CURRENT Diagnosis & Treatment: Surgery, 14e >

Chapter 3: Preoperative Preparation

David McAneny

INTRODUCTION
The preoperative management of any patient is part of a continuum of care
that extends from the surgeon’s initial consultation through the patient’s full
recovery. While this ideally involves a multidisciplinary collaboration,
surgeons lead the effort to assure that correct care is provided to all patients.
This involves the establishment of a culture of quality care and patient safety
with high, uniform standards. In addition, the surgeon is responsible for
balancing the hazards of the natural history of the condition if left untreated
versus the risks of an operation. A successful operation depends upon the
surgeon’s comprehension of the biology of the patient’s disease and keen
patient selection.

This chapter will consider preoperative preparation from the perspectives of

the patient, the operating room facility and equipment, the operating room
staff, and the surgeon.

PREPARATION OF THE PATIENT

History & Physical Examination

The surgeon and team should obtain a proper history from each patient. The
history of present illness includes details about the presenting condition,
including establishing the acuity, urgency, or chronic nature of the problem.
Inquiries will certainly focus on the specific disease and related organ system.
Questions regarding pain can be guided by the acronym OPQRST, relating to
Onset (sudden or gradual), Precipitant (eg, fatty foods, movement, etc),
Quality (eg, sharp, dull, or cramps), Radiation (eg, to the back or shoulder),
Stop (what offers relief?), and Temporal (eg, duration, frequency, crescendo-
decrescendo, etc). The presence of fevers, sweats, or chills suggests the
possibility of an acute infection, whereas significant weight loss may imply a
chronic condition such as a tumor. The history of present illness is not
necessarily confined to the patient interview. Family members or guardians
provide useful information, and outside records can be indispensable.
Documents might include recent laboratory or imaging results that preclude
the need for repetitive, costly testing. The surgeon should request CD-ROM
disks of outside imaging, if appropriate. In the case of reoperative surgery,
prior operative reports and pathology reports are essential (eg, when
searching for a missing adenoma in recurrent primary hyperparathyroidism).

The past medical history should include prior operations, especially when
germane to the current situation, medical conditions, prior venous
thromboembolism (VTE) events such as deep vein thromboses (DVT) or
pulmonary emboli (PE), bleeding diatheses, prolonged bleeding with prior
operations or modest injuries (eg, epistaxis, gingival bleeding, or
ecchymoses), and untoward events during surgery or anesthesia, including
airway problems. One must secure a list of active medications, with dosages
and schedule. Moreover, it is beneficial to inquire about corticosteroid usage
within the past 6 months, even if not current, to avoid perioperative adrenal
insufficiency. Medication allergies and adverse reactions should be elicited,
although knowledge about environmental and food allergies is also valuable
and should be recorded so that these exposures are avoided during the
hospital stay. Some anesthesiologists are reluctant to use propofol in patients
with egg allergies, and reactions to shellfish suggest the possibility of
intolerance of intravenous iodinated contrast agents.

The social history classically involves inquiries into tobacco, alcohol, and illicit
drug usage, but this moment also offers the opportunity to establish a
personal relationship with patients (and their loved ones). It is fun and often
stimulating to learn about patients’ occupations, avocations, exercise,
interests and accomplishments, fears and expectations, and family lives.
Patients’ regular activities offer insight into physiologic reserve; an elite
athlete should tolerate nearly any major operation, whereas a frail, sedentary
patient can be a poor candidate for even relatively minor operations.

A family history includes queries pertinent to the patient’s presenting

condition. For example, if a patient with a colorectal cancer has relatives with
similar or other malignancies, genetic conditions such as familial
adenomatous polyposis or hereditary nonpolyposis colorectal cancer could be
indicted. This scenario would have screening implications for both the patient
and family members. In addition, one should also elicit a family history of VTE
complications, bleeding disorders, and anesthesia complications. For
example, a sudden and unexpected death of a relatively young family
member during an operation could suggest the possibility of a
pheochromocytoma, particularly in the setting of a medullary cancer or
related endocrine disorder. A strong family history of allergic reactions might
imply hypersensitivity to medications.

A review of systems assesses the patient’s cardiovascular, pulmonary, and

neurologic status, including questions about exertional chest pain or dyspnea,
palpitations, syncope, productive cough, or central nervous symptoms. It is
also important to have a basic understanding of the patient’s symptoms
relative to other major organ systems. For example, while one might not
necessarily expect an orthopedic surgeon to have an interest in a patient’s
gastrointestinal or genitourinary habits or problems, these issues may bear
grave consequences if a patient experiences postoperative incontinence
following joint replacement. Regardless of degree of specialization, surgeons
and their designated teams are capable of identifying and investigating
potentially confounding conditions.

A thorough physical examination is also an essential part of the patient

assessment. Even if the surgeon already knows from imaging that there will
be no pertinent physical findings, human touch and contact are fundamental
to the development of a trusting physician-patient relationship. In addition to
the traditional vital signs of pulse, blood pressure, respiratory rate, and
temperature, for many operations it is also important to record the patient’s
baseline oxygen saturation on room air, weight, height, and body mass index
(BMI). The physical examination includes an assessment of general fitness,
exercise tolerance, cachexia, or obesity, as well as focusing on the patient’s
condition. Additional observations may detect findings such as
cardiopulmonary abnormalities, bruits, absent peripheral pulses or bruits,
adenopathy, skin integrity, incidental masses, hand dominance, neurologic
deficits, or deformities. A thorough abdominal examination may include
digital anorectal and pelvic examinations. The surgeon should also appreciate
potential airway problems, particularly if general anesthesia is anticipated.

Preoperative Testing
Laboratory and imaging investigations are tailored to the individual patient’s
presenting condition, as discussed in later chapters. However, there should be
no “routine” battery of preoperative laboratory studies for all patients. In fact,
published data do not support an association between routine studies and
outcome. In addition, laboratory tests are costly and may result in harm due
to false-positive and fortuitous findings. Instead, tests should be selected
based upon the patient’s age, comorbidities, cardiac risk factors, medications,
and general health, as well as the complexity of the underlying condition and
proposed operation. For example, children uncommonly require preoperative
laboratory tests for most operations. On the other hand, a complete blood
count, chemistries, and an electrocardiogram are proper for high-risk patients
before complex operations. Algorithms and grid matrices are available to
individualize the selection of preoperative tests (Table 3–1). Importantly, each
system should establish a practice for managing abnormal test results,
whether germane to the patient’s active condition or a serendipitous finding.

Table 3–1. Sample preoperative testing grid.

INR Urine
Basic Liver
CBC or PTT Urinalysis EKG CXR Pregnancy
Chemistries Chemistries
PT Test
Cardiac disease (MI, CHF,
pacemaker/AICD, X X
coronary stents)
Pulmonary disease
X X X
(COPD, active asthma)
End-stage renal disease
X X X
on dialysis
Renal insufficiency X X
Liver disease X X X X
Hypertension X
Diabetes X X
Vascular disease X X
Symptoms of urinary
X
tract infection
Chemotherapy X X
Diuretics X
Anticoagulants X X
Major operation (eg,
cardiac, thoracic, X X X X
vascular, or abdominal)
Menstruating women X
AICD, automated implantable cardioverter-defibrillator; CBC, complete blood
count; CHF, congestive heart failure; COPD, chronic obstructive pulmonary
disease; CXR, chest radiograph; EKG, electrocardiogram; INR, international
normalized ratio; MI, myocardial infarction; PT, prothrombin time; PTT,
partial thromboplastin time.

Adapted from Surgical Directions LLC © 2009-2010, with permission.

A complete blood cell count and basic chemistries are reasonable for some
operations, but their likelihood of predicting abnormal or meaningful results
should be considered. Coagulation factors such as prothrombin time (PT),
international normalized ratio (INR), and partial thromboplastin time (PTT)
are not routinely indicated but should be pursued when patients report
prolonged bleeding or the usage of anticoagulants. Moreover, INR and PTT
may be warranted for operations that have little threshold for intraoperative
or postoperative bleeding, such as those on the brain, spine, or neck. Bile duct
obstruction, malnutrition, or an absent terminal ileum can affect vitamin K
absorption, and a preoperative assessment of INR is important in those
instances as well. A pregnancy test (eg, urine beta-human chorionic
gonadotropin [beta-HCG]) should be performed shortly before surgery on
women with childbearing potential. Other laboratory testing will be dictated
by specific conditions, including liver chemistries, tumor markers, and
hormone levels. A blood bank specimen should be selectively submitted in
advance of operations that are associated with significant hemorrhage or in
the setting of anemia with prospects for further blood loss. The preparation of
blood for transfusion is costly, so blood-typing alone may suffice without
actual cross-matching.

Routine preoperative testing of blood glucose is an intriguing concept, given

the relationship between elevated blood sugars and surgical site infections
(SSIs), although hemoglobin A1C levels have not correlated with postoperative
infections. Some reckon that nondiabetic patients comprise 30%-50% of
cases with perioperative hyperglycemia, perhaps constituting an argument
for measuring preoperative glucose levels in all candidates for major
operations. While it is accepted that diabetic patients require close
monitoring of perioperative glucose levels, including immediately before the
operation, the value of doing this for all patients is evolving and warrants
thoughtful investigation.
Some investigators have advocated routine nasal swab screening to identify
carriers of Staphylococcus aureus. The results can guide decontamination
measures such as intranasal application of antibiotic ointment (eg, mupirocin)
and local hygiene with 2% chlorhexidine showers for 5 days before surgery.
Patients with methicillin-resistant S aureus (MRSA) receive appropriate
antibiotic prophylaxis and contact precautions. Although the issue of routine
MRSA screening is not fully resolved, this practice may be ideal at least for
immunocompromised patients and for those undergoing open cardiac
operations and implantations of foreign bodies, particularly in orthopedics
and neurosurgery. Prospective wound or abscess culture results should also
influence decisions about perioperative antibiotics.

Electrocardiograms are not routinely performed but are justified for patients
older than 50 years; those having vascular operations; and those with a
history of hypertension, cardiac disease, significant respiratory disease, renal
dysfunction, and diabetes mellitus. Chest radiographs are no longer
performed on a regular basis but are primarily reserved for patients with
malignancies or perhaps with significant pulmonary disease. Further special
tests are selectively obtained when clinically indicated and often with
guidance from consultants; these tests may include echocardiography,
cardiac stress testing, baseline arterial blood gases, and pulmonary function
tests. Carotid ultrasonography may be valuable in patients with carotid bruits
or histories of cerebrovascular accidents or transient ischemia attacks.
Noninvasive venous studies may be considered in patients who have had
prolonged immobility and/or hospital stays before surgery.

PREOPERATIVE PROCESS
At its simplest, the process of preparing a patient for an operation can involve
a rapid assessment in the clinic or emergency room followed by an
expeditious trip to the operating room. However, like most care in the
contemporary health care system, the process is more commonly complex
and involves a formal series of integrated steps to assure best outcomes. It is
incumbent upon the surgery team to create an efficient and cost-effective
preoperative system and scheduling protocol that result in optimally
prepared patients, rare cancellations of operations, and few disruptions of the
operating room schedule. A systemic approach to patient preparation focuses
upon risk assessment and reduction, as well as education of the patient and
family. This effort begins during the first encounter with the surgeon and
continues through the moments before the operation. Ideal preoperative
systems assign risk based upon evaluations that are derived from sound
published evidence and best practices and driven by standardized algorithms
to identify and then modify hazards before operations.

Risk Assessment & Reduction

Overview

The essence of preparing a patient for an operation regards considering

whether the benefits of the operation justify the risks of doing harm, along
with deciding how to minimize or eliminate those hazards. The American
Society of Anesthesiologists (ASA) classification system (Table 3–2) stratifies
the degree of perioperative risk for patients. While somewhat rudimentary,
this system has faithfully served anesthesiologists and surgeons in predicting
how well patients might tolerate operations, and the scores have been
validated by several recent publications. The Acute Physiology and Chronic
Health Evaluation (APACHE II and III) is an example of a severity of illness
scoring system that may be applied to intensive care unit patients to predict
mortality. The value of such assessments lies in numerically designating the
severities of patients’ conditions, permitting comparisons of outcomes.

Table 3–2. American Society of Anesthesiologists (ASA) classification system.

ASA Preoperative Health
Example
Classification Status
No organic, physiologic, or psychiatric disturbance; excludes the
ASA 1 Normal healthy patient
very young and very old; healthy with good exercise tolerance
No functional limitations; has a well-controlled disease of one
Patients with mild body system; controlled hypertension or diabetes without
ASA 2
systemic disease systemic effects, cigarette smoking without chronic obstructive
pulmonary disease (COPD); mild obesity, pregnancy
Some functional limitation; has a controlled disease of more
than one body system or one major system; no immediate
Patients with severe danger of death; controlled congestive heart failure (CHF),
ASA 3
systemic disease stable angina, former heart attack, poorly controlled
hypertension, morbid obesity, chronic renal failure;
bronchospastic disease with intermittent symptoms
Patients with severe Has at least one severe disease that is poorly controlled or at end
ASA 4 systemic disease that is stage; possible risk of death; unstable angina, symptomatic
a constant threat to life COPD, symptomatic CHF, hepatorenal failure
Moribund patients who
Not expected to survive > 24 h without surgery; imminent risk of
are not expected to
ASA 5 death; multiorgan failure, sepsis syndrome with hemodynamic
survive without the
instability, hypothermia, poorly controlled coagulopathy
operation
 ASA Preoperative Health
Example
Classification Status
A declared brain-dead
patient whose organs
ASA 6
are being removed for
donor purposes

The University Health Systems Consortium (UHC) analyses derive from

inpatient administrative and financial datasets to predict risk-adjusted
outcomes for mortality, lengths of stay, and cost of care. The vagaries of
medical coding can result in discrepancies, and the UHC system does not
monitor patients after hospital discharge. Nevertheless, UHC data can
identify deficiencies in practice. Although clinical databases are more costly
and challenging to implement than commercially available products such as
the UHC program, they provide more robust risk-adjusted outcomes data.
Examples of clinical databases include those from the Society of Thoracic
Surgeons (STS) and the National Surgical Quality Improvement Program
(NSQIP). In NSQIP, dedicated nurses prospectively collect and validate an
established panel of defined patient variables, comorbidities, and outcomes,
and they pursue surveillance for 30 days after hospital discharge. The NSQIP
analysis considers patient factors, effectiveness of care, and random
variation, and logistic regression models calculate risk-adjusted 30-day
morbidity and mortality. These data are reported as odds ratios for
comparison with expected outcomes, allowing for the severity of the patients’
illnesses. Immediate benefits of NSQIP present the ability to identify true
risk-adjusted data and local opportunities for improvement. For example,
Veterans Administration (VA) surgeons reduced postoperative mortality from
3.2% in 2003 to 1.7% in 2005, while the complication rate declined from 17%
to 10% (p < 0.0001). This effort focuses upon systems of care, providing
reliable data to assess and reduce risks associated with operations. When
compared to UHC, NSQIP is much more likely to identify complications
because of its surveillance of patients 30 days beyond their hospitalizations.

The NSQIP program has also generated a tremendous repository of data to

develop “risk calculators” for a variety of operations and conditions, allowing
preoperative risk assessments and hopefully facilitating significant reductions
of preoperative hazards. Finally, NSQIP participants have fostered a culture of
sharing best practices and processes, both within the published literature and
through formal and personal collaborations.
Beyond the obvious physical and emotional implications of adverse outcomes
for patients and their families, the financial costs of postoperative
complications to the health care system are staggering. It has been
postulated that a major postoperative complication adds over $11,000 to the
cost of the hospital care of an affected individual and significantly extends the
duration of the inpatient confinement. In fact, the total cost of care increases
by more than half when a complication develops. Notably, respiratory
complications may increase the cost of care by more than $52,000 per
patient. Strikingly, data from NSQIP have demonstrated that the occurrence
of a serious complication (excluding superficial wound infections) after major
operations is an independent risk factor for decreased long-term survival.
Therefore, it is crucial that efforts focus upon reducing and eliminating
postoperative complications.

Well-designed, systematic preoperative assessment programs can

prospectively identify predictors of various complications and drive the ability
to attenuate risks and improve outcomes. The perspective of teams of
surgeons, physicians, nurses, and others with expertise managing
standardized, algorithm-driven preoperative evaluations, often with
checklists, is a departure from traditional care that primarily involved solitary
surgeons with disparate practices. The new paradigm recognizes that
variability in practice is the enemy of efficiency.

The financial dividends appreciated from enhanced results and diminished

death and complication rates more than compensate for the expenditures
associated with quality improvement efforts and participation in auditing
programs such as NSQIP. It is essential that surgeons monitor their patients’
outcomes, preferably in a risk-adjusted fashion, to understand their practices
and to demonstrate opportunities for improvement.

Cardiovascular

In 1977, Goldman published a multifactorial index for assessing cardiac

hazards among patients undergoing noncardiac operations. The same group
issued a Revised Cardiac Risk Index (RCRI) in 1999, reporting six independent
predictors of cardiac complications. These include a history of ischemic heart
disease, congestive heart failure, cerebrovascular disease, a high-risk
operation, preoperative treatment with insulin, and a preoperative serum
creatinine greater than 2.0 mg/dL. The likelihood of major cardiac
complications increases incrementally with the number of factors present.
Contemporary NSQIP data have led to the development of a risk calculator to
predict postoperative cardiac complications. A multivariate logistic regression
analysis demonstrated five prognostic factors for perioperative myocardial
infarction (MI) or cardiac arrest: the type of operation, dependent functional
status, abnormal creatinine, ASA class, and increasing age. The analysis has
been validated and has led to the composition of an interactive risk calculator.
Another multivariate model demonstrated criteria that predict adverse
cardiac events among patients who have had elective vascular operations,
and it also suggests improved predictive accuracy among these patients
compared to the RCRI. Independent hazards include increasing age, smoking,
insulin-dependent diabetes, coronary artery disease, congestive heart failure
(CHF), abnormal cardiac stress test, long-term beta-blocker therapy, chronic
obstructive pulmonary disease, and creatinine ≥1.8 mg/dL. Conversely, the
analysis demonstrated a beneficial effect of prior cardiac revascularization.
There is obviously overlap among the factors identified in these models.

The determination of an increased chance of a patient developing

postoperative cardiac complications will certainly influence the tenor of
preoperative discussions with patients and their family members, especially if
the surgeon can present validated data regarding the actual likelihood of a
cardiac complication or death. In addition, correctable hazards may be
addressed, including smoking cessation, optimal control of diabetes,
hypertension, and fluid status, and assurance of compliance with medical
measures. Finally, formal risk assessments guide cardiologists with respect to
cardiac stress testing, echocardiography, and coronary catheterization
among higher-risk patients. Selected patients may be candidates for
preoperative revascularization, either with coronary artery stent placement or
surgical bypass.

The American College of Cardiology (ACC) Foundation and the American

Heart Association (AHA) periodically issue joint recommendations about the
cardiac evaluation and preparation of patients in advance of noncardiac
operations. These guidelines are evidence based, include an explanation of
the quality of the data, and provide comprehensive algorithms for the
propriety of testing, medications, and revascularization to assure cardiac
fitness for operations. As important as preoperative cardiac risk stratification
is, a cardiology consultation also lays the groundwork for postoperative risk
assessment and later modifications of coronary risk factors.
Noninvasive and invasive preoperative testing should be performed only
when the results will influence patient care. Noninvasive stress testing before
noncardiac operations is indicated in patients with active cardiac conditions
(eg, unstable angina, recent MI, significant arrhythmias, or severe valvular
disease), or in patients who require vascular operations and have clinical risk
factors and poor functional capacity. Good data support coronary
revascularization before noncardiac operations in patients who have
significant left main coronary artery stenosis, stable angina with three-vessel
coronary disease, stable angina with two-vessel disease and significant
proximal left anterior descending coronary artery stenosis with either an
ejection fraction < 50% or ischemia on noninvasive testing, high-risk unstable
angina or non–ST-segment elevation MI, or acute ST-elevation MI. However,
current data do not support routine preoperative percutaneous
revascularization among patients with asymptomatic coronary ischemia or
stable angina.

The role of beta-blockers for cardiac protection is evolving, and these agents
are no longer empirically advised for all high-risk patients due to potential
adverse consequences. Beta-blockers should be continued perioperatively
among those patients who are already taking them and among those having
vascular operations and at high cardiac risk, including known coronary heart
disease or the presence of ischemia on preoperative testing. The role of beta-
blockers is uncertain for patients with just a single clinical risk factor for
coronary artery disease. Cardiac complication risk calculators may become
beneficial in the stratification of patients who should receive beta-blockers to
reduce perioperative cardiac complications.

Preoperative aspirin usage should continue among patients at moderate to

high risk for coronary artery disease, unless the risk of resultant hemorrhage
definitely outweighs the likelihood of an atherothrombotic event.
Thienopyridines, such as ticlopidine or clopidogrel, are administered in
concert with aspirin as dual antiplatelet therapy following placement of
coronary artery stents. They are intended to inhibit platelet aggregation and
resultant stent thrombosis, although they certainly increase the risk of
hemorrhage. Therefore, if an operation can be anticipated, the surgeon and
cardiologist must coordinate efforts regarding the sequence of the proposed
operation and coronary stenting, weighing the hazards of operative bleeding
while on antiplatelet therapy for a stent versus potential postoperative
coronary ischemia. Elective operations with a significant risk of bleeding
should be delayed 12 months before the discontinuation of the thienopyridine
in the presence of a drug-eluting stent, at least 4-6 weeks for bare-metal
stents, and 4 weeks after balloon angioplasty. Therefore, if a patient requires
percutaneous coronary artery intervention prior to noncardiac surgery, bare-
metal stents or balloon angioplasty should be employed rather than drug-
eluting stents. Even when thienopyridines are withheld, aspirin should be
continued, and the thienopyridine is to be resumed as soon as possible after
the operation. In circumstances such as cardiovascular surgery, the dual
antiplatelet agents are continued throughout the perioperative course to
minimize the likelihood of vascular thrombosis.

Pulmonary

Postoperative pulmonary complications (PPC), such as the development of

pneumonia and ventilator dependency, are debilitating and costly. They are
associated with prolonged lengths of hospital stay, an increased likelihood of
readmission, and increased 30-day mortality. Therefore, it is critical to
identify patients at greatest risk for PPC. Established risk factors for PPC
include advanced age, elevated ASA class, congestive heart failure, functional
dependence, known chronic obstructive pulmonary disease, and perhaps
malnutrition, alcohol abuse, and altered mental status. In addition, hazards
are greater for certain operations (eg, aortic aneurysm repair, thoracic or
abdominal, neurosurgery, head and neck, and vascular), prolonged or
emergency operations, and those done under general anesthesia. A risk
calculator was devised to predict the likelihood of PPC occurrence, indicating
seven independent risk factors. These include low preoperative arterial
oxygen saturation, recent acute respiratory infection, age, preoperative
anemia, upper abdominal or thoracic operations, duration of operation over 2
hours, and emergency surgery.

A multivariable logistic regression has affirmed that active smoking is

significantly associated with postoperative pneumonia, SSI, and death, when
compared to nonsmokers or those who have quit smoking. Moreover, this is a
dose-dependent phenomenon, predicated upon the volume and duration of
tobacco consumption. The benefits of preoperative smoking cessation seem
to be conferred after an interval of at least 4 weeks. Conversely, the risk of
developing PPC is the same for current smokers versus those who quit
smoking for less than 4 weeks before an operation. Smoking cessation also
confers favorable effects on wound healing. Therefore, patients should be
encouraged to stop smoking at least 1 month before operations, ideally with
programmatic support through formal counseling programs and possibly
smoking cessation aids such as varenicline or transdermal nicotine.

A recent analysis of patients having general surgery and orthopedic

operations demonstrated that sleep apnea is an independent risk factor for
the development of PPC. A simple “STOP BANG” questionnaire can screen
patients for sleep apnea. The acronym queries Snoring, Tired during
day, Obstructed breathing pattern during sleep, high
blood Pressure, BMI, Age over 50 years, Neck circumference, and
male Gender. Patients with sleep apnea may be managed with continuous
positive pressure (CPAP) or bilevel positive airway pressure (BiPAP) devices,
both before and after operations. The presence of sleep apnea may also
influence anesthesia techniques.

Patients identified as being at highest risk for the development of PPC may
benefit from preoperative consultations with respiratory therapy and
pulmonary medicine experts. Pulmonary function tests and baseline arterial
blood gas tests guide the care of select patients, especially those anticipating
lung resections. In addition to smoking cessation, asthma should be medically
controlled. Patient education focuses upon inspiratory muscle training
(including the usage of incentive spirometry), the concepts of postoperative
mobilization, deep inspiration, and coughing, along with oral hygiene (tooth
brushing and mouth washes). Respiratory therapists can provide expertise
with CPAP and BiPAP systems for patients with sleep apnea. Surgeons and
anesthesiologists should collaborate regarding plans for neuromuscular
blocking agents and strategies to reduce pain, including the administration of
epidural analgesics and the consideration of minimally invasive techniques to
avoid large abdominal or thoracic incisions. Finally, formal intensive care unit
protocols can promote liberation from ventilator support.

Venous Thromboembolism

Venous thromboembolism (VTE) events such as DVT or PE are major

complications that can lead to death or serious long-term morbidity,
including chronic pulmonary hypertension and postthrombotic limb sequelae.
Scoring systems stratify patients by their probability of developing a
postoperative VTE to guide preventative measures. In the 2012 American
College of Chest Physicians (ACCP) recommendations, the patient’s score
selects the alternatives of early ambulation alone (very low risk), mechanical
prophylaxis with intermittent pneumatic compression (IPC) devices (low risk),
options of low-molecular-weight heparin (LMWH) or low-dose unfractionated
heparin or IPC (moderate risk), and IPC in addition to either LMWH or low-
dose heparin (high risk). Furthermore, an extended course (4 weeks) of
LMWH may be indicated among patients undergoing resections of abdominal
or pelvic malignancies. Of course, the surgeon must entertain the hazards of
pharmacologic prophylaxis when bleeding poses even greater harm than
VTE, in which case IPC alone may suffice. Heparin prophylaxis is associated
with a 4%-5% chance of wound hematomas, 2%-3% incidence of mucosal
bleeding and the need to stop the anticoagulation, and a 1%-2% risk of
reoperation. The ACCP 2012 guidelines do not advocate routine vein
surveillance with ultrasonography or the insertion of inferior vena cava filters
for primary VTE prevention. Notably, antiembolism graduated compression
stockings (GCS) do not promote venous blood flow from the leg and can
violate skin integrity and result in the accumulation of edema. The efficacy of
stocking for VTE prevention is unproven.

Caprini has developed a more elaborate risk calculation that has been
validated in a variety of clinical settings and specialties, and is adaptable to
standardized order sets (Figure 3–1). This scoring system acknowledges the
gravity of individual hazards, including personal and family histories of VTE,
the diagnosis of a malignancy, a history of obstetrical complications or known
procoagulants, and prolonged operations, among several other factors. It also
identifies patients who may either entirely avoid anticoagulation or benefit
from an extended duration of LMWH. There is no doubt that the cumulative
incidence of VTE extends many weeks after operations, particularly for
malignancies and in an era when the duration of hospital stays (and inpatient
prophylaxis) has declined. In fact, about one-third to half of patients who
manifest a postoperative VTE after cancer surgery do so following hospital
discharge. Therefore, regimens of pharmacologic prophylaxis should be
maintained after the discharge of patients who have elevated risk scores. The
ACCP and Caprini systems are two among several VTE risk assessment tools,
each of which has advantages and disadvantages. The system adopted in any
hospital or surgery center will be a function of local resources and culture, but
it is ideal that surgeons develop and maintain a local standard to minimize the
threat of postoperative VTE.
Figure 3–1.

Sample order set page with “Caprini” calculation of venous

thromboembolism risk. The total value of checked-off factors indicates the
proper preoperative and postoperative prophylaxis regimens, including upon
discharge from hospital. (© Boston Medical Center Corporation 2012.)

Diabetes Mellitus
Patients with diabetes mellitus are more likely to undergo operations than are
those without diabetes, and their care is associated with longer lengths of
hospital stay, increased rates of postoperative death and complications, and
relatively greater utilization of health care resources. It has been established
that elevated postoperative blood glucose levels in diabetic patients translate
to progressively greater chances of SSIs following cardiac operations, as well
as a greater likelihood of postoperative infections and prolonged hospital
stays in patients with noncardiac operations. In fact, increased perioperative
glucose levels have correlated with a higher risk of SSIs in general surgery,
cardiac surgery, colorectal surgery, vascular surgery, breast surgery,
hepatobiliary and pancreas surgery, orthopedic surgery, and trauma surgery.
The relative risk of an SSI seems to incrementally increase in a linear pattern
with the degree of hyperglycemia, with levels greater than 140 mg/dL being
the sole predictor of SSI upon multivariate analysis. In one study, the
likelihood of an adverse postoperative outcome increased by 30% for every
20 mg/dL increase in the mean intraoperative glucose level. Interestingly,
about one-third of patients with perioperative hyperglycemia are not
diabetics. Furthermore, the risk of death relative to perioperative
hyperglycemia among patients undergoing noncardiac operations has been
shown to be greater for those without a history of diabetes than for those
with known diabetes. Nevertheless, these data pertain to intraoperative and
postoperative blood sugars, not preoperative values.

Current recommendations for desirable glucose ranges in critically ill patients

are commonly about 120-180 mg/dL, but the best range for perioperative
glucose levels is not yet established, and low levels may result in harm when
clinicians try to achieve “tight” control of blood sugars. In fact, trials and
meta-analyses have failed to prove a clinical benefit of maintaining glucose
levels in the normal laboratory reference range (80-110 mg/dL). Although
preoperative blood sugar and hemoglobin A1Clevels have not clearly
correlated with adverse outcomes, good control of glucose before operations
likely facilitates blood sugar management during and after operations. An
abundance of data support postoperative glucose control as a major
determinant of postoperative complications, with emerging data also
indicating an adverse effect of intraoperative hyperglycemia. Interestingly,
surgeons may actually be more influential than are patients’ primary care
physicians in terms of encouraging preoperative compliance with diabetes
medications, at least in the short term. Patients are commonly motivated to
attend to medical conditions such as diabetes to enhance chances of
postoperative success.

Patients having operations that require fasting status are advised about oral
antihyperglycemic medications on the day of surgery in accordance to Table
3–3. Injectable medications such as exenatide and pramlintide are not
administered on the day of surgery, and insulin therapy is determined by the
duration of action of the particular preparation, as outlined in Table 3–4.
Patients with type 1 diabetes require basal insulin at all times. Patients with
insulin pumps may continue their usual basal rates.

Table 3–3. Instructions for preoperative management of oral

antihyperglycemic medications.
Medication Prior to Procedure After Procedure
Short-acting sulfonylureas: Glipizide (Glucotrol), Do not take the morning of
Resume when eating
glyburide (DiaBeta, Glynase, Micronase) procedure
Do not take the evening
Long-acting sulfonylureas: ƒ Glimepiride (Amaryl),
prior to or the morning of Resume when eating
glipizide XL (Glucotrol XL)
procedure
Resume when eating.
Do not take the morning of
Biguanides: After contrast dye wait
procedure; do not take the
ƒ Metformin (Glucophage), metformin ER 48 h and repeat
day prior to procedure if
(Glucophage XL) creatinine prior to
receiving contrast dye
restarting
Thiazolidinediones: ƒ Pioglitazone Do not take the morning of
Resume when eating
(Actos), rosiglitazone (Avandia) procedure
Alpha-glucosidase inhibitors: Acarbose (Precose), Do not take the morning of
Resume when eating
miglitol (Glyset) procedure
Do not take the morning of
DPP-4 Inhibitors: ƒ Sitagliptin (Januvia) Resume when eating
procedure
Meglitinides: ƒ Nateglinide (Starlix), repaglinide Do not take the morning of
Resume when eating
(Prandin) procedure

© Boston Medical Center Corporation 2012.

Table 3–4. Instructions for preoperative management of injectable

antihyperglycemic medications and insulin.
Medication Prior to Procedure After Procedure
Injectable Medications
Do not take the morning of
Exenatide (Byetta) Resume when eating
procedure
Do not take the morning of
Symlin (Pramlintide) Resume when eating
procedure
Insulins
 Medication
Glargine (Lantus)
Detemir (Levemir)
NPH (Humulin N, Novolin N)
Humalog mix 70/30, 75/25, Humulin
70/30, 50/50 Novolin 70/30 (all
mixed insulins)
Regular insulin (Humulin R,
Novolin R)
Lispro (Humalog), Aspart
(Novolog), Glulisine (Apidra)
Subcutaneous insulin infusion
pumps
Prior to Procedure After Procedure
Take usual dose the night before or Resume usual schedule after
the morning of procedure procedure
Take usual dose the night before or Resume usual schedule after
the morning of procedure procedure
Take ½ of usual dose the morning Resume usual schedule when
of procedure eating, ½ dose while NPO
Do not take the morning of Resume usual schedule when
procedure eating
Do not take the morning of
Resume when eating
procedure
Do not take the morning of
Resume when eating
procedure
Requires tailored recommendations. In general, most patients may
continue their usual basal rate and correction doses, and resume
meal-time boluses when eating again

© Boston Medical Center Corporation 2012.

Multidisciplinary teams, including endocrinologists, surgeons,

anesthesiologists, nurses, pharmacists, information technology experts, and
others, have developed formal protocols and algorithms for perioperative
glycemic control, and an example of a preoperative order set is illustrated
in Table 3–5. A typical protocol is nurse-driven and involves checking glucose
levels on all diabetic patients in the holding area shortly before an operation.
As an example of one protocol, glucose values ≤180 mg/dL are satisfactory
and require no treatment. Glucose levels of 181-300 mg/dL prompt the nurse
to begin an infusion of intravenous (IV) insulin before the operation, along
with a 5% dextrose solution to minimize the chances of hypoglycemia.
Endocrinologists are automatically consulted to assist with postoperative
insulin management in these patients and in those with insulin pumps. In
general, insulin pump therapy is continued along with the infusion of
a dextrose solution. Patients with pumps may also require the addition of IV
insulin, as per the protocol.

Table 3–5. Example of adult perioperative glycemic control protocol.

Patients with glucose levels > 300 mg/dL are assessed for ketones or for
acidosis prior to starting an insulin infusion. Markedly elevated preoperative
blood sugars warrant special deliberation by all involved. Matters to be
considered include the urgency of the operation, whether the underlying
condition itself may be contributing to hyperglycemia, metabolic
consequences such as the presence of ketoacidosis, the risks of proceeding
with an operation at that moment, the likelihood of establishing better
control at a later date, and the dangers imposed by postponing the operation.
Dramatic elevations (eg, > 300 mg/dL) are typically indicative of chronic poor
glucose control, but the clinician often does not have the luxury of perfectly
managing diabetes before operations.

Intravenous insulin is best for perioperative glucose control due to its rapid
onset of action, short half-life, and immediate availability (as opposed to
subcutaneous absorption). Insulin may be administered with an IV bolus
technique or via continuous IV infusion, but regular glucose monitoring (eg,
hourly for continuous insulin infusions) is necessary in either system to assure
adequate control and to avoid hypoglycemia. The insulin administration
method before, during, and after an operation (infusion vs bolus) is a function
of local resources (eg, glucose meters, blood sample processing, and staffing),
as well as the patient’s individual circumstances. After the operation, a
patient should be assessed for an insulin infusion regimen if being transferred
to a critical care setting, a basal-bolus insulin program, or the resumption of
the patient’s usual diabetes medications.

Surgical Site Infection

Surgical site infections (SSIs) are major contributors to postoperative

morbidity and can be monitored and reduced by multiple complex
interventions that are institution-specific. Excellent surgical technique is
obviously a major factor in eliminating SSIs, and this involves limiting wound
contamination, blood loss, the duration of the operation, and local tissue
trauma and ischemia (eg, using sharp dissection rather than excessive
electrocoagulation). However, a variety of adjuvant preoperative measures,
beyond glycemic control described above, also contribute to the prevention
of SSIs. Antibiotics should be administered within the 1-hour period before
incision for certain clean operations and for all clean-contaminated,
contaminated, and dirty operations. In addition, further dosages of the
antibiotics should be infused about every two half-lives during the operation
(eg, every 4 hours for cefazolin). Correct antibiotic selection is determined by
several factors, such as the bacterial flora that are most likely to cause an
infection, local bacterial sensitivities, medication allergies, the presence of
MRSA, and the patient’s overall health and ability to tolerate an infection. In
clean operations with low rates of infections, the surgeon should contrast the
cost and hazards of antibiotics with the likelihood, cost, and morbidity of a
postoperative infection. Antibiotic choices for prophylaxis against SSIs are
cited in Table 3–6 for a variety of operations. Operations that involve
bacteroides should prompt the addition of metronidazole to the regimen, and
operations with a dirty wound classification may be guided by culture results
and hospital-specific bacteria sensitivities. When antibiotics are administered
for SSI prophylaxis rather than for treatment of an established or suspected
infection, they are typically not continued after surgery, except in special
circumstances such as vascular grafts, cardiac surgery, or joint replacements.
Even then, prophylaxis should expire within one to two days. Order sets,
automated reminders, and team vigilance are essential to assure the
consistent usage of the correct antibiotics at the right time and for the proper
duration.

Table 3–6. Examples of prophylactic antibiotic selections for various

operations.a
Operation Standard Selection Penicillin Allergy MRSA Colonization
Clean
Adrenalectomy Cefazolin Vancomycin Vancomycin
Breast Cefazolin Vancomycin Vancomycin
Cardiac surgery Cefazolin/vancomycin Vancomycin/gentamicin Cefazolin/vancomycin
Distal
Cefazolin Vancomycin Vancomycin
pancreatectomy
Hernia Cefazolin Gentamicin/clindamycin Vancomycin/gentamicin
Neurosurgery Cefazolin Vancomycin Vancomycin
Orthopedic
Cefazolin Vancomycin Vancomycin
Arthroscopy ORIF
Plastic surgery Cefazolin Vancomycin Vancomycin
Renal
Cefazolin Vancomycin Vancomycin
transplantation
Vancomycin (foreign
Soft tissue Cefazolin body) Clindamycin (no
foreign body)
Splenectomy Cefazolin Vancomycin Vancomycin
Thoracotomy or
Cefazolin Vancomycin Vancomycin
laparotomy
Thyroid/parathyroid Cefazolin Clindamycin Cefazolin
Vascular (no foreign Cefazolin Vancomycin Vancomycin
 Operation Standard Selection Penicillin Allergy MRSA Colonization
body)
Vascular (with
Cefazolin/vancomycin Vancomycin/gentamicin Cefazolin/vancomycin
foreign body)
Clean-
contaminated
Bariatric surgery Cefazolin/metronidazole Vancomycin/metronidazole Vancomycin/metronidazole
Biliary (elective) Cefazolin Clindamycin/gentamicin Cefazolin
Biliary (emergency) Ceftriaxone Gentamicin
Colorectal surgery
Cefazolin/metronidazole Clindamycin/gentamicin Cefazolin/metronidazole
(elective)
Esophageal
Cefazolin Vancomycin Vancomycin
resection
Gastroduodenal
Cefazolin Clindamycin/gentamicin Cefazolin
resection
Cefoxitin or Cefoxitin or
Gynecology Clindamycin/gentamicin
cefazolin/metronidazole cefazolin/metronidazole
Head and neck
(incision through
the oral or Cefazolin or clindamycin Clindamycin Cefazolin or clindamycin
pharyngeal
mucosa)
Lung resection Cefazolin Vancomycin Vancomycin
Urology (no entry
into urinary tract or Cefazolin Clindamycin Cefazolin
intestine)
Urology (entry into
urinary tract or Cefoxitin Clindamycin/gentamicin Cefoxitin
intestine)
Whipple resection Cefazolin/metronidazole Clindamycin/gentamicin Cefazolin/metronidazole
Contaminated or
dirty
Gastrointestinal
Ceftriaxone/metronidazole Clindamycin/gentamicin
(emergency)

a
These recommendations differ depending on local antibiotic resistance
patterns.

Wound perfusion and oxygenation are also essential to minimize the

likelihood of SSIs. A sufficient intravascular blood volume provides end-organ
perfusion and oxygen delivery to the surgical site. The maintenance of
perioperative normothermia also has salutary effects on wound oxygen
tension levels and can consequently reduce the incidence of SSIs. Therefore,
the application of warming blankets immediately prior to the operation may
support the patient’s temperature in the operating room, especially for high-
risk operations such as bowel resections that often involved a prolonged
interval of positioning and preparation when a broad surface area is exposed
to room air. Similarly, some data support hyperoxygenation with Fio2 ≥80%
during the first 2 hours after a major colorectal operation.

Several other adjuvant measures are employed at the surgical site to reduce
the incidence of SSIs. Protocols with mupirocin nasal ointment application
and chlorhexidine soap showers have reduced the incidence of SSIs among
patients colonized with methicillin-sensitive S aureus. During an operation,
wound protectors may be deployed to minimize the chances of a superficial
or deep SSI developing. Some surgeons (and their teams) change gloves and
gowns, and may use a separate set of instruments (that have not come into
contact with potential contaminants) for wound closure.

Fluid & Blood Volume

Likely out of concerns about incurring renal insult, surgeons and

anesthesiologists have traditionally advocated liberal perioperative fluid
resuscitation during recent decades, often overestimating insensible and
“third space” fluid losses. As a result, patients can develop significant volume
overload that is associated with serious complications. Recent data instead
support goal-directed (or protocol-based) fluid restriction as likely resulting in
a decreased incidence of cardiac and renal events, pneumonia, pulmonary
edema, ileus, wound infections, and anastomosis and wound healing
problems, as well as shorter durations of hospital stay. Unfortunately,
traditional vital signs, including even central venous pressure, do not reliably
correlate with intravascular volume or cardiac output. Moreover, pulmonary
artery catheterization has actually been associated with increased mortality,
and its implementation for the optimization of hemodynamic status is rarely
required. Pulmonary artery catheterization is valuable for few, highly selected
patients who exhibit clinical cardiac instability along with multiple comorbid
conditions. Newer, minimally invasive modalities for monitoring cardiac
output offer promise to determine optimal preload volume and tissue oxygen
delivery before and during operations, including esophageal Doppler and
analyses of stroke volume variation and pulse pressure variation. The precise
standards of goal-directed volume resuscitation remain elusive, but surgeons
and anesthesiologists should prospectively collaborate regarding plans for
both volume resuscitation and the selection of the type of anesthesia. This is
especially so during the management of challenging problems such as
pheochromocytomas, when patients require preoperative vasodilatation and
then intravascular volume expansion. Another clinical dilemma involves
patients with end-stage renal failure. Dialysis should be performed within
about 24-36 hours before an operation to avoid electrolyte disturbances, but
the surgeon should confer with the nephrologist to minimize intravascular
blood volume depletion.

Blood transfusions may be necessary before operations, especially in the

setting of active hemorrhage or profound anemia. However, transfusions
have been associated with increased operative mortality and morbidity,
decreased long-term survival, greater lengths of hospital stay, and higher
chances of tumor recurrence due to immunosuppressive effects imparted by
transfused blood. The benefits of transfusions must be balanced against their
hazards. Of course, bleeding diatheses require preoperative correction,
including transfusions of blood products such as fresh frozen plasma, specific
clotting factors, or platelets. Hematology consultations are invaluable when
blood incompatibilities or unusual factor deficiencies are present.

Nutrition

Preoperative nutritional status bears a major impact on outcome, especially

with respect to wound healing and immune status. A multivariate analysis
recognizes hypoalbuminemia (albumin < 3.0 mg/dL) as an independent risk
factor for the development of SSIs, with a fivefold increased incidence versus
patients with normal albumin levels, corroborating the results of previous
studies. Among moderately to severely malnourished patients, efforts may
be focused upon preoperative feedings, ideally via the gut, although at least 1
week of the regimen is necessary to confer benefit. Total parenteral nutrition
is an option for select patients in whom the gut cannot be used, but it conveys
potential hazards. Immune modulating nutrition (IMN), with agents such as l-
arginine, l-glutamine, ω-3 fatty acids, and nucleotides, can enhance immune
and inflammatory responses. A recent meta-analysis of randomized
controlled trials suggests that perioperative IMN with open, elective
gastrointestinal operations is associated with fewer postoperative
complications and shorter lengths of hospital stay compared to results for
patients with standard enteral nutrition. However, the value of preoperative
IMN is not firmly established.
At the other end of the spectrum, investigators have demonstrated that
severe obesity is associated with increased rates of postoperative mortality,
wound complications, renal failure, and pulmonary insufficiency, as well as
greater durations of operative time and hospital stays. The AHA has issued
guidelines for the assessment and management of morbidly obese patients,
including an obesity surgery mortality score for gastric bypass. Unfavorable
prognostic elements include BMI ≥50 kg/m2, male sex, hypertension, PE risks
(eg, presence of a VTE event, prior inferior vena cava filter placement, history
of right heart failure or pulmonary hypertension, findings of venous stasis
disease), and age ≥45 years. Bariatric surgeons typically enforce a
preoperative regimen of weight reduction before proceeding with surgery to
enhance outcomes and to assure the patient’s commitment to the process.

Endocrine

Endocrine deficiencies pose special problems. Patients may have either

primary adrenal insufficiency or chronic adrenal suppression from chronic
corticosteroid usage. Inadequate amounts of perioperative steroids can result
in an Addisonian crisis, with hemodynamic instability and even death. The
need for perioperative “stress” steroid administration is a function of the
duration of steroid therapy and the degree of the physiologic stress imposed
by the operation. Supplemental corticosteroids should definitely be
administered for established primary or secondary adrenal insufficiency, for a
current regimen of more than the daily equivalent of 20 mg of prednisone, or
for those with a history of chronic steroid usage and a Cushingoid
appearance. Perioperative steroids should be considered if the current
regimen is 5 to 20 mg of prednisone for 3 weeks or longer, for a history of
more than a 3-week course of at least 20 mg of prednisone during the past
year, for chronic usage of oral and rectal steroid therapy for inflammatory
bowel disease, or for a significant history of chronic topical steroid usage (> 2
g daily) on large areas of affected skin. Increased amounts of corticosteroids
are not necessary for patients who have received less than a 3-week course of
steroids. Patients having operations of moderate (eg, lower extremity
revascularization or total joint replacement) and major (eg, cardiothoracic,
abdominal, central nervous system) stress should receive additional
corticosteroids as outlined in Table 3–7. Minor or ambulatory operations,
including those under local anesthesia, do not require supplemental steroids.
Excessive amounts of steroids can have adverse consequences, including
increased rates of SSIs, so hydrocortisone should not be indiscriminately
prescribed. Of course, glucose levels should be closely monitored while
patients receive steroids. Conversely, patients with advanced Cushing
syndrome require expeditious medical and perhaps surgical treatment due to
the potential for rapid deterioration, including fungal sepsis. Cushing
syndrome and pheochromocytomas are separately addressed in Chapter 33.

Table 3–7. Recommendations for perioperative corticosteroid management.

Type of Operation Corticosteroid Administration
Minor/ambulatory operationa
Take usual morning steroid dose; no supplementary steroids are
Example: inguinal hernia repair
needed.
or operation under local
anesthesia
Day of surgery: Take usual morning steroid dose.

Just before induction of anesthesia: Hydrocortisone 50 mg IV,

then hydrocortisone 25 mg IV every 8 h × 6 doses (or until able to take
Moderate surgical stressa
oral steroids).

Example: lower extremity

When able to take oral steroids, change to daily oral prednisone
revascularization, total joint
equivalent of hydrocortisone, or preoperative steroid dose if that dose
replacement
was higher.

On the second postoperative day: Resume prior outpatient dose,

assuming the patient is in stable condition.a
Day of surgery: Take usual morning steroid dose.

Just before induction of anesthesia: Hydrocortisone 100 mg IV,

Major surgical stressa
Example: major cardiac, brain,
abdominal, or thoracic surgery
Inflammatory bowel diseaseb
then hydrocortisone 50 mg every 8 h × 6 doses (or until able to take oral
steroids).
On the second postoperative day: Reduce to hydrocortisone 25 mg q8h
if still fasting, or oral prednisone 15 mg daily (or preoperative steroid
dose if that was higher).

Postoperative day 3 or 4: Resume preoperative steroid dose if the

patient is in stable condition.a

a
For patients who have a complicated postoperative course or a prolonged
illness, consider endocrinology consultation for dosing recommendations. If
the steroid-requiring disease may directly impact the postoperative course
(eg, autoimmune thrombocytopenia [ITP] or hemolytic anemia), specific
dosing programs and tapers should be advised prior to surgery and in
consultation with the appropriate service (eg, hematology for ITP patients)
during hospital stay.
b
For patients with inflammatory bowel disease in whom all affected bowel
was resected, taper to prednisone 10 mg daily (or IV equivalent) by discharge
(or no later than postoperative day 7), followed by an outpatient taper over
the next 1-3 months, depending on the duration of prior steroid usage and
assuming that there are no concurrent indications for steroids (eg, COPD). ©
Boston Medical Center Corporation 2012.

Thyrotoxicosis must be corrected to avoid perioperative thyroid storm.

Management includes antithyroid medications
(eg, methimazole or propylthiouracil) and beta-blockers; saturated solution
of potassium iodide controls hyperthyroidism and reduces the vascularity of
the gland in patients with Graves disease. On the other hand, significant
hypothyroidism can progress to perioperative hypothermia and
hemodynamic collapse and thus requires preoperative hormone replacement.
This is normally accomplished with daily oral levothyroxine, but greater doses
of IV thyroid hormone may be necessary to acutely reverse a significant
deficit. Large goiters can affect the airway and require collaboration between
surgeon and anesthesiologist, possibly including a review of imaging to
demonstrate the extent and location (eg, substernal) of the goiter. When
possible, computed tomography contrast should be avoided in patients with
significant goiters as the iodine load may provoke thyrotoxicosis.

Geriatric Patients

As the elderly demographic expands, surgeons are confronted with

increasingly frail patients who have multiple comorbidities. Simple,
noninvasive, yet focused elements from the patient’s history and physical
examination serve as prognostic factors based upon the patient’s well-being
or frailty. Makary has reported graded scores (allowing for BMI, height, and
gender) that are predicated upon degree of weight loss, diminished dominant
grip strength, self-reported description of exhaustion levels, and weekly
energy expenditure in the course of routine activities, along with walking
speed. Preoperative frailty is predictive of an increased chance of
postoperative complications, prolonged lengths of hospital stay, and
discharge to a skilled or assisted-living facility after having previously lived at
home. A recent multivariate analysis demonstrated that among more than
58,000 patients undergoing colon resection, independent predictors of major
complications were an elevated frailty index, an open (vs laparoscopic)
operation, and ASA Class 4 or 5, but interestingly not wound classification or
emergency status. The care of the elderly requires thoughtful considerations
of their diminished physiologic reserve and tolerance of the insult of an
operation. Interventions may include preoperative and early postoperative
physical therapy, prospective discharge planning, and the introduction of
elder-specific order sets. Simple scoring systems can provide valuable
information for the surgeon to present to the patient and family so that they
can anticipate the nature of the postoperative care and recovery, including
potential transfer to a rehabilitation facility and long-term debility.

Illicit Drug & Alcohol Usage

The value of routine testing for the presence of illicit drugs, at least among
patients with suggestive histories, is uncertain. The presence of drugs in
blood or urine might result in a cancellation of an operation, particularly if it is
not immediately required. Conversely, some clinicians are not concerned
about proving recent drug usage as long as the patient does not exhibit
current evidence of toxicity or a hypermetabolic state. The confirmation of
illicit drug usage obviously heightens awareness about the possibility of
postoperative withdrawal. In general, patients should be advised to refrain
from taking illicit drugs for at least a couple of weeks before an operation.
Similarly, a history of heavy alcohol consumption raises the possibility of a
postoperative withdrawal syndrome, which can be associated with significant
morbidity and even death. It is ideal if patients can cease drinking alcohol for
at least one week before an operation. Regardless of whether the patient can
suspend alcohol consumption, the surgeon must closely monitor for
symptoms of withdrawal among these patients and consider the regular
administration of a benzodiazepine during recovery to prevent or treat acute
withdrawal.

Cancer Therapy

Many patients undergo neoadjuvant therapy for malignancies involving the

breast, esophagus, stomach pancreas rectum, soft tissues, and other sites.
The surgeon is responsible for restaging the tumor before proceeding with a
resection. In general, the interval between the completion of the external
beam radiation and the operation is commensurate with the duration of the
radiation therapy. Similarly, a reasonable amount of time should elapse after
systemic therapy to permit restoration of bone marrow capacity and
nutrition, to the extent possible. Angiogenesis inhibitors such as bevacizumab
disrupt normal wound perfusion and healing. The duration of time between
biological therapy and an operation is not firmly established. However, it is
probably best to allow 4 to 6 weeks to elapse after treating with bevacizumab
before proceeding with an operation, and the therapy should not be resumed
until the wound is fully healed, perhaps 1 month later.

Emergency Operations

Emergency operations generally permit little time for risk reduction, although
fluid and blood resuscitation can be instituted and antibiotics administered.
Emergency operations among patients who have undergone chemotherapy
within the past month are associated with increased rates of major
complications and death. In patients with profound neutropenia, operations
should be deferred to the extent possible due to severely impaired wound
healing and the likelihood of irreversible postoperative sepsis.

INFORMED CONSENT
The informed consent process is far more that a signed document or
“permission slip.” Consent involves a conversation between the surgeon and
patient (and perhaps family members or a legal guardian) that extends from
the initial consultation through subsequent clinic visits or correspondence and
into the preoperative holding area. The discussion addresses indications for
the operation and its expected outcome, alternative treatments, the natural
history of the underlying condition without intervention, the basic mechanics
and details of the operation, potential risks, the impact of the operation on
the patient’s health and quality of life, the extent of hospitalization and
recuperation (including possible rehabilitation care), the timing of resumption
of normal activities, and residual effects. The informed consent process may
also indicate that a resident will participate in the patient’s care, under the
supervision of the teaching surgeon and with the appropriate level of
competence. Spouses and other family members should be included in the
consent process for major operations that present chances of death or major
debilitation.

In some circumstances, the patient may not be able to provide consent and
no family members or guardians may be available. The surgeon should
consider the acuity of the patient’s condition and whether it requires an
immediate operation. If emergency surgery is indicated, the surgeon should
document the situation and advise a hospital administrator, if possible. Some
unusual, nonacute scenarios may require seeking legal consent for an
operation through the judicial process.

PREOPERATIVE INSTRUCTIONS
In some settings, all preoperative preparation is conducted through surgeons
and their office staffs. Conversely, more robust systems may employ an
elaborate process to prepare patients for operations. Regardless of the
preoperative process, education constitutes a major component. In addition
to learning about the actual operation, patients (and family members or
caretakers) need to understand both preparation for and recovery from the
operation.

Consistent information should be provided about how long a patient should

fast and what medications are to be taken on the morning of the operation.
The ASA has issued guidelines about preoperative fasting. To minimize
retained gastric volume and maximize gastric pH, anesthesiologists advise
adults and children to refrain from drinking clear liquids for at least 2 hours
before general anesthesia, regional anesthesia, or sedation/analgesia (vs 4
hours for infants taking breast milk, or 6 hours for infant formula). Patients
should avoid eating light meals for at least 6 hours and fatty meals for 8 hours
before receiving anesthetics or sedatives.

In general, it is ideal for patients to continue to take their usual critical

medications with a sip of water on the morning of an operation, including
beta-blockers, calcium channel blockers, nitrates, and other hypertension
control agents, alpha agonists or alpha antagonists, statins, hormones such
as levothyroxine, psychotropic agents, oral contraceptives, and medications
for cardiac rhythm problems, chronic obstructive pulmonary disease,
gastroesophageal reflux, peptic diatheses, and neurologic disorders. Some
surgeons and anesthesiologists advise patients to not take angiotensin-
converting enzyme (ACE) inhibitors on the day of surgery due to the
possibility of patients developing refractory hypotension during general
anesthesia, although ACE inhibitors should be resumed shortly after the
operation. Similarly, diuretics are commonly withheld on the morning of
operations that involve potentially significant amounts of fluid losses and
resuscitation. Of course, these recommendations are tempered by individual
circumstances and clinical judgment; for example, patients probably should
take their ACE inhibitors and diuretics before operations that do not require
general anesthesia or involve much intravenous fluid, and when inadequately
controlled hypertension could postpone the operation. Glucose and
corticosteroid management have already been addressed.

Chronic narcotics (eg, methadone) are continued on the day of surgery to

avoid possible withdrawal. Monoamine oxidase (MAO) inhibitors are
associated with drug interactions with indirect sympathomimetics such
as ephedrine (resulting in severe hypertension) or with phenylpiperidine
opioids such as meperidine, tramadol, methadone, dextromethorphan, and
propoxyphene (causing a serotonin syndrome with potential coma, seizures,
or even death). Acute withdrawal of MAO inhibitors can provoke major
depression, so they can be continued preoperatively, but without the
concomitant usage of confounding medications.

The management of aspirin and thienopyridines for active coronary (or

cerebrovascular) disease was reviewed earlier. Aspirin taken for other
reasons, nonsteroidal anti-inflammatory agents, herbal preparations,
and vitamin E can disrupt normal coagulation and should be stopped one
week before an operation. Epoprostenol is a prostaglandin that is used to
treat pulmonary hypertension; it also inhibits platelet aggregation and
behaves like “liquid aspirin.” The discontinuation of epoprostenol will provoke
pulmonary hypertension, so it is best to continue the infusion, accepting
possible oozing from surgical sites that can be controlled with standard
measures. Estrogen receptor antagonists (eg, tamoxifen) can be associated
with an increased risk of VTE. Therefore, the surgeon should consider
stopping such medications 2-4 weeks before an operation and resuming them
after a similar postoperative interval, especially in patients at a heightened
risk of developing VTE.

Patients receiving anticoagulants require consideration of the indication for

this therapy, the potential hazards of thrombosis developing while the
anticoagulation is suspended, and the dangers of perioperative hemorrhage.
Stopping warfarin 5 days before the operation will ordinarily allow
normalization of INR, and the surgeon will determine if a “bridge” of a quickly
reversible infusion of unfractionated heparin or LMWH injections is necessary
to minimize the duration of time during which anticoagulation is withheld.
Patients should bring asthma inhalers to the hospital for usage shortly before
being anesthetized. Similarly, eye drops, particularly those with beta-
blockade properties, should be taken in accordance with their usual schedule.

Additional preoperative instructions include skin hygiene (eg, preoperative

chlorhexidine showers, although their benefit is not absolutely proven), local
care of preexisting wounds or ulcers, and discussions about tobacco, drug,
or alcohol cessation, glucose management, and nutrition. Nurses may mark
potential sites for bowel stomae. Some patients will require vaccinations
when a splenectomy is possible.

Education also addresses what patients can expect during convalescence.

This includes the importance of early postoperative mobilization and
ambulation, pulmonary toilet, oral care, wound care, diet, physical therapy,
rehabilitation, later adjuvant care, and even complementary or alternative
options. Patients may be shown videos or provided brochures, which can be
available in multiple languages. The team should definitely provide details
about the logistics of the operation, including when and where the patient will
report for preoperative visits and tests and for the operation itself. Finally,
patients should know whom to contact with questions.

PREOPERATIVE HOLDING AREA

The time in the preoperative holding unit offers a final opportunity to educate
the patient and family and to coordinate care before proceeding into the
operating room. Patients (and their loved ones) are often anxious before
operations and will be reassured by an organized, professional, and collegial
environment. Members of the surgery team should introduce themselves and
discuss the proposed operation and the anticipated postoperative care and
recovery, including the possibilities of transfer to an intensive care unit or
later to a rehabilitation facility. Traditional vital signs are recorded, ideally
including baseline oxygen saturation. Special instructions address
postoperative mobilization and pulmonary care for those patients undergoing
general anesthesia or at high risk for PPC and might involve breathing
exercises with incentive spirometry. This setting is definitely a good moment
to formally mark the correct site and laterality of the operation, when
pertinent, and to confirm fasting status, medications taken during the past 24
hours (especially beta-blockers), allergies, recent corticosteroid usage, and
pregnancy status. Checklists (Figure 3–2) have become an important
mechanism to assure the application of standard practices, and a section can
be devoted to the preoperative unit. In addition, order sets greatly contribute
to the delivery of consistent and correct care, including the administration of
prophylactic antibiotics, adequate VTE prophylaxis (including the application
of compression boots), and hydrocortisone for those patients with a recent
history of significant corticosteroid usage. The infusion of antibiotics is not
necessarily begun in the holding area, as it may still be more than 1 hour
before the actual incision, but antibiotics can be secured for delivery to the
operating room with the patient. Glycemic control protocols are begun in the
holding area, as outlined earlier. For patients having bowel resections, the
effectiveness of the mechanical prep may be investigated, and warming
blankets can be applied. Finally, surgeons and anesthesiologists have the
chance to discuss blood volume status and strategies for fluid administration,
which may begin in the holding area.
Figure 3–2.

Sample of Universal Checklist for perioperative care. © Boston Medical

Center Corporation 2012.
OPERATING ROOM
Preparation of the patient continues in the operating room, up to the
moment of the incision. When local hair removal is necessary for exposure,
this should be done immediately before the operation, with electric clippers.
Razors traumatize skin and have been associated with a greater chance of
infection. Most surgical site skin preparations contain iodine-based
compounds or chlorhexidine, but the addition of isopropyl alcohol to either of
these agents seems to confer the best outcomes. Regardless of the agent
selected, it is important that the skin prep be applied in a standard fashion—
ideally by an assigned, trained individual to assure consistency—and that it
dries prior to the application of the sterile drapes. Iodine-impregnated
adherent drapes can also be used to cover the skin surrounding the surgical
site. The role of mechanical bowel preparations and antibiotic prophylaxis
(oral and/or parenteral) in colorectal operations is addressed in another
chapter. The placement of urinary catheters in the operating room merits
special comment. Urinary tract infections (UTI) are costly and can be reduced
in frequency by sterile placement and prompt postoperative removal. The
routine practice of two people (one for exposure and one for insertion)
catheterizing obese women can decrease the incidence of UTI.

Proper positioning of the patient for an operation is critical to enhance

exposure, to protect potential pressure points or muscle compartments, and
to avoid traction injuries to nerves. Surgeons, nurses, and anesthesia staff
share responsibility for patient safety during operations and should concur
about how the patient is situated on the operating room table.

PREPARATION OF THE OPERATING ROOM FACILITY

Beyond the hazards for SSIs discussed earlier, wound sepsis is also related to
the bacteriologic status of both the hospital setting in general and the
operating room in particular. The entire hospital environment must be
protected from undue contamination to avoid colonization and cross-
infection of patients with virulent strains of microorganisms that could invade
surgical sites despite the practice of asepsis, antisepsis, and sterile surgical
technique. All staff should diligently wash their hands before and after
contact with patients, regardless of location (ie, in the operating room or
elsewhere in the facility). Patients with especially dangerous or resistant
organisms (eg, Clostridium difficile, MRSA, and vancomycin-
resistant Enterococcus) may warrant special precautions such as isolation and
staff wearing gowns and gloves during direct contact with the patient and
secretions. Notably, alcohol-based hand sanitizers are not effective against C
difficile.

In the United States, it is standard for members of the operating room team
to wear issued “scrub” clothes, caps, shoe covers, and masks, although this
practice is less dogmatic in other countries. Surgeons and staff who perform
the operation and handle sterile instruments wear sterile gowns, protective
eye gear, and gloves. “Universal precautions” are practiced for the safety of
the team, under the presumption that any patient’s blood or fluids can convey
communicable diseases such as human immunodeficiency virus (HIV) or
hepatitis. Formal procedures and policies should be developed locally for
injured staff or those exposed to blood or other potential hazards during
operations.

Sterilization

Items used during an operation are sterilized to destroy microorganisms on

the surface of the instrument or in a fluid. Current sterilization methods
include steam autoclave, hydrogen peroxide gas plasma, gamma irradiation,
ethylene oxide gas, and dry heat. An autoclave system uses saturated steam
under pressure. This is the most widely used method due to its ability to
rapidly sterilize devices while being relatively inexpensive and nontoxic. The
two most common types of steam autoclaves are gravity displacement, which
must reach temperatures of 121°C, and prevacuum sterilizers, which must
reach temperatures of 132°C. Minimum exposure periods for wrapped devices
are 30 minutes for the former technique and 4 minutes for the latter system.
Of course, the implementation of steam is limited by its corrosive effect on
heat-sensitive items.

Liquid hydrogen peroxide is a nontoxic sterilizing agent that initiates the

inactivation of microorganisms on a heat-sensitive device within 75 minutes.
Liquid hydrogen peroxide is vaporized and diffused through the sterilization
chamber to contact the surfaces of the device. An electrical field is created
within the chamber, changing the vapor to gas plasma. Microbicidal free
radicals are generated in the plasma, rendering the device sterile.

Gamma sterilization utilizes Cobalt-60 radiation to inactivate microorganisms

on single-use medical supplies, pharmaceuticals, and biological-based
products, although the US Food and Drug Administration does not approve
gamma irradiation in health care facilities. Liquid and gaseous ethylene oxide
is a toxic, flammable sterilizing agent that initiates the inactivation of
microorganisms on a heat-sensitive device within 1-6 hours, with 8-12 hours
required for aeration. Ethylene oxide gas is diffused through the sterilization
chamber at temperatures between 37°C and 63°C and a relative humidity of
40%-80%. The gas bonds with water molecules to reach the device surfaces
and render the device sterile. Due to the extended aeration time requirement
and high level of toxicity, ethylene oxide gas sterilization is being replaced
with nontoxic processes that have shorter process times.

Dry heat sterilization utilizes heating coils to raise the temperature of the air
inside the sterilization chamber to sterilize surfaces of devices. It is
appropriate only for items that have a low moist heat tolerance but high
temperature tolerance. The most common time-temperature relationships
for dry heat sterilization are 170°C for 1 hour, 160°C for 2 hours, and 150°C for
2.5 hours.

Operating Room Plans

Surgeons should prospectively communicate with the operating room staff

about what operation will be performed, including its anticipated duration
and all necessary items, to enhance efficiency and avoid delays. “Case cards”
contain information about standard equipment, devices, and sutures.
Surgeons must also anticipate special needs such as unusual instruments or
hardware, prosthetic materials for implantation, coagulation devices (eg,
electrocautery, ultrasound or radiofrequency energy devices, lasers),
intraoperative laboratory testing (eg, glucose, hematocrit, parathyroid
hormone), imaging (eg, fluoroscopy, ultrasonography), nerve monitoring, and
any other details specific to the operation. The primary surgeon is responsible
for coordinating surgery teams when multiple consultants and allied
professionals collaborate in a patient’s care, including surgeons,
anesthesiologists, nurses, technicians, and others. A checklist hopefully
promotes communication about these matters to assure that it is safe to
proceed with an operation.

Preparations also include the development of contingency plans for a variety

of dangerous scenarios. These could include environmental problems in the
operating room (eg, a fire, the loss of humidity control or power, or computer
failure), or threatening clinical conditions (eg, massive hemorrhage, cardiac
arrest, air embolus, malignant hyperthermia, etc). Plans can be composed as
algorithms and documented on paper or online and even projected on
monitors for the entire team to review.

Preparation of the Surgery Team

Attention is being increasingly focused upon the development of teams in the

operating room. Much of this work has been modeled upon the concepts of
crew resource management (CRM), as promulgated by the aviation
profession. Psychologists analyzed behaviors of flight crews in the 1970s and
proposed measures to improve safety, including reducing the hierarchy of
that time, empowering junior team members to express concerns about
potential problems, and training senior crew members to listen to the
perspectives of other team members while accepting questions as honest
communication rather than insubordination. This approach encourages the
crew to participate in the enterprise and offer their expertise and talents,
while the captain remains the ultimate authority.

As in the airline industry, the implementation of CRM in the operating room is

supported by a series of activities before the main event. The ideal
preoperative briefing establishes the team leader, facilitates communication,
outlines the team’s work, and specifies protocols, responsibilities,
expectations, and contingency plans. This collaboration can result in
improved outcomes, greater patient satisfaction, and better morale among
team members. Checklists should not merely be perfunctory recitations of
goals; they should promote a culture of teamwork. These checklists can be
modified to suit local circumstances, resources, and cultures, and they codify
critical steps, such as having necessary materials and medications on hand as
well as indicating the appropriate location and side of the operation in
instances when wrong-site mistakes could be made. Simulation training is
also becoming more readily available, particularly regarding rare, complex, or
high-risk scenarios, as well as the introduction of new members to teams.

Preparation of the Surgeon

The professional development of a surgeon is a privilege and an enduring

pursuit involving emotional and intellectual growth, discipline, creativity,
dedication, equanimity, technical talent, and formal education. College,
postgraduate, and medical school curricula are certainly preludes to
accredited surgery residencies and fellowships. That certain personalities are
drawn to different surgical specialties is part of the joy and diversity of the
profession.

Board certification confirms that a surgeon has completed the requisite years
of residency and passed a rigorous examination to indicate competence.
Learning continues well beyond formal training, as exemplified by specialty
board certification and the recent Maintenance of Certification program,
instituted by the American Board of Surgery and 23 other member boards of
the American Board of Medical Specialties to assure lifelong professional
development. The surgeon must be familiar with contemporary literature and
adapt to emerging technologies and operative techniques, building upon
established knowledge and skills. Moreover, the surgeon critically assesses
data to decide the wisdom and value of new developments for the individual
patient, the surgeon, and the prevailing health care system. Fellowship in the
American College of Surgeons (or comparable organizations outside the
United States and Canada) endorses that the surgeon has successfully
completed a thorough evaluation of professional competence and ethical
fitness. The qualifications include board certification, commitment to the
welfare of patients above all else, and pledges regarding appropriate
compensation and the avoidance of unjustified operations.

The surgeon must also be versed in and a leader of quality improvement

within the process of caring for patients. Naturally, the proficiency provided
by performing large numbers of certain high-risk operations results in
improved outcomes. This is a matter of designing excellent systems that
support surgical care, rather than the exclusive talents of a solitary surgeon.
Ideal care involves a coordinated series of steps and collaborations—bundles
of care—among teams of professionals so that the system and culture are
sustained despite the loss of any individual, and the surgeon is the leader of
that team. Crew Resource Management, as described earlier, has defined
seven characteristics of leaders of high-performance teams:

1. Command: One person retains the ultimate authority and

responsibility for the team and outcomes.
2. Leadership: The leader establishes a culture of open communication,
accountability, and teamwork, serves as a mentor, manages conflict,
and establishes high standards of excellence and professionalism. An
effective leader inspires the team with strength and humanity.
 3. Communication: A work environment thrives upon an effective and
timely exchange of ideas among professionals to create the essential
bond within the team. Members of the team should be empowered to
raise concerns and to ask questions, particularly when doing so might
prevent harm to a patient.
4. Situational Awareness: This involves a comprehension of the present
circumstances through active communication with team members and
knowledge of preceding events.
5. Workload Management: Tasks are delegated among team members
commensurate with their skills and training so that everybody is doing
the right job in synergy with others.
6. Resource Management: This trait prospectively identifies the local
resources to result in optimal outcomes.
7. Decision Making: This process includes collecting data from the
environment and soliciting opinions from team members to permit
informed judgments.

Leadership traits are not necessarily intuitive, and they require introspection,
training, and practice. The surgeon remains the proverbial captain of the ship
regarding the care of patients having operations, but as a consultative leader
among trusted colleagues.

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