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.
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.