Chapter 7. Perioperative Management

Overview

Initiative sponsored by several organizations to improve the surgical care and reduce preventable surgical complications (morbidity and mortality). Linked to pay-for-performance quality parameters.

Four major targets for prevention:

• • Surgical site infections.
• • Venous thromboembolism.
• • Cardiac morbidity.
• • Respiratory morbidity.

Prevention of Surgical Site Infection

Surgical site infection is responsible for 15% of all nosocomial infections: 2–5% of clean extra-abdominal cases and up to 20% of intra-abdominal cases.

Measures:

• • Appropriate selection of prophylactic antibiotics: eg, cephalosporin + metronidazole, ertanpenem, fluorochinolone + metronidazole. Betalactam allergy: fluoroquinolone + metronidazole, clindamycin + fluoroquinolone, clindamycin + aztreonam, etc.
• • Prophylactic antibiotics received within 1 hour before surgical incision.
• • Prophylactic antibiotics limited to 24 hours (longer duration okay for therapeutic indication).
• • Appropriate hair removal for surgical field preparation (clipper, no razor).
• • Monitoring and correction of peri-postoperative glucose levels.
• • Maintenance of peri-/postoperative normothermia.

Prevention of Venous Thromboembolism

Without appropriate prophylaxis, DVT is a complication in 20–50% of major operations → pulmonary embolism in 10–30%.

Measures:

• • Recommended DVT prophylaxis ordered.
• • Appropriate DVT prophylaxis initiated within 24 hours before surgery to 24 hours after surgery.

Prevention of Adverse Cardiac Events

Adverse cardiac events (eg, myocardial infarction, sudden cardiac death, congestive heart failure) complicate 2–5% of noncardiac surgeries overall, causing increased mortality rate, length of stay, cost.

Measures:

• • Perioperative β-blocker administration if previously required (eg, for angina, hypertension, arrhythmias).

Prevention of Respiratory Complications

Patients on respirator with mechanical ventilation are at increased risk of ventilator-associated pneumonia (10–30%), stress ulcer disease, and GI bleeding.

Suggested (but not yet approved) measures:

• • Elevation of head of bed.
• • Provision of stress ulcer disease prophylaxis.
• • Use of ventilator weaning protocols to reduce duration of mechanical ventilation.

Cross-Reference

General perioperative management—abdominal (Ch. 7)

Comorbidities—cardiac disease (Ch. 7)

Antibiotic prophylaxis (Ch. 7)

Prophylaxis of venous thromboembolism (DVT, PE) (Ch. 7)

Overview

Colorectal surgery encompasses an enormously broad spectrum of diseases and conditions through all age and risk groups. Treatment equally varies in a wide range of approaches and is delivered in several different settings (office, OR, endoscopy suite, outpatient/inpatient).

Hence, management is not “one-size-fits-all.” Nonetheless, a few principles have evolved that should be considered in the perioperative management of a patient undergoing an abdominal procedure.

Risk Assessment

• • < 40 years, no risk factors/symptoms → no specific workup needed.
• • > 40 years, no risk factors → ECG, chest ...