Preoperative Management Of Specific Problems

Prophylaxis for Deep Venous Thrombosis and Pulmonary Embolism

The morbidity and mortality of deep vein thrombosis and pulmonary embolism make it mandatory to provide prophylaxis against these catastrophes. Patients at high risk include older individuals, those with previous abdominal surgery, varicose veins, increased antithrombin III levels, history of cigarette smoking, and high platelet counts. The risk is increased in patients older than 40 years who undergo general anesthesia for more than 30 min.

The routine use of sequential compression devices on both lower extremities began in the operating room even prior to induction of anesthesia is advised. This can be continued until the patient is ambulating. These devices stimulate endothelial cell fibrinolytic activity and as such can be used on one leg alone or on the upper extremity if lower extremity application is contraindicated.

Low-dose heparin, 5000 units administered 2 h prior to induction and continued twice a day on a daily basis is effective prophylaxis. However, it is not advisable for patients with major fractures, recent head injury, or gastrointestinal bleeding. In such patients, prophylactic percutaneous placement of an inferior vena cava filter is appropriate.

Therapeutic Anticoagulation

There are several recommendations for the perioperative management of anticoagulation in patients who cannot tolerate oral anticoagulants. If a patient's INR is between 2.0 and 3.0, four scheduled doses of warfarin should be withheld to allow the INR to fall spontaneously to 1.5 or less before surgery. Warfarin should be withheld for a longer period if the INR is normally maintained above 3.0 or if it is necessary to keep it at a lower value (i.e., less than 1.3). The INR should be measured a day before surgery to ensure adequate progress in the reversal of anticoagulation; the physician then has the option of administering a small dose (1 mg subcutaneously) of vitamin K, if required (i.e., if the INR is 1.8 or higher). Alternative preoperative or postoperative prophylaxis, or both, against thromboembolism should be considered16 for the period during which the INR is less than 2.0.

Antimicrobial Prophylaxis

Prophylactic antibodies are indicated for clean contaminated or contaminated cases. Even for clean cases, prophylactic antibodies may decrease the rate of infection. This includes cases where prosthetic mesh is to be used. A prophylactic antibiotic covering typical skin organisms is adequate in these cases. In cases where an infection is already established, the choice of the antibiotic should be based on culture and sensitivity results and continued for the appropriate length of time. Antibiotics should be administered in a timely fashion so that therapeutic blood levels of the antibiotic are present at the start of the procedure.

In patients with open wounds or ongoing infections, culture and antibiotic sensitivities should be obtained. Surface cultures do not yield adequate information. Instead quantitative cultures of punch biopsies from the wounds are more precise indicators. Greater than 105 organisms per gram of tissue correspond to greater than 50 percent graft failure, whereas below 105 organisms per gram of tissue correspond to greater than 80 percent graft take.

Duration of the procedure correlates with higher rate of wound infection, and therefore in procedures lasting more than 4 h a second dose of the antibiotic should be administered intraoperatively. Recent work suggests that better glycemic control with insulin infusions may reduce the incidence of deep sternal wound infections in diabetic patients who have undergone cardiac surgery. This observation is supported by a study demonstrating better preservations of neutrophil function with aggressive glycemic control using an insulin infusion compared with intermittent therapy, in diabetic cardiac patients.

Preoperative Orders Regarding Diet

Patients should avoid solid foods for 12 h and liquids for 8 h prior to surgery. They are generally advised to remain nil by mouth after midnight on the night before operation. Patients undergoing esophageal surgery for achala-sia are requested to begin clear liquids 2 days prior to surgery and continue this until midnight, the night before surgery. Similarly, patients undergoing surgery on the small intestine, colon, and rectum are advised to start clear liquids 2-3 days prior to surgery.

Bowel Preparation

In addition to limiting intake of clear liquids, starting 3 days prior to surgery, patients undergoing small intestine, colon, and rectal surgery are advised to undergo a bowel preparation. Various preparations can be used. The polyethylene glycol electrolyte preparation consists of 4 L of solution that should be consumed over a 2-3 h period the day before surgery, before administration of the oral antibiotics. Alternatively, two doses of a IV2 fl oz bottle of Fleet's Phospho-Soda (hypertonic sodium phosphate solution) diluted with half a glass of water can be consumed the day before surgery; one in the early afternoon and the other in the early evening. A bottle of magnesium citrate taken 3 days prior to surgery and then again the morning before surgery can also provide an adequate bowel preparation. As part of the bowel preparation, patients are advised to take neomycin and ery-thromycin base, 1 g each orally at 1, 2, and 11 p.m. the day before surgery. Metronidazole can be substituted for erythromycin.

Preoperative Orders Regarding Medications

Long-acting sulfonylureas should be stopped 48 h prior to surgery; short-acting agents should be omitted on the morning of surgery. These medications should be restarted when the patient resumes adequate oral intake. Patients are advised to take their antihypertensive medications on the day of surgery, with the exception of diuretics. These are withheld to avoid hypov-olemia or hypokalemia. The route of administration of certain drugs may need to be changed to parenteral in the preoperative period. This may be necessary for drugs such as digitalis, other cardiac drugs, and immunosup-pressive drugs in transplant patients.

Information Regarding Postoperative Hospital Stay, Diet, Exercise, and Return to Work

Patients should be advised about what to expect in the perioperative period. Information regarding duration of the procedure, ambulatory or in-patient status following surgery, and duration of hospital stay should be given. Advice regarding diet, exercise, and possible return to work allays some of the traditional fears about surgery. Intraoperative risks of bleeding, infection, injury to adjacent structures, and need for conversion to open procedures for laparoscopic cases should be discussed, as also the perioperative risks of developing an MI, pulmonary embolism, or loss of life. The technical details of the procedure should be explained and informed consent obtained.

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