Pre-/Peri-/Postoperative

PREOPERATIVE

Preoperative testing should be guided by the patient’s clinical history, comorbidities, and physical examination. Some hospitals also have their own preoperative protocols. Common preoperative testing includes SMA 6, CBC, UA, PT/PTT, EKG, pregnancy test, and CXR. Aspirin and smoking should be discontinued 1 week prior to surgery. Patients should be NPO after midnight, or a minimum of 6 hours prior to surgery. Children (more prone to dehydration) may have clear liquids up to 4 hours before surgery.

American Society of Anesthesiologists Surgical Risk Classification

CLASS DESCRIPTION

I	Healthy patient
II	Patient with mild systemic disease (i.e., essential HTN, NIDDM)
III	Patient with severe systemic disease that limits activity (i.e., angina, COPD)
IV	Patient with incapacitating systemic disease that is a constant threat to life
V	Moribund patient not expected to survive 24 hours with or without surgery
IV	Patient declared legally brain dead and awaiting organ harvesting

When to Cancel Elective Surgery (General Guidelines)

Test	Cancel Elective Surgery
CBC
Hemoglobin	10 g/dL or less
Hematocrit	30% or less
WBC	Values <2,400/mm³ or >16,000/mm³
Neutropenia	1,000/mm or less
Platelets	Less than 50,000 to 100,000 cells/mm³
SMA
Potassium	3 mEq/L or less (important cardiac electrolyte)
Glucose	200 or more (may adjust with sliding scale)
BUN	50 or greater (R/O renal insufficiency)
Creatinine	3.0 or greater (R/O renal insufficiency)
Creatine kinase	Increased levels may indicate a threat of developing malignant hyperthermia.

Used to R/O infection, renal dz (proteinuria), and diabetes

Coagulation Studies

Important if patient is on blood thinners

EKG

Useful for identifying recent MIs, frequent premature ventricular contractures (PVCs)

A poor indicator of ischemic heart disease

CXR

Recommended for patients with a positive history of lung or heart disease and smokers

Antibiotic Prophylaxis

Prophylactic antibiotics are given IV 30 minutes prior to surgery. Conditions that warrant prophylactic antibiotics include surgery on dirty wounds, preexisting valvular heart disease, surgery longer than 2 hours, blood transfusion, preexisting infection, and implants.

Cefazolin (Ancef)

Ancef is a first-generation cephalosporin used for prophylaxis against wound infections during surgery. Ancef is a popular choice because it provides good coverage against Staphylococcus aureus and Streptococcus, both of which are likely pathogens of infection whenever the skin is broken. This drug also has an appropriate long half-life. Dosage is 1 to 2 g IV pre-op.

Vancomycin

Vancomycin is used for prophylaxis against wound infections during surgery in penicillin-allergic patients. Vancomycin is the best choice for implant surgery because it covers Staphylococcus epidermis, which is a common pathogen in implant surgery. Dosage is 1 g IV.

Amoxicillin

Amoxicillin is used for prophylaxis against bacterial endocarditis. Dosage is 3 g PO before and 1.5 g PO 6 hours after the procedure or 2 g IV 30 minutes before and 1 g IV 6 hours after the procedure.

Erythromycin

Used for prophylaxis against bacterial endocarditis in penicillin-allergic patients. Dosage depends on the preparation.

Clindamycin

Used for prophylaxis against bacterial endocarditis in penicillin-allergic patients. Dosage is 300 mg PO before and 150 mg PO 6 hours after the procedure or 300 mg IV 30 minutes before and 150 mg IV 6 hours after the procedure.

Pregnancy Test

All female patients of childbearing age. All elective surgery should be postponed on pregnant women.

Pituitary-Adrenal Suppression

Patients on 7.5 mg of corticosteroids a day or more should be tested for endogenous cortisol suppression. Low plasma concentrations of cortisol and ACTH indicate suppression. Even if exogenous corticosteroids are discontinued, the pituitary-adrenal negative feedback can take up to a year to recover. Adrenal-pituitary axis suppression leaves patients unable to produce extra steroids in response to the stress of surgery. Patients on steroids often require increased dosing peri- and postoperatively. Steroids delay the wound healing process. This may be counteracted with the use of topical vitamin A. Usual dose is 1,000 U applied tid to the open wound bed for 7 to 10 days.

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