Preoperative, Intraoperative, and Postoperative Considerations

PREOPERATIVE, INTRAOPERATIVE, AND POSTOPERATIVE CONSIDERATIONS

Any surgical procedure carries risks. Naturally, more inva-sive procedures carry higher risks. Before patients sign preoperative surgical consent forms, they should be coun-seled on the risks of infection, hemorrhage, damage to surrounding structures (bowel, bladder, blood vessels, and other anatomic structures). Many hospitals require that patients also sign a consent form for a blood transfusion in case of an emergency. Some patients refuse to sign such consents for blood transfusion for personal or religious reasons, and this should be clearly documented in the chart. A discussion with the patient regarding the safety of the blood used for transfusion should address the risk of acquiring human immunodeficiency virus (HIV), hepati-tis B and C viruses, and other blood-borne pathogens.

Preoperative testing, which could include blood work, urinalysis, other laboratory tests (glucose, creatinine, hemoglobin, coagulation parameters), pregnancy testing, electrocardiogram, and imaging studies (e.g., CT, MRI) should be individualized based on the patient’s age (espe-cially in pediatric patients), concurrent medical problems, route of anesthesia, and surgical procedure planned.

Minor procedures are now more commonly performed in the office setting for patient convenience, avoidance of general anesthesia, and improved reimbursement. In addition, not allpatients are surgical candidates, and nonsurgical therapeu-tic options should always be considered. Patients may have such significant medical problems (e.g., poorly controlled diabetes, heart disease, pulmonary disease) that they might not tolerate anesthesia or surgery.

Several intraoperative and perioperative issues should be considered. Prophylactic antibiotics are indicated for some gynecologic surgeries and should be administered within 30 minutes of surgery. Often, a Foley catheter is inserted prior to surgery to prevent the bladder from becoming distended during the procedure. A preoperative pelvic examination of the anesthetized patient can some-times prove useful.

Postoperatively, a nurse and a member of the anesthe-sia team assess the patient in the postanesthesia care unit. The patient is either discharged to home or admitted to the hospital, depending on the type of procedure performed and the condition of the patient. An operative note will have been written in the chart immediately postoperatively, out-lining the preoperative diagnosis, postoperative diagnosis, procedure, surgeon(s), type of anesthesia, amount and type of intravenous fluid administered, any other fluids given (transfusions or other products), urine output (if indicated), findings, pathology specimens sent, complications, and a statement of patient’s condition upon completion of the procedure. Postoperative orders for inpatient stays should include a notation of the procedure performed, the name of the attending physician and service, frequency of vital signs, parameters for calling the physician, diet, activity, intra-venous fluids, pain medications, resumption of any home medications (antihypertensives, diabetic drugs, antidepres-sants, etc.), antiemetic medications, deep venous thrombo-sis (DVT) prophylaxis, Foley catheter, incentive spirometer, and any necessary laboratory studies.During a postoperative hospitalization, the patient should be seen at least daily. Careful assessment and moni-toring of pain, bladder and bowel function, nausea and vomiting, and vital signs are routine. Early ambulation can reduce the risk of thromboembolism. The most common surgical complications are fever, urinary tract infections, surgical site drainage and bleeding, minor separation of skin incisions, hemorrhage, pneumonia, ileus, and minor surgi-cal site infection(s). Less common postoperative complica-tions include skin and subcutaneous wound separation, fascial dehiscence or evisceration, bowel perforation, uri-nary tract injury, severe hemorrhage requiring reoperation, DVT, pulmonary embolism (PE), abscess, sepsis, fistulas, and anesthetic reactions.

Fever is defined as two oral temperatures of greater than or equal to 38°C at 4-hour intervals. Primary sources of fever include the respiratory and urinary tracts, the inci-sion(s), thrombophlebitis, and any medications or transfu-sions. Atelectasis occurs when patients do not take large inspiratory breaths due to abdominal discomfort. Use of an incentive spirometer can minimize the risk of atelectasis and pneumonia. Use of an indwelling urinary catheter should be minimized, because placement for more than 24 hours increases the risk of urinary tract infection (cystitis or pyelonephritis). Ambulatory status affects breathing (hypoventilation) and possible thrombosis (DVT or PE). The wound should be assessed for any signs of infection. If there are no easily visible incisions as with vaginal surgery, a pelvic examination and/or imaging of the pelvis may be needed. If the fever resolves after withdrawal of a medica-tion, then a presumptive diagnosis of drug reaction can be made. If the patient has received blood products, the pos-sibility of a reaction to antigens in the transfusion should be investigated as a cause of the fever. Antibiotics should be ordered only when infection is suspected.