The care of the patient with a major surgical problem commonly involves distinct phases of management that occur in the following sequence:
1. Preoperative care
2. Anesthesia and operation
3. Postoperative care
The diagnostic workup is concerned primarily with determining the cause and extent of the present illness. Preoperative evaluation consists of an overall assessment of the patient’s general health in order to identify significant abnormalities that
might increase operative risk or adversely influence recovery. Preoperative
preparation includes interventions dictated by the findings
on diagnostic workup and preoperative evaluation and by the nature
of the expected operation. This includes interventions specifically
imposed to modify the risk of perioperative complications.
The postanesthetic observation phase of management
is the few hours immediately after operation during which the acute
reaction to operation and the residual effects of anesthesia subside.
A postanesthetic recovery unit with special staff and equipment
is usually provided for this purpose. Patients who need continued
cardiopulmonary support or continued invasive monitoring to avoid
major morbidity and death should be transferred to an intensive
Intermediate care is usually provided on an inpatient nursing
unit until the patient’s recovery can continue at home during
the convalescent phase.
The Continuum of Surgical Care
The continuum of surgical care is represented above as progressing through a series of preoperative and postoperative phases. In practice,
these phases merge, overlap, and vary in relative importance from
patient to patient. Complications, death, and the therapeutic end
result in the surgical patient depend upon the competence with which
each succeeding phase is managed. The rapid progression and severe
episodic stress of major surgical illness leave small margin for
errors in management. The care immediately preceding and following
operation, which includes preoperative evaluation and preparation
and postanesthetic observation and intensive care, is especially
critical. The increased complexity of surgical critical care has resulted
in a team approach to the ICU patient, with management directed
by the primary surgeon and the critical care specialists in the
ICU, whose role it is to maintain optimum care.
General Health Assessment
The initial diagnostic workup of the surgical patient is focused on the cause of the presenting complaints. Except in strictly minor
surgical illness, this initial workup should be supplemented by
a complete assessment of the patient’s general health.
This evaluation, which should be completed prior to all major operations, seeks
to identify abnormalities that may influence operative risk or may
have a bearing on the patient’s future well-being. Preoperative
evaluation includes at least a complete history and physical examination.
The evaluation should initially focus on the clinical assessment
of risk based on the patient’s history and current symptoms.
This assessment should guide the remainder of ...