Perioperative Care

台北榮民總醫院婦產部 主治醫師國立陽明大學部定講師陳怡仁

Introduction Are there absolute contraindications to surgery

related to cardiac, pulmonary, or renal disease? What is the optimal method of perioperative de

ep venous thrombosis prophylaxis? What constitutes optimal perioperative manag

ement of the gastrointestinal tract? What constitutes the optimal incision or approa

ch for a gynecologic cancer procedure?

Cardiac Risk High-risk surgical procedure ( intraperito

neal) Hisotry of ischemic heart disease (excludi

ng coronary revascularization) History of heart failure, History of stroke or transient ischemic att

ack Preoperative insulin therapy Creatinine levels > 2 mg/dl

Cardiac Risk

James W, et al.Gynecologic cancer: controversies in management, 2004.

Benefit of perioperative B-blocker therapy Randomized in high-risk surgical patients

(abdominal aortic aneurysm repair) Bisoprolol versus placebo Cardiac mortality ( 17% versus 3.4%, p=0.

002) Myocardial infarction (17.4% versus 0%,

p<0.001)

Poldermans D et al.Eur Heart J 2001;22:1353-1358.

Pulmonary risk Postoperative pulmonary complications (POP

C) after abdomnal surgery: more frequently (10-30%) than cardiac complications.

Postanesthetic changes in vital capacity, functional residual capacity, ventilation-perfusion abnormality, diaphragmatic dysfuction, decreased number, activity of alveolar macrophages inhibiting mucocilicary clearance, increased alveolar-capillary permeability.

Pulmonary risk Postoperative respiratory failure, periope

rative pneumonia, COPD, asthma, atelectasis and pleural effusion.

Formal spirometry may predict risks: lacks sensitivity and specificity.

Lack of preoperative predictability in creating an effective plan for prevention of pulmonary morbidity.

Smetana GW.N Engl J Med.1999;340:937-944.

Pulmonary risk

Smoking

Effect of short-term smoking cessation has not been effective in preventing perioperative morbidity.

Perioperative morbidity: stop smoking < 8 versus > 8weeks (33% versus 14%)

Smetana GW. Clin Geriatr Med 2003;19:35-55.

Pulmonary risk

Absence of risk assessment stragegy and inability to modify pulmonary risk factors for morbidity.

Early involvement of a pulmonary consultant may be the best strategy.

In most situations, patient benefits from an intensive postoperative pulmonary program.

Renal disease risk Renal failure:rise in serum creatinine over basel

ine by 0.5 mg/dL, a reduction of calculated creatininte clearance of 50%, or the need for dialysis.

Postoperative renal failure is associated with a dramatic increase in mortality (45%), particularly in presence of hypotension, sepsis and exposure to nephrotoxic drugs.

Gynecology cancer: Renal disease risk Radical surgery: risk for prerenal, intrinsi

c renal or postrenal dysfunction. Dehydration, sepsis, blood loss, 3rd-space

of fluid, and exposure to nephrotoxic agents (intravenous radiocontrast media, specific antibiotic, cisplatin, NSAID, ACE inhibitors.

Current popular strategies for renal protection

Aggressive hydration by pulmonary artery catheters.

Renal-dose dopamine Induction of mannitol or furosemide diur

essis Unfortunately, none of these strageies ha

s prove effective.

Sadovnikoff N. Int Anesthesiol Clin 2001;39:95-109.

No renal protective strategy exists Careful preoperative analysis of patients’ med

ication Perioperateive supportive care Minimizing exposure to nephrotoxic agent Postoperative surveillance to detect and treat p

ostoperative renal insufficiency. Anxiously await new renal protective drugs and

new strategies.

What is the optimal method of perioperative deep venous thrombosis prophylaxis? DVT:1.5-38% after routine

gynecologic surgery. Prophylaxis: reduce risk by 75% . Cancer patients : high risk for DVT. Developing clinical DVT may extend

for weeks. Delayed DVT: a poor cancer

prognosis.

IPC: intermittent pneumatic compression.(Efficacy, ease, low side effect)

LDUH: low-dose unfractionated heparin.

ES:elastic stockings.

Deep venous thrombosis prophylaxis

Elastic stock: not represent sufficient prophylaxis for the higher risk patients. (history of DVT, older than 60 years, gynecologic cancer).

332 patients, 6-10 in –hospital days of LMWH.

Randomized to placebo or LMWH for an additional 21 days.

DVT rate placebo versus study group( 12 versus 4.8%, p:0.02)

Bergqvist D et al. N Engl J Med 2002;346:975-980.

Treatment of venous thromboembolic disease Low molecular weight heparin (LMWH, cl

exaneSC, 30mg q12h). Heparine (initial IV bolus 5000-10000 unit

s, then IV infusion 20000-40000 or initial SC 10000-20000 units then 10000units q8h)

Placement of an inferior vena cava filter.

Heparin

Heparin temporary discontinuation of therpay 6 hours before surgery and resumption 6-12 hours after surgery.

LMWH: lower reported incidence of bleeding complications.

Highest risk for intraoperative bleeding IVC filter placement Delay surgery for up to 1 month after

the diagnosis of VTE. If delay is not feasible, LMWH for

several days after the diagnosis of VTE

Prevent recurrence of VTE

Warfarin ( coumadin): International normalized ration of 2-3, planned more than 6 months treatment.

50% risk reduction for recurrent VTE in cancer paitents.

What constitutes optimal perioperative management of the gastrointestinal tract?

Preoperative sigmodioscopy Correct prediction to avoid resection

(21/25, 84%) Correct prediction to resection (5/9) Although no strict guidelines, pelvic

surgeon should offer preoperative colon or intestinal evaluation in clinical situations in which abnormalities are likely to be present.

Gornall R. Eur J Cynaecol Oncol 1999:20;13-15.

(Evac enema)

Preoperative preparation NO single drug or regimen has

documented superiority, a short course of a broad-spectrum antibiotic ( single dose if the surgery is not twice as long as the drug half-life) is appropriate.

99% colorectal surgeons use mechanical bowel preparation before intestinal resection.

Preoperative mechanical preparation Failed to demonstrate a lessened risk of

wound or abdominal infection. The incidence of anastomotic breakdow

n was not lowered. Colonic anastomoses can be safely perfo

rmed in women even in the absence of a mechanical preparation.

Postoperative GI care Normal function returns in the

stomach and intestine at 8 hours, right colon at 48 hours, sigmoid colon at 72 hours after an abdominal procedure.

Little adverse effect on return of bowel function related to duration of surgery, intestinal manipulation, narcotics, retroperitoneal dissection.

Nasogastric suction Surgical dogma to use NG suction. A 1999 survery suggested gynecologic oncologi

st commonly incorporate NG suction after cytoreduction (57%), LN dissection (34%), radical hysterectomy (29%) and routine hyestereocmty (15%).

Always used NG suction after colon resection( 90%) and small bowel resection (97%).

Rationale for use was to decrease distension (67%), avoid an ananstomic leak (39%) and lessen nausea (36%).

Brewer M. Gynecol Oncol 1998;68:126.

No difference in deaths, aspiration, nausea, vomiting, abdominal distention, wound dehiscence, wound infection, anastomotic leak or length of stay.

In extreme risk of a prolonged postoperative ileus ( extensive dissection after irradiation). Intraoperative gastrostomy tube placement should be considered as a comfortable alternative.

Early oral feeding

Well tolearted Shorter hospital stays No increase the risk of ileus or other com

plication.

Routine NG drainage does not lessen risks.

Infectious complications are controlled by broad-spectrum antibiotics.

Intra-abdominal abscesses are usually (85%) manage successfully with percutaneous drainage.

Postoperative obstruction After excluding the possibility of

strangulation, adhesive postoperative obstruction is typically successfully managed conservatively, with resolution frequently occurring with 48 hours.

Early use of contrast enhanced radiology should be considered to those without resolution in 48 hours .

Summary Are there absolute contraindications to s

urgery related to cardiac, pulmonary, or renal disease?

What is the optimal method of perioperative deep venous thrombosis prophylaxis?

What constitutes optimal perioperative management of the gastrointestinal tract?

Thank you for your attention