Page 19 - Medicine and Surgery

P1: JYS
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Chapter 1: Perioperative care 15

appropriate, arterial blood gas analysis should be ob- form of central venous access. Peripheral parenteral
tained without additional delay. Any anaemia, fluid and nutrition may cause significant injury if extravasation
electrolyte imbalance or cardiac failure should be cor- occurs. Other complications of parenteral nutrition
rected prior to surgery wherever possible. include line infection and septicaemia, thrombosis and
embolism, liver damage and metabolic disturbance
(osmotic diuresis, acute hyperosmolar syndrome and
Prophylactic antibiotics in surgery
electrolyte imbalances).
Specific guidelines regarding the use of perioperative an-
tibiotic prophylaxis vary between hospitals but these are Postoperative complications
generally used if there is a significant risk of surgical
site infection. They are indicated in most gastrointesti- Postoperative complications may occur at any time
nal surgery, neurosurgery, surgery involving insertion of post-surgery and include general surgical complications
aprosthesis (including joint replacement), transurethral (bleeding, infection, deep vein thrombosis), those spe-
prostate resection, coronary artery bypass surgery and cific to the procedure (anastomotic leaks, fistulae, adhe-
lower limb vascular surgery. Prophylaxis for immunod- sions, wound dehiscence) and complications secondary
eficient patients requires expert microbiological advice. to coexisting disease (ischaemic heart disease, chronic
However, it is important to note that antibiotic use obstructive airways disease, diabetes mellitus).
is associated with acute hypersensitivity reactions, in- Immediate complications arise during the first post-
creasing antibiotic resistance and the development of operative day:
pseudomembranous colitis (see page 150). Haemorrhage: Primary haemorrhage refers to con-
tinuation of bleeding from surgery. It requires
aggressive management and may necessitate return
Nutritional support in surgical patients
to theatre. Reactive haemorrhage occurs from small
Significantnutritionaldeficiencyimpairshealing,lowers vessels, which only begin to bleed as the blood pres-
resistance to infection and prolongs the recovery period. sure rises postoperatively. Blood replacement may be
Malnutrition may be present preoperatively particularly required and in severe cases the patient may need to
in the elderly and patients with malignancy. Periopera- return to theatre.
tive nutritional support may be necessary if the patient Myocardial infarction is a significant risk in patients
is unable to maintain sufficient intake to balance the in- with ischaemic heart disease. Surgery may contraindi-
creased postoperative nutritional requirement. cate the use of thrombolytic agents.
Enteral nutrition is the treatment of choice in all pa- Alow-grade pyrexia is normal in the immediate post-
tients with a normal, functioning gastrointestinal tract. operative period but may also arise due to infection,
It is generally safer than intravenous nutrition and it collections or deep vein thrombosis.
helps to maintain the integrity of gastrointestinal mu- Low urine output may occur as a result of volume de-
cosa. Liquid feeds either as a supplement or replacement pletion, renal failure, poor cardiac output or urinary
may be taken orally, via a nasogastric tube or via a gas- obstruction.Thepatientmayrequireurinarycatheter-
trostomy. Liquid feeds may be whole protein, oligopep- isation (or flushing of the catheter if already in situ)
tide or amino acid based. These also provide glucose, and a clinical assessment of cardiovascular status in-
essential fats, electrolytes and minerals. cluding heart rate, blood pressure (including assess-
Parenteral nutrition is indicated when patients cannot mentofposturaldrop),inspectionoftheJVP,evidence
maintain a sufficient calorie intake via the enteral route. of pulmonary oedema and where needed CVP mea-
Indications include intestinal resection, fistulae, motil- surement (see page 3).
ity disorders and extensive small bowel disease. Mixed Early postoperative complications occur in the subse-
preparations of amino acid, glucose and lipid are used quent days.
withtraceelements,vitaminsandelectrolytesalsoadded. Deep vein thrombosis and risk of thromboembolism.
Parenteralnutritionishypertonic,irritantandthrom- High-risk patients should receive prophylaxis (see
bogenic. They should ideally be infused through some section The Preoperative Assessment). Patients may