Perioperative Management refers to the period of time extending from the day prior to surgical intervention to several days after said intervention. It consists of the preoperative, intraoperative and postoperative period.
Aims: to provide diagnostic and prognostic information. To ensure the patient understand the nature, aims and expected outcome of surgery. To allay anxiety and pain.
Assessment of Presenting Illness
Assessment of General Health & Comorbid disease
Assessment of Airway - Assesses the likely ease of intubation (LEMON)
Assessment of Relevant Anatomical Sites
|ECG + CXR|
|Nil by mouth|
There are four Key Legal requirements of consent (VICS):
|Remember Patient on wafarin PAP: previous PE, atrial fibrillation, prosthetic valve|
More information on Post-operative surgical complications
Acute Wound: is the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.
Chronic Wound: fails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection
|Stages of Wound healing||Description|
|Haemostasis (immediate)||Vasoconstriction, Platelet aggregation and Coagulation cascade|
|Inflammation (0-3days)||Vasodilation, increased vascular permeability, chemotaxis, immune cells clean up debris and microbes|
|Proliferation (3days - 3weeks)||Fibroblasts migrate into the wound and synthetise collagen. Fibroblasts become myofibroblast which causes wound contraction. Angiogenesis is stimulated by hypoxia and cytokine production|
|Remodelling (3weeks - 1year)||Reorientation and maturation of collagen fibres increases wound strength|
Granulation tissue is the combination of capillary loops and myofibroblasts
Factors affecting wound healing
Watch video on Wound healing
Infection Most caused by patients own flora. Staphylococcus aureus and staphylococcus epidermidis are skin organisms that make up the majority of causes. Escherichia coli and pseudomonas are responsible for many wound infections from opened viscera during surgery.
Diabetes Diabetes Mellitus is a Clinical Syndrome characterised by an increase in Plasma Blood Glucose (Hyperglycaemia). Classical symptoms: Polyuria ( Urination), Polydipsia ( Thirst), Polyphagia (hunger). There are 3 main types of Diabetes according to aeitiology:
Approximately half of all diabetics will require surgery at some point during their life, often to manage complications of the disease.
Specific perioperative risks
Management of the diabetic patient
|Remember Ketoacidosis in the perioperative period is associated with a very high morbidity and mortality and should be avoided.|
Medication and surgery Depending on the surgery and if it is minor or major surgery oral controlled or insulin control must be stopped on day of surgery. Following surgery it is important to continuously monitor blood glucose level and restart normal medication regime. That is why diabetic patients should be first in line for surgery (for monitoring).
Diabetes Medication plan for the perioperative period