Perioperative Management

Clinical description

While perioperative management is individualized to the specific patient and condition requiring surgical intervention, certain steps should be performed.

Signs and symptoms

History/Exam/Investigations Document clearly the indication for surgery in the file.

Treatment

Pre-operative management

• Ensure patient is identified and well clerked (thorough history and physical, including clear indication for

surgery)

• Always consider alternatives to surgery including medical management or more conservative surgical

options

• Explain operation in detail, including risks of additional procedures (i.e. myomectomy may lead to

hysterectomy), and then obtain written consent from patient, which should include a detailed summary of risks, benefits, indications and alternatives explained to the patient.

• If major surgery, then anaesthetist to see the patient on the day before
• Starve patient ≥ 6 hrs for elective cases (emergency surgeries are excluded from this rule)
• Consider baseline investigations
• Urine pregnancy testing
• FBC or Hb
• Group and save (Xmatch for 2U if heavy blood loss anticipated)
• Renal function tests: only if age >50 years or pre-existing medical conditions (i.e. hypertension)

and high-risk surgery

• U&Es: only if on diuretics or known kidney disease
• ECG: if CVD history or BMI >40 and at least 1 risk factor for coronary heart disease (HTN, DM,

smoking)

• Chest X-ray only if history of pulmonary disease or current symptoms refractory to medical

Treatment

• Prior to surgery, give antibiotics as indicated (see Antibiotic Prophylaxis for Gynaecologic Surgery section)

Post-operative management

• Keep nil per os (no oral intake) for procedures done under GA until patient is fully awake; consider slowly

advancing diet as tolerated vs. allowing regular diet, dependent on surgery

• Maintenance IV fluids: RL or NS (preferably with D5-mix-mix D50 in NS or RL to proper dilution) or

Dextrose in NS 2L/24 hrs. May need much more if large blood loss before or during surgery.

• Caution in hypertensive patients.
• Remember 3:1 crystalloid to blood loss and consider transfusion based on pre-op Hb, EBL, risk

factors.

• Pain control
• Paracetamol 1,000 mg po q6h and NSAIDS (i.e. ibuprofen, diclofenac) for minor operations
• Pethidine 100 mg IM every 6 hrs for at least 24 hrs for major operations plus Diclofenac and/or

Paracetamol and/or Tramadol.

• Can combine analgesics but do not duplicate drugs in same class (i.e. do not give Brufen and

Diclofenac or Pethidine and Morphine)

• Encourage early ambulation and incentive spirometery to prevent deep venous thrombosis and atelectasis.
• Use compression stockings when available.
• Keep head elevated at 30◦ to prevent atelectasis and aspiration.

Patients with cardiac disease

• Consult Medicineand Anesthesia for pre-operative assessment and post-operative follow-up.