1.7 Preparation of patients for surgery, ERAS protocol, perioperative nutrition

Question 1

Essential steps of preoperative assessment and preparation

Answer 1

1. make sure it is the correct patient
2. make sure there is proper indication for surgery
3. history and anamnesis
4. physical examination (general preparation): state of the heart, lungs etc. and any drugs the may currently take or has taken in the past
5. collect information about the diagnosis and any further diagnostic investigations
6. make special preparation for the particular surgery
7. discuss the surger and recovery period with the patient and obtain signed consent; patient should be informed on all aspects and possible complications
8. anesthesiologic examination (estimation of perioperative risk): patient and procedure related factors
9. prescribe medication, prophylactic antibiotics and thromboembolism prophylaxis
10. plan for rehabilitation and recovery

Question 2

How do we prepare for surgery?

Answer 2

1. psychological preparation
2. nutrition:
   - enteral nutrition (1500-2000kcal/day), feeding tube (nasogastric, nasojejunal)
   - parenteral nutrition
3. hygienic preparation: shaving, shower/antiseptic scrubbing
4. handling of previous medication
   - hypertensive therapy, insulin treatment, cardiac drugs
5. premedication:
   - anxiolytics
   - reduction of vagal and sympathoadrenal reflexes
   - reduction of secretion, decrease of gastric pH
   - prevention of postoperative nausea and vomiting
6. preoperative fasting (variable):
   - 8 hours prior: fatty meals
   - 6 hours prior: light meals
   - 4 hours prior: breastfeeding
   - 2-3 hours prior: clear fluids only
7. GI-tract preparation:
   - mechanical bowel cleansing (bowel preparation): purging with laxatives; or enema using injections to stimulate emptying
   - decontamination with non-absorbable, local antibiotics
8. correction of homeostasis
   - acid-base balance
   - fluid/electrolyte balance
   - status of blood (correction of hematocrit and coagulation)
9. provide route of IV administration: insert a peripheral venous cathether
10. nasogastric decompression: in cases of increased risk of aspiration (ie. patient has not been fasting)
11. urinary catheter
    - surgical indications: pelvic procedures, laparoscopic colon resections
    - anesthesiologic indications: easy to monitor renal function and circulatory parameters
12. antibiotic prophylaxis
    - necessary in case of abdominal emergencies, elective colon resection and malignancies of upper GI-tract
    - considered in cholecystectomy, vascular graft surgeries, plastic surgeries and hernioplasties
13. thrombosis prophylaxis (mechanical):
    - early mobilization, movement of the limb by either active or passive movement
    - graded compression stocking
    - mechanical calf compression device
14. pharmacological prevention of venous thromboembolism:
    - unfractionated heparin: binds anti-thrombin to inhibit thrombin, factors Xa, IXz and XIIa
    - LMWH: inhibits effects of factor Xa; absorbed uniformly with longer duration of action
    - Xa inhibitors, direct blockers of thrombin: used when heparin is contraindicated
    - vitamin K anatagonists: coumarin derivativees that inhibit vitamin K synthesis and in turn vitamin K dependent coagulation factors
15. pharmacological prevention of arterial thromboembolism
    - inhibition of platelet aggregation by COX inhibitors
16. laboratory evaluation, in case patient has pre-existing diseases

Question 3

How is operative risk evaluated?

Answer 3

• surgical risk + the anesthesiologic risk
• how well the patient endures this operative burden

Question 4

What is low operative risk?

Answer 4

• minimal physiological stress and risk to the patients; rarely requires blood transfusion, invasive monitoring or intensive care
• expected blood loss is <200mL
• ie. breast surgery, groin hernia repair, cataract surgery

Question 5

What is moderate operative risk?

Answer 5

• moderate physiological stress (fluid shifts, cardiorespiratory effects) with minimal blood loss
• expected blood loss is <1000mL
• ie. laparoscopic cholestectomy, hysterectomy, bowel resection

Question 6

What is high operative risk?

Answer 6

• significant perioperative physiological stress and often require blood transfusion or large fluid volumes, invasive monitoring and intensive care
• expected blood loss is >1000mL
• ie. aortic/heart surgery, majory GI resections, thoracic surgery

Question 7

What are some special operative risk factors?

Answer 7

• elderly patients: above 65 years
• pregnancy
• malnutrition
• obesity (BMI>30)
• cancer patients

Question 8

What is ERAS protocol?

Answer 8

enhanced recovery after surgery
- different perioperative techniques for planned surgeries
- epidural or regional anesthesia
- minimal invasive surgical procedures
- optimal pain management
- aggressive postoperative rehabilitation (early oral nutrition, mobilization, drain removal)
- application of above mentioned techniques reduce stress response and therefore organ dysfunction

Question 9

What is pre-rehabilitation?

Answer 9

a multidisciplinary preoperative program designed to improve the patient’s physical, nutritional and mental state
- ideally 6-8 weeks
- part of permanent treatment containing pre-, peri- and post-operative period