Ebook The washington manual of surgery: Part 1

(BQ) Part 1 book The washington manual of surgery presentation of content: Common postoperative problems, nutrition for the surgical patient, critical care, chest trauma, abdominal trauma, extremity trauma, common surgical procedures, the surgical management of obesity, acute abdomen, small intestine,... and other contents.

UnitedVRG - Tahir

[+] 1 - General and Perioperative Care of the Surgical Patient

[+] 2 - Common Postoperative Problems

[+] 3 - Nutrition for the Surgical Patient

[+] 4 - Fluid, Electrolytes, and Acid-Base Disorders

[+] 5 - Anticoagulation, Hemostasis, and Transfusions

[+] 20 - Surgical Diseases of the Liver

[+] 21 - Surgical Diseases of the Biliary Tree

[+] 22 - Surgical Diseases of the Pancreas

[+] 23 - Spleen

[+] 24 - Colon and Rectum

[+] 25 - Anorectal Disease

[+] 26 - Cerebrovascular Disease

[+] 27 - Thoracoabdominal Vascular Disease

[+] 28 - Peripheral Arterial Disease

[+] 29 - Venous and Lymphatic Disease

[+] 36 - Skin and Soft-Tissue Tumors

[+] 37 - Fundamentals of Laparoscopic, Robotic and Endoscopic Surgery

[+] 38 - Hernias

[+] 39 - Diseases of the Adrenal and Pituitary Gland and Hereditary Endocrine Syndromes

[+] 40 - Thyroid and Parathyroid Glands

[+] 41 - Otolaryngology for the General Surgeon

[+] 42 - Plastic and Hand Surgery

[+] 43 - Urology for the General Surgeon

[+] 44 - Obstetrics and Gynecology for the General Surgeon

[+] 45 - Biostatistics for the General Surgeon

[+] 46 - Patient Safety and Quality Improvement in Surgery

BACK OF BOOK

[+] Answer Key

[+] Index

School of Medicine

St Louis, Missouri

Foreword by

Timothy J Eberlein, MD

Bixby Professor and Chair of Surgery

Director, Siteman Cancer Center

Assistant Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Joshua A F Balderman, MD

Resident in Vascular Surgery

Washington University School of Medicine

Assistant Professor of Surgery

Washington University School of Medicine

Assistant Professor of Surgery

Washington University School of Medicine

Chun-Cheng (Richard) Chen, MD, PhD

Niess-Gain Professor of Surgery

Washington University School of Medicine

Maria B Majella Doyle, MD

Associate Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Bernard J DuBray Jr., MD

Resident in Surgery

Washington University School of Medicine

St Louis, Missouri

J Christopher Eagon, MD

Associate Professor of Surgery

Washington University School of Medicine

Assistant Professor of Surgery

Washington University School of Medicine

Neidorff Family and Robert C Packman Professor of Surgery

Washington University School of Medicine

Resident in Plastic and Reconstructive Surgery

Washington University School of Medicine

Steven R Hunt, MD

Associate Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Kareem D Husain, MD

Assistant Professor of Surgery

Washington University School of Medicine

Assistant Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

John P Kirby, MD

Associate Professor of Surgery

Washington University School of Medicine

Washington University School of Medicine

Associate Professor of Surgery

Washington University School of Medicine

Assistant Professor of Orthopedics

Washington University School of Medicine

Associate Professor of Surgery

Washington University School of Medicine

Resident in Vascular Surgery

Washington University School of Medicine

Varun Puri, MD, MSCI

Assistant Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Kathleen G Raman, MD, MPH

Assistant Professor of Surgery

Washington University School of Medicine

Resident in Urologic Surgery

Washington University School of Medicine

Resident in Surgery

Washington University School of Medicine

St Louis, Missouri

Jacqueline M Saito, MD

Assistant Professor of Pediatric Surgery

Washington University School of Medicine

Gregorio A Sicard Professor of Surgery

Washington University School of Medicine

Associate Professor of Surgery

Washington University School of Medicine

Surendra Shenoy, MD

Associate Professor of Surgery

Washington University School of Medicine

Tracey Wagner Stevens, MD

Assistant Professor of AnesthesiologyWashington University School of Medicine

Pruett Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Isaiah R Turnbull, MD

Assistant Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Chandu Vemuri, MD

Assistant Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Thomas J Wade, MD

Fellow in Minimally Invasive Surgery

Washington University School of Medicine

Jason R Wellen, MD, MBA

Assistant Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Ivy Wilkinson-Ryan, MD

Fellow in Obstetrics and Gynecologic Surgery

Washington University School of Medicine

St Louis, Missouri

Robert D Winfield, MD

Assistant Professor of Surgery

Washington University School of Medicine

St Louis, Missouri

Paul E Wise, MD

Associate Professor of Surgery

Washington University School of Medicine

Welcome to the seventh edition of The Washington Manualª of Surgery Over the past 100 years,

an important focus of our Department of Surgery has been medical education of students,

residents, fellows, and practicing surgeons This commitment is clearly evident in the currentedition of The Washington Manualª of Surgery

The educational focus of our Department of Surgery has a rich tradition The first full-time head

of the Department of Surgery at Washington University was Dr Evarts A Graham (1919Ñ1951)

Dr Graham was a superb educator Not only was he an outstanding technical surgeon, but hisinsightful comments at conferences and ward rounds were well known and appreciated by ageneration of surgeons who learned at his elbow Dr Graham was a founding member of theAmerican Board of Surgery and made many seminal contributions to the management of surgicalpatients His work in the development of oral cholecystography actually helped establish theMallinckrodt Institute of Radiology at Washington University Dr Graham was among the first toidentify the epidemiological link of cigarette smoking to lung cancer and was instrumental inraising public health consciousness about the deleterious effect on health from cigarette smoke

Dr Carl Moyer (1951Ñ1965) succeeded Dr Graham Dr Moyer is still regarded as a legendaryeducator at Washington University He was particularly known for his bedside teaching

techniques, as well as for linking pathophysiology to patient care outcomes Dr Walter Ballinger(1967-1978) came from the Johns Hopkins University and incorporated the Halsted tradition ofresident education Dr Ballinger introduced the importance of laboratory investigation and began

to foster development of the surgeon/scientist in our department Dr Samuel A Wells 1997) is credited with establishing one of the most accomplished academic departments of

(1978-surgery in the United States Not only did he recruit world-class faculty, but he increased thefocus on research and patient care Dr Wells also placed a great emphasis on educating thefuture academic leaders of surgery

As in previous editions, this seventh edition of The Washington Manualª of Surgery combinesauthorship of residents, ably assisted by faculty coauthors and our senior editor, Dr Mary

Klingensmith, who is vice-chair for education in our department Dr Klingensmith is joined in thisedition by a new senior editor, Dr Chandu Vemuri This combination of resident and facultyparticipation has helped to focus the chapters on issues that will be particularly helpful to thetrainee in surgery This new edition of the manual provides a complete list of updated referencesthat will serve medical students, residents, and practicing surgeons who wish to delve moredeeply into a particular topic This manual does not attempt to extensively cover pathophysiology

or history, but it presents brief and logical approaches to the management of patients with

comprehensive surgical problems In each of the chapters, the authors have attempted to provide

> Table of Contents > Foreword

the most up-to-date and important diagnostic and management information for a given topic, aswell as algorithms for quick reference We have attempted to standardize each of the chapters sothat the reader will be able to most easily obtain information regardless of subject matter

The seventh edition has undergone a reorganization of chapters with an emphasis on clarity andconsistency As with the past edition, evidence-based medicine has been incorporated into each

of the chapters, with updated information and references to reflect current knowledge and

practice All of the sections have been updated

and rewritten to reflect the most current standards of practice for each topic These updates havebeen carefully edited and integrated so that the volume of pages remains approximately the

same Our goal is to keep this volume concise, portable, and userfriendly I am truly indebted toDrs Klingensmith and Vemuri for their passion for education and devotion to this project

Additionally, I am proud of the residents in the Department of Surgery at Washington Universitywho have done such an outstanding job with their faculty co-authors in this seventh edition I

hope that you will find The Washington Manualª of Surgery a reference you commonly utilize in

the care of your patient with surgical disease

Timothy J Eberlein, MD

St Louis, Missouri

As with the previous six editions, this seventh edition of The Washington Manualª of Surgery isdesigned to complement The Washington Manual of Medical Therapeutics Written by residentand faculty members of the Department of Surgery, it presents a brief, rational approach to themanagement of patients with surgical problems The text is directed to the reader at the level ofthe second- or third-year surgical resident, although surgical and nonsurgical attendings, medicalstudents, physician assistants, nurse practitioners, and others who provide care for patients withsurgical problems will find it of interest and assistance The book provides a succinct discussion ofsurgical diseases, with algorithms for addressing problems based on the opinions of the physicianauthors Although multiple approaches may be reasonable for some clinical situations, this

manual attempts to present a single, effective approach for each We have limited coverage ofdiagnosis and therapy; this is not an exhaustive surgical reference Coverage of pathophysiology,the history of surgery, and extensive reference lists have been excluded from most areas

This is the seventh edition of the manual; the first edition was published in 1997, followed byeditions in 1999, 2002, 2005, 2007, and 2012 New to this volume is a set of multiple-choicereview questions at the end of each chapter so that readers can self-assess their knowledge.Additionally, we have added chapters on ÒBiostatistics for the General Surgeon,Ó ÒQuality

Improvement and Patient Safety,Ó and ÒFundamentals of Endoscopic, Laparoscopic, and RoboticSurgeryÓ; many chapters have been consolidated and reorganized to best reflect the nature ofsurgical practice In addition, chapters have been updated with evidence-based medicine, withthe latest information and treatment algorithms in each section In many chapters, additionaltreatment algorithms have been added for quick reference As with previous editions, this seventhedition includes updates on each topic as well as substantial new material

This is a resident-prepared manual Each chapter was extensively updated and revised (or

authored) by a resident with assistance from a faculty coauthor Editorial oversight for the manualwas shared by four senior resident coeditors (Lola Fayanju, MD, Chapters 35, 36, 38, 39, 40, 41,

42, 43, 44, 45 and 46; Pamela Samson, MD, Chapters 6 and 7, 26, 27, 28, 29, 30 and 31, 33 and34; Dominic Sanford, MD, Chapters 15, 16, 17 18, 19, 20, 21, 22, 23, 24 and 25 and 37; andJason Robertson, MD, Chapters 1, 2, 3, 4 and 5, 8, 9, 10, 11, 12, 13 and 14 and 32) Additionally,

Dr Chandu Vemuri, assistant professor and vascular surgeon extraordinaire, provided some

editorial and leadership assistance for this edition The tremendous effort of all involvedÑ

residents and faculty members and particularly the senior resident coeditorsÑis reflected in thequality and consistency of the chapters

I am indebted to the former senior editor of this work, Gerard M Doherty, MD, who developedand oversaw the first three editions, then handed over to me an exceptionally well-organized

> Table of Contents > Preface

project I am grateful for the continued tremendous support from Wolters Kluwer Health, whohave been supportive of the effort and have supplied dedicated assistance Keith Donnellan hasbeen tremendously helpful, and Brendan Huffman has been a terrific developmental editor,

keeping me in line and on schedule

Finally, I am grateful to have a fantastic mentor and leader in my department chair, Timothy J.Eberlein, MD He is an inspiration for his leadership, and dedication To my family, thank you forall you do to keep it all fun and interesting

M E K

I PREOPERATIVE EVALUATION AND MANAGEMENT

A General Evaluation of the Surgical Patient The goals of preoperative evaluation are to

(1) identify the patient's medical problems and functional status; (2) determine if further

information is needed to characterize the patient's medical status; (3) estimate the patient's level

of risk for the planned procedure; and (4) establish if the patient's condition is medically

optimized Much of this can be accomplished with a thorough history and physical examination.For minor surgical procedures and procedures on young, healthy patients, routine diagnostictesting is often unnecessary For patients with existing comorbidities, or in patients undergoingcertain complex procedures, preoperative laboratory studies and imaging should be decided on anindividual basis

B Specific Considerations in Preoperative Management

1 Cardiovascular disease is one of the leading causes of death after noncardiac surgery.

Patients who experience a myocardial infarction (MI) after noncardiac surgery have a hospitalmortality rate of 15% to 25% (CMAJ 2005;173:627) A study of 4,315 patients older than 50years of age undergoing nonemergent, noncardiac surgery with expected postoperative staysgreater than 48 hours found that major perioperative cardiac events occur in 1.4% of patients(Circulation 1999;100:1043) Risk stratification for major adverse cardiac events (MACE, defined

as death, Q-wave MI, and need for revascularization) by the operating surgeon, anesthesiologist,and consulting internist is important

a Risk factors A number of patient factors have been identified and are associated with

perioperative cardiac morbidity and mortality These include age above 70 years, unstable angina,recent (prior 6 months) MI, untreated CHF, diabetes mellitus, valvular heart disease, cardiacarrhythmias, peripheral vascular disease, and functional impairment Factors related to the

surgical procedure under consideration also convey risk In their most recent guidelines published

in 2014, the American Heart Association has condensed procedures into two risk levels: low risk(MACE risk <1%) and elevated risk (MACE risk >1%) The category of intermediate risk is nolonger used, as the management of patients undergoing these and elevated risk procedures issimilar

> Table of Contents > 1 - General and Perioperative Care of the Surgical Patient

P.2

b Cardiac risk indices/calculators Several tools have been created to aid in predicting

preoperative risk of a MACE The Revised Cardiac Index is one such tool, and its criteria are

shown in Table 1-1 The American College of Surgeons NSQIP Surgical Risk Calculator combinescardiac and noncardiac factors to calculate risk of overall postoperative complications and can befound at riskcalculator.facs.org

c Functional status Patients with poor functional status are at significantly elevated risk of

perioperative cardiac events This can usually be assessed from a patient's activities of daily living(ADLs) and is often expressed in metabolic equivalents (METs), with 1 MET equaling the restingoxygen consumption of an average 40-year-old male (Table 1-2) Functional capacity can be

classified as excellent (>10 METs), good (7 to 10 METs), moderate (4 to 6 METs), or poor (<4

METs) Moderate functional capacity is classified as the ability to perform usual ADLs

d Preoperative testing Specific preoperative workup is based on several factors including

medical history, urgency of surgery, risk

of surgical procedure, patient functional status, and goals of care A treatment algorithm guidingthe preoperative cardiac workup is shown in Figure 1-1 When it is determined that a patient

requires further testing prior to surgery, a multidisciplinary approach including a cardiologist is

employed to determine which noninvasive or invasive measures should be taken to optimize thepatient

Risk Factor Comment

History of CHF History of CHF, pulmonary edema, or paroxysmal nocturnal

dyspnea, bilateral rales, S3 gallop, chest x-ray showing pulmonaryvascular redistribution

TABLE 1-2 Assessment of Functional Status

Functional

Capacity

MET Range

Example Activities

Poor <4 Sleeping, writing, watching TV, walking 2-3 mph on flat

land, golfing with a cartModerate 4-7 Climbing a flight of steps, slow bicycling, sexual activityGood 7-10 Jogging, calisthenics

Excellent >10 Rope jumping

e Preoperative management

(1) Patients with pacemakers should have their pacemakers turned to the uninhibited mode

(e.g., DOO) before surgery In addition, bipolar cautery should be used when possible in these

patients If unipolar cautery is necessary, the dispersive electrode should be placed away from

the heart

(2) Patients with internal defibrillators should have these devices turned off during surgery (3) Perioperative beta-blockade should be considered as part of a thorough evaluation of

each patient's clinical and surgical risk Preoperative evaluation should involve identification of

active cardiac conditions that would require intensive management and may result in delay or

cancellation of nonemergent operations Over the past 15 years, there has been conflicting and

poorly supported evidence regarding the efficacy of beta-blockers in reducing perioperative

cardiac events However, recent studies, including the PeriOperative ISchemic Evaluation (POISE)trial, suggest that beta-blockers reduce perioperative ischemia and may reduce the risk of MI andcardiovascular death in high-risk patients (Lancet 2008;371:1839-1847) Routine administration

of higher-dose, long-acting metoprolol on the day of surgery should be avoided in beta-blocker

na•ve patients, as its use is associated with an overall increase in mortality Beta-blockers shouldideally be started in appropriate patients days to weeks before elective surgery Preoperatively,

each patient's dose should be titrated to achieve adequate heart rate control to benefit from blockade while avoiding the risks of hypotension and bradycardia (Circulation 2009;120:2123-

beta-2151)

Figure 1-1 Algorithm for preoperative workup of cardiac disease (Adapted from Flelisher

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 Col Cardiol 2014;64(22):e77-e137.)

(4) Patients with recent angioplasty or stenting Over the past two decades, use of

coronary angioplasty and stenting has increased dramatically Several studies have shown a highincidence of cardiovascular complications when noncardiac surgery is performed shortly after

coronary angioplasty or stenting Current guidelines are to delay noncardiac surgery at least 6

weeks after coronary angioplasty or placement of bare metal stents, which require 6 weeks of

dual antiplatelet therapy with aspirin and clopidogrel In contrast, dual antiplatelet therapy should

be continued for at least 12 months following placement of a drug-eluting stent (DES), which canaffect timing of elective operations For all patients, the risk of bleeding and thrombosis need to

be weighed against each other Surgery in an open body space such as the abdomen is possible

on patients taking these medications, albeit with an elevated bleeding risk

2 Pulmonary disease Preexisting lung disease confers a dramatically increased risk of

perioperative pulmonary complications Risk factors for pulmonary complications include chronicobstructive pulmonary disease, smoking, asthma, obstructive sleep apnea, advanced age, obesity,surgical site located near the diaphragm, smoking, and functional status

a Preoperative evaluation and screening

(1) Physical examination should be performed carefully, with attention paid to signs of lung

disease (e.g., wheezing, prolonged expiratoryÑinspiratory ratio, clubbing, or use of accessory

muscles of respiration)

(2) Diagnostic evaluation

(a) A chest x-ray (CXR) should only be performed for acute symptoms related to pulmonary

disease, unless it is indicated for the specific procedure under consideration

(b) An arterial blood gas (ABG) can be considered in patients with a history of lung disease or

smoking to provide a baseline for comparison with postoperative studies, but is not reliable to

accurately predict postoperative pulmonary complications

(c) Preoperative pulmonary function testing is controversial and probably unnecessary in

stable patients with previously characterized pulmonary disease undergoing nonthoracic

procedures

b Preoperative prophylaxis and management

(1) Pulmonary toilet Increasing lung volume by the use of preoperative incentive spirometry is

potentially effective in reducing pulmonary complications

(2) Antibiotics do not reduce pulmonary infectious complications in the absence of preoperative

infection Elective operations should be postponed in patients with respiratory infections If

emergent surgery is required, patients with acute pulmonary infections should receive

intravenous (IV) antibiotic therapy

(3) Cessation of smoking All patients should be encouraged to and assisted in smoking

cessation before surgery There has been debate over timing of smoking cessation, in particularover whether smoking cessation within weeks of surgery may paradoxically increase pulmonary

complications This concern, however, is not supported by evidence, and current guidelines favorsmoking cessation prior to surgery regardless of timeframe

(4) Bronchodilators In the patient with obstructive airway disease and evidence of a

significant reactive component, bronchodilators may be required in the perioperative period

Elective operation should be postponed in the patient who is actively wheezing

3 Renal disease

a Preoperative evaluation of patients with existing renal insufficiency

(1) Evaluation

(a) History Patients with hypertension or diabetes and CRI are at a substantially increased risk

of perioperative morbidity and mortality The timing and quality of the patient's last dialysis

session, the amount of fluid removed, and the preoperative weight provide important informationabout the patient's volume status In nonanuric patients, the amount of urine made on a daily

basis should also be documented

(b) Physical examination should be performed to assess the volume status Elevated jugular

venous pulsations or crackles on lung examination can indicate intravascular volume overload

(c) Diagnostic testing

(i) Laboratory data Serum electrolyte and bicarbonate levels should be measured, as well as

blood urea nitrogen (BUN) and creatinine A complete blood cell count (CBC) should be obtained

to evaluate for significant anemia or a low platelet level Normal platelet numbers can mask

platelet dysfunction in patients with chronic uremia

(2) Management

(a) Timing of dialysis Dialysis should be performed within 24 hours of the planned operative

procedure

(b) Intravascular volume status Cardiac events are the most common cause of death in

patients with CRI Both hypovolemia and volume overload are poorly tolerated, and invasive

monitoring in the intraoperative and postoperative periods may assist in optimizing fluid balance

b Preventing perioperative renal dysfunction

(1) Risk factors Patients without preexisting CRI ranges may be at risk of developing

postoperative acute renal failure (ARF), depending on certain patient and procedure risk factors.Incidence of postoperative ARF ranges from 1.5% to 2.5% for

cardiac surgical procedures to more than 10% for patients undergoing repair of supraceliac

abdominal aortic aneurysms (AAAs) Other risk factors for the development of ARF include

elevated preoperative BUN or creatinine, CHF, advanced age, intraoperative hypotension, sepsis,aortic cross-clamping, intravascular volume contraction, and use of nephrotoxic and

radionucleotide agents

(2) Prevention

(a) Intravascular volume expansion Adequate hydration is the most important preventive

measure for reducing the incidence of ARF

(b) Radiocontrast dye administration Patients undergoing radiocontrast dye studies have an

increased incidence of postoperative renal failure Fluid administration (1 to 2 L of isotonic saline)alone appears to confer protection against ARF Additional commonly used but unproven

measures for reducing the incidence of contrast dye-mediated ARF include the use of

low-osmolality contrast agents, a bicarbonate drip, and oral N-acetylcysteine

(c) Other nephrotoxinsÑincluding aminoglycoside antibiotics, nonsteroidal anti-inflammatory

drugs (NSAIDs), and various anesthetic drugsÑcan predispose to renal failure, as well, and should

be avoided in patients at high risk for postoperative renal failure

4 Infectious complications Infectious complications are a major cause of morbidity and

mortality following surgery They may arise at the surgical site itself or in other organ systems It

is impossible to overemphasize the importance of frequent handwashing or antiseptic foam use

by all healthcare workers to prevent the spread of infection In addition to impacting the patient,rates of postsurgical infections are closely monitored by hospitals and healthcare providers, and

are increasingly being used as a metric by which hospitals, departments, and surgeons are

measured

a Assessment of risk Risk factors for infectious complications after surgery can be grouped

into procedure-specific and patient-specific risk factors

(1) Procedure-specific risk factors include the type of operation, the degree of wound

contamination (whether the case is classified as clean, cleanÑcontaminated, contaminated, or

dirty), and the duration and urgency of the operation

(2) Patient-specific risk factors include age, diabetes, obesity, immunosuppression,

malnutrition, preexisting infection, and other chronic illness

b Prophylaxis

(1) Surgical site infection Several modifiable factors under control of various members of the

recommendations for specific procedures are shown in Table 1-4.

(2) Respiratory infections Risk factors and measures for preventing pulmonary complications

are discussed in Section I.B.2

(3) Genitourinary infections may be caused by instrumentation of the urinary tract or

placement of an indwelling urinary catheter Preventive measures include avoiding catheterizationfor short operations, sterile insertion of the catheter, and removal of the catheter on

postoperative day 1 Some operations that include a low pelvic dissection, will require longer

catheterization because of local trauma

TABLE 1-3 Recommendations for Prevention of

Surgical Site Infection

The guidelines provided by the CDC and accrediting agents have been followed

These include techniques for asepsis, air handling, cleaning of surfaces, sterilization

techniques, and activities and attire of the surgical team

Members of the operative team have double gloved and changed gloves when any

perforation is identified

Preoperative showering with chlorhexidine the night prior and few hours of the

operation was done and preoperative cleansing of the site with a

chlorhexidine-impregnated cloth just before entering the operating room

Clippers used for hair removal shortly before operation

Reduction of skin organisms of patient and surgical team done with a combination of

alcohol and chlorhexidine, or iodophors

Antimicrobial impregnated adherent drape used at operative site

Suture material resistant to infection used wherever possible

Dead spaces obliterated, where possible

Minimal trauma to the wound itself with limited use of electrocautery, with devitalized

tissue removed

Drainage through a working incision not used

Prophylactic topical antibiotics used by pressure irrigation during operation and prior

to closure in all but simplest cases

Prophylactic systemic antibiotics used according to guidelines in all cases with

incidence of infection >0.5% and all cases with foreign body implantation

Core temperature maintained above 36¡C or higher throughout perioperative period

Inspired oxygen given to maintain SpO2 >96%

All diabetic and hyperglycemic patients received tight glucose control (blood glucose

<180 mg/dL) during perioperative period and for 2-3 days afterward in high-risk

patients

Transfusion of blood products limited

Patients have stopped smoking for at least 4 weeks prior to any highly elective

operation

Adapted from Alexaner JW, et al Annals of Surgery 2011:1082-93

TABLE 1-4 Recommendations for Antibiotic Prophylaxis

Antibiotics

Cardiac: Prosthetic valve

and other procedures

Staphylococci,corynebacteria, entericGramnegative bacilli

Vancomycin andCefazolin

Vancomycin andAztreonamThoracic Staphylococci Cefazolin Vancomycin

Vascular: Peripheral

bypass or aortic surgery

with prosthetic graft

Staphylococci, streptococci,enteric

Gram-negative bacilli,clostridia

CefazolinVancomycin andAztreonama

Orthopedic: Total joint

replacement or internal

fixation of fractures

Staphylococci Cefazolin

Vancomycin

Colorectal Enteric Gramnegative bacilli,

anaerobes, enterococci

Cefoxitin CefotetanErtapenem Cefazolinand Metronidazole

Obstetrics/gynecology Enteric Gramnegative bacilli,

anaerobes, group Bstreptococci, enterococci

CefotetanCefoxitinCefazolinClindamycin andGentamicin

a IV, intravenous

From Casabar E, Portell J The Tool Book: Drug Dosing and Treatment Guidelines,

Jewish Hospital 12th ed St Louis, MO: Department of Pharmacy,

Barnes-Jewish Hospital; 2014

5 Diabetes mellitus Diabetic patients are at increased risk of morbidity and mortality Vascular

disease is common in diabetics, and MI, often with an atypical presentation, is the leading cause

of perioperative death among diabetic patients

a Preoperative evaluation All diabetic patients should have their blood glucose measured in

pre-op holding and intraoperatively to prevent unrecognized hyperglycemia or hypoglycemia

(1) Patients with diet-controlled diabetes mellitus can be maintained safely without food or

glucose infusion before surgery

(2) Oral hypoglycemic agents should be discontinued the evening before scheduled surgery.

Long-acting agents such as chlorpropamide or glyburide should be discontinued 2 to 3 days prior

(3) Insulin-dependent diabetics require insulin and glucose preoperatively to prevent ketosis

and catabolism Patients undergoing major surgery should receive one-half of their morning

insulin dose and 5% dextrose intravenously Subsequent insulin administration by either

subcutaneous (SC) sliding-scale or insulin infusion is guided by frequent blood glucose

determinations SC insulin pumps should be inactivated the morning of surgery

6 Anticoagulation The most common indications for warfarin therapy are atrial fibrillation,

venous thromboembolism (VTE), and mechanical heart valves Warfarin's anticoagulant effect

endures for several days following cessation of the drug Recommendations for the management

of anticoagulation in the perioperative period require weighing the risks of thromboembolic events(Table 1-5) against the risk of perioperative bleeding

a Preoperative anticoagulation Surgery is generally safe when the international normalized

ratio (INR) value is below 1.5 Patients whose INRs are maintained between 2.0 and 3.0 normallyrequire withholding of the medication for 5 days preoperatively

b Patients with high risk of thrombotic complications should be managed with bridging

anticoagulation This can consist of transitioning as an outpatient with low-molecular-weight

heparin (LMWH, stopped 24 hours prior to surgery) or as an inpatient with an unfractionated

heparin (UFH, stopped 4 to 6 hours prior to surgery) infusion when Coumadin is stopped

c Postoperative anticoagulation Coumadin requires several days to reach therapeutic levels,

so therapy can be resumed on postoperative days 1 or 2 High-risk patients should be bridged

with therapeutically dosed SC LMWH or IV UFH until their INR is therapeutic; moderate-risk

patients can be bridged with therapeutically dosed SC LMWH, therapeutically dosed IV UFH, or

prophylactically dosed SC LMWH Low-risk patients do not need to be bridged

d Emergent procedures In urgent or emergent situations in which there is no time to reverse

anticoagulation before surgery, plasma products, such as fresh frozen plasma (FFP), must be

administered Vitamin K can be administered, but its effects will not be seen for 8 hours if given

orally and it will continue to counteract Coumadin given postoperatively

TABLE 1-5 Risk Stratification for Perioperative

ThromboembolismIndication for Anticoagulation

High Any mitral valve prosthesis;

recent stroke or TIA; high

CHADS2 score

5 or 6; stroke

Recent (<3 mo) VTE;

severe thrombophilia

risk aortic prostheses or TIA within

3 mo;

Rheumaticheart valvedisease

(protein C or Sdeficiency, anti-phospholipidsyndrome)

Moderate Bileaflet aortic prosthesis

plus one of: atrialfibrillation (AF), priorstroke or TIA,

hypertension, diabetes,congestive heart failure,age >75

CHADS2 score

3 or 4

VTE within 3-12 mo;

less severethrombophilia (Factor

V Leiden, prothrombinmutation); recurrentVTE; active cancer

Low Bileaflet aortic prosthesis

with no other stroke riskfactors

CHADS2 score

of 0-2

VTE >12 mo and noother risk factors

Adapted from Douketis JD, et al Chest 2012;141:e326S-e30S

II POSTOPERATIVE CARE OF THE PATIENT

A Routine Postoperative Care

1 Intravenous fluids The intravascular volume of surgical patients is depleted by both

insensible fluid losses and redistribution into the third space As a general rule, patients should bemaintained on IV fluids until they are tolerating oral intake Extensive open abdominal proceduresare associated with a loss of 500 to 1,000 mL/hour and require aggressive resuscitation

2 Deep venous thrombosis prophylaxis It is important to provide prophylactic therapy to

nonambulatory patients to reduce the risk of deep venous thrombosis (DVT) and pulmonary

embolism (PE) (Table 1-6) Risk of DVT development depends on both patient and procedure riskfactors Surgery for major trauma, hip or leg fractures, spinal cord injury, intra-abdominal cancer,joint replacement, and bariatric surgery are particularly of high risk The most significant patient

risk factor is a prior history of DVT Other patient risk factors include malignancy, thrombophilias,oral contraceptive therapy, obesity, immobility, and indwelling central venous lines Prophylaxis

should be started

preoperatively in patients undergoing major procedures because of venous stasis and relative

hypercoagulability occur during the operation Prophylaxis and management of patients with a

history of DVT or PE are discussed in Chapter 29.

TABLE 1-6 Recommendations for VTE Prophylaxis

Risk and Consequences of Major Bleeding

Risk of

Symptomatic

High (>2% or Severe Consequences)

High (6%) LDUH, LMWH, plus mechanical

prophylaxis with ES or IPC

Mechanical prophylaxis,preferably with IPC, untilbleeding risk allow addition

Modified from Gould MK, et al Chest 2012:e227s

3 Pulmonary toilet Pain and immobilization in the postoperative patient decrease the

clearance of pulmonary secretions and the recruitment of alveoli Patients with inadequate

pulmonary toilet can develop fevers, hypoxemia, and pneumonia Early mobilization, incentive

spirometry, and cough and deep breathing exercises are indispensable to avoid these

complications

CHAPTER 1: PERIOPERATIVE CARE

Multiple Choice Questions

1 Which of the following factors is associated with the highest elevated cardiac risk?

a Diabetes controlled with metformin and glyburide

b Mild renal impairment with a preoperative creatinine level of 1.7 mg/dL

c History of a transient ischemic attach 9 months ago

d History of hypertension controlled with three medications

View Answer

2 Classify the functional status of a patient who is able to golf with a

cart and climb two flights of steps but unable to jog or do push ups:

3 Which of the following is a recommendation endorsed by the

American College of Surgeons to reduce the risk of surgical site

infection?

a Hair removal from surgical site by shaving

b Tight glucose control perioperatively with goal of <200 mg/dL

c Core body temperature maintained above 35.5°C

d Use of supplementary oxygen during surgery to maintain SpO2 greater

than 96%

View Answer

4 Which of the following patients with a history of venous

thromboembolism (VTE) is at highest risk for recurrent VTE when

undergoing a surgical procedure?

a A patient with a spontaneous VTE 3 years ago

b A patient with VTE 6 months ago who was diagnosed with Factor V

Leiden deficiency

c A patient with a VTE 4 months ago from Protein C deficiency

d A patient with a diagnosis of ovarian cancer who was diagnosed with a

pulmonary embolism 9 months ago

View Answer

5 Which patient with a prosthetic heart valve is at greatest risk of

perioperative thromboembolism?

a A diabetic with a bileaflet aortic prosthesis

b An asymptomatic patient with mitral prosthesis

c A patient with CVA diagnosed 1 year ago who has a bileaflet aortic

prosthesis

d A patient with atrial fibrillation who has a bileaflet aortic prosthesis

View Answer

6 Which of the following patients would require pharmacologic stress

testing prior to surgery?

a A patient presenting with sepsis from perforated diverticulitis who has

known coronary artery disease

b A patient with history of coronary artery disease and three-vessel

CABG with moderate functional status presenting for elective knee

replacement

c A diabetic set to undergo peripheral arterial bypass who has no

dyspnea on exertion but for whom claudication limits walking to ˜10

paces

d An elderly male with coronary artery disease and diabetes who is able

to bicycle several miles without dyspnea and is scheduled for major liver

resection

View Answer

7 For an elective operation, how many days prior to surgery should

Coumadin be discontinued?

a It need not be stopped

a A potassium level of 6.2 in an oliguric patient with no EKG changes

b Removal of fluid in an intubated and anuric patient with pulmonary

edema

c Oliguria and sepsis in a patient with creatinine 2× baseline and a

moderate metabolic acidosis

d A severely under-resuscitated patient with creatinine on 6.8

a Immediately following the procedure

problem that does not respond to initial intervention (e.g., hypovolemia unresponsive to fluidchallenge) should be considered for transfer to an intensive care unit (ICU) The stable patientcan be efficiently evaluated and treated in the inpatient ward This chapter offers descriptions ofcommonly encountered postoperative complaints, their initial workup and treatment.

I NEUROLOGIC COMPLICATIONS

A Diagnostic Considerations The physiologic changes from surgical stress

can alone affect neurologic function The patient in postoperative day 0 is

recovering from general anesthesia, the effects of which can last up to 48

hours In addition, after major surgery, patients are placed in unfamiliar

surroundings, are woken throughout the night, and are administered powerfulmedications to which they may not have been previously exposed When

evaluating neurologic concerns, initial differentiation should be made betweenthe patient with altered sensorium characterized by somnolence, confusion,disorientation, and other deficits in executive function and the patient with focalneurologic changes such as slurred speech, changes in sensation or motor

function, or cranial nerve deficits This delineation will guide the development of

a differential diagnosis Altered sensorium primarily results from systemic

problems such as hypoxemia, shock, or delirium Focal neurologic deficits areconcerning for an acute neurologic process such as stroke

B Basic Differential Diagnosis: Respiratory insufficiency, hypoglycemia,

stroke, hypotension, arrhythmia, seizure, delirium, alcohol withdrawal,

infection, medication related, and electrolyte abnormalities

C Initial Workup A full set of vital signs including pulse oximetry and a

fingerstick blood glucose should be immediately obtained For somnolent

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