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Perioperative Care

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... to avoid resection (21/25, 84%) Correct prediction to resection (5/9) ... Always used NG suction after colon resection( 90%) and small bowel resection (97 ... – PowerPoint PPT presentation

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Title: Perioperative Care


1
Perioperative Care
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2
Introduction
  • Are there absolute contraindications to surgery
    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?
  • What constitutes the optimal incision or approach
    for a gynecologic cancer procedure?

3
Cardiac Risk
  • High-risk surgical procedure ( intraperitoneal)
  • Hisotry of ischemic heart disease (excluding
    coronary revascularization)
  • History of heart failure,
  • History of stroke or transient ischemic attack
  • Preoperative insulin therapy
  • Creatinine levels gt 2 mg/dl

4
Cardiac Risk
James W, et al.Gynecologic cancer controversies
in management, 2004.
5
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, p0.002)
  • Myocardial infarction (17.4 versus 0, plt0.001)

Poldermans D et al.Eur Heart J 2001221353-1358.
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Pulmonary risk
  • Postoperative pulmonary complications (POPC)
    after abdomnal surgery more frequently (10-30)
    than cardiac complications.
  • Postanesthetic changes in vital capacity,
    functional residual capacity, ventilation-perfusio
    n abnormality, diaphragmatic dysfuction,
    decreased number, activity of alveolar
    macrophages inhibiting mucocilicary clearance,
    increased alveolar-capillary permeability.

8
Pulmonary risk
  • Postoperative respiratory failure, perioperative
    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.1999340937-944.
9
Pulmonary risk
10
Smoking
  • Effect of short-term smoking cessation has not
    been effective in preventing perioperative
    morbidity.
  • Perioperative morbidity stop
    smoking lt 8 versus gt 8weeks (33 versus 14)

Smetana GW. Clin Geriatr Med 20031935-55.
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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.

13
Renal disease risk
  • Renal failurerise in serum creatinine over
    baseline 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.

14
Gynecology cancer Renal disease risk
  • Radical surgery risk for prerenal, intrinsic
    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.

15
Current popular strategies for renal protection
  • Aggressive hydration by pulmonary artery
    catheters.
  • Renal-dose dopamine
  • Induction of mannitol or furosemide diuressis
  • Unfortunately, none of these strageies has prove
    effective.

Sadovnikoff N. Int Anesthesiol Clin
20013995-109.
16
No renal protective strategy exists
  • Careful preoperative analysis of patients
    medication
  • Perioperateive supportive care
  • Minimizing exposure to nephrotoxic agent
  • Postoperative surveillance to detect and treat
    postoperative renal insufficiency.
  • Anxiously await new renal protective drugs and
    new strategies.

17
What is the optimal method of perioperative deep
venous thrombosis prophylaxis?
  • DVT1.5-38 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.

18
IPC intermittent pneumatic compression.(Efficacy,
ease, low side effect) LDUH low-dose
unfractionated heparin. ESelastic stockings.
19

20
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, p0.02)

Bergqvist D et al. N Engl J Med 2002346975-980.
21
Treatment of venous thromboembolic disease
  • Low molecular weight heparin (LMWH, clexaneSC,
    30mg q12h).
  • Heparine (initial IV bolus 5000-10000 units, then
    IV infusion 20000-40000 or initial SC 10000-20000
    units then 10000units q8h)
  • Placement of an inferior vena cava filter.

22
Heparin
  • Heparin temporary discontinuation of therpay 6
    hours before surgery and resumption 6-12 hours
    after surgery.
  • LMWH lower reported incidence of bleeding
    complications.

23
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

24
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.

25
What constitutes optimal perioperative management
of the gastrointestinal tract?
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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 19992013-15.
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(Evac enema)
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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.

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Preoperative mechanical preparation
  • Failed to demonstrate a lessened risk of wound or
    abdominal infection.
  • The incidence of anastomotic breakdown was not
    lowered.
  • Colonic anastomoses can be safely performed in
    women even in the absence of a mechanical
    preparation.

36
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.

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Nasogastric suction
  • Surgical dogma to use NG suction.
  • A 1999 survery suggested gynecologic oncologist
    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 199868126.
39
No difference in deaths, aspiration, nausea,
vomiting, abdominal distention, wound dehiscence,
wound infection, anastomotic leak or length of
stay.
40
  • In extreme risk of a prolonged postoperative
    ileus ( extensive dissection after irradiation).
    Intraoperative gastrostomy tube placement should
    be considered as a comfortable alternative.

41
Early oral feeding
  • Well tolearted
  • Shorter hospital stays
  • No increase the risk of ileus or other
    complication.

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  • 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.

44
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 .

45
Summary
  • Are there absolute contraindications to surgery
    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?

46
Thank you for your attention
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