Dr.

Hartwinder singh

I. Assessment of Operative Risk A. Natural History - relative harm (risk - relative good (!enefit

". #tages of the disease - error in $lini$al staging produ$es the greatest num!er of $ontroversies regarding management %. %lini$al &udgment - deviations of standard treatment is asso$iated with signifi$ant in$rease in mortality and mor!idity

D. "asi$ 'a$tors Affe$ting Operative Risk (. Age over )* years +. Overall physi$al status ,. -le$tive vs. emergen$y surgery .. /hysiologi$ e0tent of the tumor 1. Asso$iated illnesses

II. /ersonal Relationship A. 2enuine !ond of $ommuni$ation and personal responsi!ilities. ". /hysi$ian should not $onvey a sense of hurry and inade3uate time for e0planations. %. Involve physi$ians who have parallel skills to $ontri!ute to diagnosis and treatment. D. #pe$ifi$ treatment. -. Informed $onsent

III. 2eneral /reparation of the /atient A. /sy$hologi$al preparation (. /re-op steps should !e enumerated4 5ustified and e0plained. +. #urgeons should not e3uivo$ate in dis$ussing possi!le disfiguring operations.

". /hysiologi$ $onsiderations (. "lood volume $onsiderations a. anemia 6 $hroni$ or a$ute !. minimal re3uirement for anesthesia 6 (* gm7(** ml Hg!

+. Determine the physiologi$ limit for tissue o0ygen delivery. a. ta$hy$ardia !. in$rease in stroke volume $. in$rease in o0ygen e0tra$tion

,. /lasma and e0tra$ellular fluid defi$it - volume and $on$entration a. hourly urine output !. urine $on$entration $. mu$ous mem!ranes d. skin turgor

%. Nutrition (. #erum transferrin +. #erum al!umin ,. 8"% $ount D. /revent infe$tion (. 9reat distant infe$tions +. /rophyla$ti$ anti!ioti$s

I:. /ost-operative %are A. /ost-op fever - elevated temperature o!served in post-op patients does not ne$essarily signal a serious $ompli$ation - a spe$ifi$ $ause is identified in +*; of patients with pyre0ia during the initial +. hours - $omprehensive $lini$al evaluation is essential

i
(. Infe$tive $auses of post-op fever a. $ommunity a$3uired infe$tion !. $ontamination $. inade3uate !lood supply d. neonates and the elderly e. systemi$ fa$tors i. D< II ii. hepati$ disease iii. immunosupression iv. malnutrition

v.. o!esity 6 due to relatively poor !lood supply of the large reservoirs of fat vi. disseminated malignan$y 6 due to the $a$he$ti$ influen$es of the primary neoplasm and immunosuppression !y $hemothera peauti$ drugs vii. a$tive infe$tion viii. A$ute and $hroni$ al$ohol intake

+. Diagnosis and management - should !e dire$ted toward re$ognition and eradi$ation of the primary sour$e of e0ogenous pyrogens a. 'ever within +. hours 6 atele$tasis !. 1th to (*th day 6 wound infe$tion $. %lini$al evaluation is needed - rales and ron$hi - pneumonia

,. Other $auses of post-op fever a. suppurative parotitis i. usually elderly or de!ilitated patients ii. $aused !y dehydration and poor oral hygiene iii. + weeks post-op iv. #taph. aureus

!. operative site i. must always !e $onsidered for post-op fever ii. 1th post-op day $. I: lines i. re3uest for !lood $ulture ii. presents as $ellulitis iii. %: line sepsis due to infe$ted throm!us at the tip

d. throm!ophle!itis i. +nd post-op day ii. $atheter should !e removed at first sign of infe$tion iii. more fre3uent in the lower e0tremities iv. pus may !e present v. high fever and (= !lood $ulture vi. treatment $onsists of e0$ising vein

". Non-infe$tive $auses of /ost-op 'ever (. Disseminated malignan$y +. 9ransfusion rea$tion ,. Hematoma .. Administration of irritant fluids or 1. A$ute pan$reatitis >. 9hyroid storm ). /heo$hromo$ytoma ?. Dehydration

drugs

%. 'a$tors influen$ing likelihood of post-op infe$tion (. Definite de$rease in host resistan$e a. in$reasing age !. o!esity7malnutrition $. dia!eti$ ketoa$idosis d. a$ute7$hroni$ steroid use e. immunosuppressive drugs f. remote infe$tions

+. /ossi!le de$rease in host resistan$e a. some forms of $an$er !. radiation therapy $. adreno$orti$al insuffi$ien$y d. foreign !ody e. early shaving of the operative site

,. No effe$t on host resistan$e a. gender !. ra$e $. $ontrolled D< d. a$ute nutritional deprivation

%. Operations !enefiting from anti!ioti$ prophla0is (. Head and ne$k surgery with open aerodigestive tra$t +. -sophageal e0$ept hiatal hernia repair ,. 2astroduodenal e0$ept for $ompli$ations of un$orre$ted hypera$idity

.. "iliary tra$t surgery a. patients over )* years old !. a$ute $hole$ystitis $. $holedo$hostomy 1. "owel rese$tion >. /erforated or gangrenous appendi$itis ). Hystere$tomy ?. Revas$ulari@ation and prostheti$ graft surgery A. Orthopedi$ surgeries with implantation of prosthesis

D. Operative te$hni3ue to minimi@e infe$tion (. -liminate hair4 if ne$essary4 5ust prior to in$ision time +. -ffe$tive skin preparation ,. 2entle and effe$tive handling of tissues .. -ffe$tive hemostasis 1. -radi$ate dead spa$e >. <inimi@e operative time ). %losed su$tion drain a distan$e from the in$ision

-. /re-operative fa$tors asso$iated with postoperative $ardia$ $ompli$ation in order of dis$overy signifi$an$e (. &ugular vein distention or #, gallop (( points +. <yo$ardial infar$t within > months or #, gallop 6 (* points

,. /remature atrial $ontra$tions or rhythm other than sinus on -%2 6 ) points .. ,-1 /:%Bs7minute 6 ) points 1. Age over )* 6 1 points >. #ignifi$ant aorti$ stenosis 6 , points

). /oor general medi$al $ondition 6 , points a. /aO+C>* mm Hg /a%O+D1* mm Hg !. /otassiumC, me3 "i$ar!onateC+* me3 $. "EN D 1* mg7(** ml %rea D ,.* mg7(** ml

d. in$reased transaminases e. signs of $hroni$ liver disease f. patient !edridden for non-$ardia$ $auses ?. Operation a. emergen$y 6 . points !. intraperitoneal4 intrathora$i$4 aorti$ 6 , points 9O9AF 6 1, points

'. /re 6operative risk fa$tors for postoperative pulmonary $ompili$ations (. 9hora$i$ and upper a!dominal surgery +. /re-op history of %O/D ,. /urulent produ$tive $ough .. Anesthesia time greater than , hours >. Age greater than >* years old

). O!esity ?. /oor state of nutrition A. #ymptoms of respiratory disease (*. A!normal findings on /.-. ((. A!normal $hest film findings

2. /eri-operative prophla$ti$ pulmonary maneuvers (. %essation of smoking +. "ron$hodilators ,. %hest physiotherapy and postural drainage

.. /re-operative edu$ation and postoperative use of in$entive spirometry and deep !reathing e0$er$ises 1. /re-operative anti!ioti$s if sputum is purulent >. -arly post-operative anti!ioti$s

H. A sample of pre-operative $he$klist (. Operative permit 6 appropriately +. Dietary $onsiderations ,. Review of life support systems a. vital sign re$ordings !. $0r and other pulmonary studies $. -%2 and other $ardia$ studies
d. "EN7%reatinine and other renal studies

signed and witnessed

.. Ade3uate hydration up to time of surgery 1. Area of operation to !e washed and shaved with antimi$ro!ials >. /repare !lood for possi!le transfusion ). Order that the patient void on $all ?. /re-operative medi$ations A. #pe$ial medi$ations