BASIC CONSIDERATIONS


I. In general, the history & physical should be used to identify risk factors for perioperative problems; workup should be tailored to these risk factors; don't overdo it.

II. NO formal pre-op evaluation is needed in patients who satisfy all of these conditions:
  1. Young
  2. Basically asymptomatic
  3. Negative pulmonary, cardiac, & hematologic ROS
  4. No significant PMHx
  5. Normal physical exam
  6. On no meds
  7. Is not pregnant
  8. No anesthesia in past 3 months
  9. No personal or family h/o anesthesia problems
III. Prophylaxis of surgical infections
  1. Intranasal antibiotics to reduce risk of postoperative staph infections
    1. Nasal carriage with Staphylococcus aureus is ass'd with increased risk of postoperative staph infections
    2. In a randomized trial in 3,864 pts undergoing elective surgery (including cardiothoracic, general, gynecologic, oncologic, & neurologic) randomized to mupirocin vs. placebo topically to anterior nares BID x 5d before surgery, over 30d f/u, incidence of S. aureus infection was not sig. different overall but in pts with positive preop nasal culture for S. aureus, incidence was sig. lower (4.0% vs. 7.7%) (NEJM 346:1871, 2002--JW)
    3. In a study in 991 pts > 18yo undergoing elective cardiac surgery randomized to (chlorhexidine intranasal ointment 0.12% + chlorhexidine oropharyngeal rinse) vs. placebo QID from time of hospitalization to time nasogastric tube removed, the active-tx group had sig. lower incidence of nosocomial infections (19.8% vs. 26.2%) and mean hospital stay (9.5 vs. 10.3d); there was no sig. diff. in in-hospital mortality. (JAMA 296:2460, 2006--JW)
    4. In a study in 918 pts scheduled to undergo surgery who screened positive (with PCR) for nasal carriage of S. aureus randomized to (nasal mupirocin ointment 2% BID + "Betasept" chlorhexidine soap 40mg/mL QD) vs. placebo, the risk of "healthcare-associated" S. aureus infections was reduced significantly (3.4% vs. 7.7%, RR 0.42) as was total length of hospital stay (12.2 vs. 14d) (NEJM 362:9, 2010-JW; AFP)
  2. Intraoperative antibiotics may reduce incidence of infection for certain types of surgery
    1. Recent guidelines: Clin. Inf. Dis. 38:1706, 2004.

IV. Prophylaxis of post-operative nausea/vomiting

  1. In a meta-analysis of five randomized studies among 363 pts 31-46yo who were undergoing gynecologic or lower-extremity surgery, administration of oral ginger root powder 1g 1 hour before induction of anesthesia was associated with RR 0.65 for nausea and vomiting in the 24h after surgery c/w placebo. (Am. J. Obs. Gyn. 194:95, 2006--JW)

V. Important things not to forget:

  1. In pts felt to be at "high risk" for major elective surgery either because of the type of surgery or because of an existing medical condition, a regimen designed to "Optimize oxygen delivery" with invasive hemodynamic monitoring, inotropic Rx (dopexamine or epinephrine), and careful fluid management from 4h before to 12h after surgery may reduce perioperative mortality (BMJ 318:1099, 1999--JW)
  2. Prophylaxis against Endocarditis when indicated
  3. Prophylaxis against Deep Vein Thrombosis!
  4. Consider postoperative incentive spirometry to reduce risk of postoperative pneumonia.
  5. For patients on moderate-to-high doses of chronic Corticosteroids--consider "stress-dose" steroids
  6. Calcium channel blockers tend to inhibit platelet aggregation. Nifedipine users undergoing surgery for hip fx had a RR of requiring transfusion of 2.0 after controlling for age, sex, HTN, vascular disease, and preoperative Hb concentration (BMJ 314:643, 1997-JW). Therefore, it might be prudent to discontinue Ca-channel blockers a week or two before surgery, esp. with nifedipine!
  7. Consider beta-blockers or alpha-adrenergic agonists in patients at high risk for cardiac complications of surgery--See "Cardiac risk in Non-cardiac surgery" for more info