Perioperative Care
Kristina A. Butler
Introduction
All surgical procedures involve risk of complications and the possibility of long-term morbidity, loss of function, or death. These complications may include infection, bleeding, thromboembolism, damage to surrounding structures, and need for additional surgery. Much of the risk to an individual patient is based on the pathology necessitating surgery and her medical comorbidities. Pelvic organ prolapse and urinary and fecal incontinence are disabling conditions with significant burden of disease and loss of function. They are not, however, fatal diseases. Every consideration must be made to weigh the risks of surgery against the natural history of the disease being treated. Many interventions are available to both assess and reduce an individual patient’s risk of complications. Additionally, there are some time-honored practices and routines that increase the risk of certain complications. It is every surgeon’s responsibility to remain current on the best practices for perioperative care and to advocate for their implementation in an organized fashion in hospital practices and operating rooms. Selecting the appropriate surgery for the patient balancing risk and morbidity is also a surgeon responsibility. Offering a minimally invasive approach when possible provides better outcomes.1,2,3
The goals of perioperative care are to minimize the risk to the individual patient and to maximize the likelihood of a successful surgical outcome and return to normal function. Within this framework are the preoperative medical evaluation, immediate preoperative care, and intraoperative care. The goals of the preoperative medical evaluation are to maximize the functional status of individual patients with known disease and to screen based on history and risk factors for subclinical conditions that may affect their response to surgery. Patients undergoing reconstructive pelvic surgery are often older and have a greater number of comorbidities or risk factors that must be addressed prior to surgery.
Symptoms of pelvic floor dysfunction affect up to 50% of women. The lifetime risk of surgery for pelvic organ prolapse is estimated to be up to 19%.4 Rates of operative complications and perioperative morbidity are low in benign gynecologic surgery. However, pelvic reconstructive surgery involves a higher risk due to the extent of procedure and population characteristics. Patients undergoing reconstructive pelvic surgery are often older, undergo lengthy surgeries, and have histories of prior pelvic surgery.5 All of these are known to increase surgical morbidity and mortality. In addition, patients undergoing reconstructive pelvic surgery often have distorted anatomy that increases the risk of surgical injury. This chapter reviews topics in perioperative care, including preoperative testing and preparations. In addition, intraoperative management is discussed.
PREOPERATIVE CARE
Preoperative Testing
A thorough history and physical exam inclusive of current medications and allergies is necessary for safe surgical care. Baseline laboratory testing in women without systemic disease who are otherwise healthy is not beneficial. The American Society of Anesthesiologists (ASA) recommends patients ASA 1 or 2 not undergo lab testing specifically complete blood count, basic or comprehensive metabolic panel, and coagulation studies when blood loss is expected to be minimal.6 Preoperative hemoglobin A1c (HgA1c) elevation may be an indication to delay surgery and optimize diabetes management. Diabetes poses significant perioperative risk when poorly controlled and can result in infectious complications (HgA1c >7%), prolonged length of stay (HgA1c >8%), and mortality (HgA1c >9%) following surgery.7,8 Women without cardiopulmonary disease do not need chest X-ray as only 2% of such images lead to a change in management. Those with chronic stable cardiopulmonary diseases older than age 70 years may benefit if chest radiography has not been performed within 6 months.9 Similarly, routine 12-lead electrocardiogram is not useful for asymptomatic patients undergoing low-risk surgical procedures.10 In women with known cardiac disease and asymptomatic, cardiac stress testing and echocardiography provide no advantage when undergoing low or moderate risk noncardiac surgery. These tests do not change the patient’s clinical management or outcomes and may result in increased cost and unnecessary additional procedures.11,12 β-Blockers should
be continued in those with preexisting daily use but not started on the day of surgery to avoid harm or cardiovascular instability. Continuation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers perioperatively is reasonable.10 Smoking cessation is encouraged to improve cardiopulmonary health.
be continued in those with preexisting daily use but not started on the day of surgery to avoid harm or cardiovascular instability. Continuation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers perioperatively is reasonable.10 Smoking cessation is encouraged to improve cardiopulmonary health.
Pregnancy screening may be safely performed with questionnaire to avoid costs and time associated with laboratory analysis.13 Alternately, urine pregnancy could be performed. Type and screen antibody testing is costly, and transfusion during pelvic reconstructive surgery is low at 1.26%; therefore, many institutions safely limit its use.14 Suspected existing infections should be identified and treated prior to elective surgery, for example, urinary tract infection and bacterial vaginosis.15,16 Additionally, vaginal health improvements gained from topical estrogen use preoperatively in postmenopausal patients have been shown to improve pelvic reconstruction outcomes, although ongoing study continues.17 Any bleeding in menopausal women prompts evaluation of the cervical, uterine, vulvar, vaginal, and anal areas to screen for malignancy. Pap smear or office biopsy can be performed timely and return results quickly. The uterus can be evaluated with ultrasound or endometrial biopsy.18
Preoperative Preparations
Enhanced Recovery after Surgery pathways begin preoperatively with patient education (Table 19.1). The goal is to maintain baseline physiology and patient comfort while providing surgery with improved outcomes, cost savings in reduced hospitalization, and decreased complications. Avoid unnecessary perioperative fasting for elective surgical procedures. Fasting after midnight was thought to reduce pulmonary aspiration; however, data does not support this practice. Prolonged fasting is associated with increased insulin resistance, delayed recovery, and poorer outcomes.19,20 The ASA and other organizations recommend discontinuing solid food 6 hours before surgery and encourage intake of clear fluids until 2 hours before surgery for improved outcomes and patient satisfaction. Mechanical bowel preparation for pelvic reconstructive surgery is not needed and outcomes are improved without this practice. Return to general diet and hospital dismissal following surgery are significantly improved. Enemas may be used without adverse effect.21,22,23 Preoperative showering is encouraged as it aim to reduce the number of microorganisms on the skin near the incision and may reduce the risk of infection.24 Same-day dismissal to reduce the need for hospitalization and nosocomial infection exposure is safe for women undergoing pelvic floor reconstruction surgery; this can be individualized and does not increase the rate of complications.25,26
Pain management begins before the incision is made, and this preemptive strategy has proven to reduce opiate use, nausea and vomiting, impaired bowel function, immobilization, and perioperative morbidity. Medications given may include acetaminophen, nonsteroidal anti-inflammatory agents, and antiemetics. Local injection of an analgesia is also recommended for pain relief. This may be in the form of wound infiltration, using a nerve block, or deep pelvic injection, for example, at the uterosacral ligaments during vaginal surgery.27
INTRAOPERATIVE CARE
Preventing hypothermia and maintaining euvolemia during surgery is key. Discussions with the anesthesia team are encouraged on fluid balance and warming devices. Unnecessary costs are accrued from frozen section pathology evaluation if the result will not affect immediate perioperative management.28 It is preferable to submit the specimen for routine processing and permanent section evaluation if no therapeutic decision for the patient on the day of the surgical procedure is needed.
Antibiotic Use
The use of antibiotics to prevent surgical site infections in hysterectomy patients is well established and used as a quality metric.29 Surgical site infections are the most common source of health care-associated infections (HAI) in the United States, comprising 22% of all HAI.30 Prevention and the appropriate use of prophylactic antibiotics has received much attention. The Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services, University Health System Consortium, and American College of Surgeons National Surgical Quality Improvement Program have all contributed to guidelines and performance standards aimed at reducing the incidence of surgical quality.
Current guidelines recommend that prophylactic antibiotics be administered within 60 minutes of incision time and be discontinued within 24 hours of surgery. The antimicrobial agent chosen should be active against the likely infectious organisms to be encountered in the surgery performed and should have an appropriate safety profile for the patient.15,16 For gynecologic surgery, cefazolin is endorsed as appropriate for nonallergic patients. For patients unable to tolerate cephalosporins, alternate regimens are recommended. Immediate hypersensitivity reaction (anaphylaxis, hives, bronchospasm) would be a contraindication to use penicillin or cephalosporin; however, allergy testing is encouraged as time allows because true allergies are not common. Ten percent of the population reports a penicillin allergy; however, research shows that 90% of them are not allergic to penicillin. Patients receiving a penicillin alternate have higher medical costs and longer hospital stays and are more likely to develop complications such as infections with vancomycin-resistant
Enterococcus and Clostridium difficile. Alternate antibiotics have also been shown to be less effective in infection prevention. Allergy skin testing can be performed easily with excellent negative predictive value approaching 100%.31,32
Enterococcus and Clostridium difficile. Alternate antibiotics have also been shown to be less effective in infection prevention. Allergy skin testing can be performed easily with excellent negative predictive value approaching 100%.31,32
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