Perioperative care

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See also preoperative care

Perioperative care is defined as "interventions to provide care prior to, during, and immediately after surgery."[1]

[edit intro]

Classification

Intraoperative Care

Postoperative Care

Components of postoperative care may include incentive spirometry.

Complications

Myocardial ischemia and infarction

In noncardiac surgery, myocardial ischemia is more common during the postoperative period than during or before surgery.[2]

In coronary artery bypass surgery, ischemia is common after release of aortic occlusion.[3] Ischemia may be better detected by transesophageal echocardiography than by continuous electrocardiography.[4]

Perioperative myocardial infarction has been reviewed.[5]

Myocardial infarction is usually NSTEMI.[6][2][7] Transmural infarctions may occur, but tend to occur later (one week) during hospitalization and are more likely to be transmural.[6]

Older studies showed higher mortality, perhaps due to only detecting large infarctions.[8]

Respiratory complications and pneumonia

Pulmonary embolism

For more information, see: Pulmonary embolism.


Septic shock

Sepsis and septic shock may be the most common complications in perioperative care.[9]

Specific interventions

Medical consultation

The benefits of medical consultation are not clear in an observational study.[10]

Anemia

"The administration of oral iron supplements to elderly, healthy orthopedic patients postoperatively did not hasten the recovery of hemoglobin levels, provided adequate tissue iron stores were present." according to a randomized controlled trial.[11]

"Both modified epoetin alfa regimens were effective compared with placebo in reducing allogeneic transfusion in patients undergoing hip arthroplasty" according to a randomized controlled trial.[12]

Among patients receiving coronary artery bypass grafting, there may be no meaningful difference between transfusing to maintain a hemoglobin levels > 8 g/dL versus a hemoglobin levels > 9 g/dL.[13] However, hemoglobin levels < 8 g/dL may increase complications.[14]

Among patients undergoing surgery for hip fracture, there may be no meaningful difference between transfusing to maintain a hemoglobin levels > 8 g/dL versus a hemoglobin levels > 10 g/dL.[15]

Glucose control

Randomized controlled trials of intraoperative glucose control.[16][17][18]
Trial Patients Intervention Comparison Outcome Results Sources of bias
Intervention Control
Lazar[16]
2011		 82 diabetic patients undergoing coronary artery bypass Continuous insulin infusion with target glucose 90-120 mg/dl Continuous insulin infusion with target glucose 120-180 mg/dl Composite of "30-day mortality, myocardial infarction, neurologic events, deep sternal infections, and atrial fibrillation" 37% 42% Insignificant results, but underpowered
Subramaniam[17]
2009		 236 patients for vascular surgery or lower limb amputation Continuous insulin infusion with target glucose 100-150 mg/dl Intermittent insulin bolus if glucose > 150 mg/dl "Composite of all-cause death, myocardial infarction, and acute congestive heart failure" (stroke not studied)
Blinding not stated		 3.5% 12.3% Unblinded
Early termination and without adjustment of p-value
Gandhi[18]
2007		 400 patients for cardiac surgery Continuous insulin infusion with target glucose 80-100 mg/dl Insulin bolus or continuous if glucose > 200 mg/dL "Composite of death, sternal infections, prolonged ventilation, cardiac arrhythmias, stroke, and renal failure within 30 days"
Blinded end point assessment		 44%
(but significantly more strokes)		 46% None

Regarding intraoperative control of glucose, a randomized controlled trial concluded "the increased incidence of death and stroke in the intensive treatment group raises concern about routine implementation of this intervention."[18] An second randomized controlled trial that was unblinded, stopped early, and had an imbalance in the age between the two treatment groups found benefit.[17][19]

Hemodynamic interventions

"The use of a preemptive strategy of hemodynamic monitoring and coupled therapy reduces surgical mortality and morbidity" according to a meta-analysis of trials. [20]

References

  1. ↑ National Library of Medicine. Perioperative care. Retrieved on 2007-11-21.
  2. ↑ 2.0 2.1 Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM (December 1990). "Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group". N. Engl. J. Med. 323 (26): 1781–8. PMID 2247116. [e]
  3. ↑ Jain U, Laflamme CJ, Aggarwal A, et al. (March 1997). "Electrocardiographic and hemodynamic changes and their association with myocardial infarction during coronary artery bypass surgery. A multicenter study. Multicenter Study of Perioperative Ischemia (McSPI) Research Group". Anesthesiology 86 (3): 576–91. PMID 9066323. [e]
  4. ↑ Comunale ME, Body SC, Ley C, et al. (April 1998). "The concordance of intraoperative left ventricular wall-motion abnormalities and electrocardiographic S-T segment changes: association with outcome after coronary revascularization. Multicenter Study of Perioperative Ischemia (McSPI) Research Group". Anesthesiology 88 (4): 945–54. PMID 9579503. [e]
  5. ↑ Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH (September 2005). "Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk". CMAJ 173 (6): 627–34. DOI:10.1503/cmaj.050011. PMID 16157727. PMC 1197163. Research Blogging.
  6. ↑ 6.0 6.1 Cohen MC, Aretz TH (1999). "Histological analysis of coronary artery lesions in fatal postoperative myocardial infarction". Cardiovasc. Pathol. 8 (3): 133–9. PMID 10722235. [e] Cite error: Invalid <ref> tag; name "pmid10722235" defined multiple times with different content
  7. ↑ Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW (March 1998). "Myocardial infarction after noncardiac surgery". Anesthesiology 88 (3): 572–8. PMID 9523798. [e]
  8. ↑ Plumlee JE, Boettner RB (July 1972). "Myocardial infarction during and following anesthesia and operation". South. Med. J. 65 (7): 886–9. PMID 5038186. [e]
  9. ↑ Moore, Laura J.; Frederick A. Moore, S. Rob Todd, Stephen L. Jones, Krista L. Turner, Barbara L. Bass (2010-07-01). "Sepsis in General Surgery: The 2005-2007 National Surgical Quality Improvement Program Perspective". Arch Surg 145 (7): 695-700. DOI:10.1001/archsurg.2010.107. Retrieved on 2010-07-20. Research Blogging.
  10. ↑ Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J (2007). "Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery". Arch. Intern. Med. 167 (21): 2338–44. DOI:10.1001/archinte.167.21.2338. PMID 18039993. Research Blogging.
  11. ↑ Zauber NP, Zauber AG, Gordon FJ, Tillis AC, Leeds HC, Berman E et al. (1992). "Iron supplementation after femoral head replacement for patients with normal iron stores.". JAMA 267 (4): 525-7. PMID 1729575. [e]
  12. ↑ Feagan BG, Wong CJ, Kirkley A, Johnston DW, Smith FC, Whitsitt P et al. (2000). "Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial.". Ann Intern Med 133 (11): 845-54. PMID 11103054. [e]
  13. ↑ Bracey AW, Radovancevic R, Riggs SA, et al (1999). "Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome". Transfusion 39 (10): 1070–7. PMID 10532600. [e]
  14. ↑ Carson JL, Noveck H, Berlin JA, Gould SA (2002). "Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion". Transfusion 42 (7): 812–8. PMID 12375651. [e]
  15. ↑ Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG et al. (2011). "Liberal or restrictive transfusion in high-risk patients after hip surgery.". N Engl J Med 365 (26): 2453-62. DOI:10.1056/NEJMoa1012452. PMID 22168590. PMC PMC3268062. Research Blogging.
  16. ↑ 16.0 16.1 Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H (2011). "Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients.". Ann Surg 254 (3): 458-64. DOI:10.1097/SLA.0b013e31822c5d78. PMID 21865944. Research Blogging.
  17. ↑ 17.0 17.1 17.2 Subramaniam B, Panzica PJ, Novack V, Mahmood F, Matyal R, Mitchell JD et al. (2009). "Continuous perioperative insulin infusion decreases major cardiovascular events in patients undergoing vascular surgery: a prospective, randomized trial.". Anesthesiology 110 (5): 970-7. DOI:10.1097/ALN.0b013e3181a1005b. PMID 19387173. Research Blogging. Cite error: Invalid <ref> tag; name "pmid19387173" defined multiple times with different content
  18. ↑ 18.0 18.1 18.2 Gandhi GY, Nuttall GA, Abel MD, et al (2007). "Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial". Ann. Intern. Med. 146 (4): 233–43. PMID 17310047. [e] Cite error: Invalid <ref> tag; name "pmid17310047" defined multiple times with different content
  19. ↑ Houle TT (2009). "Reporting the results of a study that did not go according to plan.". Anesthesiology 110 (5): 957-8. DOI:10.1097/ALN.0b013e3181a0ff04. PMID 19387171. Research Blogging.
  20. ↑ Hamilton MA, Cecconi M, Rhodes A (2011). "A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients.". Anesth Analg 112 (6): 1392-402. DOI:10.1213/ANE.0b013e3181eeaae5. PMID 20966436. Research Blogging.

See also

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