Lesson 14.4: Perioperative and Hospital Medicine

Introduction

In surgical practice, managing the patient's health before, during, and after surgery is crucial. This lesson focuses on preoperative risk assessments, perioperative management, and monitoring inpatient complications such as delirium, thromboembolism, and pain control. By the end of this lesson, students will be equipped to assess and manage surgical patients medically, prevent common complications, and articulate key concepts in perioperative and hospital medicine.

Learning Objectives

• Understand preoperative risk assessment and perioperative management strategies.
• Analyze inpatient complications, including delirium and thromboembolism prophylaxis.
• Assess perioperative risk and manage surgical patients.
• Prevent and manage common inpatient complications effectively.
• Explain the key ideas and terminology of perioperative and hospital medicine.

Preoperative Risk Assessment

Understanding Preoperative Risk Assessment

Preoperative risk assessment is essential for identifying patients at risk for complications due to surgery. Risk factors can include patient's age, comorbidities, and the nature of the surgical procedure.

Key Components of Preoperative Risk Assessment

1. Patient History: Collect detailed medical history including past surgeries, comorbid conditions (e.g., diabetes, hypertension), and any history of complications during previous surgeries.
2. Physical Examination: A thorough physical assessment should evaluate system functions (cardiovascular, respiratory, renal, etc.) relevant to the surgical procedure.
3. Laboratory Tests: Depending on the patient’s history and physical examination, necessary lab tests (e.g., CBC, electrolytes, coagulation profile) should be performed to inform risk assessment.
4. Risk Scoring Systems: Utilize scoring systems like the ASA (American Society of Anesthesiologists) classification or the MET (Medical Emergency Team) score to quantify risk levels.

Example: Preoperative Risk Assessment Scenario

Case Scenario: A 72-year-old female patient with a history of COPD and hypertension is scheduled for a hip replacement surgery.

• Patient History: The patient is a smoker, takes medication for hypertension, and has had one previous surgery with complications.
• Physical Examination: The patient shows signs of diminished breath sounds and has a blood pressure reading of 150/90 mmHg.
• Laboratory Tests: CBC shows normal hemoglobin levels, but the ECG shows signs of left ventricular hypertrophy (due to older age and hypertension).
• Risk Classification: Using the ASA classification, this patient is classified as ASA III (a patient with severe systemic disease).
• Conclusion: Given her age, history of COPD, and borderline high blood pressure, she has a higher risk of surgical complications and may require optimization measures, including preoperative pulmonary rehabilitation or medication adjustment.

Perioperative Management

Key Aspects of Perioperative Management

During the perioperative phase, management focuses on minimizing the risk of complications and ensuring optimal recovery conditions.

1. Anesthesia Considerations: Selection of appropriate anesthesia is essential. Monitor carefully for adverse reactions.
2. Fluid Management: Establish intravenous access for fluid administration. Calculate fluid requirements based on the patient characteristics and surgical needs.
3. Monitoring: Continuous monitoring of vital signs during surgery is crucial. This includes assessing heart rate, oxygen saturation, respiratory rate, and blood pressure.
4. Pain Management: Employ multimodal pain management strategies, including PCA (patient-controlled analgesia) and regional anesthesia techniques if applicable.

Worked Example: Intraoperative Management

Case Scenario: A 55-year-old male undergoes laparoscopic cholecystectomy.

• Anesthesia Choice: General anesthesia is chosen, and the anesthesiologist premedicates with midazolam for sedation.
• Fluid Management: The estimated blood loss is minimal, and a standard intravenous fluid maintenance of $100 \text{ mL/hr}$ is initiated.
• Intraoperative Monitoring: The patient's vital signs are stable: heart rate $75 \text{ bpm}$, blood pressure $120/80 \text{ mmHg}$, and oxygen saturation $98\%$ throughout surgery.
• Pain Control: Postoperatively, the patient receives an opioid via PCA as well as scheduled acetaminophen and NSAIDs.

Inpatient Complications

Understanding Inpatient Complications

In the hospital setting, patients may experience a range of complications that could prolong recovery or even threaten lives.

1. Delirium: A common acute confusion state in hospitalized elderly patients; causes can include medications, infections, dehydration, and metabolic imbalances.
2. Thromboembolism Prophylaxis: With immobilization and surgery, patients are at risk for venous thromboembolism (VTE). Prophylactic measures should include anticoagulation therapy and mechanical devices like compression stockings.
3. Pain Control: Adequate pain management is crucial for recovery. It should be assessed using pain scales and adjusted based on patient feedback.

Common Complications and Management Strategies

• Delirium Management: Delirium is managed by addressing the underlying causes, ensuring hydration, promoting sleep, and using sedation judiciously if needed.
• Thromboembolism Prophylaxis: Patients undergoing surgery lasting longer than 30 minutes should receive VTE prophylaxis. This can include low molecular weight heparin ($LMWH$) or unfractionated heparin ($UFH$) dosage based on risk factors.
• Pain Management Strategies: Understanding that pain control should not be delayed. Use a combination of medications, including opioids for severe pain and non-opioids for mild pain.

Example: Preventing Thromboembolism

Case Scenario: A patient recovering from knee surgery is at risk for VTE.

• Initiate LMWH at $40 \text{ mg}$ once daily starting $12$ hours post-surgery.
• Encourage early mobilization and active ankle pumps while in bed to promote venous return.
• Assess the need for compression stockings based on the patient's mobility and risk stratification.

Conclusion

Understanding perioperative and hospital medicine is essential for managing surgical patients effectively. By mastering preoperative risk assessment and recognizing and managing inpatient complications, students will be equipped to provide high-quality care in acute and emergent settings.

Study Notes

• Preoperative assessment involves history, physical examination, lab tests, and risk scoring.
• Intraoperative management includes anesthesia, fluid management, monitoring, and pain control.
• Delirium, thromboembolism, and pain control are key inpatient considerations.
• Strategies for preventing VTE include medications and early mobilization.
• Effective pain control is critical for patient recovery and should be evaluated continuously.