlled to near

160/90 mmHg. If a new antihypertensive is introduced, a stabilisation
period of at least 2 weeks should be allowed.
SMOKING

Information should be provided to indicate perioperative risks associated

with smoking. Stopping smoking reduces carbon monoxide levels and the
patient is better able to clear sputum.
Asthma It is important to establish the severity of the asthma,
precipitating causes, frequency of bronchodilator and steroid use, PEFR
(peak expiratory flow rate) and any previous intensive care unit
admissions. 
C H R O N I C O B S T R U C T I V E P U L M O N A RY
DISEASE(COPD)
qPreoperative chest x-ray or scans are useful in patients
with known emphysematous bullae, pulmonary cancer, metastasis or effusions.
qPatients with significant COPD who are undergoing major surgery will need to be
referred to the respiratory physicians for optimisation of their condition. 
qAn arterial blood gas analysis may also be useful as it can give an indication of
carbon dioxide retention. This is associated with an increased risk of perioperative
respiratory complications
LIVER DISEASE

In patients with liver disease, the cause of the disease needs to be known,
as well as any evidence of clotting problems, renal involvement, and
encephalopathy
Elective surgery should be postponed until any acute episode has settled
(e.g. cholangitis). The blood tests which need to be performed are liver
function tests, coagulation, blood glucose, urea and electrolyte levels. 
U R I N A RY T R A C T I N F E C T I O N

Urinary tract infection Uncomplicated urinary infections are common in

women, while outflow uropathy with chronically infected urine is common in
men. 
These infections should be treated before embarking on elective surgery where
infection carries dire consequences,  
          e.g. joint replacement. For emergency procedures, antibiotics should be
started and care taken to ensure that the patient maintains a good urine output
before, during and after surgery
P R E O P E R AT I V E A S S E S S M E N T I N
E M E R G E N C Y S U R G E RY
In urgent or emergency surgery, the principles of preoperative assessment
should be the same as in elective surgery, except that the opportunity to
optimise the condition is limited by time constraints.
 Medical assessment and treatments should be started (e.g. according to the
Advanced Trauma Life Support (ATLS) guidelines) even if there is no time to
complete those before the surgical procedure is started.
Some risks may be reduced, but some may persist and whenever possible these
need to be explained to the patient
C O N T. . .

Start: Similar principles to that for elective surgery 

constraints: Time, facilities available 
Consent: May not be possible in life-saving emergencies 
Organisational efforts: For example, local/national algorithms for
treatment of multi-trauma patient
C O N T. . .

Adults are presumed to have capacity to consent unless there is contrary

evidence. For adults who are not deemed competent to give consent,
treatment can still proceed in their best interests by filling in an inability to
consent form. 
Those under 16 years who demonstrate the ability to appreciate the risks
and benefits fully are deemed competent. This is known as Gillick
competence 
NUTRITION AND FLUID THERAPY

Fluid therapy and nutritional support are fundamental to good surgical

practice. Accurate fluid administration demands an understanding of
maintenance requirements and an appreciation of the consequences of
surgical disease on fluid losses.
 This requires knowledge of the consequences of surgical intervention and,
in particular, intestinal resection. Malnutrition is common in hospital
patients.
C O N T. . .

The success or otherwise of nutritional support should be determined by

tolerance to nutrients provided and nutritional end points, such as weight. 
It is unrealistic to expect nutritional support to alter the natural history of
disease.
It is imperative that nutrition-related morbidity is kept to a This necessitates the
appropriate selection of feeding method, careful assessment of fluid, energy and
protein requirements, which are regularly monitored, and the avoidance of
overfeeding.
I N T R A O P E R AT I V E
CARE
DEFINITION 

The term "intraoperative" refers to the time during surgery. Intraoperative

care is patient care during an operation and ancillary to that operation.
Activities such as monitoring the patient's vital signs , blood oxygenation
levels, fluid therapy, medication transfusion, anesthesia, radiography, and
retrieving samples for laboratory tests, are examples of intraoperative care.
C O N T. . .

The purpose of intraoperative care is to maintain patient safety and

comfort during surgical procedures.
Some of the goals of intraoperative care include maintaining homeostasis
during the procedure, maintaining strict sterile techniques to decrease the
chance of cross-infection, ensuring that the patient is secure on the
operating table, and taking measures to prevent hematomas from safety
strips or from positioning.
C O M P L I C AT I O N S

Intraoperative complications are surgery related, anesthesia related, or

position related. One complication occurring during the intraoperative
period that is not common but can be life threatening is an anaphylactic
(allergic) reaction to anesthesia.
The intraoperative staff is trained extensively in the treatment of such a
reaction, and emergency equipment should always be available in the
event it is needed for this purpose.
C O N T. . .

Another anesthesia-related complication is called "awareness under

anesthesia." This occurs when the patient receives sufficient muscle
relaxant (paralytic agent) to prohibit voluntary motor function but
insufficient sedation and analgesia to block pain and the sense of hearing .
Patients are aware
      P O S T O P E R AT I V E
       CARE
C O N T. . .

The aim of postoperative care is to provide the patient with as quick,

painless and safe recovery from surgery as possible. 
Trainees should acquire knowledge and skills to manage surgical, as well
as medical, postoperative problems.
GENERAL MANAGEMENT

Patient’s vital parameters, consciousness, pain and hydration status are

monitored in the recovery room and supportive treatment is given .
 Specific monitoring, such as Doppler flow for a free flap, observations
like neurological evaluation and laboratory tests such as blood gas analysis
may also be requested where necessary
C O N T. . .

The patient can be discharged from the recovery room when they fulfil the
following criteria:  
 Patient is fully conscious. 
 Respiration and oxygenation are satisfactory.
 Patient is normothermic, not in pain nor nauseous. 
 Cardiovascular parameters are stable.
S Y S T E M - S P E C I F I C P O S T O P E R AT I V E
C O M P L I C AT I O N S

The presentation of complications may be similar for more than one

underlying condition.
Shortness of breath can be due to respiratory or cardiac problems,
abdominal pain can be due to surgical causes or sepsis, while chest pain
may be present in cardiac, respiratory and even in gastrointestinal
problems. 
R E S P I R AT O R Y C O M P L I C AT I O N S

The most common respiratory complications in the recovery room are

hypoxaemia, hypercapnia and aspiration. Pneumonia and pulmonary
embolism tend to appear later in the postoperative period.
C A R D I O VA S C U L A R C O M P L I C AT I O N S

Hypotension in the immediate postoperative period may be due to

inadequate fluid replacement, vasodilatation from subarachnoid and
epidural anaesthesia or rewarming of the patient. 
However, other causes of hypotension such as surgical bleeding, sepsis,
arrhythmias, myocardial infarction, cardiac failure, tension pneumothorax,
pulmonary embolism, pericardial tamponade and anaphylaxis should be
also sought
C O N T. . .

Patients with hypotension are likely to have cold clammy extremities,

tachycardia and a low urine output ≤0.5 mL/kg per hour and low CVP. 
Hypovolaemia should be corrected with intravenous crystalloid or colloid
infusions 
MYOCARDIAL ISCHAEMIA
A N D   I N FA R C T I O N

Patients with previous cardiac problems undergoing major surgery are at

risk of developing an acute coronary syndrome.
They commonly present with retrosternal pain radiating into the neck, jaw
or arms and may also have nausea, dyspnoea or syncope. 
U R I N A RY R E T E N T I O N

Inability to void after surgery is common with pelvic and perineal

operations or after procedures performed under spinal anaesthesia. 
Pain, fluid deficiency, problems in accessing urinals and bed pans, and
lack of privacy on wards may contribute to the problem of urine retention. 
Catheterisation should be performed prophylactically when an operation is
expected to last 3 hours or longer or when large volumes of fluid are
administered.
U R I N A RY I N F E C T I O N

Urinary infection is one of the most commonly acquired infections in the

postoperative period.
Patients may present with dysuria and/or pyrexia. Immunocompromised
patients, diabetics and those patients with a history of urinary retention are
known to be at higher risk. 
Treatment involves adequate hydration, proper bladder drainage and
antibiotics depending on the sensitivity of the microorganisms.
G E N E R A L P O S T O P E R AT I V E P R O B L E M S
AND MANAGEMENT

Hypothermia and shivering Anaesthesia induces loss of

thermoregulatory control. Exposure of skin and organs to a cold operating
environment, volatile skin preparation (which cool by evaporation), and
the infusion of cold i.v. fluids all lead to hypothermia. 
.
FEVER

About 40 per cent of patients develop pyrexia after major surgery;

however, in most cases no cause is found.
The inflammatory response to surgical trauma may manifest itself as
fever, and so pyrexia does not necessarily imply sepsis.
However, in all patients with a pyrexia, a focus of infection should be
sought.
C O N T. . .

Patients with a persistent pyrexia need a thorough review. Relevant

investigations include full blood count, urine culture, sputum microscopy
and blood cultures
C O N T. . .

Bacteria can be incorporated into the biofilm that forms on the surface of
the implant, where they are protected from antibiotics and from the natural
defences of the body; prophylactic antibiotics appear to reduce the risk of
any contamination developing into infection by destroying bacteria before
they are incorporated into the biofilm
PRESSURE SORES

These occur as a result of friction or persisting pressure on soft tissues.

They particularly affect the pressure points of a recumbent patient,
including the sacrum, greater trochanter and heels.
 Risk factors are poor nutritional status, dehydration and lack of mobility
and also include the use of a nerve block anaesthesia technique.
C O N T. . .

Early mobilisation prevents pressure sores, while those who are unable to turn in
bed should be turned every 30 minutes to prevent pressure sores from developing.
High-risk patients may be nursed on an air filter mattress, which automatically
relieves the pressure areas 
Preventing pressure sores
 ■ Recognise patients at risk 
■ Address nutritional status 
■ Keep patients mobile or regularly turned if bed-bound
E N H A N C E D R E C O V E RY

Enhanced recovery is an approach to the perioperative care of patients

undergoing surgery. It is designed to speed clinical recovery of the patient,
and reduce the cost and the length of stay of the patient in the hospital.
It is achieved by optimising the health of the patient before surgery and
then delivering evidence-based best care in the perioperative period. 
C O N T. . .

Postoperative strategies for enhanced recovery include: 

Early planned physiotherapy and mobilisation. 
Early oral hydration and nourishment. 
 Good pain control using regular paracetamol with nonsteroidal anti-
inflammatory drugs (NSAIDs). Epidurals and nerve blocks are managed
by acute pain teams.
C O N T. . .

Discharge planning is started before the patient is even admitted to

hospital and involves support from stoma care nurses, physiotherapists and
other community care workers
C O N T. . .

Early mobilisation is encouraged to reduce the risks of DVT, urinary

retention, atelectasis, pressure sores and faecal impaction.
Telephone follow up is carried out to make sure that the patient is
recovering well once discharged.
REFERENCE