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Perioperative Management

By

Paul K. Mohabir

, MD, Stanford University School of Medicine;


André V Coombs

, MBBS, Texas Tech University Health Sciences Center

Last full review/revision Nov 2020| Content last modified Nov 2020
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The Surgical Care Improvement Project (SCIP) was initiated in 2005 out of the Surgical Infection Prevention (SIP) project. Recognized as an American multi-year partnership, the project aimed to reduce perioperative morbidity and mortality.

The SCIP guidelines were adopted and published in the Specifications Manual for Joint Commission National Quality Core Measures (Specifications Manual). This continually evolving manual was created by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission. Despite the multitude of participating organizations and noble aim of the project, recent evidence has challenged the association of adherence to process measures with good surgical outcomes.

General SCIP recommendations are as follows:

As of December 31, 2015, hospitals accredited by The Joint Commission are required to follow the Oryx® Performance Measurement Initiative by The Joint Commission for reimbursement purposes; however, nearly all hospitals continue to rely on SCIP as good clinical practice and for developing internal quality standards. 

Perioperative care is based on individual as well as general recommendations. Many drugs can interact with anesthetic drugs or have adverse effects during or after surgery. Thus, usually before surgery the patient's drugs are reviewed and which should be taken on the day of surgery is decided.

Recently, Enhanced Recovery After Surgery (ERAS) protocols have been developed and validated with the aim of standardizing perioperative care and improving overall surgical outcomes for various surgical specialties (see ERAS Society).

Anticoagulants and antiplatelets

In most cases, antiplatelet drugs (eg, aspirin) are stopped 5 to 7 days before surgery. However, in patients with coronary artery stents, stopping antiplatelet therapy, whether aspirin or dual antiplatelet therapy, increases the risk of coronary tent thrombosis, which may be fatal. This risk may outweigh the risk of surgical bleeding, and decisions regarding management of single or dual-agent regimens should be individualized with input from a multidisciplinary team. Factors to consider include the type of stent (bare or drug-eluting), time since placement, type of surgery, and whether an elective procedure can be postponed until periods of increased risk have passed (1).

Except for certain minor procedures, warfarin is stopped for 5 days before surgery; INR (international normalized ratio) at the time of surgery should be ≤ 1.5. Patients who are at significant risk of an embolic event (eg, patients who have history of pulmonary embolism or atrial fibrillation with history of stroke) are given a short-acting anticoagulant such as low molecular weight heparin after stopping warfarin (called bridging anticoagulation—see Deep Venous Thrombosis). Because it takes up to 5 days for warfarin to achieve therapeutic anticoagulation, it can be started the day of or after surgery unless the risk of postoperative bleeding is high. Patients should receive bridging anticoagulation until the INR has reached the therapeutic target.

Corticosteroids

Patients may require supplemental corticosteroids to help prevent inadequate responses to perioperative stress if they have taken > 5 mg of prednisone daily (or an equivalent dose of another corticosteroid) for > 3 weeks within the past year. Empiric stress dose corticosteroid coverage is also often given when the dose and duration of corticosteroid therapy is unknown. However, whether stress dose corticosteroids are necessary is now being questioned. Corticosteroids are unnecessary for minor procedures.

Diabetes

On the day of surgery, patients with insulin-dependent diabetes are typically given one third of their usual insulin dose in the morning. Patients who take oral drugs are given half of their usual dose. If possible, surgery is done early in the day. The anesthesiologist monitors glucose levels during surgery and gives additional insulin or dextrose as needed. Close monitoring with fingerstick testing continues throughout the perioperative period. In the immediate postoperative period, insulin is given on a sliding scale. The usual at-home insulin regimen is not restarted until patients resume their regular diet. Oral hypoglycemic drugs are usually restarted when the patient is discharged from the hospital.

Drug dependence

Patients who are dependent on drugs or alcohol may experience withdrawal during the perioperative period. Alcoholics should be given prophylactic benzodiazepines (eg, chlordiazepoxide, diazepam, lorazepam) starting at admission. Opioid addicts may be given opioid analgesics to prevent withdrawal; for pain relief, they may require larger doses than patients who are not addicted. Rarely, opioid addicts require methadone to prevent withdrawal during the perioperative period.

Heart disease

Patients with known coronary artery disease or heart failure should undergo preoperative evaluation and risk stratification by their cardiologist. If patients are not medically optimized, they should undergo additional testing before elective surgery.

Pulmonary disease

Preoperative pulmonary function tests can help quantify the degree of obstructive, restrictive, or reactive airway disease. Pulmonary function should be optimized by carefully adjusting the use and doses of inhalers, other drugs, and airway clearance techniques.

Other drugs that control chronic disorders

Most drugs taken to control chronic disorders, especially cardiovascular drugs (including antihypertensives), should be continued throughout the perioperative period. Most oral drugs can be given with a small sip of water on the day of surgery. Other drugs may have to be given parenterally or delayed until after surgery. Anticonvulsant levels should be measured preoperatively in patients with a seizure disorder.

Smoking

Smokers are advised to stop smoking as early as possible before any procedure involving the chest or abdomen. Several weeks of smoking cessation are required for ciliary mechanisms to recover. An incentive inspirometer should be used before and after surgery.

Upper airway

Before intubation, dentures must be removed. Ideally, before patients are moved from the preanesthetic holding area, they should give dentures to a family member. Patients with a deviated septum or another airway abnormality should be evaluated by an anesthesiologist before surgery requiring intubation.

Preprocedural checklist

In the operating room, before the procedure begins, a time out is held during which the team confirms several important factors:

  • Patient identity

  • Verification of correct procedure and location and side of the operative site

  • Availability of all needed equipment

  • Verification of administration of indicated prophylaxis (eg, antibiotics, anticoagulants, beta-blockers)

Reference

  • 1. Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 64(22):e77-e137, 2014. doi:10.1016/j.jacc.2014.07.944

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