Chapter 1 - INTRODUCTION - GENERAL PRINCIPLES
Perioperative medicine refers to the medical care of the surgical patient, particularly in the time frame just before, during, and after the actual surgical procedure. It is not a subspecialty of medicine, but rather a body of medical knowledge which enables the physician to manage medical illness during the perioperative period, assess operative risk, and deal with complications. The purpose of this pocket manual is to provide an easy reference to that body of knowledge, certainly not in its entirety but at least enough to deal with the majority of inpatient perioperative issues that I have encountered here at Bellflower Hospital. Although the intended use of this manual is primarily for inpatient practice, there is a substantial amount of information which is applicable to outpatients as well.
Intentionally I have directed the focus of this manual more on the management of medical illness and dealing with complications and less on assessing operative risk. I do make notes regarding operative risk for the majority of conditions presented, but to thoroughly address the topic of perioperative risk assessment is beyond the scope of this simple pocket manual. As an aside, to put things into perspective, an old study showed that approximately 80% of post-op deaths on surgical services were attributable to underlying medical conditions, whereas only 20% were due to surgery or anesthesia, hence the importance of perioperative medical care.
For inpatients, the decision as to whether or not surgery is necessary-for the most part-has already been made. The main objective of the pre-operative evaluation then is to ASSESS patients, PREPARE them for surgery, and ASSIST in postoperative management. The decision to delay an inpatient surgery on medical grounds must be weighed against the urgency of the surgical procedure and should be made in collaboration with the surgeon. To completely cancel an inpatient surgery should only be done if the patient has some active contraindication to surgery or if, for some other reason, the perceived risk of death or significant morbidity is greater with the procedure than without it.
COMPONENTS OF THE MEDICAL PRE-OP:
1) History and Physical
2) Pertinent labs/studies
3) *Assessment-the identification of underlying diseases AND the current status of control of these diseases on present therapy. Finally, a general assessment of medical stability and optimization for surgery. An overall estimate of operative risk may also be included; this can be simply stated as low, moderate, or high-even prohibitive if patient is felt to be contraindicated for surgery in the current state. (Never write Cleared for surgery, as this implies no surgical risk involved.)
4) *Recommendations/Plan-be as clear and concise as possible. Always keep in mind the goal is to reduce risk and increase the likelihood of a good outcome from surgery.
CONTRAINDICATIONS TO SURGERY
In reality, there are no ABSOLUTE contraindications to surgery in the sense that if a surgical procedure is emergent and the patient will die immediately without it, then the patient must go to the OR right away regardless of their medical condition. Examples would be a ruptured AAA with unstable angina or a perforated viscous in active CHF. Barring these or other clear-cut surgical emergencies, the following is a list of some examples of what I would consider contraindications to immediate major surgery:
This list is certainly not all-inclusive, but it at least gives you some idea of what sort of things might contraindicate non-emergent surgery. If any of these conditions actively exists at the time of surgery, then the risk of perioperative death is exceedingly high. (The exact numbers are unknown, but for major procedures I would estimate on the order of 30%-likely higher in many cases.) Delay of non-emergent surgery is warranted for medical stabilization. Actual cancellation of the procedure may also be appropriate if surgery is not deemed absolutely necessary and the underlying medical condition cannot be stabilized in a timely manner. *This must always be addressed with the surgeon directly.