Chapter 2: Preoperative and Postoperative Management

INTRODUCTION

Surgeons of every specialty face increasingly complex surgical challenges. In addition, modern surgical treatment can be offered to more fragile patients, with successful outcomes. Mastery of the scientific fundamentals of perioperative management is required to achieve satisfactory results. The organ system–based approach presented here allows the surgeon to address the patient’s pre- and postoperative needs with a comprehensive surgical plan. This chapter will serve as a summary guide to best practices integral to conducting surgical procedures in the modern era.

MANAGEMENT OF PAIN AND DELIRIUM

The most common neuropsychiatric complications following abdominal surgery are pain and delirium. Moreover, uncontrolled pain and delirium prevent the patient from contributing to vital aspects of his or her care, such as ambulation and respiratory toilet, and promote an unsafe environment that may lead to the unwanted dislodgment of drains and other supportive devices, with potentially life-threatening consequences. Pain and delirium usually coexist in the postoperative setting, and each can contribute to the development of the other. Despite high reported rates of overall patient satisfaction, pain control is frequently inadequate in the perioperative setting,¹ with high rates of complications such as drowsiness from overtreatment and unacceptable levels of pain from undertreatment. Therefore, it is mandatory that the surgical plan for every patient include close monitoring of postoperative pain and delirium and regular assessment of the efficacy of pain control.

Pain management, like all surgical planning, begins in the preoperative assessment. In the modern era, a large proportion of surgical patients will require special attention with respect to pain control. Patients with preexisting pain syndromes, such as sciatica or interspinal disc disease, or patients with a history of opioid use may have a high tolerance for opioid analgesics. Every patient’s history should include a thorough investigation for chronic pain syndrome, addiction (active or in recovery), and adverse reactions to opioid, nonsteroidal, or epidural analgesia. The pain control strategy may include consultation with a pain control anesthesiology specialist, but it is the responsibility of the operating surgeon to identify complicated patients and construct an effective pain control plan.

Opioid Analgesia

Postoperative pain control using opioid medication has been in use for thousands of years. Hippocrates advocated the use of opium for pain control. The benefits of postoperative pain control are salutary and include improved mobility and respiratory function and earlier return to normal activities. The most effective strategy for pain control using opioid analgesia is patient-controlled analgesia (PCA), wherein the patient is instructed in the use of a preprogrammed intravenous pump that delivers measured doses of opioid (usually morphine or meperidine). In randomized trials, PCA has been shown to provide superior pain control and patient satisfaction compared to interval dosing,² but PCA has not been shown to improve rates of pulmonary and cardiac complications³ or length of hospital stay,⁴ and there is evidence that PCA ...