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Perioperative Management

by Paul K. Mohabir, MD, Jennifer Gurney, MD

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) has published guidelines and recommendations to standardize and improve surgical care. The guidelines include a set of measures created by the Surgical Care Improvement Project (SCIP) referred to as the SCIP guidelines. The SCIP guidelines are published as part of a continually evolving manual that is intended to provide standard quality measures to unify documentation and track standards of care. The SCIP guidelines target complications that account for a significant portion of preventable morbidity as well as cost. Seven SCIP initiatives pertain to perioperative care. Among the general recommendations are the following:

  • Maintain a near-normal blood glucose level (eg, < 180 mg/dL) during the first 2 postoperative days, particularly in cardiac surgery patients.

  • Use clippers or depilatory methods, not a blade, to remove hair from the surgical site immediately before surgery.

  • Remove urinary catheters within the first 2 postoperative days except when required by specific clinical circumstances.

  • Standardize antibiotic choices based on type of surgery and patient factors (see Antibiotic Prophylaxis for Surgical Procedures).

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.

Anticoagulants and antiplatelets

Antiplatelet drugs (eg, aspirin) are usually stopped 5 to 7 days before surgery. Warfarin is stopped for 5 days before surgery; INR 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 (DVT)). 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 wk within the past year. 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.

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.

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.

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

  • Correct procedure and operative site (if applicable)

  • Availability of all needed equipment

  • Completion of indicated prophylaxis (eg, antibiotics, anticoagulants)

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.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • No US brand name
  • PANHEPRIN
  • COUMADIN
  • RAYOS
  • DOLOPHINE
  • LIBRIUM
  • VALIUM
  • ATIVAN

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