17 - 21 Bailey-Loves-Peroperative-Care-Principle of Surgery-3

Bailey & Love Bailey & Love Bailey & Love

Bailey & Love Bailey & Love Bailey
PART
& Love
Bailey & Love Bailey & Love Bailey & Love 3
Perioperative care
17 Preoperative care including the high-risk surgical patient ...... 254
18 Anaesthesia and pain relief ................................................................... 269
19 Nutrition and fluid therapy .................................................................... 278
20 Postoperative care .................................................................................... 290
21 Day case surgery ....................................................................................... 301
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17
Chapter
Preoperative care including the high-risk

surgical patient
Learning objectives
To be able to organise the preoperative care and the oper- • How to optimise the patient’s condition
ating list • How to identify and optimise the patient at higher risk
To understand preoperative preparation for surgery: • Importance of critical care in management
• Surgical, medical and anaesthetic aspects of • How to take consent
assessment • How to organise an operating list
INTRODUCTION Summary box 17.1

The stress of major surgery can lead to increased oxygen
demand by about 40%. Changes such as cytokine release-re- Preoperative plan for the best patient outcomes
lated inflammatory changes, endocrine responses, hyperco- ●● Gather and record all relevant information
agulability and redistribution of fluid between compartments ●● Optimise patient condition
may last several postoperative days. The purpose of careful ●● Choose surgery that offers minimal risk and maximum benefit
preoperative planning is to minimise the unwanted effects of ●● Anticipate and plan for adverse events
these physiological changes. ●● Adequate hydration, nutrition and exercise are advised
Systematic history taking, examination and ordering of
investigations at the preoperative clinic should include not
only an assessment of functional reserve but also the formula-
tion of advice on optimisation, to best cope with the antici- PATIENT ASSESSMENT
pated operative stress. General practitioner (GP) records and Evidence suggests that correction of anaemia, better diabetes
hospital notes are useful sources of baseline information. GPs control, preoperative exercises and better nutrition leads to
can help by monitoring chronic conditions, adjusting medi- better patient outcomes and fewer postoperative complica-
cations, and facilitating in weight reduction, exercise and the tions. Based on population statistics, associated comorbidities
cessation of smoking. and the type of surgery, one can estimate risks for an individ-
A simple questionnaire, working within agreed guide- ual undergoing surgery and various tools and scores (see later)
lines, can identify high-risk patients undergoing high-risk can be used as risk predictors.
surgery needing specific tests and optimisation (see later).
Patients with severe comorbidities or undergoing high-risk
surgery should be referred to specialists to quantify and to History taking
reduce perioperative risks. Risks of surgery, anaesthesia and Each organ system problem should be noted with dates, aeti-
the effects of comorbid conditions should be discussed so that ology and treatment delivered (Table 17.1). Screening ques-
the patient can make an informed decision. Patients should tions will reveal ‘fitness’ for surgery and anaesthesia. Patients
be given advice on ‘nil by mouth’ (NBM) and regular medica- with recent chest infections should be assessed for anaesthetic
tion and premedication at the preoperative visit. risks and postoperative surgical infection. Increasing severity
A plan for the operating list should be drawn-up and all of symptoms generally indicates worsening of the condition
those involved in making the list run smoothly should be and possible need for a change in medication. Inability to
informed. The World Health Organization (WHO) check- achieve four metabolic equivalents, e.g. climbing a flight of
list, which is started just prior to induction of anaesthesia and stairs, increases cardiac risk after major surgery. Some factors
continued during and after the surgery, aims to improve the leading to these findings may be amenable to treatment pre-
safety of anaesthesia and surgery. operatively such as anaemia, angina, palpitations or obesity.
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ve PART 3 | PERIOPERATIVE CARE
Patient assessment 255
ve The history of past surgery and anaesthesia can reveal the to communicate and mobility are important in planning reha-
problems one may face during current hospitalisation (e.g. bilitation after surgery.
intra-abdominal adhesions for planned laparoscopic surgery,
suxamethonium apnoea). The use of recreational drugs and
alcohol consumption should be noted as they are known to be Examination
associated with adverse outcomes. Check for allergies and risk Patients should be treated with respect and dignity, receive a
factors for deep vein thrombosis (DVT). Social history, ability clear explanation of the examination undertaken and be kept
as comfortable as possible (Table 17.2). A chaperone should
be present, especially for intimate examinations. This is will
often be part of a local guideline or policy.
Summary box 17.2
In symptomatic patients one should look specifically for
Principles of history-taking evidence of cardiac failure (raised jugular venous pressure
●● Listen. What is the problem? (Open questions)
(JVP), fine pulmonary crackles, gallop rhythm), peripheral
●● Clarify. What does the patient expect? (Closed questions)
vascular disease (loss of peripheral pulses, ulcerations) and
●● Narrow. Differential diagnosis (Focused questions)
valvular heart disease with characteristic murmurs (e.g. ejec-
●● Fitness. Comorbidities (Fixed questions)
tion systolic murmur in aortic stenosis, pansystolic murmur
in tricuspid regurgitation and mid-diastolic murmur in mitral
stenosis heard at respective areas on auscultation). When pos-
sible, the medical or surgical treatments for these conditions
TABLE 17.1 Key topics in past medical history. should be started and the patient stabilised before elective
Cardiovascular surgery. UK statistics show that patients with cardiac failure
●● Ischaemic heart disease – angina, myocardial infarction or cirrhosis even though on treatment have a high (8%) ‘30-
●● Hypertension day mortality’ after major surgery.
●● Heart failure The presence of a rapid respiratory rate, reduced air entry,
●● Dysrhythmia crepitations and rhonchi may indicate respiratory problems.
●● Peripheral vascular disease A history of dyspnoea along with examination findings of
●● Deep vein thrombosis and pulmonary embolism tachycardia, raised JVP, tricuspid regurgitation, hepatomegaly
Respiratory and oedematous feet will indicate severe respiratory disease
●● Chronic obstructive pulmonary disease
with pulmonary hypertension and right ventricular failure.
●● Asthma
●● Respiratory infections
Gastrointestinal
●● Peptic ulcer disease and gastro-oesophageal reflux Summary box 17.3
●● Liver disease
Genitourinary tract Examination

●● Urinary tract infection ●● General. Positive findings even if not related to the proposed
●● Renal dysfunction procedure should be explored further
Neurological ●● Surgery related. Type and site of surgery, complications
●● Epilepsy occurred due to underlying pathology
●● Cerebrovascular accidents and transient ischaemic attacks
●● Systemic. Comorbidities and extent of limitation of each organ
●● Psychiatric disorders
function
●● Cognitive function
●● Specific. For example, suitability for positioning during surgery
Endocrine/metabolic
●● Diabetes
●● Thyroid dysfunction
●● Phaeochromocytoma
●● Porphyria
TABLE 17.2 Medical examination.
Locomotor system General Anaemia, jaundice, cyanosis, nutritional
●● Osteoarthritis status, sources of infection (teeth, feet, leg
●● Inflammatory arthropathy such as rheumatoid arthritis
ulcers)
Other Cardiovascular Pulse, blood pressure, heart sounds, bruits,
●● Human immunodeficiency virus peripheral oedema
●● Hepatitis Respiratory Respiratory rate and effort, chest expansion
●● Tuberculosis and percussion note, breath sounds, oxygen
●● Malignancy saturation
●● Allergy Gastrointestinal Abdominal masses, ascites, bowel sounds,
Previous surgery hernia, genitalia
●● Problems encountered Neurological Consciousness level, cognitive function,
●● Family history of problems with anaesthesia sensation, muscle power, tone and reflexes
Entries in bold need to be recorded even when negative. Airway assessment
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PART 3 | PERIOPERATIVE CARE
256 CHAPTER 17 Preoperative care including the high-risk surgical patient
Examination specific to surgery exposure mean that chest radiographs should be restricted
to specific patients, such as those with cardiac failure,
At preoperative assessment, the clinical findings, site, side, severe chronic obstructive pulmonary disease (COPD),
specific imaging or investigation findings related to the acute respiratory symptoms, pulmonary cancer, metastasis
pathology for which the surgery is proposed should be noted. or effusions or those who are deemed to be at risk of active
Suitability of the patient for the proposed surgical option and pulmonary tuberculosis.
vice versa should also be assessed. For example, laparoscopic ● Clotting screen. If a patient has a history suggestive of
procedures are less invasive and are therefore preferred in a bleeding diathesis, liver disease, eclampsia, cholesta-
most; however, not all patients can tolerate pneumoperito- sis or has a family history of bleeding disorder, or is on
neum and positioning. antithrombotic or anticoagulant agents then coagulation
The type of surgery along with patient comorbidities deter- screening will be needed. However, the effects of anti-
mine perioperative risks, for example perioperative mortality platelet agents, low molecular weight heparins and newer
in major surgery such as that of open aortic aneurysm repair in agents affecting factor Xa cannot be measured by routine
the UK is 3% and that with endovascular repair is 1%. laboratory tests.
Sources of potential bacteraemia can compromise surgical ● Urinalysis. Dipstick testing of urine should be performed
results especially if artificial material is implanted, such as in on all patients to detect urinary infection, biliuria, glycos-
joint replacement surgery or arterial grafting. Check for and uria and inappropriate osmolality.
treat infections in the preoperative period, e.g. infected toes, ● β-Human chorionic gonadotrophin. Women of child-bear-
pressure sores, teeth and urine; screen the patients for methi-
ing age should be asked sensitively about their pregnancy
cillin-resistant Staphylococcus aureus colonisation.
status. If in doubt a laboratory test or a reliable pregnancy
kit (low cost) can be used, after obtaining consent from
Investigations the patient, to avoid danger of exposure to surgery and
anaesthesia on the foetus.
The National Institute of Health and Care Excellence, UK ● Blood glucose and HbA1c. Poor control of diabetes can
(NICE) guidelines lay out the investigations needed for vari-
lead to perioperative infection and slow recovery in
ous categories of surgery.
patients with diabetes mellitus and endocrine problems.
HbA1C indicates how well diabetes has been controlled
over a longer duration. Early mobilisation, oral intake and
Summary box 17.4
return to routine medication should be the goals in man-
Investigations needed agement of diabetes.
●● Type of surgery. Major surgery can lead to organ system
● Arterial blood gases. A low-cost tool that can give quick
dysfunction needing most investigations and vital information in acute or chronic severe respira-
●● Patient. For example, sickle cell test for patients of Afro- tory conditions, acid–base disturbances and conditions
Caribbean origin with family history of sickle cell disease where there is changing milieu, e.g. immediately before
●● Comorbidities. For example, peak flow rates for severe kidney transplant.
asthmatics ● Liver function tests. These are indicated in patients with
jaundice, known or suspected hepatitis, cirrhosis, malig-
nancy or in patients with poor nutritional status.
● Full blood count. A full blood count (FBC) is needed for
● Other investigations. Specialist radiological views and
major operations, in the elderly and in those with anaemia
recent imaging are sometimes required. If imaging is going
or pathology with ongoing blood loss and chronic disease.
to be needed during surgery, then this needs to be planned
In case of suspicion or history of sickle crisis, a sickle cell
test is needed in patients of Afro-Caribbean and Indian in advance.
subcontinent origin.
● Urea and electrolytes. Urea and electrolytes (U&Es) are SPECIFIC PREOPERATIVE
needed before all major operations, in most patients over
65 years of age especially with cardiovascular, renal and PROBLEMS AND MANAGEMENT
endocrine disease, or if significant blood loss is antic- Specific medical problems encountered during preoperative
ipated. It is also needed in those on medications that assessment should be corrected to the best possible level.
affect electrolyte levels, e.g. steroids, diuretics, digoxin, Many patients with severe disease (see later) will need to be
non-steroidal anti-inflammatory drugs, intravenous fluid referred to specialists; the referral letter should include all
or nutrition therapy and endocrine problems. the details including history, examination and investigation
● Electrocardiography. Electrocardiography (ECG) is results.
required for those patients over 65 years of age and symp-
tomatic patients with a history of rheumatic fever, dia-
betes, cardiovascular, renal and cerebrovascular disease, Cardiovascular disease
with and without severe respiratory problems. It will also Perioperative cardiovascular complications are frequent.
depend on if the surgery is minor/intermediate or major. Patients who can climb a flight of stairs without getting
● Chest radiograph. Cost-effectiveness and risks of radiation short of breath or chest pain or needing to stop are likely to
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Specific preoperative problems and management 257
Summary box 17.5 Hypertension, ischaemic heart

disease (IHD) and coronary stents
Preoperative management of patients with systemic
disease Prior to elective surgery blood pressure should be controlled
to near 160/100 mmHg. If a new antihypertensive agent is
●● Capacity. Baseline organ function capacity should be
assessed introduced, a stabilisation period of at least 2 weeks should
●● Optimisation. Medication, lifestyle changes, specialist referral be allowed.
will improve organ capacity Patients with angina, that is not well controlled, should
●● Alternative. Minimally impacting procedure, appropriate be investigated further by a cardiologist. The indications for
postoperative care will improve outcomes coronary revascularisation in these patients before major sur-
●● Theatre preparations. Timing, teamwork, special instruments gery are the same as the medical indications. Pharmacological
and equipment protection is indicated. Patients on β-blockers and on statins
should be maintained on their medication. Initiating statins
preoperatively should be considered. Most long-term car-
tolerate a wide range of surgeries with an acceptable risk of diac medications should be continued over the perioperative
perioperative cardiovascular morbidity and mortality. How- period. Angiotensin-converting enzyme (ACE) inhibitors
ever, at preoperative assessment it is important to identify and receptor blockers are often omitted 24 hours prior to sur-
the patients who have a high perioperative risk of major gery and reintroduced gradually in the postoperative period.
adverse cardiovascular events (MACE) including myocar- After a proven myocardial infarction (Figure 17.1), elec-
dial infarction (MI), and make appropriate arrangements tive surgery should be postponed for 3–6 months to reduce
to reduce this risk. Patients at high risk are those with isch- the risk of perioperative reinfarction. As primary percutane-
aemic heart disease (IHD), congestive cardiac failure (CCF), ous intervention is the treatment of choice for acute coro-
arrhythmias, severe peripheral vascular disease, cerebrovas- nary syndromes, many patients receive stents and are on dual
cular disease or significant renal impairment, especially if antiplatelet therapy for 12 months. If surgery is absolutely
they are undergoing major intra-abdominal or intra-thoracic necessary within the period of dual antiplatelet therapy, the
surgery. management strategy should be decided jointly by surgeon,
cardiologist, anaesthetist and patient, as it is essential to
In patients with ischaemic heart disease the cardiac and
consider the balance of risk of continuing antiplatelet agents
coronary reserve can be evaluated using a stress test (stress
(with the risk of increased bleeding) and stopping them (with
ECG, stress echocardiogram, myocardial scintigraphy). The
the risk of stent thrombosis).
tests have a high negative predictive value but a relatively
The risk of stent thrombosis with consequences of MI and
low positive predictive value. If the test is negative, the death is reduced if elective surgery is delayed until after dual
patient is unlikely to have IHD; conversely, if it is positive antiplatelet therapy is no longer needed (about 6 weeks after
the chances of the patient actually having IHD is not neces- bare metal and 12 months after drug-eluting stent insertion,
sarily very high, but there is a need for further investigation although with the newest drug-eluting stents 6 months dual
such as coronary angiography. Recently, measurement of the antiplatelet therapy may be enough).
fractional coronary flow reserve (FFR) during coronary angi-
ography using a pressure wire, has made it possible to identify
coronary lesions that have the largest impact on myocardial
perfusion.
In patients with any suggestion of valvular heart disease
or poor left ventricular function, an echocardiogram should V1 V4
be obtained. Pressure gradients across the valves, dimensions
of the chambers and contractility can be determined using
echocardiography; an ejection fraction of less than 30% is
associated with poor patient outcomes.
Cardiopulmonary exercise testing provides a non-invasive
assessment of combined pulmonary, cardiac and circulatory V2 V5
function.
The patient should be referred to a cardiologist if:
● A murmur is heard and the patient is symptomatic.
● The patient is known to have poor left ventricular func-
tion or cardiomegaly.
● Ischaemic changes can be seen on ECG even if the V3 V6
patient is not symptomatic (silent ischaemia, silent MIs
are frequent). Figure 17.1 Preoperative electrocardiogram of a patient who com-
● There is an abnormal rhythm on the ECG, for example plained of chest pain the previous day, showing recent transmural
tachy-/bradycardia or heart block. anterior myocardial infarction with Q waves and ST elevation.
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If surgery cannot be postponed and the risk of significant

perioperative bleeding is low, dual antiplatelet therapy can
be continued during surgery. If the benefits of surgery can be
negated by bleeding in closed cavities (spinal, intracranial, V1
cardiac, posterior chamber of the eye and prostate surgery)
clopidogrel or ticagrelor therapy may have to be stopped and,
if possible, aspirin continued. However, a cardiology opinion
should be sought.
II
Dysrhythmias
In patients with atrial fibrillation, β-blockers, digoxin or cal-
cium channel blockers should be started preoperatively (or V5
continued if the patient is already on such medication) in
order to control rate and possibly rhythm. Cardiac output Figure 17.2 Routine preoperative electrocardiogram in an 83-year-
can increase by 15% if sinus rhythm is restored. Warfarin in old patient with no symptoms other than lethargy for the last 3 months.
patients with atrial fibrillation (AF) should be stopped 5 days This shows complete heart block with dissociated P waves and QRS
preoperatively to achieve an international normalised ratio complexes, requiring preoperative pacing.
(INR) of 1.5 or less, which is safe for most surgery. The newer
anticoagulants such as dabigatran (direct thrombin inhib-
itor) or rivaroxaban, apixaban and edoxaban (direct factor
Xa inhibitors) do not have antagonists and must be stopped V1
preoperatively, generally for 2–3 days in patients with normal
renal function and longer when renal function is impaired.
Alternative anticoagulation is not required in the periopera-
tive period unless the risk of stroke is high (high CHA2DS2-
VACs score). Bridging therapy with unfractionated heparin II
or low molecular weight heparin (LMWH) is recommended
for patients with AF and a mechanical heart valve under-
going procedures that require interruption of warfarin. Deci-
sions on bridging therapy should balance the risks of stroke
and bleeding. V5
Implanted pacemakers and cardiac Figure 17.3 Atrial flutter.
defibrillators
In patients with mechanical heart valves, warfarin needs
Checks and appropriate reprogramming should be done to be stopped for 5 days before surgery, and an infusion of
preoperatively by specialists. Monopolar diathermy activ-
unfractionated heparin started when the INR falls below 1.5.
ity during surgery may be sensed by the pacemaker as ven-
The activated partial thromboplastin time (APTT), should
tricular fibrillation. Therefore, cardioversion and overpace
be monitored to keep it at 1.5 times normal and the infusion
modes must be turned off (and switched on after surgery) or
is then stopped 2 hours before surgery. Heparin and warfarin
converted to ‘ventricle paced, not sensed with no response
should be started in the postoperative period, and heparin is
to sensing’ (VOO) mode. Bipolar diathermy should be made
available at surgery. stopped when the full effect of warfarin takes effect. Throm-
Symptomatic heart blocks and asymptomatic second- bin inhibitors and factor Xa inhibitors are not licensed and
(Mobitz II) and third-degree heart blocks, if discovered at pre- should not be used in patients with mechanical valves.
operative assessment clinic, will need cardiology consultation
and temporary or permanent pacemaker insertion. Anaemia and blood transfusion
Figures 17.2 and 17.3 illustrate ECGs from two cases
requiring preoperative optimisation. Patients found to be anaemic at preoperative assessment
should be investigated for the cause of their anaemia. They
should be treated with iron and vitamin supplements.
Valvular heart disease Chronic anaemia is well tolerated in the perioperative period;
While anaesthetic management is altered to achieve haemo- however, if the patient is undergoing a major procedure pre-
dynamic stability in moderate valvular diseases, the patients operative transfusion may be considered. If excessive bleeding
with severe aortic and mitral stenosis may benefit from val- is expected, then a preoperative ‘group and save’ should be
vuloplasty before elective non-cardiac surgery. Appropriate performed and an appropriate number of units of blood cross-
referral to anaesthetist and cardiologist should be made. matched.
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Some patients may refuse blood transfusion, for example Gastrointestinal disease
a Jehovah’s witness. In such a case, during the consent pro-
cess (see later) discussion should include which blood prod- Nil by mouth and regular medications
uct and/or device system (e.g. cell salvage, reinfusion from Patients are advised not to take solids within 6 hours and
drains) is acceptable. The discussion should extend to other clear fluids (isotonic drinks and water) within 2 hours before
areas, for example whether refusal of transfusion would apply anaesthesia to avoid the risk of acid aspiration syndrome.
in life-threatening situations. As in all consent processes, the These restrictions are further reduced in infants, as keeping
discussion and outcome should be clearly documented (see hydrated reduces discomfort and is known to improve post-
Further reading; RCS 2016). operative outcomes.
If the surgery is delayed, oral intake of clear fluids should
be allowed until 2 hours before surgery or intravenous fluids
Respiratory disease should be started, especially in vulnerable groups of patients,
e.g. children, the elderly and diabetics.
Postoperative respiratory complications, such as pneumo-
Patients can continue to take their specified routine med-
nia, are a major cause of morbidity and mortality especially
ications with sips of water in the NBM period.
after major abdominal and thoracic surgery. A patient’s cur-
rent respiratory status should be compared with their ‘normal Regurgitation risk
state’. Make a note of the severity of the asthma and COPD,
Patients with hiatus hernia, obesity, pregnancy and diabetes
such as past hospital admissions for treatment of the condi-
are at high risk of pulmonary aspiration, even if they have
tion, records of pulmonary function tests, use of oral steroids,
been NBM before elective surgery. Clear antacids, H2-recep-
home oxygen, non-invasive ventilation support and evidence
tor blockers, e.g. ranitidine, or proton pump inhibitors, e.g.
of right heart failure.
omeprazole, may be given at an appropriate time in the pre-
A preoperative chest radiograph or scan is useful in a operative period.
patient with known emphysematous bullae, pulmonary can-
cer, metastasis or effusions. Liver disease
Patients on oral steroid treatment, oxygen therapy or who In patients with liver disease, the cause of the disease needs
have a forced expiratory volume in the first second (FEV1) to be known, as well as any evidence of clotting problems,
less than 30% of predicted value (for age, weight and height), renal involvement and encephalopathy. Elective surgery
or PaCO2 level of greater than 6kPa, have severe disease and should be postponed until any acute episode has settled
are at risk of pneumonia and respiratory failure in the postop- (e.g. cholangitis). The blood tests that need to be performed
erative period. include liver function tests, coagulation, blood glucose and
Patients should continue to use their regular inhalers U&Es. The presence of ascites, oesophageal varices, hypo-
until the start of anaesthesia. Brittle asthmatics may also need albuminaemia and sodium and water retention should be
extra steroid cover. Encourage the patients to be compliant noted, as all can influence the choice and outcome of anaes-
with the medications, take a balanced diet and stop smok- thesia and surgery.
ing. Information should be provided to indicate perioperative
risks associated with smoking. Stopping smoking reduces car- Genitourinary disease
bon monoxide levels and offers the patient a better ability to
clear sputum. Evidence suggests that preoperative inspiratory Renal disease
muscle training significantly improves respiratory (muscle) Underlying conditions leading to chronic renal failure such
function in the early postoperative period, reducing the risk as diabetes mellitus, hypertension and ischaemic heart dis-
of pulmonary complications. ease, should be stabilised before elective surgery. Appropriate
Regional anaesthetic techniques and less invasive surgical measures should be taken to treat acidosis, hypocalcaemia
options should be considered in severe cases. Elective surgery and hyperkalaemia of greater than 6 mmol/L. Arrangements
should be postponed until acute exacerbations are treated. should be made to continue peritoneal or haemodialysis until
a few hours before surgery. After the final dialysis before sur-
The patient should be referred to a respiratory physician if:
gery, a blood sample should be sent for FBC and U&Es.
● There is a severe disease or significant deterioration. Chronic renal failure patients often suffer chronic micro-
cytic anaemia that is well tolerated; therefore, preoperative
● Major surgery is planned in a patient with significant
blood transfusion is often not necessary.
respiratory comorbidities.
Acute kidney injury can present with an acute surgical
● Right heart failure is present – dyspnoea, fatigue, tricuspid problem, for example bowel obstruction needing emergency
regurgitation, hepatomegaly and oedematous feet. surgery. In these patients, medical treatment should be started
● The patient is young and has severe respiratory problems at the earliest opportunity and carried on through surgery and
(indicates a rare condition). through into the critical care unit.
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Urinary tract infection levels should be checked 2 hourly. For those on the after-
Uncomplicated urinary infections are common in women, noon list, breakfast can be given with half their regular dose
while outflow uropathy with chronically infected urine is of intermediate-acting insulin (or full dose oral antidiabetic
common in men. These infections should be treated before agents) and then managed with regular blood sugar checks as
embarking on elective surgery where infection carries dire above. An intravenous insulin sliding scale should be started for
consequences, e.g. joint replacement. For emergency proce- insulin-dependent diabetes mellitus patients undergoing major
dures, antibiotics should be started and care taken to ensure surgery, or if blood sugar is difficult to control for other reasons.
that the patient maintains a good urine output before, during
Adrenocortical suppression
and after surgery.
Patients receiving oral adrenocortical steroids should be asked
about the dose and duration of the medication in view of sup-
Endocrine and metabolic disorders plementation with extra doses of steroids perioperatively, to
avoid an Addisonian crisis.
Malnutrition
Body mass index (BMI) is weight in kilograms divided by
height in metres squared. A BMI of less than 18.5 indicates
Coagulation disorders
nutritional impairment and a BMI below 15 is associated with Thrombophilia
significant hospital mortality. Nutritional support for a mini- Patients with a strong family history or previous personal his-
mum of 2 weeks before surgery is required to have any impact tory of thrombosis should be identified (Table 17.3). They will
on subsequent morbidity. need thromboprophylaxis in the perioperative period.
If a patient is unlikely to be able to eat for a significant The progesterone-only contraceptive pill should be con-
period, arrangements should be made by the preoperative tinued; however, the risks of continuing the combined pill
assessment team to start nutritional support in the immediate (slight increase risk of significant thrombosis) should be
postoperative phase. weighed against the risks of an unplanned pregnancy. Con-
sider stopping oestrogen-containing oral contraceptives or
Obesity hormone replacement therapy 4 weeks before surgery (NICE
Morbid obesity can be defined as BMI of more than 35 (other guidance; see Further reading). The reader is advised to use an
definitions exist) and is associated with increased risk of post- appropriate resource for precise formulation information and
operative complications. Patients should be made aware of current guidance.
risks involved and advised on healthy eating and taking reg- Patients with a low risk of thromboembolism can be
ular exercise. given thromboembolism-deterrent stockings to wear during
Associated sleep apnoea can be predicted by using a clin- the perioperative period. High-risk patients with a history of
ical scoring system, the perioperative sleep apnoea prediction recurrent DVT, pulmonary embolism and arterial thrombosis
(P-SAP) score or sleep apnoea studies. There is evidence will be on warfarin. This should be stopped before surgery and
to suggest that patient outcomes improve with more than 6 replaced by low molecular weight heparin or factor Xa inhib-
weeks of use of a continuous positive airway pressure (CPAP) itors. Local or national guidelines advise what type of DVT
device preoperatively, and cholesterol reducing agents in the prophylaxis should be used for each type of surgery.
perioperative phase.
If possible surgery should be delayed until the patient is Neurological and psychiatric
more active and has lost weight. If this fails, prophylactic
measures need to be taken (such as preventative measures disorders
for acid aspiration and DVT) and associated risks need to be In patients with a history of stroke, pre-existing neurological
explained prior to the surgery. deficit should be recorded. These patients may be on anti-
Diabetes mellitus TABLE 17.3 Risk factors for thrombosis.
Diabetes and associated cardiovascular and renal complications ●● Age >60 years
should be controlled to as near normal level as possible before ●● Obesity BMI >30 kg/m2
embarking on elective surgery. Any history of hyper- and ●● Trauma or surgery (especially of the abdomen, pelvis and lower
hypoglycaemic episodes, and hospital admissions, should be limbs), anaesthesia >90 minutes
noted. HbA1c levels should be checked. For elective surgery, ●● Reduced mobility for more than 3 days
HBA1c of <69 mmol/mol is recommended. Lipid-lowering ●● Pregnancy/puerperium
medication should be started in patients who are in a high- ●● Varicose veins with phlebitis
risk group for cardiovascular complications of diabetes. ●● Drugs, e.g. oestrogen contraceptive, HRT, smoking
Patients with diabetes should be first on the operating list ●● Known active cancer or on treatment, significant medical
and, if the operation is in the morning, advised to omit the comorbidities, critical care admission
morning dose of medication and breakfast. Though tight con- ●● Family/personal history of thrombosis, e.g. deficiencies in
antithrombin III, protein S and C
trol of blood sugar is not needed, the patient’s blood sugar
Thomas Addison, 1795–1860, physician, Guy’s Hospital, London, UK, described the effects of disease of the suprarenal capsules in 1849.
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platelet agents or anticoagulants. If it is felt that the neurolog-

ical and cardiovascular thrombotic risks are low, antiplatelet
agents should be withdrawn (7 days for aspirin, 10 days for
clopidogrel). If the thrombotic risks are perceived to be high
and the patient is undergoing surgery with a high risk of
bleeding, aspirin alone should be continued.
Anticonvulsants and anti-Parkinson medication is contin-
ued perioperatively to help early mobilisation of the patient.
Lithium should be stopped 24 hours prior to surgery; blood
levels should be measured to exclude toxicity. The anaesthe-
tist should be informed if patients are on psychiatric medica-
tions such as tricyclic antidepressants or monoamine oxidase
inhibitors, as these may interact with anaesthetic drugs.
Musculoskeletal disorders
Rheumatoid arthritis can lead to an unstable cervical spine
with the possibility of spinal cord injury during intubation. Figure 17.4 Extension view of cervical spine in patient with rheuma-
Therefore, flexion and extension lateral cervical spine radio- toid arthritis.
graphs should be obtained in symptomatic patients (Figures
17.4 and 17.5).
Assessment of the severity of renal, cardiac valvular and
pericardial involvement as well as restrictive lung disease,
should be carried out. Rheumatologists will advise on steroids
and disease-modifying drugs so as to balance immunosuppres-
sion (chance of infections) against the need to stabilise the
disease perioperatively (stopping disease modifying drugs can
lead to flare-up of the disease).
In ankylosing spondylitis patients, in addition to the prob-
lems discussed above, techniques of spinal or epidural anaes-
thesia are often challenging. Patients with systemic lupus
erythematosus may exhibit a hypercoagulable state along
with airway difficulties.
With certain types of orthopaedic operations, such as joint
replacement, antibiotic prophylaxis will be required, and will
usually follow specific local or national guidelines.
Airway assessment Figure 17.5 Flexion view in the same patient as in Figure 17.4. Note
the large increase in the atlantodens interval, implying significant
The ability to intubate the trachea and oxygenate the patient instability at this level.
are basic and crucial skills of the anaesthetist. The ease or
difficulty encountered when performing airway manoeuvres
can be predicted by simple examination findings of full mouth Preoperative assessment in
opening (modified Mallampati class), jaw protrusion, neck
movement and thyromental distance. The anaesthetist should emergency surgery
look for loose teeth, obvious tumours, scars, infections, obe- In urgent or emergency surgery the principles of preoperative
sity, thickness of the neck, etc., which will indicate difficulty assessment should be the same as in elective surgery, except
in visualising the airway. When more than one of the above that the opportunity to optimise the condition is limited by
tests are positive, the chances of experiencing difficulty in time constraints. Medical assessment and treatments should
obtaining and securing the airway become greater. To obtain be started (e.g. as per Advanced Trauma Life Support guide-
the modified Mallampati class, the anaesthetist sits in front lines) even if there is no time to complete them before the
of the patient who is asked to open their mouth and protrude start of the surgical procedure. Some risks may be reduced but
the tongue (Figure 17.6). The higher the grade, the higher some may persist and, whenever possible, these need to be
the risk in obtaining and securing an airway (Table 17.4). explained to the patient.
SR Mallampati published the original article suggesting that the size of the base of the tongue is an important factor determining the degree of difficulty of direct
laryngoscopy in the Canadian Anaesthetists’ Society Journal in 1985. The original Mallampati classifications was modified from a total of three to four classes by
GLT Sampsoon and JRB Young after reviewing a series of obstetric and general surgical patients who had had difficult intubations.
03_17B-B&L27_Pt5_Ch17.indd 261 25/10/2017 08:05

anxiety result in increased demands for oxygen delivery to the

tissues. This demand increases from an average of 110 mL/
min/m2 at rest to 170 mL/min/m2 in the postoperative period.
Most patients meet this increase in demand by increasing
their cardiac output and tissue oxygen extraction. Patients
who are unable to meet these demands, as a result of a limited
cardiorespiratory reserve, are at a risk of oxygen debt.
Occult hypovolemia resulting from fluid shift or blood loss
can further impair oxygen delivery. Splanchnic vasoconstric-
tion to compensate for this may result in gut ischaemia. Those
with coronary or cerebrovascular disease are also at a higher
risk of myocardial ischaemia or stroke.
Factors contributing to risk

Figure 17.6 Normal mouth opening view.
Risk is a complex interaction of multiple factors that can be
classified into patient and surgical factors. Patient factors are
TABLE 17.4 Airway assessment (Samsoon and Young listed in Table 17.5. The elderly, though not independently
modified Mallampati test). at higher risk, not only suffer more cardiac, pulmonary and
●● Fauces, pillars, soft palate and uvula seen Grade 1 renal disease but also require surgery four times as often as the
●● Fauces, soft palate with some part of uvula seen Grade 2 rest of the population. Around 10% of the population over
●● Soft palate seen Grade 3 65 have frailty with increasing incidence with age. Frailty is
●● Hard palate only seen Grade 4 a distinctive state that is related to ageing. Multiple body sys-
tems lose their in-built reserves in the elderly.
The type of surgery contributes independently and is listed
Summary box 17.6 in Table 17.6. This risk increases if the surgery is performed
as an emergency. Often, the underlying condition necessitat-
Preoperative assessment for emergency surgery
ing surgery itself may be associated with an increased risk of
●● Start. Similar principles to that for elective surgery complications. For example, a patient with severe peripheral
Constraints. Time, facilities available
vascular disease resulting from heavy smoking, may need a
●●
Consent. May not be possible in life-saving emergencies

femoral-popliteal bypass graft and can be expected also to
●●
Organisational efforts. For example, local/national algorithms

have significant COPD and IHD.
●●
for treatment of the patient with multiple injuries

Moreover, when mortality by type of surgery is adjusted
for patient risk factors, the apparent hierarchy of surgical risk
may change. The average mortality risk for an individual
patient undergoing thoracic surgery, for example, is likely to
ASSESSMENT OF THE HIGH- be higher than the average risk for that same patient undergo-
RISK PATIENT ing vascular surgery. Complications associated with the latter
are nevertheless more frequent because vascular patients have
Despite higher-risk patients presenting for surgery, the greater medical risk factors (Table 17.7).
perioperative mortality has decreased significantly over the
last half a century, especially in resource-rich countries. In
a published systematic review in The Lancet (Bainbridge et
al., 2012), perioperative mortality has declined from 10 603 TABLE 17.5 Patient factors that predispose to high risk of
per million (95% CI: 10 423–10 784) in the 1970s to 1176 morbidity and mortality.
per million (1148–1205) in the 1990s–2000s (p<0·0001). Previous severe cardiorespiratory illness, e.g. acute myocardial
However, there remains a subgroup of patients who are infarction, COPD or stroke
at higher risk of morbidity and mortality after surgery. By Late stage vascular disease involving aorta
Age >70 years with limited physiological reserve in one or more
identifying high-risk patients in the preoperative phase and
vital organs
planning their perioperative management, morbidity and Extensive surgery for carcinoma
mortality can be reduced. Acute abdominal catastrophe with haemodynamic instability (e.g.
Patients who have a predicted mortality ≥5% should be peritonitis)
considered as ‘high risk’. It is estimated that although the Acute massive blood loss >8 units
Septicaemia
high-risk group accounts for less than 15% of all surgical pro- Positive blood culture or septic focus
cedures, they contribute to more than 80% of all periopera- Respiratory failure: PaO2 <8 kPa or FiO2 >0.4 or mechanical
tive deaths in UK. ventilation >48 h
What causes these patients to be at a high risk of death Acute renal failure: urea >20 mmol or creatinine >260 mmol/L
and complications after surgery? After surgery tissue destruc- (Based on clinical criteria used by Shoemaker and colleagues modified by
tion, blood loss, fluid shifts, changes in temperature, pain and Boyd.)
03_17B-B&L27_Pt5_Ch17.indd 262 25/10/2017 08:05

Assessment of the high-risk patient 263
TABLE 17.6 Surgery specific estimates of risk optimisation may take the form of measures to minimise myo-
cardial ischaemia or measures to improve oxygen delivery to
High risk (cardiac Intermediate risk Low risk (cardiac
risk >5%) (cardiac risk 1–5%) risk <1%) the other major organs, depending on the prevailing risks.
Optimisation before surgery can be more effective in a crit-
Open aortic Elective abdominal Breast
Major vascular Carotid Dental ical care environment and patients may need to be admitted
Peripheral vascular Endovascular Thyroid to a high dependency unit (HDU) or intensive therapy unit
Urgent body cavity aneurysm Ophthalmic (ITU) preoperatively. The likelihood of the high-risk patient
Head and neck Gynaecological requiring postoperative critical care should be planned preop-
Major neurosurgery Reconstructive
Arthroplasty Minor orthopaedic
eratively and discussed with the duty critical care physician.
Elective pulmonary Minor urology The identification of patients who will benefit the most
Major urology from these interventions is important, not only for the
(From Eagle et al. J Am Coll Cardiol 2002; 39(3): 542–53.) improvement of outcomes but also the effective allocation of
resources. As discussed above, emergency surgery is associated
with higher risks because by its very nature there is less time
TABLE 17.7 The effect of adjustment for patient factors and opportunity to organise these additional levels of care.
on surgery-specific operative mortality.
Type of surgery Unadjusted 30-day Adjusted 30-day
mortality (% (rank)) mortality (%(rank)) Summary box 17.7
Vascular 5.97 (1) 0.98 (5)
Thoracic 3.40 (2) 2.28 (1) A practical approach to the care for the high-risk
Abdominal 2.73 (3) 1.83 (2) patient
Cardiac 2.70 (4) 1.13 (4)
●● Identify the high-risk patient
Neurosurgery 1.74 (5) 1.60 (3)
Orthopaedic 1.25 (6) 0.49 (7) ●● Assess the level of risk
ENT 0.85 (7) 0.68 (6) ●● Detailed preoperative assessment
Urology 0.81 (8) 0.38 (8) ●● Adequate resusciatation
Gynaecology 0.13 (9) 0.17 (9) ●● Optimise medical management
Breast 0.07 (10) 0.08 (10)
●● Investigation to define the underlying surgical problem
(Modified from Noordzij et al. 2010.) ●● Immediate and definitive treatment of underlying problems
●● Consider admission to a critical care facility postoperatively
In summary, the typical high-risk patient is the elderly Identification of the high-risk patient
patient with coexisting conditions such as IHD and/or COPD
undergoing major surgery. The risk will increase if the surgery A number of scoring systems have been developed over the
is performed as an emergency. years with the aim of identifying high-risk patients (Table 17.8).
American Society of Anaesthesiologists

Management of risk system
The key to managing patients effectively is the identification The American Society of Anaesthesiologists (ASA) scoring
and accurate quantification of the risk, and subsequent mea- system is widely used. Although not designed to be used as a
sures taken to minimise it. risk prediction score, it has a quantitative association with the
Realistic estimates of risk are the cornerstone of informed predicted percentage of postoperative mortality (Table 17.9).
patient consent and shared decision making. The patient However, it does not account for age or nature of surgery and
and the surgeon may choose a less extensive or even a non- the term ‘systemic disease’ in ASA grading introduces an ele-
surgical option where risks of the definitive procedure are ment of ‘subjectivity’.
deemed to be too high or unacceptable. The Royal College
of Surgeons (RCS) of England has recommended that the Metabolic equivalent
patients who are predicted to have greater than 5% mor- As discussed earlier, overall functional physical fitness can be
tality risk should have active consultant input in all stages judged by the ability to tolerate metabolic equivalent tasks
of their management. (METs) (Table 17.10). One MET is equivalent to the oxygen
Surgical procedures in those with predicted mortality of consumption of an adult at rest (~3.5 mL/kg/min). Different
>10% should be conducted under the direct supervision of tasks are assigned a number of METs. If the patient is able to
consultant surgeon or anaesthetist, unless the consultants are perform >4 METs (e.g. climbing at least one flight of stairs)
satisfied with the seniority and competence of the staff man- they are considered suitable candidates for major surgery.
aging these patients. Moreover, those with a mortality >10% However, once again this depends on a subjective assessment
should be managed in the critical care facility. of the ability of a patient and may be overestimated by them.
Depending on particular comorbidities, it may be possi- Objective indices based on weighted scores pertaining to
ble for a patient’s underlying conditions to be improved by surgery and comorbidity, have been created to stratify cardiac
optimising their medical therapy. Additional physiological risk. Examples include the Goldman cardiac risk index and
03_17B-B&L27_Pt5_Ch17.indd 263 25/10/2017 08:05

TABLE 17.8 Surgical risk scores classified by outcome measures and need for intraoperative information.
Scores predicting mortality Scores predicting morbidity
Scores not requiring ASA ASA
operative information APACHE-II APACHE-II
Donati score Goldman cardiac risk index
Hardman index Veltkamp score
Glasgow aneurysm score VA respiratory failure score
Sickness assessment VA pneumonia prediction index
Boey score ACS NSQIP surgical risk score
Hacetteppe score
Physiological POSSUM
ACS NSQIP surgical risk score
Scores requiring operative Mannheim peritonitis index POSSUM
information Reiss index P-POSSUM
Fitness score
POSSUM
P-POSSUM
Cleveland colorectal model
Surgical risk scale
APACHE-II, Acute Physiology and Chronic Health Evaluation II; VA, Veterans Affairs; P-POSSUM, Portsmouth-POSSUM; see text for additional abbreviations.
(Modified from Rex TE, Bates T. World J Emerg Surg 2007; 2: 16.)
TABLE 17.9 Operative mortality by ASA grade. TABLE 17.11 The revised cardiac risk index (RCRI) of
ASA Description 30 day Lee.
Grade mortality (%) Risk factors Risk of major
I Healthy 0.1 cardiac
II Mild systemic disease, no functional 0.7 complications (%)
limitation History of ischaemic heart disease Number of factors
III Severe systemic disease, definite 3.5 History of compensated or prior heart failure 0 = 0.4
functional limitation History of cerebrovascular disease 1 = 0.9
IV Severe systemic disease, constant threat 18.3 Diabetes mellitus 2 = 7.0
to life Renal insufficiency (creatinine >177 µmol/L) 3+ = 11.0
V Moribund patient unlikely to survive 24 93.3 High-risk surgery
hours with or without operation
E Emergency operation –
(From Boyd O, Jackson N. Crit Care 2005; 9: 390–6.) ACS NSQIP score
The American College of Surgeons (ACS) National Surgi-
TABLE 17.10 Metabolic equivalent of task (MET).
cal Quality Improvement Programme (NSQIP) surgical risk
score estimates the chance of a complication or death after
●● 1 MET = 3.5 mL O2/kg/min (oxygen consumption by 40-year-
old,70 kg man at rest)
surgery for more than a thousand different surgical proce-
●● 1 MET = eating and dressing
dures. It compares the patient’s risk with an average person’s
●● 4 MET = climbing 2 flights of stairs
risk. It is a web based tool done preoperatively. The risk is
●● 6 MET = short run calculated based on surgical procedure and 19 patient-specific
●● >10 MET = able to participate in strenuous sport preoperative risk factors.
●● Patients who can exercise at 4 METS or above have lower risk
of perioperative mortality Cardiopulmonary exercise testing
Cardiopulmonary exercise testing (CPET) can be used as a
screening tool to identify high-risk patients. The oxygen (O2)
the revised cardiac risk index (RCRI) of Lee (Table 17.11). consumption and carbon dioxide (CO2) production of the
Although they can predict risk of cardiac complications, they patient are measured while they undergo a 10 minute period of
are not designed to predict mortality. incrementally demanding exercise (usually on a cycle ergom-
eter) up to their maximally tolerated level (Figure 17.7).
POSSUM score CPET is based on the principle that when a subject’s
The POSSUM score (Physiologic and Operative Sever- delivery of O2 to active tissues becomes inadequate, anaerobic
ity Score for the enUmeration of Mortality and Morbidity) metabolism begins; lactate is buffered by bicarbonate and the
and its modifications (P-POSSUM, CR-POSSUM) are used resulting CO2 increases out of proportion to the escalation
to predict all-cause mortality in postoperative critical care in physical difficulty and O2 consumption. The ‘anaerobic
patients as well as non-cardiac morbidity. threshold’ (AT) is the O2 consumption in mL/kg/min above
Lee Goldman, b.1948, Dean of Health Sciences and Medicine, Columbia University, New York, NY, USA, since 2006. He developed his Index in 1977.
Thomas H Lee, Professor of Medicine, Harvard Medical School, Professor of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.
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Assessment of the high-risk patient 265
hypotension, tachycardia and procoagulant states (of which

the inflammatory response to surgery is an example).
Preparation of these patients for surgery should aim to
optimise myocardial oxygen supply and demand ratio and so
minimise the risk of myocardial ischaemia developing. This
work may involve further investigations or even the decision
to postpone non-cardiac surgery for 3–6 months after an MI.
Some patients may require preoperative revascularisation,
using either a coronary artery bypass grafting (CABG) or per-
cutaneous coronary intervention (PCI) with a stent or angio-
plasty.
Minimising myocardial ischaemia

Anaesthesia techniques that dampen the stress response
to surgery (especially minimising pain) and provide a good
degree of cardiac stability should be used. Anaesthesia should
avoid tachycardia, systolic hypertension and diastolic hypo-
tension, and may be facilitated by the use of invasive arte-
rial blood pressure monitoring. Blood loss must be accurately
Figure 17.7 Cardiopulmonary exercise testing (CPET).
monitored and haemoglobin maintained at a level suitable
for the patient’s cardiac risk factors. Perioperative use of
β-blockers may be considered but this is controversial.
which this occurs. Peak oxygen consumption (VO2) is also Troponin testing allows early diagnosis of perioperative
measured. They are the end product of a subject’s combined MIs, but there are limited reperfusion options due to risk of
respiratory, cardiac, vascular and musculoskeletal fitness, and bleeding from the surgical site. Admission to HDU should be
subjects with either an AT above a somewhat arbitrary cut- considered for patients with IHD and supplemental oxygen
off of 11 and a VO2 below 15 mL/kg/min are at higher risk of therapy continued for 3–4 days.
morbidity and mortality after surgery.
When CPET is not available, a simple walk test, such as Cardiac failure
the 6-minute walk test (6MWT) and the incremental shut- Left ventricular failure is the end result of several conditions
tle walk test (ISWT), can be used to assess the functional including IHD, hypertension, cardiomyopathies and valve
capacity of the patient. They depend on the patient’s ability dysfunction. Decompensated heart failure puts the patient
to walk for a fixed 6 minute period or at increasing speed over at risk of multiorgan failure. Those with ejection fractions of
a flat surface. less than 35%, and in whom the failure is undiagnosed or its
severity underestimated, are at the highest risk. The patient’s
Optimisation of the high-risk patient functional capacity needs to be assessed and surgery may have
to be delayed for investigations such as an echocardiogram
As discussed above, all coexisting disease processes should be and/or for optimisation of medical therapy. Drugs used in
reviewed and optimised. Simple measures include stopping chronic heart failure have significant implications for periop-
smoking (maximal benefit only seen if stopped for 8 weeks erative care, and β-blockers and probably ACE inhibitors
prior to surgery), reducing alcohol intake, losing weight, (unless renal perfusion is to be significantly affected) should
improving nutrition and/or haemoglobin levels. be continued. Anaesthesia should ensure minimal myocardial
In the high-risk group there may a need for more complex depression and change in afterload during surgery. Arrhyth-
investigations, review of medication or even consideration of mias must be rapidly brought under control, particularly AF,
further surgery. Patients scheduled for abdominal aortic aneu- and correcting any electrolyte imbalance is crucial in this
rysm (AAA) repair surgery for example, frequently require respect. Invasive monitoring of trends in central venous and
carotid duplex scans. If the scans reveal a significant blockage arterial pressure monitoring may help management, particu-
and a high risk of perioperative stroke, a carotid endarterec- larly when large fluid shifts are expected to occur.
tomy may be indicated prior to AAA repair.
All high-risk patients benefit from multidisciplinary team Respiratory failure
care and the involvement of experienced physicians in the peri- Around 1.5% of patients develop lower respiratory tract
operative period. The impact and management of the comor- infection after surgery with a 30-day mortality over 20%.
bidities that commonly contribute to risk are outlined below. Surgery, particularly open abdominal procedures under gen-
eral anaesthesia, result in changes to respiratory physiology.
Ischaemic heart disease The functional residual capacity of the lungs is reduced. This
Perioperative myocardial infarction (MI) is associated with combined with the respiratory depressant effect of residual
a high mortality (15–25%). Ischaemia, and ultimately MI, anaesthetic agents, the patient’s limited mobility and pain
occur when the supply of oxygen to the myocardium is from surgery causes atelectasis (failure of gas exchange due to
exceeded by its demand. This situation can be precipitated by alveolar collapse) and predisposes patients to postoperative
03_17B-B&L27_Pt5_Ch17.indd 265 25/10/2017 08:05

respiratory infection. Other complications including bron- els with appropriate intravenous fluids. It is also important to
chospasm, pneumothorax and acute respiratory distress syn- deal with the source of sepsis as early as possible.
drome (ARDS) contribute as much to morbidity and length
of hospital stay as cardiac complications. Respiratory failure
defined as a PaO2 <8 kPa in air, PaO2/FiO2 <40 kPa or inabil- Minimising the impact of surgery in
ity to extubate a patient 48 hours after surgery, is by far the the high-risk patient
most significant of these and is associated with a mortality of There are situations where the selection of one surgical tech-
27–40%. nique over another may be significantly influenced by patient
Again, as with cardiac risk management, it may be nec- risk factors. Some procedures are not primarily high-risk but
essary to postpone surgery to allow medical optimisation or may become so in unsuitable patients. Laparoscopic surgery,
consider a non-operative option. Preoperatively, bronchodi- for example, has come of age as a preferred technique for
lator therapy will be required in those with reversible obstruc- patients predisposed to postoperative respiratory complica-
tive airway disease and steroids may need to be started or tions, but its effect on cardiac physiology means the same may
increased. Nutritional status should be optimised and albu- not apply to patients at risk of cardiac complications. The
min levels corrected. Physiotherapy for postural drainage, and expanding demand and indications for minimal access surgery
deep breathing exercises or incentive spirometry should be are now pushing the boundaries of intraoperative physiolog-
considered for patients at increased risk of respiratory com- ical tolerance. Robotic prostatectomy and some laparoscopic
plications. General anaesthesia is associated with more respi- colorectal procedures require a pneumoperitoneum with steep
ratory complications and so regional techniques should be Trendelenburg (head down) positioning for several hours
considered where possible in these patients. Hypoxemia and (Figure 17.9). This can be associated with adverse cardio-
CO2 retention leading to the need for reintubation is better vascular and neurological complications, such as myocardial
avoided in those at risk, by delaying extubation until anal- ischaemia and increased intracranial pressure in the high risk
gesia, hydration and acid–base status have been corrected. group. This risk may be minimised by attention to patient
Patients may benefit from ITU admission and this needs plan- selection.
ning. Application of non-invasive respiratory support (Figure
17.8) may allow certain patients to be extubated earlier.
Role of critical care and outreach
Other comorbidities services
Acute kidney injury, chronic kidney disease, diabetes, periph-
eral vascular disease and liver dysfunction are some of the Optimal care in the high-risk group should be extended to
medical conditions that contribute to risk and need to be include postoperative support, which for a majority of these
optimised. patients means admission to a critical care bed. Reports from
the National Confidential Enquiry into Surgical Deaths
Sepsis (NCEPOD) show that the majority of postoperative deaths
Sepsis needs urgent identification and treatment, as if not
treated early it can lead to either a prolonged admission to
a critical care unit or death. Early resuscitative measures in
sepsis include administering broad spectrum antibiotics and
treating hypotension, hypovolemia and elevated lactate lev-
Figure 17.8 Non-invasive ventilation. Figure 17.9 Robotic surgery.
03_17B-B&L27_Pt5_Ch17.indd 266 25/10/2017 08:05

Arranging theatre list 267
Furthermore, the guide explains that consent:

● should be written and recorded on a form;
● the key points of the discussion should be recorded in the
case notes.
*Material risk: “whether, in the circumstances of the par-
ticular case, a reasonable person in the patient’s position
would be likely to attach significance to the risk, or the
doctor is or should reasonably be aware that the particular
patient would likely attach significance to it” (Source RCS
2016).
Clearly in certain emergency situations, it may not be
possible to follow all of the key principles. For consent to be
given, the patient must have capacity, which includes the
ability to understand the information provided, to retain
and use the information to make a decision and to indicate
Figure 17.10 A high-risk patient admitted to the intensive care unit what that decision is (see Further reading; RCS). The sur-
postoperatively.
geon should presume the patient has capacity for consent
(Mental Capacity Act, 2005) unless during the process it is
in the UK occur more than 5 days after surgery. Admission demonstrated that this is not the case. Generally, children are
to a critical care unit allows for early intervention and a level presumed to have capacity at 16 and for those under that age,
of care that is difficult to deliver in the ward environment capacity can be assessed (GMC guidance, 2007).
during this crucial period (Figure 17.10). The high-risk sur- The person obtaining consent must be appropriately
gical population accounts for 80% of postoperative deaths but experienced to do so.
only about 15–30% of high-risk surgical patients are admitted
to a critical care unit at any time following surgery. One study Summary box 17.8
that compared surgical mortality in the UK and the USA
found an observed mortality of 9.95 % in the UK as compared Consent
to 2.1% in USA. It is suggested that the difference may be ●● Consent should be voluntary and informed
related to the provision of critical care services, with 8.6 crit- ●● Supported decision-making is considered good practice
ical care beds per 100 000 population in the UK compared to ●● Explain all treatment options and material risks
30.5 in the USA. ●● Capacity is needed for a patient to give their consent
In the last decade, the role of critical care has been
expanded to the concept of ‘critical care without walls’. The
intensive care outreach services (ICORS) grew from a recog-
nition that there were many patients in the hospital who are ARRANGING THEATRE LIST
at risk of being critically ill, and early identification of these The date, place and time of operation should be matched
patients using ‘early warning scores’ could allow for early with availability of personnel. Appropriate equipment and
intervention. The outreach team functions to bridge the gap instruments should be made available. The operating list
between critical care unit and ward. should be distributed as early as possible to all staff who are
involved in making the list run smoothly (Table 17.12). If this
CONSENT is done electronically, familiarity with the computer system is
required.
Consent should be both voluntary and informed. The pro- Prioritise patients, e.g. children and diabetic patients
cess of consent has evolved over the years and in the UK, should be placed at the beginning of the list; life- and
following a recent legal judgement, new guidance has been limb-threatening surgery should take priority; cancer patients
published (see Further reading; RCS). This describes the need to be treated early.
importance of supported decision-making concerning a treat-
ment or operation. The guidance outlines the key principles
of consent and how the discussion should: TABLE 17.12 Perioperative teams.
● give the patient the information required to make a deci- ●● Ward, theatre and specialist nursing staff
sion; ●● Anaesthetic and surgical teams
● be tailored to the individual patient; ●● Radiology, pathology involvement
● explain all reasonable treatment options; ●● Rehabilitation and social care workers
● discuss all material* risks. ●● Specific personnel in individual cases
03_17B-B&L27_Pt5_Ch17.indd 267 25/10/2017 08:05

FURTHER READING Mental Capacity Act (2005) UK.

Minto G, Biccard B. Assessment of the high-risk perioperative patient.
Bainbridge D1, Martin J, Arango; Task Force on Practice Guidelines BJA Education 2014; 14(1): 12–17.
(Committee to Update the 1996 Guidelines on perioperative car- National Confidential Enquiry into Patient Outcome and Death. Know-
diovascular M, Cheng D; Evidence-based Perioperative Clinical ing the risk. A review of the peri-operative care of surgical patients.
Outcomes Research (EPiCOR) Group. Perioperative and anaes- 2011. Available from www.ncepod.org.uk/2011report2/downloads/
thetic-related mortality in developed and developing countries: POC_fullreport.pdf.
a systematic review and meta-analysis. Lancet 2012; 380(9847): National Institute for Health and Care Excellence. CG3 preoperative
1075–81. tests: NICE guideline, June 2003.
Boyd O, Jackson N. How is risk defined in high-risk surgical patient National Institute for Health and Care Excellence. Venous thrombo-
management? Crit Care 2005; 9: 390–6. embolism: reducing the risk for patients in hospital. Clinical guide-
Fleisher LA, Beckman JA, Buller CE et al. ACCF/AHA focused update line (CG92), 2010, updated 2015.
on perioperative beta blockade. J Am Coll Cardiol 2009; 54: 2102– Noordzij PG1, Poldermans D, Schouten O et al. Postoperative mortality
28. in The Netherlands: a population-based analysis of surgery-specific
Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemody- risk in adults. Anesthesiology 2010; 112(5): 1105–15.
namic therapy and gastrointestinal complications in major surgery: Pearse RM1, Holt PJ, Grocott MP. Managing perioperative risk in
a meta-analysis of randomised controlled trials. Br J Anaesth 2009; patients undergoing elective non-cardiac surgery. BMJ 2011; 343:
103: 637–46. d5759.
Eagle KA, Berger PB, Calkins H et al.; American College of Cardiol- Poldermans D, Bax JJ, Boersma E et al. Guidelines for preoperative
ogy; American Heart Association. ACC/AHA guideline update cardiac risk assessment and perioperative cardiac management in
for perioperative cardiovascular evaluation for noncardiac surgery: non-cardiac surgery: the Task Force for preoperative cardiac risk
executive summary: a report of the American College of Cardiology/ assessment and perioperative cardiac management in non-cardiac
American Heart Association evaluation for noncardiac surgery. J surgery of the European Society of Cardiology (ESC) and European
Am Coll Cardiol 2002; 39(3): 542–53. Society of Anaesthesiology (ESA). Eur Heart J 2009; 30: 2769–812.
European Society of Anaesthesiology, Task Force on preoperative eval- Ramachandran SK, Kheterpal S, Consens F et al. Derivation and valida-
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Society, Society of Cardiovascular Anesthesiologists, Society for Shoemaker WC, Appel PL, Kram HB et al. Prospective trial of supra-
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ve Bailey & Love Bailey & Love Bailey & Love
18Love
ve Bailey & Love Bailey & Love Bailey & Chapter
Anaesthesia and pain relief
Learning objectives
To gain an understanding of: • Local and regional anaesthesia techniques
• Techniques of anaesthesia and airway maintenance • The management of chronic pain and pain from
• Methods of providing pain relief malignant disease
HISTORY The use of a set of safety checklists in the operating theatre

in the form of the World Health Organisation’s Surgical Safety
Anaesthesia, as we know it today, was first successfully demon- Checklist has shown a reduction in incidence of perioperative
strated by William Morton, a local dentist, at the Massachu- untoward events.
setts General Hospital Boston, USA on 16th October 1846 The role of the modern anaesthetist has evolved from just
when he administered ether to Gilbert Abbot for operation being responsible for the patient in the operating suite into
on a vascular tumour on his neck. Earlier Horace Wells had a ‘perioperative physician’ who optimises the patient for sur-
successfully used nitrous oxide in 1844 for painless extraction gery, assessing and minimising risk, cares for them during the
of teeth. operation, and then manages both pain and homeostasis in
Simpson at Edinburgh University overcame some of the the postoperative period (Table 18.1).
technical difficulties of ether administration by introducing
chloroform. The benefits of anaesthesia were then universally
recognised and antagonism by religious leaders was countered TABLE 18.1 Key features of commonly used intravenous
when Queen Victoria accepted chloroform from John Snow anaesthetic agents.
during the birth of Prince Leopold in 1853. Propofol (di-isopropyl phenol) Smooth induction, better
haemodynamic stability, blunting of autonomic reflexes and ability
to use as a continuous infusion
KEY PRINCIPLES OF Thiopentone (barbiturate) Rapid induction, myocardial
ANAESTHESIA depression. Reduced metabolic rate and lowering of intracranial
pressure is useful in neurosurgical patients but drop in blood
Optimum patient care is dependent on a collaborative pressure can give detrimental effects
approach from anaesthetic and surgical teams, together with Etomidate (steroid derivative) Good haemodynamic stability,
the other perioperative care providers. The importance of brief duration of action, but concern over adrenocortical
multidisciplinary collaboration has been clearly demon- depression
strated by national audits such as the Confidential Enquiries Ketamine (phencyclidine derivative) Preservation of blood
in Perioperative Deaths (CEPOD) and Enquiries into Maternal pressure and respiratory reflexes together with excellent analgesia
Deaths UK. These audits have led to changes in clinical and makes it an ideal choice for field anaesthesia. Emergence delirium
is associated with administration of ketamine
non-clinical practice to improve morbidity and mortality.
Anaesthesia; the name was suggested by Oliver Wendell-Homes and first appeared in Bailey’s English Dictionary in 1751.
Humphrey Davy, 1800, suggested that nitrous oxide inhalation might be used to relieve pain of surgical operations and named it ‘laughing gas’.
Henry Edmund Gaskin Boyle in 1917 obtained his gas-oxygen machine which became the first ‘Boyle apparatus’.
William Thomas Gren Morton, 1819–1868, dentist who practised in Boston, MA, USA.
Sir James Young Simpson, 1811–1870, Professor of Midwifery, Edinburgh, UK.
Alexandrina Victoria, Queen of the United Kingdom of Great Britain and Ireland, 1837–1901.
John Snow, 1813–1858, general practitioner, London, UK, was one of the pioneers of anaesthesia.
Prince Leopold, 1853–1884, who later became Duke of Albany, was the eighth of Queen Victoria’s nine children, and her fourth son.
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270 CHAPTER 18 Anaesthesia and pain relief
Summary box 18.1
Ground rules for anaesthesia

●● Safe surgery is achieved by close teamwork between
surgeon, anaesthetist and perioperative care providers
●● Safety checklists make sure that things are not forgotten
●● Risk assessments allow the best strategy to be chosen
●● Anaesthetists are extending their care into the pre- and
postoperative phase
PREPARATION FOR
ANAESTHESIA
In the previous chapter, the preoperative preparation for
anaesthesia was discussed in detail, and its importance is
emphasised (Chapter 17). Moreover, a careful preassess-
ment, multidisciplinary approach, standardised care pathway
with a carefully chosen anaesthetic and analgesic technique
form the cornerstone of ‘enhanced recovery programmes’
being introduced recently across the surgical specialities (see
Chapter 20).
Figure 18.1 Anaesthetic machine.
GENERAL ANAESTHESIA
General anaesthesia is commonly described as the triad of better haemodynamic stability, excellent recovery profile and
unconsciousness, analgesia and muscle relaxation. concerns over environmental effects of inhalational agents
have made TIVA an attractive choice. TIVA is routinely used
in neurosurgery, airway laser surgery, during cardiopulmonary
Summary box 18.2 bypass and for day-case anaesthesia (Figure 18.2).
The general anaesthetic triad

●● Amnesia: loss of awareness
●● Analgesia: pain relief
●● Muscle relaxation
Induction of general anaesthesia is most frequently done by

intravenous agents. Propofol has replaced thiopentone as the
most widely used induction agent and can be used for main-
tenance of anaesthesia. Other infrequently used intravenous
agents include etomidate and ketamine. Newer agents based
on benzodiazepine receptor agonists, etomidate derivatives
and fospropofol are still in the experimental stage.
Inhalational induction using agents such as non-pungent
sevoflurane is useful in children, needle-phobic adults and
those in whom a difficult airway is anticipated. These patients
will have a higher risk of developing airway obstruction (Fig-
ure 18.1). Figure 18.2 Total intravenous anaesthesia pumps in use.
Rapid sequence induction (RSI) using a predetermined
dose of intravenous anaesthetic agent together with rapidly
acting muscle relaxant is used in those with high risk of regur- Summary box 18.3
gitation in order to secure the airway quickly. Commonly
needed in emergency surgery it is also a technique of choice Special terms in anaesthesia
in any non-emergency surgery in a patient with delayed emp- ●● Rapid sequence induction (RSI) is a technique that allows the
tying of stomach. airway to be rapidly secured. It is used when there is a high
Total intravenous anaesthesia (TIVA ) is becoming popu- risk of regurgitation that may lead to pulmonary aspiration
lar following the introduction of propofol and the ultra-short- ●● Total intravenous anaesthesia (TIVA) is becoming increasingly
popular
acting opioid remifentanil. The lack of a cumulative effect,
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General anaesthesia 271
Maintenance of anaesthesia, on the other hand, can be

done using continuous infusion of intravenous agent (propofol)
or inhaled vapour such as isoflurane, sevoflurane or desflurane.
The use of nitrous oxide is declining despite its analgesic
and weak anaesthetic properties due to concerns over postop-
erative nausea and vomiting. It also increases the size of the
air bubble causing adverse effects, for example in eye, ear and
abdominal surgery. Finally, it is possibly mutagenic and is a
powerful greenhouse gas.
Management of airway during

anaesthesia
Loss of muscle tone as a result of general anaesthesia means
that the patient can no longer keep their airway open. There-
Figure 18.3 The laryngeal mask airway. The laryngeal mask airway
fore, the patients need their airway maintained for them. The (left), i-Gel airway (centre) and reinforced laryngeal mask airway (right).
use of muscle relaxants will mean that they will also be unable
to breathe for themselves and so will require artificial venti-
lation. Head tilt, chin lift and jaw thrust manoeuvres, along ● Difficult intubation. Endotracheal intubation is feasible
with adjuncts such as oropharyngeal airways, are used to facil- in most patients, but in a certain proportion of patients
itate bag-mask ventilation while induction agents exert full this may be difficult or impossible; if compounded by
effect. Laryngeal mask airway or endotracheal tube are then inability to ventilate the patient by bag-mask, conse-
inserted and the patient is allowed to breathe spontaneously quences can be catastrophic hypoxia. Many devices have
or is ventilated during the procedure. been developed to aid intubation if difficulty is anticipated
The addition of a cuff to the endotracheal tube facilitates and protocols created by specialised societies to deal with
positive pressure ventilation and protects the lungs from aspi- such situations. One specialised method for intubation in
ration of regurgitated gastric contents. difficult situations is the use of the fibreoptic intubating
bronchoscope facilitated by topical local anaesthetic in
Supraglottic airways awake patients or using general anaesthesia. The anaes-
● Laryngeal mask airway (LMA). Developed by Dr thetist places the endotracheal tube in the trachea by
Archie Brain in the UK, the original LMA is a first- threading the tube over the bronchoscope, and so places
generation supraglottic airway. The mask with an inflat- the tube in the trachea under direct bronchoscopic vision.
able cuff is inserted via the mouth and produces a seal An awake intubation requires careful patient selection, as
around the glottic opening, providing a very reliable it may not be a suitable technique for all patient groups
means of maintaining the airway. Its placement is less irri- (Figures 18.4, 18.5 and 18.6).
tating and less traumatic to a patient’s airway than endo-
tracheal intubation. The technique can be easily taught
to non-anaesthetists and paramedics and can be used as
an emergency airway management tool. Several varieties
of first generation LMAs are available, including the clas-
sic LMA and the flexible LMA. Further advancement has
led to the development of second-generation supraglottic
devices such as the ProSeal LMA, the i-Gel and LMA
Supreme (Figure 18.3). These devices usually have an
in-built ‘bite-block’ and an oesophageal drain tube; they
can be used for ventilation of the lungs at higher inflation
pressures and are more suitable for patients with a higher
body mass index. There are also modified versions of the
LMA including the intubating LMA (ILMA) that allow
a blind technique in aiding insertion of a tracheal tube
in difficult conditions. There is increasing evidence that
second-generation devices have a good safety and efficacy Figure 18.4 The Macintosh laryngoscope with a standard blade (left)
profile and should be replacing all first-generation devices. and McCoy’s modification of the Macintosh blade (right).
Archibald Ian Jeremy Brain, formerly anaesthetist, The Royal Berkshire Hospital, Reading, UK.
Sir Robert Reynolds Macintosh, 1897–1989, Nuffield Professor of Anaesthetics, The University of Oxford, Oxford, UK. First Chair in anaesthesia in 1937. First
Chair in anaesthesia in USA: Ralph Waters, Wisconsin, USA in 1933. First examination for the Diploma in anaesthesia was held in London in 1935.
Sir Ivan Whiteside Magill, 1888–1986, anaesthetist, The Westminster Hospital, London, UK. During the First World War Sir Ivan Magill and Stanley Row-
botham, while working with Harold Gillies (pioneer of plastic surgery), developed tracheal intubation. Sir Magill is also remembered for his laryngoscope, Magill
attachment and laryngeal forceps.
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Summary box 18.5
Complications of intubation
●● Failed intubation
●● Accidental bronchial intubation
●● Trauma to teeth, pharynx, larynx
●● Aspiration of gastric contents during intubation
●● Disconnection, blockage, kinking of tube
●● Delayed tracheal stenosis
Muscle relaxation and artificial

Figure 18.5 Endotracheal devices. From left to right: an uncut ventilation
orotracheal tube; reinforced orotracheal tube; oral version of a Ring,
Adair and Elwyn (RAE) preformed tube; nasal version of an RAE Pharmacological blockade of neuromuscular transmission
preformed tube; tracheostomy tube. provides relaxation of muscles allowing easy surgical access,
but the patient requires artificial ventilation.
Neuromuscular blocking agents are broadly classified into
depolarising and non-depolarising groups according to their
mode of action.
Suxamethonium is the most commonly used depolarising
agent. It binds to the nicotinic acetylcholine receptors, result-
ing in opening of the cation channel leading to depolarisation
and rapid relaxation of muscles. Despite its adverse effects
such as hyperkalaemia, muscle pain, anaphylaxis and poten-
tially life-threatening malignant hyperthermia, suxametho-
nium is still widely used because of its quick onset and short
duration of action. These properties are useful where rapid
endotracheal intubation is necessary to protect the patient’s
airway or short-duration surgery is performed.
Non-depolarising muscle relaxants act by competitive
blockade of postsynaptic receptors at the neuromuscular junc-
tion. They provide longer, predictable activity, but require
Figure 18.6 Fibreoptic intubating bronchoscope. careful monitoring, appropriate timing and reversal of their
action by agents such as neostigmine and sugammadex at the
Double lumen tubes and endobronchial tubes are used in end of the procedure. A peripheral nerve stimulator is rou-
procedures such as thoracoscopic, pulmonary and oesopha- tinely used to monitor the depth of neuromuscular block and
geal surgery to allow collapse of one lung (while ventilating also to confirm satisfactory recovery of muscle power prior
the other) for ease of surgery. Their use is also essential to to extubation (Table 18.2). With the increasing availability
isolate the healthy lung in pyopneumothorax and in the case and evidence of the use of sugammadex, the non-depolarising
of a bronchopleural fistula. muscle relaxant rocuronium is an alternative to suxametho-
Ventilating bronchoscopes and endobronchial catheters nium in the ‘rapid-sequence’ induction, as it allows reversal of
can be used to maintain oxygenation during laryngo-tracheal its actions with sugammadex in a rapid manner.
surgery or bronchoscopy by using intermittent jets of oxygen.
Summary box 18.4

Ventilation during anaesthesia
Mechanical ventilation is required when the patient’s spon-
Techniques for maintaining an airway taneous ventilation is inadequate or when the patient is not
●● Chin lift and jaw thrust: suitable for short term when no aid breathing because of the effects of the anaesthetic, analgesic
available agents or muscle relaxants.
●● Guedel airway: holds tongue forward but does not prevent In volume control ventilation, a preset volume is deliv-
aspiration
ered by the machine irrespective of the airway pressure. The
Supraglottic device: easy insertion, reliable airway, allows
pressure generated will be in part dependent on the resistance
●●
ventilation
and compliance of the airway. In laparoscopic surgery requir-
●● Endotracheal intubation: secure and protected airway
ing the Trendelenburg position (the patient is positioned
The RAE tube takes its name from the initials of the surnames of the people who introduced it, Wallace Harold Ring, John Adair and Richard Elwyn.
Arthur Ernest Guedel, 1883–1956, Clinical Professor of Anaesthesiology, University of Southern California, Los Angeles, CA, USA.
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Local anaesthesia 273
TABLE 18.2 Properties of commonly used muscle relaxants.

Suxamethonium Quickest onset, very short duration, Muscle pain, hyperkalaemia, prolonged apnoea and life-
spontaneous recovery. Ideal for rapid intubation and for threatening malignant hyperthermia
short procedures
Vecuronium Long acting, minimal cardiovascular effect and less allergic Dependent on hepatic metabolism and renal clearance,
reaction hence caution if hepatic and renal impairment
Atracurium Intermediate acting. Non-enzymatic Hoffmann Histamine release and allergic reactions
degradation.
Suitable in renal and hepatic failure
Rocuronium Rapid onset, intermediate action. Allergic reactions.
Suitable for rapid intubation. Excreted unchanged via bile and urine
Rapid reversal possible using sugammadex
head down), and in morbidly obese patients and those with LOCAL ANAESTHESIA
lung disease, this may result in excessive pressures being
developed, which may lead to barotrauma (pneumothorax). Local anaesthetic drugs may be used to provide anaesthesia
In pressure control mode, the ventilator generates flow and analgesia as a sole agent or as adjuncts to general anaes-
until a preset pressure is reached. The actual tidal volume thesia. Available techniques include topical anaesthesia,
delivered is variable and depends on airway resistance, local infiltration, regional nerve blocks and central neuroax-
intra-abdominal pressure and the degree of relaxation. ial blocks (spinal and epidural anaesthesia) (Table 18.3).
Positive end expiratory pressure (PEEP) is often applied to
help maintain functional residual capacity (FRC). This avoids
TABLE 18.3 The common local anaesthetic drugs.
lung collapse by opening collapsed alveoli, and maintains a
greater area of gas exchange so reducing vascular shunting. Name Maximum dose Comments
Lignocaine 3 mg/kg (7 mg/kg Early onset, short acting,
with adrenaline) good sensory block
Summary box 18.6
Bupivacaine 2 mg/kg Long lasting, more
cardiotoxic, must never
Intermittent positive pressure ventilation be used intravenously
●● Volume controlled, which ensures adequate gas entry but
Prilocaine 6 mg/kg (9 mg/kg Least systemic
risks high pressure damage
with adrenaline) toxicity, causes
●● Pressure controlled, which avoids high pressure damage but methaemoglobinaemia
risks inadequate ventilation
Ropivacaine 3–4 mg/kg Less cardiotoxic,
●● Positive end expiratory pressure (PEEP) reduces alveolar
greater sensory–motor
collapse and reduces vascular shunting so improving
separation
perfusion
Levobupivaciane 2 mg /kg Isomer of bupivacaine
with fewer cardiotoxic
properties
Monitoring and care during
anaesthesia Local anaesthesia techniques can lead to complications
A minimum basic monitoring of cardiovascular parameters is that may be local, such as infection or haematoma, or sys-
required during surgery. This includes: temic due to overdose or accidental intravascular injection.
● Vascular: The systemic effects of local anaesthetic agents are dose
● electrocardiogram (ECG); dependent and manifest as cardiovascular (cardiac arrhyth-
● blood pressure; mia, cardiac arrest) or neurological (depressed consciousness,
● Adequacy of ventilation: convulsions). Prilocaine overdose causes methaemoglobinae-
● inspired oxygen concentration; mia while bupivacaine overdose causes treatment-resistant
● oxygen saturation by pulse oximetry; ventricular arrhythmia and cardiac arrest.
● end tidal carbon dioxide concentration. The addition of adrenaline to local anaesthetic solutions
Monitors of temperature, ventilation parameters and hastens onset, prolongs duration of action and permits a higher
delivery of anaesthetic agents are also routinely used, while upper dose limit. The use of adrenaline is contraindicated in
measurement of urine output and central venous pressure are patients with cardiovascular disease, those taking tricyclic and
recommended for major surgery. monoamine oxidase inhibitors and in end-arterial locations.
Appropriately skilled personnel, resuscitation equipment
and oxygen should always be available with local anaesthetic
Anaesthesia for day case surgery use because of the potential risks of life-threatening compli-
This is discussed in Chapter 21. cations.
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Regional anaesthesia (a)
Regional anaesthesia involves central neuroaxial or periph-

eral nerve or plexus blocks. It has a clear advantage where
general anaesthesia carries a higher risk of morbidity and
mortality, such as in patients with debilitating respiratory
and cardiovascular disease and obstetric cases. It also provides
excellent pain relief in the postoperative period, reducing the
need for analgesics such as opioids.
As with general anaesthesia obtaining venous access,
monitoring vital parameters should be performed during
regional anaesthesia.
Localising nerves using anatomical landmarks and elicit- (b)
ing paraesthesia alone carries a high risk of nerve damage,
intravascular injection and has lower success rate. The use of
nerve stimulators to localise nerves improves success rate and
reduces risks. Ultrasound-guided regional anaesthesia allows
the visualisation of nerves and the spread of local anaesthet-
ics, enabling the use of a smaller dose of local anaesthetic
agents, with improved success rates and safety.
Summary box 18.7

Figure 18.7 (a, b) Ultrasound scans of brachial plexus block.
Types of anaesthesia
●● General anaesthesia may be more acceptable to the patients
TRANSVERSUS ABDOMINIS PLANE BLOCK
●● Regional anaesthesia has major advantages in obstetrics and
patients with respiratory compromise Transversus abdominis plane block (TAP) is growing rapidly
●● Local blocks have been transformed by nerve stimulators and in popularity. The technique has been shown to provide effec-
ultrasound guidance tive analgesia after a wide range of abdominal surgery. The
●● All require full resuscitation and monitoring equipment to be T6–L1 segmental nerves enter the triangle of Petit just medial
available to the anterior axillary line. Injection of local anaesthetic into
the fascial plane between the internal oblique and transversus
abdominis muscles allows a block of all these nerves, and excel-
lent anaesthesia of the anterior abdominal wall (Figure 18.8).
Common local anaesthesia
techniques
Topical anaesthesia (a)
● EMLA (eutectic mixture of local anesthetics). This is a

mixture of lignocaine and prilocaine for application to the
skin for venepuncture in children.
● Cocaine. It may be called Mofatt’s solution (with an added
mixture of adrenaline and sodium bicarbonate) and used
in nasal surgery for anaesthesia and vasoconstriction.
● Lignocaine 2/4/10%. Spray to anaesthetise the airway
during awake fibreoptic intubation.
(b)
Nerve blocks
● Interscalene block for shoulder surgery produces excellent
postoperative analgesia. Complications include phrenic
nerve block, Horner’s syndrome, as well as accidental
intravascular and spinal injection.
● Axillary brachial plexus block can be used as the sole
anaesthetic technique for upper limb surgery (Figure
18.7).
● Femoral and sciatic nerve blocks are often used for anaes- Figure 18.8 (a, b) Ultrasound scans of lateral abdominal wall and
thesia and analgesia for lower limb surgery. the spread of local anaesthetics.
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Local anaesthesia 275
INTRAVENOUS REGIONAL ANAESTHESIA (BIER’S

BLOCK)
Bier’s block produces excellent anaesthesia for short surgery,
particularly for the upper limb (e.g. carpal tunnel release).
Exsanguination using an Esmarch bandage, inflation of
proximal cuff of the double tourniquet is followed by intra-
venous injection of prilocaine into the vein on the back of
the hand that is being operated on. After 5–10 minutes the
distal cuff of the tourniquet is inflated and then the proxi-
mal one deflated. Even if surgery is finished, the tourniquet
should be left inflated until the local anaesthetic has bound
to tissues (20 minutes), so that release of local anaesthetic
into the systemic circulation does not occur. Lignocaine can
be used with caution (consider safe dose and time of tour- Figure 18.9 Equipment for epidural/spinal anaesthesia.
niquet inflation) but bupivacaine should never be used for
Bier’s block.
excellent analgesia for a wide variety of upper abdominal and
Spinal anaesthesia thoracic surgical operations, enabling early mobilisation and
Spinal anaesthesia alone, and in combination with general reducing respiratory complications.
anaesthesia or sedation is used extensively for lower limb, Epidural anaesthesia is technically more difficult than spi-
obstetric and pelvic surgery. Injection of a ‘single shot’ local nal anaesthesia, with a higher failure rate and carries the risk
anaesthetic agent intrathecally produces intense and rapid of nerve damage, spinal injuries, accidental spinal injection
block for surgery. Addition of opioids provides prolonged of large volume of local anaesthetics and risk of infection and
postoperative analgesia but carries the risk of late respiratory epidural haematoma (Figure 18.9).
depression.
Autonomic sympathetic blockade produces hypoten-
sion, particularly if the level of block is above T10. Caution Chronic pain management
is needed in patients with hypovolemia and cardiovascular
disease. In surgical practice, the patient with chronic pain may pres-
The incidence of dural puncture headache can be mini- ent for treatment of the cause (e.g. pancreatitis, malignancy),
mised by limiting the number of punctures and use of fine bore or concomitant benign pathology. Acute pain after surgery
pencil tip needles designed to split rather than cut the dura. may progress to chronic pain and is believed to be due to
inadequate treatment of acute pain itself.
Epidural anaesthesia Chronic pain may be of several types:
Epidural anaesthesia is slower in onset than spinal, but has ● Nociceptive pain may result from musculoskeletal dis-
the advantage of prolonged analgesia by multiple dosing or orders or cancer activating cutaneous nociceptors (pain
continuous infusion through a catheter placed in the epidural receptors). Prolonged ischaemic or inflammatory pro-
space. Being slower in onset, the resulting hypotension from cesses result in sensitisation of peripheral nociceptors and
sympathetic blockade can be better controlled and can reduce altered activity in the central nervous system, leading to
blood loss. exaggerated responses in the dorsal horn of the spinal
Continuous infusion (with a patient-controlled bolus) of cord. The widened area of hyperalgesia and increased sen-
weak local anaesthetic combined with opioids (such a fen- sitivity (allodynia) has been attributed to the increased
tanyl) is routinely used for postoperative analgesia. Placement transmission in the central nervous system.
of an epidural catheter in the high thoracic region provides ● Neuropathic (or neurogenic) pain is dysfunction in
peripheral or central nerves (excluding the ‘physiologi-
cal’ pain due to noxious stimulation of the nerve termi-
Summary box 18.8 nals). It is classically of a ‘burning’, ‘shooting’ or ‘stabbing’
type and may be associated with allodynia, numbness and
Local anaesthetics diminished thermal sensation. It is poorly responsive to
●● EMLA cream for children needing injections opioids. Examples include trigeminal neuralgia, posther-
●● Regional and nerve blocks for limb surgery petic and diabetic neuropathy. Monoaminergic, tricyclic
●● Spinal anaesthesia offers quick onset and short duration of inhibitors and anticonvulsant drugs are the mainstay of
anaesthesia
treatment.
Epidurals are more difficult but can then be topped-up
Psychogenic pain is associated with depressive illness;
●●
●
postoperatively and used as continuous infusion
chronic pain and the illness may exacerbate each other.
August Karl Gustav Bier, 1861–1949, Professor of Surgery, Bonn (1903–1907) and Berlin, Germany (1907–1932).
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Summary box 18.9 Drugs in chronic non-malignant pain

Paracetamol and the non-steroidal anti-inflammatory drugs
Types of pain (NSAIDs) are the mainstay of musculoskeletal pain treat-
●● Nociceptive pain arises from inflammation and ischaemia ment. The tricyclic antidepressant drugs and anticonvulsant
●● Neuropathic pain arises from a dysfunction in the central agents are often useful for the pain of nerve injury, although
nervous system side effects can prove troublesome and reduce compliance.
●● Psychogenic pain is modified by the mental state of the patient Both pregabalin and gabapentin reduce spontaneous neuronal
activity by their action on the alpha-2-delta subunit of cal-
cium channels, and are now used for managing neuropathic
chronic pain. In more severe and debilitating non-malignant
Chronic pain control in benign chronic pain, opioid analgesic drugs are used in slow release
disease oral preparations of morphine and oxycodone, and trans-
Surgical patients may present with chronic persistent pain cutaneous patches delivering fentanyl and buprenorphine.
(more than 3 months’ duration) from a variety of disorders Tapentadol with its dual action on opioid and noradrenaline
including postoperative neuropathic pain, chronic inflamma- selective reuptake inhibition pathways may provide relief in
tory disease, recurrent infection, degenerative bone or joint patients with pain of both neuropathic and nociceptive ele-
disease, nerve injury and sympathetic dystrophy. This may ments. Combinations of drugs often prove useful to achieve
result from persistent excitation of the nociceptive pathways the optimum of efficacy with minimal side effects.
causing spontaneous firing of pain signals at N-methyl-D-
aspartate receptors in the ascending pathways. This pain does Treatment of pain dependent on
not respond to opiates or neuroablative surgery and would sympathetic nervous system activity
merit neuropathic pain management. Even minor trauma and surgery, (often of a limb) can pro-
Amputation of limbs may result in phantom limb pain; the voke chronic burning pain, allodynia, trophic changes and
likelihood is increased if the limb was painful before surgery. resultant disuse due to excessive sympathetic adrenergic
Continuous regional local anaesthetic blockade (epidural or activity inducing vasconstriction and abnormal nociceptive
brachial plexus) established before operation and continued transmission.
postoperatively for a few days, is believed to effectively reduce Management includes antineuropathic pain medications
the risk of phantom limb pain. (pregabalin, gabapentin, amitriptyline) as part of multimodal
analgesia with a multidisciplinary pain management approach
● Local anaesthetic and steroid injections can be effective including considerable input of psychological, targeted phys-
around an inflamed nerve and they reduce the cycle of iotherapy and counselling. Interventional treatment may
constant pain transmission with consequent muscle spasm. include local anaesthetic injection of stellate ganglion for
Transforaminal selective root blocks in the epidural space upper limb symptoms. Percutaneous chemical lumbar sympa-
are used for the pain of nerve root irritation associated thectomy with local anaesthetic is used for relief of rest pain
with or without minor disc prolapse, followed by active in advanced ischaemic disease of the legs.
physiotherapy and rehabilitation to promote mobility.
● Nerve stimulation procedures such as acupuncture and
transcutaneous nerve stimulation, increase the endorphin
production in the central nervous system. Nerve decom-
Pain control in malignant disease
pression craniotomy rather than percutaneous coagu- Pain is a common symptom associated with cancer, more so
lation of the ganglion is now performed for trigeminal during the advanced stages. In intractable pain, the underly-
neuralgia. Spinal cord stimulation by dorsal column stim- ing principle of treatment is to encourage independence of
ulation is now a recognised and effective management of the patient and an active life in spite of the symptom. The
intractable neuropathic pain. This involves placement of World Health Organisation’s booklet advises use of a ‘pain
electrodes in the posterior epidural space to allow dorsal stepladder’:
column stimulation through an implantable pulse genera- ● First step. Simple analgesics: aspirin, paracetamol,
tor inserted in the body. non-steroidal anti-inflammatory agents, tricyclic drugs or
anticonvulsant drugs.
● Second step. Intermediate strength opioids: codeine,
Summary box 18.10 tramadol or dextropropoxyphene.
● Third step. Strong opioids: morphine (pethidine has now
Pain control in benign disease
been withdrawn).
●● Bring pain under control before amputation to avoid phantom
pain Oral opiate analgesia is necessary when the less power-
●● Local anaesthetic and steroid injected around a nerve may ful analgesic agents no longer control pain on movement, or
reduce muscle spasm enable the patient to sleep. Fear that the patient may develop
●● Transcutaneous nerve stimulators (TNS) modifies pain by an addiction to opiates is usually not justified in malignant
increasing endorphin production
disease. It is also important to distinguish between the
●● Trigeminal neuralgia responds to decompression of the nerve
addiction and dependence; the former being a psychosocial
03_18-B&L27_Pt3_Ch18.indd 276 25/10/2017 08:06

Further reading 277
phenomenon while the latter is a pure physiological response Alternative strategies include:
to a given drug. Some patients experience ‘breakthrough
● The development of antipituitary hormone drugs, such
pain’ (acute, excruciating and incapacitating), which occurs
as tamoxifen and cyproterone, enables effective pharma-
either spontaneously or in relation to a specific predictable
cological therapy for the pain of widespread metastases
or unpredictable trigger, experienced by patients who have
instead of pituitary ablation surgery.
relatively stable and adequately controlled background pain.
● Palliative radiotherapy can be most beneficial for the relief
Oral morphine, often used for chronic pain, can be pre-
of pain in metastatic disease.
scribed in short-acting liquid or tablet form and should be
● Adjuvant drugs such as corticosteroids to reduce cerebral
administered regularly every 4 hours until an adequate dose
oedema or inflammation around a tumour may be useful
of drug has been titrated to control the pain over 24 hours.
in symptom control. Tricyclic antidepressants, anticon-
Once this is established, the daily dose can be divided into
vulsants and flecainide are also used to reduce the pain of
two separate administrations of enteric-coated, slow-release
nerve injury.
morphine tablets (MST morphine) every 12 hours. Addi-
tional short-acting opioids (morphine/fentanyl) can then be In the management of chronic pain, a multidisciplinary
used to cover episodes of ‘breakthrough pain’. Nausea treated approach by a team of medical and nursing staff working with
using antiemetic agents does not usually persist, but constipa- psychologists, physiotherapists and occupational therapists
tion is frequently a persistent complication requiring regular can often achieve much more benefit than the use of pow-
prevention by laxatives. erful drugs. ‘Pain Management Programmes’ lay out a logical
structure for this.
Infusion of subcutaneous, intravenous,
intrathecal or epidural opiate drugs
Summary box 18.11
The infusion of opiate is necessary if a patient is unable to
take oral drugs. Subcutaneous infusion of diamorphine is sim- Options for controlling severe pain in malignant
ple and effective to administer. Epidural infusions of diamor- disease
phine with an external pump can be used on mobile patients. ●● Oral morphine using slow-release enteric-coated tablets
Intrathecal infusions with pumps programmed by external ●● Slow infusion of opiates subcutaneously, by epidural or
computers are used; however, there is a possibility of develop- intrathecally
ing infection with catastrophic effects. Intravenous narcotic ●● Neurolysis for patients with limited life expectancy
agents may be reserved for acute crises, such as pathological ●● Palliative hormone, radiotherapy, or steroids control pain from
fractures. swelling
Neurolytic techniques in cancer pain

These should only be used if the life expectancy is limited and
the diagnosis is certain. The useful procedures are:
FURTHER READING
Aitkenhead AR, Moppett IK, Rowbotham DJ, Thompson J. Smith and
● Subcostal phenol injection for a rib metastasis. Aitkenhead’s textbook of anaesthesia, 6th edn. Edinburgh: Churchill
● Coeliac plexus neurolytic block with alcohol for pain of Livingstone Elsevier, 2013.
pancreatic, gastric or hepatic cancer. McLeod G, McCartney C, Wildsmith T (eds). Principles and practice
● Intrathecal neurolytic injection of hyperbaric phenol. of regional anaesthesia, 4th edn. Edinburgh: Churchill Livingstone,
2012.
● Percutaneous anterolateral cordotomy divides the spi- Rawal N (ed.). Management of acute and chronic pain. London: BMJ
nothalamic ascending pain pathway. It is a highly effective Books, 1998.
technique in experienced hands, selectively eliminating Sneyd JR. Recent advances in intravenous anaesthesia. Br J Anaesth
pain and temperature sensation in a specific limited area. 2004; 93: 725–36.
03_18-B&L27_Pt3_Ch18.indd 277 25/10/2017 08:06

19
Chapter
Nutrition and fluid therapy
Learning objectives
To understand: • The nutritional requirements of surgical patients and the
• The causes and consequences of malnutrition in the nutritional consequences of intestinal resection
surgical patient • The different methods of providing nutritional support
• Fluid and electrolyte requirements in the pre- and and their complications
postoperative patient
INTRODUCTION who suffer starvation or have signs of malnutrition have a

higher risk of complications and an increased risk of death
Malnutrition is common. It occurs in about 30% of surgical in comparison with patients who have adequate nutritional
patients with gastrointestinal disease and in up to 60% of those reserves.
in whom hospital stay has been prolonged because of postop- Long-standing protein–calorie malnutrition as seen in
erative complications. It is frequently unrecognised and con- cachexia or general frailty is easy to recognise (Figure 19.1).
sequently patients often do not receive appropriate support. Short-term undernutrition, although less easily recognised,
There is a substantial body of evidence to show that patients frequently occurs in association with critical illness, major
trauma, burns or surgery, and also impacts on patient recov-
ery. The aim of nutritional support is to identify those patients
at risk of malnutrition and to ensure that their nutritional
requirements are met by the most appropriate route and in a
way that minimises complications.
PHYSIOLOGY
Metabolic response to
starvation
After a short fast, lasting 12 hours or less, most food from the
last meal will have been absorbed. Plasma insulin levels fall
and glucagon levels rise, which facilitates the conversion of
liver glycogen (approximately 200 g) into glucose. The liver,
therefore, becomes an organ of glucose production under fast-
ing conditions. Many organs, including brain tissue, red and
white blood cells and the renal medulla, can initially utilise
only glucose for their metabolic needs. Additional stores of
glycogen exist in muscle (500 g), but these cannot be utilised
directly. Muscle glycogen is broken down (glycogenolysis)
Figure 19.1 Severely malnourished patient with wasting of fat and and converted to lactate, which is then exported to the liver
muscle. where it is converted to glucose (Cori cycle). With increasing
Carl Ferdinand Cori, 1896–1984, Professor of Pharmacology and later Biochemistry, Washington University Medical School, St Louis, MI, USA and his wife
Gerty Theresa Cori, 1896–1957, also Professor of Biochemistry at the Washington University Medical School. In 1947, the Coris were awarded a share of the
Nobel Prize for Physiology or Medicine for their discovery of how glycogen is catalytically converted.
03_19-B&L27_Pt3_Ch19.indd 278 25/10/2017 08:07

Nutritional assessment 279
ve duration of fasting (>24 hours), glycogen stores are depleted

Summary box 19.2
and de novo glucose production from non-carbohydrate pre-
cursors (gluconeogenesis) takes place, predominantly in the Metabolic response to trauma and sepsis
liver. Most of this glucose is derived from the breakdown of ●● Increased counter-regulatory hormones: adrenaline,
amino acids, particularly glutamine and alanine as a result of noradrenaline, cortisol, glucagon and growth hormone
catabolism of skeletal muscle (up to 75 g per day). This pro- ●● Increased energy requirements (up to 40 kcal/kg per day)
tein catabolism in simple starvation is readily reversed with ●● Increased nitrogen requirements
the provision of exogenous glucose. ●● Insulin resistance and glucose intolerance
With more prolonged fasting, there is an increased reli- ●● Preferential oxidation of lipids
ance on fat oxidation to meet energy requirements. Increased ●● Increased gluconeogenesis and protein catabolism
breakdown of fat stores occurs, providing glycerol, which can ●● Loss of adaptive ketogenesis
be converted to glucose, and fatty acids, which can be used as ●● Fluid retention with associated hypoalbuminaemia
a tissue fuel by almost all of the body’s tissues. Hepatic pro-
duction of ketones from fatty acids is facilitated by low insulin
levels and, after 48–72 hours of fasting, the central nervous of high-energy intake is associated with an amelioration of
system may adapt to using ketone bodies as their primary fuel the catabolic process and it may indeed be harmful; there is
source. This conversion to a ‘fat fuel economy’ reduces the mounting evidence for the benefits of permissive underfeed-
need for muscle breakdown by up to 55 g per day. ing in critically ill surgical patients.
Another important adaptive response to starvation is a
significant reduction in the resting energy expenditure, pos-
sibly mediated by a decline in the conversion of inactive NUTRITIONAL ASSESSMENT
thyroxine (T4) to active tri-iodothyronine (T3). Despite
these adaptive responses, there remains an obligatory glucose
Laboratory techniques
requirement of about 200 g per day, even under conditions of There is no single biochemical measurement that reliably
prolonged fasting. identifies malnutrition. Albumin is not a measure of nutri-
tional status, particularly in the acute setting. Although a low
serum albumin level (<30 g/L) is an indicator of poor prog-
Summary box 19.1 nosis, hypoalbuminaemia invariably occurs because of alter-
ations in body fluid composition and because of increased
Metabolic response to starvation capillary permeability related to ongoing sepsis. Malnutri-
●● Low plasma insulin tion is associated with defective immune function, and mea-
●● High plasma glucagon surement of lymphocyte count and skin testing for delayed
●● Hepatic glycogenolysis hypersensitivity frequently reveal abnormalities in malnour-
●● Protein catabolism ished patients. Immunity is not, however, a precise or reliable
●● Hepatic gluconeogenesis indicator of nutritional status, nor is it a practical method in
●● Lipolysis: mobilisation of fat stores (increased fat oxidation) – routine clinical practice.
overall decrease in protein and carbohydrate oxidation
●● Adaptive ketogenesis
●● Reduction in resting energy expenditure (from approximately Body weight and anthropometry
25–30 kcal/kg per day to 15–20 kcal/kg per day
A simple method of assessing nutritional status is to esti-
mate weight loss. Measured body weight is compared with
ideal body weight obtained from tables or from the patient’s
Metabolic response to trauma and usual or premorbid weight. Unintentional weight loss of more
than 10% of a patient’s weight in the preceding 6 months is
sepsis a good prognostic indicator of poor outcome. Body weight is
This is described in full in Chapter 1 and summarised in Sum- frequently corrected for height, allowing calculation of the
mary box 19.2. body mass index (BMI, defined as body weight in kilograms
From a nutritional point of view, two factors deserve divided by height in metres squared). A BMI of less than 18.5
emphasis. First, in contrast to simple starvation, patients indicates nutritional impairment and a BMI below 15 is asso-
with trauma have impaired formation of ketones, and the ciated with significant hospital mortality. Major changes in
breakdown of protein to synthesise glucose (gluconeogen- fluid balance, which are common in critically ill patients, may
esis) cannot be entirely prevented by the administration of make body weight and BMI unreliable indicators of nutritional
glucose. Second, although it is generally accepted that the status.
metabolic response to trauma and sepsis is always associated Anthropometric techniques incorporating measurements
with ‘hypermetabolism’ or hypercatabolism’, these terms are of skinfold thicknesses and mid-arm circumference per-
ill defined and do not indicate the need for very high-energy mit estimations of body fat and muscle mass, and these are
intakes. There is no evidence to show that the provision indirect measures of energy and protein stores. These mea-
de novo is Latin for ‘from the beginning’.
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280 CHAPTER 19 Nutrition and fluid therapy
surements are, however, insufficiently accurate in individual FLUID AND ELECTROLYTES

patients to permit planning of nutritional support regimens.
Similarly, use of bioelectrical impedence analysis (BIA) per- Fluid intake is derived from both exogenous (consumed liq-
mits estimation of intra- and extracellular fluid volumes. uids) and endogenous (released during oxidation of solid
These techniques are only useful if performed frequently on a foodstuffs) fluids. The average daily water balance of a healthy
sequential basis in individual patients; in this respect, trends adult is shown in Table 19.1.
are much more important than absolute impedance figures.
All of these techniques are significantly impaired by the pres- TABLE 19.1 Average daily water balance of a healthy
ence of oedema. adult in a temperate climate (70 kg).
Output Volume (mL) Intake Volume (mL)
Clinical Urine 1500 Water from 200
The possibility of malnutrition should form part of the beverage
workup of all patients. A clinical assessment of nutritional Insensible 900 Water from food 1000
status involves a focused history and physical examination, losses
an assessment of risk of malabsorption or inadequate dietary Faeces 100 Water from 300
intake and selected laboratory tests aimed at detecting spe- oxidation
cific nutrient deficiencies. This is termed ‘subjective global
assessment’ and encompasses historical, symptomatic and Fluid losses occur by four routes:
physical parameters. Recently, the British Association of
Parenteral and Enteral Nutrition introduced a malnutrition 1 Lungs. About 400 mL of water is lost in expired air
universal screening tool (MUST), which is a five-step screen- each 24 hours. This is increased in dry atmospheres or in
ing tool to identify adults who are malnourished or at risk of patients with a tracheostomy, emphasising the importance
undernutrition (Figure 19.2). of humidification of inspired air.
The MUST tool

(iii) Acute disease effect
(i) BMI (kg/m2) (ii) Weight loss in 3–6 months
Add a score of 2 if there
0 = !20.0 0 = "5% has been or is likely to be
1 = 18.5–2.0 1 = 5–10% no or very little nutritional
2 = "18.5 2 = !10% intake for !5 days
Add scores
Overall risk of undernutrition*

0 1 2 or more
Low Medium High
Routine clinical Observe Treat

care†
Repeat screening Hospital – document dietary Hospital – refer to dietician or
Hospital – every week and fluid intake for 3 days implement local policies.
Care homes – every month Care homes (as for hospital) Generally food first followed
Community – every year for Community – repeat screening, by food fortification and
special groups, e.g. those e.g. from "1 month to !6 months supplements
!75 years (with dietary advice if necessary) Care homes (as for hospital)
Community (as for hospital)
*If height, weight or weight loss cannot be established, use documented or recalled
Figure 19.2 The malnutrition uni-
values (if considered reliable). When measured or recalled height cannot be
versal screening tool (MUST) for
obtained, use knee height as a surrogate measure.
adults (adapted from Elia M (ed.).
If neither can be calculated, obtain an overall impression of malnutrition risk
The MUST Report. Development
(low, medium, high) using the following: and use of the ‘malnutrition uni-
(i) Clinical impression (very thin, thin, average, overweight); versal screening tool’ (MUST) for
(iia) Clothes and/or jewellery have become loose fitting; adults. A report by the Malnutrition
(iib) History of decreased food intake, loss of appetite or dysphagia up to 3–6 months; Advisory Group of the British Asso-
(iic) Disease (underlying cause) and psychosocial/physical disabilities likely to cause weight loss. ciation for Parenteral and Enteral
† Involves treatment of underlying condition, and help with food choice and eating Nutrition. Report No. 152, 2003,
when necessary (also applies to other categories). ISBN 1 899467 70X).
Marinos Elia, contemporary, Head of the Adult Clinical Nutrition Group, The Medical Research Council, Cambridge, UK.
03_19-B&L27_Pt3_Ch19.indd 280 25/10/2017 08:07

Nutritional requirements 281
2 Skin. In a temperate climate, skin (i.e. sweat) losses are examination to assess hydration status (peripheries, skin
between 600 and 1000 mL/day. turgor, urine output and specific gravity of urine), urine
3 Faeces. Between 60 and 150 mL of water are lost daily in and serum electrolytes and haematocrit.
patients with normal bowel function. ● Estimation of losses already incurred and their nature: for
4 Urine. The normal urine output is approximately 1500 mL/ example, vomiting, ileus, diarrhoea, excessive sweating or
day and, provided that the kidneys are healthy, the specific fluid losses from burns or other serious inflammatory con-
gravity of urine bears a direct relationship to volume. A ditions.
minimum urine output of 400 mL/day is required to excrete ● Estimation of supplemental fluids likely to be required
the end products of protein metabolism. in view of anticipated future losses from drains, fistulae,
Maintenance fluid requirements are calculated approxi- nasogastric tubes or abnormal urine or faecal losses.
mately from an estimation of insensible and obligatory losses. ● When an estimate of the volumes required has been made,
Various formulae are available for calculating fluid replace- the appropriate replacement fluid can be determined from
ment based on a patient’s weight or surface area. For example, a consideration of the electrolyte composition of gastro-
30–40 mL/kg gives an estimate of daily requirements. intestinal secretions. Most intestinal losses are adequately
The following are the approximate daily requirements of replaced with normal saline containing supplemental
some electrolytes in adults: potassium (Table 19.3).
● sodium: 50–90 mM/day;
● potassium: 50 mM/day; TABLE 19.3 Composition of gastrointestinal secretions
● calcium: 5 mM/day; (mmol/L).
● magnesium: 1 mM/day. Na K Cl HCO3
The nature and type of fluid replacement therapy will be Saliva 10 25 10 30
determined by individual patient needs. The composition of Stomach 50 15 110 –
some commonly used solutions is shown in Table 19.2.
Duodenum 140 5 100 –
Note that Hartmann’s solution also contains lactate
29 mmol/L. Dextrose solutions are also commonly employed. Ileum 140 5 100 30
These provide water replacement without any electrolytes Pancreas 140 5 75 115
and with modest calorie supplements (1 litre of 5% dextrose Bile 140 5 100 35
contains 400 kcal). A typical daily maintenance fluid regimen
would consist of a combination of 5% dextrose with either
Hartmann’s or normal saline to a volume of 2 litres.
There has been much controversy in the literature NUTRITIONAL REQUIREMENTS
regarding the respective merits of crystalloid versus colloid Total enteral or parenteral nutrition necessitates the provi-
replacement. There is no consensus on this topic and the sion of the macronutrients, carbohydrate, fat and protein,
usual advice is to replace like with like. If the haematocrit together with vitamins, trace elements, electrolytes and
is below 21%, blood transfusion may be required. There is water. When planning a feeding regime, the patient should
increasing recognition, however, that albumin infusions are be weighed and an assessment made of daily energy and pro-
of little value. tein requirements. Standard tables are available to permit
In addition to maintenance requirements, ‘replacement’ these calculations.
fluids are required to correct pre-existing deficiencies and Daily needs may change depending on the patient’s condi-
‘supplemental’ fluids are required to compensate for antici-
tion. Overfeeding is the most common cause of complications,
pated additional intestinal or other losses. The nature and
regardless of whether nutrition is provided enterally or
volumes of these fluids are determined by:
parenterally. It is essential to monitor daily intake to provide
● A careful assessment of the patient including pulse, blood an assessment of tolerance. In addition, regular biochemical
pressure and central venous pressure, if available. Clinical monitoring is mandatory (Table 19.4).
TABLE 19.2 Composition of crystalloid and colloid solutions (mmol/L).

Solution Na K Ca Cl Lactate Colloid
Hartmann’s 131 5 2 111 29
Normal saline (0.9% NaCl) 154 154
Dextrose saline (4% dextrose in 0.18% saline) 30 30
Gelofusine 150 150 Gelatin 4%
Haemacel 145 5.1 <1 145 Polygelin 75 g/L
Hetastarch Hydroxyethyl starch 6%
Alexis Frank Hartmann, 1898–1964, paediatrician, St Louis, MO, USA.
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TABLE 19.4 Monitoring feeding regimes. oil emulsions are rich sources of linoleic acid and provision of
only 1 litre of emulsion per week avoids deficiency. Soybean
Daily Body weight
Fluid balance emulsions contain approximately 7% alpha-linolenic acid
Full blood count, urea and electrolytes (an omega-3 fatty acid). The provision of fat as a soybean
Blood glucose oil-based emulsion on a regular basis will obviate the risk of
Electrolyte content and volume of urine essential fatty acid deficiency.
and/or urine and intestinal losses
Temperature
Safe and non-toxic fat emulsions based upon long-chain
triglycerides (LCTs) have been commercially available for
Weekly (or more Urine and plasma osmolality
frequently if Calcium, magnesium, zinc and phosphate
over 30 years. These emulsions provide a calorically dense
clinically indicated) Plasma proteins including albumin product (9 kcal/g) and are now routinely used to supplement
Liver function tests including clotting factors the provision of non-protein calories during parenteral nutri-
Thiamine tion. Energy during parenteral nutrition should be given as
Acid–base status a mixture of fat together with glucose. There is no evidence
Triglycerides
to suggest that any particular ratio of glucose to fat is opti-
Fortnightly Serum vitamin B12 mal, as long as under all conditions the basal requirements for
Folate
Iron
glucose (100–200 g/day) and essential fatty acids (100–200
Lactate g/week) are met. This ‘dual energy’ supply minimises meta-
Trace elements (zinc, copper, manganese) bolic complications during parenteral nutrition, reduces fluid
retention, enhances substrate utilisation (particularly in the
septic patient) and is associated with reduced carbon dioxide
Macronutrient requirements production.
Concerns have been expressed about the possible immu-
Energy nosuppressive effects of LCT emulsions. These are more
The total energy requirement of a stable patient with a normal likely to occur if the recommended infusion rates (0.15 g/kg
or moderately increased need is approximately 20–30 kcal/kg per hour) are exceeded. Nonetheless, these concerns have
per day. Very few patients require energy intakes in excess of prompted the development of newer emulsions based upon
2000 kcal/day. Thus, in the majority of hospitalised patients in medium-chain triglycerides, omega-3 fatty acids and, most
whom energy demands from activity are minimal, total energy recently, structured triglycerides, which combine long and
requirements are approximately 1300–1800 kcal/day. medium-chain triglycerides in the same emulsion. The evi-
dence of clinical benefit for these emulsions compared with
Carbohydrate conventional LCTs is tenuous, particularly if infusion rates
There is an obligatory glucose requirement to meet the needs are appropriate and hypertriglyceridaemia is avoided.
of the central nervous system and certain haematopoietic
cells, which is equivalent to about 2 g/kg per day. In addition, Protein
there is a physiological maximum to the amount of glucose The basic requirement for nitrogen in patients without
that can be oxidised, which is approximately 4 mg/kg per pre-existing malnutrition and without metabolic stress is
minute (equivalent to about 1500 kcal/day in a 70-kg person), 0.10–0.15 g/kg per day. In hypermetabolic patients the nitro-
with the nonoxidised glucose being primarily converted to gen requirements increase to 0.20–0.25 g/kg per day. Although
fat. However, optimal utilisation of energy during nutritional there may be a minority of patients in whom the requirements
support is ensured by avoiding the infusion of glucose at rates are higher, such as after acute weight loss when the objec-
approximating physiological maximums. Plasma glucose tive of therapy is longterm repletion of lean body mass, there
levels provide an indication of tolerance. Avoid hyperglycae- is little evidence that the provision of nitrogen in excess of
mia. Provide energy as mixtures of glucose and fat. Glucose is 14 g/day is beneficial.
the preferred carbohydrate source.
Vitamins, minerals and trace elements
Fat Whatever the method of feeding, these are all essential com-
Dietary fat is composed of triglycerides of predominantly four ponents of nutritional regimes. The water-soluble vitamins
long-chain fatty acids. There are two saturated fatty acids B and C act as coenzymes in collagen formation and wound
(palmitic (C16) and stearic (C18)) and two unsaturated fatty healing. Postoperatively, the vitamin C requirement increases
acids (oleic (C18 with one double bond) and linoleic (C18 to 60–80 mg/day. Supplemental vitamin B12 is often indi-
with two double bonds)). In addition, smaller amounts of lin- cated in patients who have undergone intestinal resection or
olenic acid (C18 with three double bonds) and medium-chain gastric surgery and in those with a history of alcohol depen-
fatty acids (C6–C10) are contained in the diet. dence. Absorption of the fat-soluble vitamins A, D, E and K
The unsaturated fatty acids, linoleic and linolenic acid, is reduced in steatorrhoea and the absence of bile.
are considered essential because they cannot be synthesised Sodium, potassium and phosphate are all subject to signi-
in vivo from non-dietary sources. Both soybean and sunflower ficant losses, particularly in patients with diarrhoeal illness.
in vivo is Latin for ‘in a living thing’.
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Fluid and nutritional consequences of intestinal resection 283
Their levels need daily monitoring and appropriate replace- water and salt absorption from the colon and, second, they are
ment. trophic to the colonocyte.
Trace elements may also act as cofactors for metabolic
processes. Normally, trace element requirements are met
by the delivery of food to the gut and so patients on long-
Effects of resection
term parenteral nutrition are at particular risk of depletion. Resection of proximal jejunum results in no significant alter-
Magnesium, zinc and iron levels may all be decreased as part ations in fluid and electrolyte levels as the ileum and colon
of the inflammatory response. Supplementation is necessary can adapt to absorb the increased fluid and electrolyte load.
to optimise utilisation of amino acids and to avoid refeeding Absorption of nutrients occurs throughout the small bowel,
syndrome. and resection of jejunum alone results in the ileum taking over
this lost function. In this situation, there is no malabsorption.
Resection of ileum results in a significant enhancement
FLUID AND NUTRITIONAL of gastric motility and acceleration of intestinal transit. Fol-
CONSEQUENCES OF lowing ileal resection, the colon receives a much larger vol-
ume of fluid and electrolytes and it also receives bile salts,
INTESTINAL RESECTION which reduce its ability to absorb salt and water, resulting
Up to 50% of the small intestine can be surgically removed in diarrhoea. Even the loss of 100 cm of ileum may cause
or bypassed without permanent deleterious effects. With steatorrhoea, which can necessitate the administration of
extensive resection (<150 cm of remaining small intestine), oral cholestyramine to bind bile salts. With larger resections
metabolic and nutritional consequences arise, resulting in the (>100 cm) dietary fat restriction may be necessary. Regular
disease entity known as short bowel syndrome. The clinical parenteral vitamin B12 is required.
presentation of patients with short bowel syndrome is depen- The most challenging patients are those with short bowel
dent upon the site and extent of intestinal resection. syndrome who have had in excess of 200 cm of small bowel
resected together with colectomy. These patients will usually
have a jejunostomy. They are conveniently divided into two
Small bowel motility groups termed ‘net absorbers’ and ‘net secretors’. Absorbers
Small bowel motility is three times slower in the ileum than characteristically have more than 100 cm of residual jejunum
in the jejunum. In addition, the ileocaecal valve may slow and they absorb more water and sodium from the diet than
transit. The adult small bowel receives 5–6 litres of endog- passes through the stomach. These patients can be managed
enous secretions and 2–3 litres of exogenous fluids per day. without supplementary parenteral fluids.
Most of this is reabsorbed in the small bowel. In the jeju- Secretors usually have less than 100 cm of residual jeju-
num, the cellular junctions are leaky and jejunal contents are num and lose more water and sodium from their stoma than
always isotonic. Fluid absorption in this region of bowel is they take by mouth. These patients require supplements.
inefficient compared with the ileum. It has been estimated Their usual daily jejunostomy output may exceed 4 litres per
that the efficiency of water absorption is 44% and 70% of 24 hours. The sodium content of jejunostomy losses or other
the ingested load in the jejunum and ileum, respectively. The high-output fistulae is about 90 mmol/L. Jejunal mucosa is
corresponding figures for sodium are 13% and 72%, respec- leaky and rapid sodium fluxes occur across it. If water or any
tively. It can be seen, therefore, that the ileum is critical in solution with a sodium concentration of less than 90 mmol/L
the conservation of fluid and electrolytes. is consumed, there is a net efflux of sodium from the plasma
into the bowel lumen. It is therefore inappropriate to encour-
age patients with high-output jejunostomies (secretors) to
Ileum drink large amounts of oral hypotonic solutions. Treatment
The ileum is the only site of absorption of vitamin B12 and begins with restricting the total amount of hypotonic fluids
bile salts. Bile salts are essential for the absorption of fats and (water, tea, juices, etc.) consumed to less than 1 litre a day.
fat-soluble vitamins. The enterohepatic circulation of bile Patients should be encouraged to take glucose and saline
salts is critical to maintain the bile salt pool. Following resec- replacement solutions, which have a sodium concentration of
tion of the ileum, the loss of bile salts increases and is not met at least 90 mmol/L. The World Health Organization (WHO)
by an increase in synthesis. Depletion of the bile salt pool cholera solution has a sodium concentration of 90 mmol/L
results in fat malabsorption. In addition, loss of bile salts into and is commonly used.
the colon affects colonic mucosa, causing a reduction in salt Complications of short bowel syndrome include peptic
and water absorption, which increases stool losses. ulceration related to gastric hypersecretion, cholelithiasis
because of interruption of the enterohepatic cycle of bile
salts and hyperoxaluria as a result of the increased absorption
Colon of oxalate in the colon predisposing to renal stones. Some
Transit times in the colon vary between 24 and 150 hours. patients with short bowel syndrome develop a syndrome of
The efficiency of water and salt absorption in the colon slurred speech, ataxia and altered affect. The cause of this syn-
exceeds 90%. Another important colonic function is the drome is fermentation of malabsorbed carbohydrates in the
fermentation of carbohydrates to produce short-chain fatty colon to d-lactate and absorption of this metabolite. Treat-
acids. These have two important functions: first, they enhance ment necessitates the use of a low carbohydrate diet.
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Anti-secretory drugs reduce the amount of fluid secreted Enteral nutrition

from the stomach, liver and pancreas. These include
H2-receptor antagonists, proton pump inhibitors and the The term ‘enteral feeding’ means delivery of nutrients into
somatostatin analogue octreotide. Octreotide also reduces the gastrointestinal tract. The alimentary tract should be
gastrointestinal motility, while proton pump inhibitors lower used whenever possible. This can be achieved with normal
gastric pH sufficiently to decrease the need for neutralisation food, oral supplements (sip feeding) or with a variety of tube-
of acid in the duodenum and proximal jejunum. This results feeding techniques delivering food into the stomach, duo-
in significant lowering of high jejunostomy outputs and dos- denum or jejunum.
age should be titrated against stoma effluent pH for optimal A variety of nutrient formulations are available for enteral
results. Anti-motility drugs include loperamide and codeine feeding. These vary with respect to energy content, osmolar-
phosphate, which also decrease water and sodium output from ity, fat and nitrogen content and nutrient complexity; most
the stoma by about 20%. contain up to 1–2 kcal/mL and up to 0.6 g/mL of protein.
Polymeric feeds contain intact protein and hence require
digestion, whereas monomeric/elemental feeds contain nitro-
ARTIFICIAL NUTRITIONAL gen in the form of either free amino acids or, in some cases,
peptides. These are less palatable and are used much less fre-
SUPPORT quently than in previous years. Newer feeding formulations
The indications for nutritional support are simple. Any are available that include glutamine and fibre to optimise
patient who has sustained 5 days of inadequate intake or who intestinal nutrition, or immunonutrients such as arginine and
is anticipated to have no or inadequate intake for this period fish oils, but these are expensive and their use is controversial.
should be considered for nutritional support. The periods may
be less in patients with pre-existing malnutrition. This con-
cept is important because it emphasises that the provision of
Sip feeding
nutritional support is not specific to certain conditions or dis- Commercially available supplementary sip feeds are used in
eases. Although patients with Crohn’s disease or pancreatitis, patients who can drink but whose appetites are impaired or
or those who have undergone gastrointestinal resections, may in whom adequate intakes cannot be maintained with ad
frequently require nutritional support, it is the fact that they libitum intakes. These feeds typically provide 200 kcal and
have had inadequate intakes for defined periods that is the 2 g of nitrogen per 200 mL carton. There is good evidence
indication rather than the specific disease process. to demonstrate that these sip-feeding techniques are associ-
ated with a significant overall increase in calorie and nitrogen
intakes without detriment to spontaneous nutrition. The evi-
dence that these techniques improve patient outcomes is less
Nasogastric/ convincing.
duodenal/jejunal
tube
Tube-feeding techniques
Enteral nutrition can be achieved using conventional naso-
gastric tubes (Ryle’s), fine-bore feeding tubes inserted into
Whole food the stomach, surgical or percutaneous endoscopic gastros-
PPN TPN
by mouth tomy (PEG) or, finally, postpyloric feeding utilising nasoje-
junal tubes or various types of jejunostomy (Figure 19.3).
The choice of method will be determined by local circum-
stances and preference in many patients. Whichever method
is adopted, it is important that tube feeding is supervised
by an experienced dietician who will calculate the patient’s
Gastrostomy requirements and aim to achieve these within 2–3 days of the
tube instigation of feeds. Conventionally, 20–30 mL are admin-
Jejunostomy istered per hour initially, gradually increasing to goal rates
tube within 48–72 hours. In most units, feeding is discontinued for
4–5 hours overnight to allow gastric pH to return to normal.
There is some evidence that this might reduce the incidence
of nosocomial pneumonia and aspiration. There is good evi-
dence to confirm that feeding protocols optimise the toler-
Figure 19.3 Techniques used for adjuvant nutritional support. PPN,
partial parenteral nutrition; TPN, total parenteral nutrition. Redrawn
ance of enteral nutrition. In these, aspirates are performed
with permission from Rick Tharp, rxkinetics.com. on a regular basis and if they exceed 200 mL in any 2-hour
ad libitum is Latin for ‘freely or as much as you wish’.

John Alfred Ryle, 1889–1950, Regius Professor of Medicine, Cambridge University and later Professor of Social Medicine, Oxford University, Oxford, UK, intro-
duced the Ryle’s tube in 1921.
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Artificial nutritional support 285
period, then feeding is temporarily discontinued or the rate of

feed administration is diminished.
Tube blockage is common. All tubes should be flushed
with water at least twice daily. If a buildup of solidified diet
occurs, instillation into the tube of agents such as chymotryp-
sin may salvage a partially obstructed tube. Guidewires should
not be used to clear blockages as these may perforate the tube
and cause contiguous damage.
Nasogastric tubes are appropriate in a majority of patients.
If feeding is maintained for more than a week or so, a fine-
bore feeding tube is preferable and is likely to cause fewer gas-
tric and oesophageal erosions. These are usually made from
soft polyurethane or silicone elastomer and have an internal
diameter of <3 mm.
Fine-bore tube insertion

The patient should be semi-recumbent. The introducer wire is
lubricated and inserted into the fine-bore tube (Figure 19.4).
The tube is passed through the nose and into the stomach via
the nasopharynx and oesophagus. The wire is withdrawn and
the tube is taped to the patient. There is a small risk of mal-
position into a bronchus or of causing pneumothorax. The
position of the tube should be checked using plain abdominal
radiography (Figure 19.5). Confirmation of position by pH Figure 19.5 Radiograph of a tube similar to that in Figure 19.4
testing is possible but limited by the difficulty of obtaining a inserted beyond the duodenojejunal flexure.
fluid aspirate with narrow lumen tubes.
Figure 19.6 Percutaneous endoscopic gastrostomy tube.
endoscopic control using local anaesthesia, known as PEG

(percutaneous endoscopic gastrostomy) tubes (Figure 19.6).
Two methods of PEG are commonly used. The first is
called the ‘direct-stab’ technique in which the endoscope is
passed and the stomach filled with air. The endoscopist then
watches a cannula entering the stomach having been inserted
directly through the anterior abdominal wall. A guidewire is
Figure 19.4 A fine-bore feeding tube with its guidewire.
then passed through the cannula into the stomach. A gastros-
tomy tube (commercially available) may then be introduced
Gastrostomy into the stomach through a ‘peel away’ sheath. The alterna-
tive technique is the transoral or push-through technique,
The placement of a tube through the abdominal wall directly whereby a guidewire or suture is brought out of the stomach
into the stomach is termed ‘gastrostomy’. Historically, these by the endoscope after transabdominal percutaneous inser-
were created surgically at the time of laparotomy. Today, tion and is either attached to a gastrostomy tube or the tube
the majority are performed by percutaneous insertion under is pushed over a guidewire. The abdominal end of the wire
03_19-B&L27_Pt3_Ch19.indd 285 25/10/2017 08:07

is then pulled, advancing the gastrostomy tube through the

oesophagus and into the stomach. Continued pulling abuts it Summary box 19.3
up against the abdominal wall. Complications of enteral nutrition
If patients require enteral nutrition for prolonged periods ●● Tube-related
(4–6 weeks), then PEG is preferable to an indwelling nasoga-
Malposition
stric tube; this minimises the traumatic complications related
Displacement
to indwelling tubes. PEG does have procedure-specific com-
Blockage
plications, although these are uncommon. Necrotising fasci-
Breakage/leakage
itis and intra-abdominal wall abscesses have been recorded.
Local complications (e.g. erosion of skin/mucosa)
Sepsis around the PEG site is more common and may necessi- ●● Gastrointestinal
tate systemic antibiotics or repositioning. A persistent gastric
Diarrhoea
fistula can occur on removal of a PEG if it has been in place
Bloating, nausea, vomiting
for prolonged periods and epithelialisation of the tract has
Abdominal cramps
occurred. This necessitates surgical closure.
Aspiration
Constipation
Metabolic/biochemical
Jejunostomy
●●
Electrolyte disorders
In recent years, the use of jejunal feeding has become increas- Vitamin, mineral, trace element deficiencies
ingly popular. This can be achieved using nasojejunal tubes Drug interactions
or by placement of needle jejunostomy at the time of lapa- ●● Infective
rotomy. Some authorities advocate the use of jejunostomies Exogenous (handling contamination)
on the basis that postpyloric feeding may be associated with Endogenous (patient)
a reduction in aspiration or enhanced tolerance of enteral
nutrition. In particular, there are many advocates of jejunos-
tomies in patients with severe pancreatitis, in whom a degree should be kept in sealed containers at 4°C and discarded once
of gastric outlet obstruction may be present, related to the opened. In all patients, it is essential to monitor intakes accu-
oedematous head of pancreas. In most patients it is appropri-
rately as target intakes are often not achieved with enteral
ate to commence with conventional nasogastric feeding and
nutrition.
progress to postpyloric feeding if the former is unsuccessful.
The complications of enteral nutrition are summarised in
Nasojejunal tubes often necessitate the use of fluoros-
Summary box 19.3.
copy or endoscopy to achieve placement, which may delay
commencement of feeding. Surgical jejunostomies, even
using commercially available needle-insertion techniques, do Parenteral nutrition
involve creating a defect in the jejunum, which can leak or
be associated with tube displacement; both of these complica- Total parenteral nutrition (TPN) is defined as the provision
tions result in peritonitis. of all nutritional requirements by means of the intravenous
route and without the use of the gastrointestinal tract.
Parenteral nutrition is indicated when energy and protein
Complications needs cannot be met by the enteral administration of these
substrates. The most frequent clinical indications relate to
Most complications of enteral nutrition can be avoided with those patients who have undergone massive resection of the
careful attention to detail and appropriate infusion rates. small intestine, who have intestinal fistula or who have pro-
Patients should be nursed semi-recumbent to reduce the longed intestinal failure for other reasons.
possibility of aspiration. Complications can be divided into
those resulting from intubation of the gastrointestinal tract
and those related to nutrient delivery. The former are more Route of delivery: peripheral or
frequent with more invasive means of gaining access to the central venous access
intestinal tract (see above under Enteral nutrition). The latter
include diarrhoea, bloating and vomiting. Diarrhoea occurs TPN can be administered either by a catheter inserted in the
in more than 30% of patients receiving enteral nutrition central vein or via a peripheral line. In the early days of paren-
and is particularly common in the critically ill. Up to 60% teral nutrition, the only energy source available was hypertonic
of patients in intensive care units may fail to receive their glucose, which, being hypertonic, had to be given into a cen-
targeted intakes. There is no evidence that the incidence of tral vein to avoid thrombophlebitis. In the second half of the
diarrhoea and bloating is reduced by the use of half-strength last century, there were a number of important developments
feeds. It is important to introduce normal feeds at a reduced that have influenced the administration of parenteral nutri-
rate according to patient tolerance. Metabolic complications tion. These include the identification of safe and non-toxic
associated with excessive feeding are uncommon in enterally fat emulsions that are isotonic; pharmaceutical developments
fed patients. There have been reports of nosocomial enteric that permit carbohydrates, fats and amino acids to be mixed
infections associated with contamination of feeds, which in single containers; and a recognition that the provision of
03_19-B&L27_Pt3_Ch19.indd 286 25/10/2017 08:07

Artificial nutritional support 287
energy during parenteral nutrition should be a mixture of glu-

cose and fat and that energy requirements are rarely in excess of
2000 kcal/day (25–30 kcal/kg per day). These changes enabled
the development of peripheral parenteral nutrition.
Peripheral
Peripheral feeding is appropriate for short-term feeding of up
to 2 weeks. Access can be achieved either by means of a dedi-
cated catheter inserted into a peripheral vein and manoeuvred
into the central venous system (peripherally inserted central
venous catheter (PICC) line) or by using a conventional short
cannula in the wrist veins. The former method has the advan-
tage of minimising inconvenience to the patient and clinician.
PICC lines have a mean duration of survival of 7 days. The
disadvantage is that when thrombophlebitis occurs, the vein
is irrevocably destroyed. In the alternative approach, intrave-
nous nutrients are administered through a short cannula in Figure 19.8 Infraclavicular subclavian line.
wrist veins, infusing the patient’s nutritional requirements on
a cyclical basis over 12 hours. The cannula is then removed
and resited in the contralateral arm. Peripheral parenteral
nutrition has the advantage that it avoids the complications under ultrasound guidance; however, this will not be prac-
associated with central venous administration, but suffers the ticable for all cases. Most intensive care physicians and
disadvantage that it is limited by the development of throm- anaesthetists favour cannulation of internal or external jug-
bophlebitis (Figure 19.7). Peripheral feeding is not indicated ular veins as these vessels are easily accessible. They suffer
if patients already have an indwelling central venous line or the disadvantage that the exit site is situated inconveniently
in those in whom long-term feeding is anticipated. on the side of the neck, where repeated movements result in
disruption of the dressing with the attendant risk of sepsis.
The infraclavicular subclavian approach is more suitable for
New cannula inserted feeding as the catheter then lies flat on the chest wall, which
optimises nursing care (Figure 19.8).
For longer-term parenteral nutrition, Hickman lines are
Cannula removed Endothelial damage preferable. These are often inserted by a radiologist with flu-
oroscopic guidance or ultrasound. They incorporate a small
cuff, which sits at the exit site of a subcutaneous tunnel. This
Extravasation/pain is thought to minimise the possibility of line dislodgement and
Venoconstriction reduce the possibility of line sepsis. Whichever technique is
PVT cycle
employed, a postinsertion chest x-ray is essential before feed-
Thrombus ing is commenced to confirm the absence of pneumothorax
(vein occlusion) and that the catheter tip lies in the distal superior vena cava,
Drug/infusion to minimise the risk of central venous or cardiac thrombosis.
administered Multilumen catheters can be used for the administration of
Inflammation/thrombosis (further TPN; one port should be employed for that sole purpose and
venoconstriction) strict protocols of aseptic care employed.
An alternative technique for central intravenous access
Inflammatory and vasoactive allows the PICC technique under ultrasound guidance to can-
mediators nulate the cephalic vein in the arm, which facilitates passage of
Figure 19.7 Cycle of causes of peripheral vein thrombophlebitis a catheter into the bracheocephalic vein or superior vena cava.
(PVT) (after Payne-James J, Grimble G, Silk D (eds). Artificial nutri- This has many advantages as it minimises the risks of insertion
tion support in clinical practice, 2nd edn. London, Greenwich Medical and ensures distance between the site of skin entry and the tip
Media, 2001). of the catheter. Thrombophlebitis, however, can occur.
Central Complications of parenteral

When the central venous route is chosen, the catheter can
be inserted via the subclavian or internal or external jugular
nutrition
vein. There is good evidence to show that the safest means The commencement of TPN may precipitate or accentuate
of establishing central venous access is by insertion of lines underlying nutrient deficiency by encouraging anabolism.
John Jason Payne-James, contemporary forensic physician and medical writer, Leigh-on-Sea, Essex, UK.
Robert O Hickman, b.1929, formerly paediatric nephrologist, Seattle Childrens’ Hospital, Seattle, WA, USA.
03_19-B&L27_Pt3_Ch19.indd 287 25/10/2017 08:07

Common metabolic complications include fluid overload,

hyperglycaemia, abnormalities of liver function and vitamin Summary box 19.4
deficiencies. Fluid overload can be avoided by daily weigh- Complications of parenteral nutrition
ing of the patient. A weight change of >1 kg/day normally ●● Related to nutrient deficiency
indicates fluid retention. Hyperglycaemia is common because
Hypoglycaemia/hypocalcaemia/ hypophosphataemia/
of insulin resistance in critically ill patients. Even modest rates hypomagnesaemia (refeeding syndrome)
of glucose administration may be associated with hyperglycae- Chronic deficiency syndromes (essential fatty acids, zinc,
mia. Hyperglycaemic patients undergoing surgery are known mineral and trace elements)
to run a substantially higher risk of infectious complications. ●● Related to overfeeding
Abnormalities of liver enzymes are common in patients Excess glucose: hyperglycaemia, hyperosmolar
who are receiving TPN. Although the precise mechanisms dehydration, hepatic steatosis, hypercapnia, increased
are unclear, intrahepatic cholestasis may occur and hepatic sympathetic activity, fluid retention, electrolyte
abnormalities
steatosis and hepatomegaly have been reported. Reducing the
Excess fat: hypercholesterolaemia and formation of
fat content or infusion of fat-free TPN may be required. If
lipoprotein X, hypertriglyceridaemia, hypersensitivity
liver enzymes continue to deteriorate, TPN should be tempo- reactions
rarily discontinued. In addition, overfeeding is a major factor Excess amino acids: hyperchloraemic metabolic acidosis,
in hepatic and other metabolic complications associated with hypercalcaemia, aminoacidaemia, uraemia
TPN. Supplemental parenteral glutamine during parental ●● Related to sepsis
nutrition should be considered, particularly in the critically Catheter-related sepsis
ill patient. Possible increased predisposition to systemic sepsis
Catheter-related sepsis occurs in 3–14% of patients. It ●● Related to line
may occur at the time of line insertion or afterwards by migra- On insertion: pneumothorax, damage to adjacent artery,
tion of skin bacteria along the external catheter surface. Some air embolism, thoracic duct damage, cardiac perforation or
studies suggest that manoeuvring of the catheter hub due to tamponade, pleural effusion, hydromediastinum
frequent manipulation is a common cause. Contamination Long-term use: occlusion, venous thrombosis
of the infusate is rare. Seeding on the catheter at the time
of bacteraemia from a remote source may also cause catheter
infection.
Diagnosis of catheter-related sepsis requires that the same occur with either enteral or parenteral nutrition, but is more
organism is grown from the catheter tip as is recovered from common with the latter. It results in hypophosphataemia,
blood and that the clinical features of infection resolve on hypocalcaemia and hypomagnesaemia. These electrolyte dis-
removal of the catheter. Traditional methods of confirming orders can result in altered myocardial function, arrhythmias,
line sepsis have necessitated removal of the line with subse- deteriorating respiratory function, liver dysfunction, seizures,
quent bacteriological assessment. An alternative approach is confusion, coma, tetany and death. Patients at risk include
to use an endoluminal brush passed down the catheter and those with alcohol dependency, those suffering severe malnu-
withdrawn into a polythene sheath. The brush tip is cultured trition, anorexics and those who have undergone prolonged
at the same time as performing blood cultures. Catheter sep- periods of fasting. Treatment involves matching intakes with
sis is confirmed if identical organisms are cultured from brush requirements and assiduously avoiding overfeeding. Calorie
and blood. A second alternative is to culture blood withdrawn delivery should be increased slowly and vitamins adminis-
through the catheter and compare this with peripheral blood tered regularly. Hypophosphataemia and hypomagnesaemia
cultures. If the colony count from the catheter sample is five require treatment.
or more times higher than that from peripheral blood, then
line sepsis is probable.
Some of the complications of TPN may not be a direct Nutrition support teams
result of the provision of nutrients by the intravenous route, Multidisciplinary nutrition teams ensure cost-effective and
but rather a consequence of the absence of luminal nutrients. safe nutritional support, irrespective of how this is adminis-
This may cause a shift in the mucosa-associated intestinal tered. The incidence of catheter-related sepsis is significantly
microbiome, an increased mucosal proinflammatory state reduced.
and the loss of epithelial barrier function leading to bacterial
translocation of enteric organisms. The gut origin of sepsis,
mediated by bacterial translocation, may be significant in SUMMARY
critical illness and multiorgan failure. Fluid therapy and nutritional support are fundamental
The complications of parenteral nutrition are summarised to good surgical practice. Accurate fluid administration
in Summary box 19.4. demands an understanding of maintenance requirements and
an appreciation of the consequences of surgical disease on
fluid losses. This requires knowledge of the consequences of
Refeeding syndrome surgical intervention and, in particular, intestinal resection.
This syndrome is characterised by severe fluid and electrolyte Malnutrition is common in hospital patients. All patients
shifts in malnourished patients undergoing refeeding. It can who have sustained or who are likely to sustain 5 days of
03_19-B&L27_Pt3_Ch19.indd 288 25/10/2017 08:07

Further reading 289
inadequate oral intake should be considered for nutritional ACKNOWLEDGEMENTS

support. This may be dietetic advice alone, sip feeding or
enteral or parenteral nutrition. These are not mutually With thanks to Marcel Gatt and Clare McNaught.
exclusive. The success or otherwise of nutritional support
should be determined by tolerance to nutrients provided
and nutritional end points, such as weight. It is unrealistic
FURTHER READING
to expect nutritional support to alter the natural history of British Association Parenteral and Enteral Nutrition. BAPEN. Avail-
disease. It is imperative that nutrition-related morbidity is able from: (www.bapen.org.uk/res_pub.html).
Elia M, Ljungqvist O, Stratton R, Lanham SA (eds). Nutrition Society
kept to a minimum. This necessitates the appropriate selection textbook: clinical nutrition, 2nd edn. Oxford: Wiley-Blackwell, 2012.
of feeding method, careful assessment of fluid, energy and Nice guideline: Nutrition support for adults: oral nutrition support,
protein requirements, which are regularly monitored, and the enteral tube feeding and parenteral nutrition. Clinical guidelines
avoidance of overfeeding. (CG32). Feb 2006.
03_19-B&L27_Pt3_Ch19.indd 289 25/10/2017 08:07

Bailey &20
Love Bailey & Love Bailey & Love
Chapter
Postoperative care
Learning objectives
To understand: • How to recognise and treat common postoperative
• What is required to deliver immediate postoperative care complications
• What are the common postoperative problems seen in • The principles of enhanced recovery
the immediate postoperative period • A system for discharging patients
• How to predict and prevent common postoperative
complications
INTRODUCTION of the patient to the PACU staff. The information provided

should include the patient’s name, age, the surgical proce-
The aim of postoperative care is to provide the patient with dure, existing medical problems, allergies, the anaesthetic
as quick, painless and safe a recovery from surgery as possible. and analgesics given, fluid replacement, blood loss, urine out-
This requires the appropriate knowledge and skills to manage put, any surgical and anaesthetic problems encountered or
medical, as well as surgical, postoperative problems. expected and a plan for the management of pain and nausea
or vomiting.
Standards of postanaesthesia care in
the immediate postoperative period Postoperative observations
Both the American Society of Anaesthesiologists (ASA) and
Association of Anaesthetists of Great Britain and Ireland The patient’s vital signs (including pulse, blood pressure and
(AAGBI) have set standards for the provision of immediate pulse oximetry reading), level of consciousness, pain and hydra-
postoperative care of patients who have undergone a pro- tion status are monitored in the recovery room and supportive
cedure requiring a general anaesthetic or central neuraxial treatment is given. In recent years, patient observations have
blockade. In brief, they both specify that care should be under- been collated in recording systems designed to provide an early
taken in a dedicated postanaesthetic care unit (PACU) with warning of clinical deterioration (Figure 20.1).
staff trained in the management of patients in the immediate Surgery-specific observations such as Doppler flow for a
postoperative care period. Standards for equipment (includ- free flap, regular neurological evaluation and laboratory tests,
ing resuscitation, difficult airway and monitoring), drugs and such as blood gas analysis, should also be performed when
schedules of measurement of patient vital signs are described, necessary.
as well as the discharge criteria each patient must satisfy prior The patient can be discharged from PACU when they ful-
to transfer out. fil the following criteria:
● Patient is fully conscious.
Respiration and oxygenation are satisfactory.
Immediate postoperative care ●
● Patient is normothermic, not in pain and not nauseous.
In many settings around the world, the process starts with a ● Cardiovascular parameters are stable.
‘sign out’ as part of the World Health Organization check list. ● Oxygen, fluids and analgesics have been prescribed.
The theatre team should then formally hand over the care ● There are no concerns related to the surgical procedure.
Christian Johann Doppler, 1803–1853, Professor of Experimental Physics, Vienna, Austria, enunciated the ‘Doppler Principle’ in 1842.
03_20-B&L27_Pt3_Ch20.indd 290 25/10/2017 08:08

Introduction 291
ve
Figure 20.1 An example of an early warning system using patient observations; the National Early Warning System from the Royal College of
Physicians.
03_20-B&L27_Pt3_Ch20.indd 291 25/10/2017 08:08

292 CHAPTER 20 Postoperative care
and early intervention are necessary to prevent harm to the

Summary box 20.1 patient. Most interventions are simple and involve manual
Postoperative period support of the jaw or insertion of an oral or nasal airway.
●● All anaesthetised patients should be recovered in a dedicated RESPIRATION
PACU
●● All vital parameters should be monitored and documented The residual effects of anaesthetic drugs (neuromuscular block-
according to local protocols ers, anaesthetic agents, opioids) can contribute to reduced or
●● Treat pain and nausea/vomiting impaired adequacy of ventilation postoperatively. Continu-
●● Observe for complications ous pulse oximetry and respiratory rate evaluation can identify
respiratory compromise and consequent hypoxia early. Supple-
mental oxygen should be given to all patients in PACU until
adequate respiration and oxygenation are restored.
SYSTEM-SPECIFIC
POSTOPERATIVE HYPOXAEMIA
This may occur, in addition to the situations already described
COMPLICATIONS above, as a consequence of acute pulmonary oedema (fluid
Postoperative complications are an important cause of mor- overload, cardiac failure, postobstructive), bronchospasm,
bidity, mortality, extended hospital stay and increased costs. pneumothorax (Figure 20.2), aspiration and, rarely, pulmo-
Most patients at increased risk of developing postoperative nary embolism (Figure 20.3). De novo pneumonia is very
complications can be identified prior to surgery at the pre-
operative assessment clinic using a variety of scoring systems
(for example the American College of Surgeons National
Surgical Quality Improvement Programme risk stratification
for perioperative myocardial infarction and cardiac arrest
(NSQiP) surgical risk calculator, see Chapter 17). Early iden-
tification of risk allows for targeted, appropriate, anticipatory
and supportive medical care, which will reduce both the inci-
dence and severity of such complications when they occur.
Classification of postoperative
complications
There are three common approaches for the classification of
postoperative complications of surgery:
1 Linked to time after surgery: Figure 20.2 Radiograph showing a right tension pneumothorax with
● immediate (within 6 h of procedure); tracheal deviation to the left (courtesy of Professor Stephen Eustace,
Dublin).
● early (6–72 h);
● late (>72 h).
2 Generic and surgery specific.
3 Clavian-Dindo: this system relates to surgical compli-
cations only and is used to objectively and reproducibly
measure the impact of the surgical complication on the
outcome of the procedure. It is included here for com-
pleteness and will be discussed no further.
Respiratory system
Early detection of respiratory complications is facilitated by
periodic assessment of airway patency, respiratory rate and
routine oxygen saturation measurement, performed during
emergence and recovery as described earlier.
Immediate respiratory complications

AIRWAY
Upper airway obstruction is one of the commonest immediate
postoperative complications and can be due to laryngospasm, Figure 20.3 Computed tomography (CT) scan showing pulmonary
persisting relaxation of airway muscles, soft tissue oedema, artery blood embolism (arrow) (courtesy of Professor Stephen Eus-
haematoma, vocal cord dysfunction or foreign body. Vigilance tace, Dublin).
03_20-B&L27_Pt3_Ch20.indd 292 25/10/2017 08:08

System-specific postoperative complications 293
unusual in the immediate postoperative period. Hypoxae-

mia develops most quickly in patients with obstructive sleep
apnoea, lung disease and obesity, who should therefore be
closely observed.
Patients with hypoxaemia should be treated urgently.
If the patient is breathing spontaneously, oxygen should be
administered at 15 L/min using a non-rebreathing mask. A
head tilt, chin lift or jaw thrust should relieve obstruction
related to reduced muscle tone. Suctioning of any blood or
secretions and insertion of an oropharyngeal airway may be
needed. Early anaesthetic intervention may be required.
SURGERY-SPECIFIC
Vocal cord palsy (as a consequence of recurrent laryngeal
nerve injury), neck haematoma and post-tonsillectomy bleed-
ing are recognised and life-threatening complications of head
and neck surgery, which need immediate medical attention
for safe resolution.
Early and late respiratory complications

Early and late postoperative pulmonary complications are a sig-
nificant cause of postoperative morbidity and mortality (figures
vary between 5% and 70%). Complications include fever (due
to microatelectasis), cough, dyspnoea, bronchospasm, hyper- Figure 20-.5 Radiograph showing classical Staphylococcus aureus
capnoea, atelectasis (Figure 20.4), pneumonia (Figure 20.5), pneumonia (courtesy of Professor Stephen Eustace, Dublin).
pleural effusion, pneumothorax and respiratory failure. The risk
of each varies with the patient and the type of surgery being
performed. Thoracic or abdominal surgery carries the highest Summary box 20.2
risk. The majority of patients at risk (obese, smokers, chronic
lung disease, obstructive sleep apnoea, poor nutritional status) Respiratory complications
can be identified preoperatively, facilitating the development ●● Respiratory complications can occur either immediately or a
of strategies that will reduce the impact of surgery on the indi- few days later on the ward
vidual patient. ●● Obesity, smoking, chronic lung disease, poor nutritional status
and obstructive sleep apnoea predispose to a higher risk of
respiratory complications
●● Early intervention and multidisciplinary involvement can
prevent life-threatening respiratory complications
Cardiovascular system
Cardiovascular complications are the leading cause of
death within 30 days after non-cardiac surgery. Recent tri-
als, reported in the New England Journal of Medicine, have
identified ways to improve safety and therefore outcome (see
Further reading).
Routine pulse, blood pressure, and electrocardiographic
(ECG) monitoring detect cardiovascular complications,
reduce adverse outcomes and should be recorded during
emergence from, and recovery after, anaesthesia. There are
certain categories of patient and procedure for which routine
cardiovascular monitoring may be required for upwards of
24 hours, usually in a PACU or high-dependency unit.
Immediate cardiovascular complications

HYPOTENSION
In the immediate postoperative period this is associated with
Figure 20.4 Radiograph showing right upper lobe atelectasis (cour- adverse outcomes. Multivariable analysis from the POISE-2
tesy of Professor Stephen Eustace, Dublin). trial showed that clinically important hypotension was an
03_20-B&L27_Pt3_Ch20.indd 293 25/10/2017 08:08

independent predictor of the subsequent risk of myocardial STROKE

infarction (see Further reading). Stroke is a recognised complication of carotid endarterectomy
Hypotension may be due to hypovolaemia, myocardial surgery both early (secondary to emboli) and later (secondary
impairment or vasodilatation from subarachnoid and to cerebral hyperperfusion syndrome). It is also a recognised
epidural anaesthesia. Other causes of hypotension consequence of both hypotension and hypertension. Throm-
such as surgical bleeding, sepsis, arrhythmias, tension bolysis may be indicated but the neurology and surgical teams
pneumothorax, pulmonary embolism, pericardial tamponade must discuss together the risks and benefits of such a treat-
and anaphylaxis should also be considered in the differential ment plan.
diagnosis.
Treatment should be aimed at the cause. Postopera- Early and late cardiovascular complications
tive hypotension leading to end-organ dysfunction, (e.g. Major postoperative cardiac complications account for at
decreased urine output <0.5 mL/kg/h, decreased level of con- least one-third of postoperative deaths, resulting in sub-
sciousness, myocardial ischaemia, capillary refill >2 seconds) stantial rates of complications, prolonged length of stay and
needs immediate management with fluid and may require the increased medical costs.
use of vasopressors and inotropes. MI, congestive heart failure, arrhythmias and stroke need
to be identified and treated early. Recent studies advocate
HYPERTENSION shared postoperative care of patients at high risk, in order that
Hypertension is also common. It may be due to pain, agi- the signs of deterioration may be identified early and treated
tation, anxiety, bladder spasm secondary to urinary cathe- (see Further reading).
terisation or pre-existing poorly-controlled hypertension.
Consequences include bleeding from vascular suture lines,
cerebrovascular haemorrhage and myocardial ischaemia or Summary box 20.3
infarction.
Cardiovascular complications
MYOCARDIAL ISCHAEMIA ●● Hypotension and hypertension in the postoperative period
Patients with a history of cardiovascular disease or with can be multifactorial and result in serious morbidity
known cardiac risk factors undergoing major surgery are ●● Arrhythmias can be prevented and corrected by treating
hypotension and electrolyte imbalance
at risk of major adverse cardiac events. This risk can be
●● Arrhythmias, myocardial ischaemia/infarction and stroke
predicted preoperatively using the ACS National Surgical will need management with the help of cardiologists and
Quality Improvement Programme (NSQIP) risk stratification neurologists
for perioperative myocardial infarction and cardiac arrest
(MICA). Symptoms can include retrosternal pain radiating
into the neck, jaw or arms, nausea, dyspnoea or syncope, but
many events in the perioperative period are silent. Renal and urinary system
ECG changes can include ST-elevation in two continuous Acute kidney injury
leads, new left bundle branch block or an arrhythmia. In the
case of a non-ST segment MI, only a rise in serial troponin About one-quarter of cases of hospital-acquired renal failure
levels will clarify the diagnosis. Cardiologists should be occur in the perioperative period and are associated with high
involved early and may start coronary reperfusion therapy mortality, especially after cardiac and major vascular surgery.
in the form of primary percutaneous coronary intervention Patients with known chronic renal disease, diabetes, liver fail-
or thrombolysis. These should be discussed with the surgical ure, peripheral vascular disease and cardiac failure are at high
team due to the risk of bleeding after major surgery. risk (Table 20.1).
According to national guidance (National Institute for
ARRHYTHMIAS Health and Care Excellence, NICE) based on several defi-
When they occur in the postoperative period, arrhythmias nitions, acute kidney injury can be detected by the following
can cause hypotension, myocardial ischaemia and cardiac criteria (see Further reading):
arrest. Treatment should be guided by the Resuscitation ● a rise in serum creatinine of 26 μmol/L or greater within
Council periarrest guidelines. 48 hours;
Tachycardia (sinus or supraventricular) may occur
due to anxiety, pain, myocardial ischaemia or infarction, TABLE 20.1 Common causes of acute kidney injury.
hypovolaemia, sepsis or hypoxia in the postoperative Prerenal Hypotension
period. Consideration should be given to correction of Hypovolaemia
the underlying causes and rate controlled with β-blockers, Renal Nephrotoxic drugs (gentamicin, diuretics,
amiodarone or cardioversion, depending on the state of the non-steroidal anti-inflammatory drugs)
patient. Surgery involving renal vessels
Sinus bradycardia may be normal in athletes but it may Myoglobinuria
Sepsis
also be associated with hypoxia, preoperative β-blockers,
digoxin and increased intracranial pressure. Pharmacological Postrenal Ureteric injury
options include glycopyrrolate or atropine intravenously. Blocked urethral catheter
03_20-B&L27_Pt3_Ch20.indd 294 25/10/2017 08:08

General postoperative complications 295
● a ≥50% rise in serum creatinine known or presumed to intraoperative administration of narcotics and benzodiaze-
have occurred within the past 7 days; pines, change of medications, electrolyte and fluid abnor-
● a fall in urine output to less than 0.5 mL/kg/h for more malities, constipation, catheterisation and an unfamiliar
than 6 hours in adults and more than 8 hours in children environment (Table 20.2).
and young people; Correcting any reversible cause, involving relatives or
● a ≥25% fall in estimated glomerular filtration rate in chil- friends whom the patient knows and pain control can all con-
dren and young people within the past 7 days. tribute to reducing the impact and duration of delirium. As a
last option, haloperidol may be given in titrated doses accord-
Urinary retention ing to local protocols.
Inability to void after surgery is common with pelvic and
perineal operations, or after procedures performed under
TABLE 20.2 Causes of delirium.
spinal anaesthesia. Pain, hypovolaemia, problems with access
to urinals and bed pans and a lack of privacy on wards may Renal Renal failure/uraemia
Hyponatraemia and electrolyte disorders
contribute to the problem of urine retention. The diagnosis Urinary tract infection
of retention may be confirmed by clinical examination and by Urinary retention
using ultrasound imaging. Catheterisation should be performed Respiratory Hypoxia, e.g. chest infection
prophylactically when an operation is expected to last 3 hours Atelectasis
or longer, or when large volumes of fluid are administered. Cardiovascular Pulmonary embolism
Dehydration
Urinary infection Septic shock
Urinary infection is one of the most commonly acquired Myocardial infarction
infections in the postoperative period. Patients may present Chronic heart failure
Arrhythmia
with dysuria and/or pyrexia. Immunocompromised patients,
diabetics and those patients with a history of urinary retention Drugs Opiates including heroin
Hypnotics
are known to be at higher risk. Treatment involves adequate Cocaine
hydration, proper bladder drainage and antibiotics depending Alcohol withdrawal
on the sensitivity of the microorganisms. Hypoglycaemia
Neurological Epilepsy
Encephalopathy
Summary box 20.4 Head injury
Cerebrovascular accident
Renal and urinary complications
Idiopathic (rare) Hypothyroidism
●● Postoperative renal failure is associated with high mortality Hyperthyroidism
●● Prophylactic measures to prevent renal failure should be taken Addison’s disease
in high-risk cases
●● Urinary retention and infection are common problems
postoperatively Stroke – has been discussed above.
Seizures – are uncommon except in those patients with
known poorly-controlled epilepsy. They may occur as a com-
Central nervous system plication of neurosurgery.
Postoperative delirium
With an increasingly frail and elderly population presenting
for elective surgery, the incidence of postoperative delirium
GENERAL POSTOPERATIVE
(POD) is increasing. POD is frequently recognised late and COMPLICATIONS
has significant postoperative sequelae.
POD can occur during recovery from anaesthesia or a few
Bleeding
days after surgery. The overall incidence of POD is 5–50%. It Postoperative haemorrhage is most common in the immediate
occurs more frequently in the elderly orthopaedic patient and postoperative period. It may be caused by an arterial or venous
those undergoing emergency surgical procedures. Delirium is leak, but also by a generalised ooze or a coagulopathy. Slow
associated with increased all-cause morbidity, mortality and bleeds may go undetected for hours and then the patient
discharge to a nursing home. There are two types of delir- suddenly decompensates. All patients must have their vital
ium – hyperactive (restlessness, incoherent speech, agitation, signs (pulse rate, blood pressure, oximetry, central venous
hallucinations) and hypoactive (withdrawn, poorly respon- pressure, if available, and urine output) monitored regularly.
sive to the environment, depressed). Preoperative risk factors Dressings and drains should be inspected regularly in the first 24
for POD include pre-existing cognitive impairment, demen- hours after surgery. If haemorrhage is suspected, blood samples
tia, frailty, Parkinson’s disease, severe illness, renal impair- should be taken for a full blood count, coagulation profile and
ment and depression. Precipitating factors include surgery, cross match. A large bore intravenous cannula should be sited
Thomas Addison, 1795–1860, physician, Guy’s Hospital. London, UK, described the effects of disease of the suprarenal capsules in 1849.
03_20-B&L27_Pt3_Ch20.indd 295 25/10/2017 08:08

and fluid resuscitation commenced. If the source of bleeding is TABLE 20.3 Stratification surgical procedure and the asso-
in doubt and the patient is stable, an ultrasound or computed ciated risk of deep vein thrombosis.
tomography (CT) scan may be required to determine the nature Low
of the bleed (most commonly if a haematoma is suspected in ●● Maxillofacial surgery
the days following surgery). If the patient’s cardiovascular ●● Neurosurgery
system is unstable or compromised in any way (for example ●● Cardiothoracic surgery
neck haematoma or bleeding tonsil) they should be taken back Medium

to the operating theatre immediately. ●● Inguinal hernia repair
The treatment of haemorrhage is both to stop the bleeding ●● Abdominal surgery
and supportive. Supportive treatment includes oxygen and ●● Gynaecological surgery
fluid resuscitation. It may require correction of coagulopathy. ●● Urological surgery
All patients will require close observation. Blood transfusion High

carries risks (acute haemolytic transfusion reaction, sensitisa- ●● Pelvic elective and trauma surgery
tion, fluid overload, hyperkalaemia, transfusion-related lung ●● Total knee and hip replacement
injury and transmission of blood-borne infection). There is

much published about what is the right transfusion trigger
and how to balance the need for adequate tissue perfusion and anticoagulation initially, followed by longer-term warfarin
the risks of transfusion. The decision about when to transfuse or new oral anticoagulant (refer to national guidance, e.g.
should be based on the individual patient; in general, how- NICE; see Further reading). In some patients with a large
ever, the accepted transfusion trigger is 75 g/L except in the DVT, a caval filter may be required to decrease the possibility
presence of known or suspected coronary artery disease when of pulmonary embolism.
a higher trigger is acceptable.
All hospitals should have a ‘major haemorrhage protocol’ Pulmonary embolus
in place. The consultant surgeon, anaesthetist and haematol-
ogist should all be involved early on in the care of unstable Pulmonary embolism (PE) is not usually an immediate com-
patients. plication, but can present in the early postoperative period.
Thrombus can arise from DVT in the legs/pelvis, venae cavae
or the right atrium. Signs and symptoms depend on the size of
Summary box 20.5 the embolus and may range from dyspnoea, cough, and pleu-
ritic chest pain to sudden cardiovascular collapse. Diagnosis
Postoperative bleeding of PE begins with history (including risk factors and recent
●● All hospitals should have a major haemorrhage protocol in surgery) and physical examination (which may include signs
place of DVT). Investigations may include, depending on the pre-
●● Need to transfuse blood in absence of continued bleeding in sentation, ECG, chest radiograph, blood tests (arterial blood
patients with haemoglobin >75 g/L should be weighed against gas and d-dimer) and radiological tests (usually CT pulmo-
the risks
nary angiography). If the presentation includes cardiovas-
cular collapse, resuscitation will be needed. Thrombolysis
can be considered with massive PE causing cardiovascular
Deep vein thrombosis collapse, but this should include senior clinical opinion and
Deep vein thrombosis (DVT) is a well-known and, when would generally follow appropriate guidelines. The patient
complicated by pulmonary embolus, potentially fatal compli- may need inotropes and admission to the intensive care unit.
cation of surgery (Table 20.3). All hospitals must have a pro- In less severe cases of PE, supportive measures include oxygen
cess for screening all surgical patients to identify those at risk therapy and analgesia. After initial resuscitation, the patient
and for implementing prophylactic measures. There is inter- will need anticoagulation, initially parenteral anticoagu-
national agreement on risk and therapeutic options. Methods lation, followed by long-term oral anticoagulation (refer to
of prevention are guided by the risk score and include the national guidance, e.g. NICE; see Further reading). A vena
use of compression stockings, calf pumps and pharmacological cava filter may be needed if anticoagulation is not possible
agents, such as low molecular weight heparin. or if the patient has an embolism while anticoagulated (see
The symptoms and signs of DVT include calf pain, swelling, Further reading).
warmth, redness and engorged veins. However, most will show
no physical signs. On palpation the muscle may be tender and
there may be a positive Homans’ sign (calf pain on dorsiflexion
Fever
of the foot), but this test is neither sensitive nor specific. About 40% of patients develop pyrexia after major surgery;
Duplex Doppler ultrasound and venography can be used however, in most cases no cause is found. The inflammatory
to assess flow and the presence of a thrombosis. Other inves- response to surgical trauma may manifest itself as fever, and
tigations include D-dimer. If a significant DVT is found (one so pyrexia does not necessarily imply sepsis. However, in all
that extends above the knee), treatment with parenteral patients with a pyrexia, a focus of infection should be sought.
John Homans, 1877–1954, Professor of Clinical Surgery, Harvard Medical School, Boston, MA, USA.
03_20-B&L27_Pt3_Ch20.indd 296 25/10/2017 08:08

Surgery-specific complications 297
The causes of a raised temperature postoperatively include: Pressure sores

● atelectasis of the lung; Patients undergoing surgery for a prolonged period of time are
● superficial and deep wound infection; vulnerable to the development of a pressure sore or to wors-
● chest infection, urinary tract infection and thrombophlebitis; ening of a pre-existing sore. Careful positioning and padding
● wound infection, anastomotic leakage, intracavitary col- of the patient is standard practice intraoperatively to reduce
lections and abscesses. risk. Pressure sores occur as a result of friction or persisting
The possible causes of pyrexia of a non-infective origin pressure on soft tissues. They particularly affect the pressure
include: points of a recumbent patient, including the sacrum, greater
trochanter and heels. Risk factors are poor nutritional status,
● DVT; dehydration and lack of mobility and nerve block anaesthesia
● transfusion reactions; technique. Early mobilisation prevents pressure sores. High-
● wound haematomas; risk patients may be nursed on an air mattress, which auto-
● atelectasis; matically relieves the pressure areas.
● drug reactions.
Patients with a persistent pyrexia need a thorough review.
Relevant investigations include full blood count, urine cul- Summary box 20.8
ture, sputum microscopy and blood cultures.
Preventing pressure sores
Summary box 20.6 ●● Recognise patients at risk
●● Address nutritional status
Fever ●● Keep patients mobile or regularly turned if bed-bound
●● A very common problem postoperatively
●● Consider infection in the lung, urine and wound
SURGERY-SPECIFIC
Wound dehiscence COMPLICATIONS
Wound dehiscence is disruption of any or all of the layers in
a wound. Dehiscence may occur in up to 3% of abdominal Abdominal surgery
wounds and is very distressing to the patient. The abdomen should be examined daily for excessive disten-
Wound dehiscence most commonly occurs from the fifth sion, tenderness or drainage from wounds or drain sites. In
to the eighth postoperative day when the strength of the certain operations, such as those for intestinal obstruction,
wound is at its weakest. It may herald an underlying abscess oesophageal and gastric procedures, a nasogastric tube may
and usually presents with a serosanguinous discharge. The be required. It is of particular value in those patients suffering
patient may have felt a popping sensation during straining from ileus or a marked level of altered consciousness, who are
or coughing. Most patients will need to return to the operat- therefore liable to aspirate.
ing theatre for resuturing. In some patients it may be appro-
priate to leave the wound open and treat with dressings or Paralytic ileus
vacuum-assisted closure (VAC) pumps. Paralytic ileus may present with nausea, vomiting, loss of
appetite, bowel distension and absence of flatus or bowel
Summary box 20.7 movements. Following laparotomy, gastrointestinal motility
temporarily decreases. Treatment is usually supportive, with
Risk factors in wound dehiscence maintenance of adequate hydration and electrolyte levels.
General However, intestinal complications may present as prolonged
●● Malnourishment ileus and so should be actively sought and treated.
●● Diabetes Return of function of the intestine occurs in the follow-
●● Obesity
ing order: small bowel, large bowel and then stomach. This
●● Renal failure
pattern allows the passage of faeces despite continuing lack
●● Jaundice
of stomach emptying and, therefore, vomiting may continue
●● Sepsis
even when the lower bowel has already started functioning
●● Cancer
normally.
●● Treatment with steroids
Local Localised infection

●● Inadequate or poor closure of wound An abscess may present with persistent abdominal pain, focal
●● Poor local wound healing, e.g. because of infection, tenderness and a spiking fever. The patient may have a pro-
haematoma or seroma longed ileus. If the abscess is deep-seated these symptoms may
●● Increased intra-abdominal pressure, e.g. in postoperative be absent. The patient will have a neutrophilic leucocytosis
patients suffering from chronic obstructive airway disease,
during excessive coughing
and may have positive blood cultures. An ultrasound or CT
scan of the abdomen should identify any suspicious collection
03_20-B&L27_Pt3_Ch20.indd 297 25/10/2017 08:08

and will identify a subphrenic abscess, which can otherwise damage to the recurrent laryngeal nerve, which can produce
be difficult to find. voice change.
Summary box 20.9 Thoracic surgery

The main complications after abdominal surgery Careful fluid management is important in patients under-
going a lobectomy or pneumonectomy as they are susceptible
●● Paralytic ileus
to fluid overload in the first 24–48 hours postoperatively.
●● Bleeding or abscess
Chest drains require regular review. If the fluid in a chest
●● Anastomotic leakage
drain swings then the drain has been correctly inserted into
the pleural cavity. If the chest drain continues to bubble then
a bronchopleural fistula probably exists. A haemothorax or
Orthopaedic surgery pleural effusion will reveal itself as a prolonged loss of blood
or fluid, respectively, into the drain. Cardiac patients require
Neurovascular supply to the extremity continuous ECG monitoring postoperatively.
Patients who have undergone extremity surgery, for example
open reduction and internal fixation of a fracture, require reg-
ular neurovascular observations, both in recovery and on the Neurosurgery
ward (this will usually follow a local or national guideline). Postoperatively the patient should be kept under close obser-
Moreover, if a tourniquet has been used, the restoration of vation. A rise in intracranial pressure may be signalled by a
the distal neurovascular supply should be established. Careful deterioration in the state of consciousness, as well as by neu-
documentation of findings before and after surgery will allow rological signs. Some patients may have an intracranial mon-
comparison. Concern about the neurovascular status requires itoring device to allow for more sensitive monitoring.
urgent and experienced surgical review and further manage-
ment. Circumferential casts can be split and dressings cut
down to skin. Vascular surgery
The patency of grafts and anastomoses, for example femo-
Compartment syndrome ropopliteal bypasses and abdominal aneurysmal, needs to be
Raised pressure in an osseofascial compartment can prevent checked by regular clinical assessment of the limbs and by
adequate tissue perfusion and present after surgery. Patients Doppler ultrasound in the postoperative phase.
with compartment syndrome complain of pain out of propor-
tion to that expected, pain that is increasing and pain on pas-
sive stretching of the muscles in the affected compartment. Plastic surgery
Other symptoms that relate to pressure on nerves (paraly- The viability of flaps is crucial and the perfusion needs to be
sis, paraesthesia) and blood vessels (pallor and pulselesness) monitored regularly. The blood supply may be compromised
occur late. When suspected, prompt senior input is required. by position, dressings or collection of fluids or blood beneath
In terms of initial management, circumferential casts can be the flap.
split, dressings cut down to skin and the limb elevated. Fur-
ther management will require experienced judgement and
may include compartment pressure monitoring and/or fasci- Urology
otomies. Compartment syndrome is considered more exten- Catheter patency must be checked regularly following uro-
sively in Chapter 28. logical surgery. In patients who have undergone transure-
thral resection of the prostate (TURP), continuous bladder
Summary box 20.10 irrigation may be used. More generalised complications can
occur, for example transurethral resection syndrome, and are
Compartment syndrome symptoms and signs discussed further in the appropriate section.
●● Pain out of proportion to that expected
Pain that is increasing
GENERAL POSTOPERATIVE
●●
●● Pain on passive stretching of the muscles in the affected
●●
compartment
Paralysis, paraesthesia, pallor and pulselessness generally
PROBLEMS AND MANAGEMENT
occur late When considering postoperative problems, the importance
of pain control and fluid management should be appreciated,
and the reader is directed to Chapters 18 and 19.
Neck surgery
Patients having neck surgery, e.g. thyroid surgery, must be
Nausea and vomiting
observed for accumulation of blood in the wound, which Postoperative nausea and vomiting (PONV) are unpleasant
may cause rapid asphyxia. Another potential complication is for patients, can delay recovery and prolong length of stay.
03_20-B&L27_Pt3_Ch20.indd 298 25/10/2017 08:08

Enhanced recovery 299
They can lead to more serious complications including aspi- Drains

ration pneumonia, precipitation of bleeding and dehiscence
of wounds by dislodging the clots and bursting suture lines. In Drains are used to prevent accumulation of blood, serosan-
neurosurgical patients PONV may precipitate raised intracra- guinous or purulent fluid or to allow the early diagnosis of a
nial pressure with disastrous effects. leaking surgical anastomosis. In clean surgery, such as joint
Risk factors for PONV include female gender, non- replacement, blood collected in drains can be transfused back
smoking, and a history of PONV, motion sickness or migraine. into the patient provided that an adequate volume is col-
Use of volatile anaesthetic agents, opioids and nitrous oxide lected rapidly and that a specifically-designed drain and filter
add to the risk. Duration and type of surgery also affect the system is used.
incidence of PONV. The use of surgical drains has decreased in recent years
The risk of PONV can be estimated by using validated risk as the evidence for their benefits has been questioned. Com-
scores such as the Apfel (Table 20.4) or Koivuranta scores plications of drains include trauma to surrounding tissues
and appropriate preoperative strategies applied to high-risk and infection. The quantity and character of drain fluid can
individuals. be used to identify an abdominal complication such as fluid
Treatment of PONV includes adequate treatment of pain, leakage (e.g. bile or pancreatic fluid) or bleeding.
anxiety, hypotension and dehydration. Antiemetics can be Drains should be removed as soon as possible and cer-
administered both prophylactically and for treatment. A mul- tainly once the drainage has stopped or become less than
timodal pharmacological approach, using drugs that work at 25 mL/day.
different sites, such as HT3 receptor antagonists (e.g. ondan-
setron), steroids (e.g. dexamethasone), phenothiazines (e.g. Wound care
prochlorperazine) and antihistamines (e.g. cyclizine), is the
most effective. Within hours of the wound being surgically closed, the dead
space fills up with an inflammatory exudate. Within 48 hours
of closure a layer of epidermal cells from the wound edge
TABLE 20.4 Apfel score to predict postoperative nausea
and vomiting (PONV). bridges the gap. Consequently, sterile dressings applied in
theatre should not be removed before this time.
Characteristics Points
Wounds should be inspected only if there is a con-
Female sex 1 cern about their condition or the dressing needs changing.
History of motion sickness or PONV 1 Inspection of the wound should be performed under sterile
Non-smoker 1 conditions. If the wound looks inflamed, a wound swab can
Postoperative opioid treatment is planned 1 be taken and sent for microbiological examination, but this
can be unreliable. Infected wounds and haematomata may
Total: ____
need treatment with antibiotics or even wound washout. If
a surgical procedure is performed it gives an opportunity to
Score Probability of PONV (%) collect samples for bacteriology (before any antibiotics, if the
0 10 patient’s general condition allows), to excise dead tissue and
to control any bleeding. Depending on location, the wound
1 21
may require packing if it is contaminated or if non-viable tis-
2 39
sue remains. The dressing should then be changed regularly
3 61 until the wound is clean.
4 78 Skin sutures or clips are usually removed between 6 and
10 days after surgery. The period can be shorter in wounds on
the face or neck, and are left longer if the incision has been
closed under tension. Wound healing is delayed in patients
who are malnourished, or have vitamin A and C deficiency.
Hypothermia and shivering Steroids also inhibit the adequate healing of wounds as they
Anaesthesia induces loss of thermoregulatory control. Expo- inhibit protein synthesis and fibroblast proliferation. Poor-
sure of skin and organs to a cold operating environment, anti- ly-controlled diabetes delays wound healing and increases the
septic skin preparation (that cools by evaporation), and the risk of infection at the surgical site.
infusion of cold intravenous fluids all lead to hypothermia.
This in turn can lead to shivering, with imbalance of oxy-
gen supply and demand (risking cardiac morbidity), a hypo- ENHANCED RECOVERY
coagulable state and immune function impairment, with the Enhanced recovery is an approach to the perioperative care
possibility of wound infection, dehiscence and anastomotic of patients undergoing surgery. It is designed to speed clini-
breakdown. It is now expected that temperature is moni- cal recovery of the patient and reduce both the cost and the
tored intraoperatively and the incidence of postoperative length of stay of the patient in the hospital. It is achieved by
hypothermia has decreased significantly as a consequence. optimising the health of the patient before surgery through
Active warming devices should be used to treat hypothermia prehabilitation and then delivering evidence-based best care
as appropriate. in the perioperative period.
03_20-B&L27_Pt3_Ch20.indd 299 25/10/2017 08:08

Postoperative strategies advocated by enhanced recovery Follow-up in clinic

protocols include:
Patients should only be reviewed in clinic when a key deci-
● Early planned physiotherapy and mobilisation. sion on management needs to be made. The findings and the
● Early oral hydration and nourishment. care plan agreed with the patient at the clinic appointment
● Opioid-sparing analgesia regimens that include the use of should be included in a letter to the patient’s GP, as well as
regional blocks, regular non-steroidal anti-inflammatory in a clear entry in the notes or electronic patient record. This
drugs and paracetamol. should include advice on how to recognise the onset of com-
● Discharge planning is started before the patient is admitted plications and what to do if there is concern. Patients should
to hospital and involves support from stoma care nurses, be discharged from clinic as soon as their GP or they them-
physiotherapists and other community care workers. selves, can manage their care.
Early mobilisation is encouraged to reduce the risks of DVT,
urinary retention, atelectasis, pressure sores and faecal impac-
tion. Telephone follow-up is carried out to make sure that the
FURTHER READING
American Society of Anesthesiologists. Practice guidelines for postanes-
patient is recovering well.
thetic care. Anesthesiology 2013; 118(2): 291–307.
Devereaux PJ, Sessier DI. Cardiac complications in patients undergoing
DISCHARGE OF PATIENTS major non-cardiac surgery. N Engl J Med 2015; 373: 2258–69.
Devereaux PJ, Sessler DI, Leslie K, et al.; POISE-2 Investigators. Cloni-
Patients discharged home need a ‘discharge letter’ detailing dine in patients undergoing noncardiac surgery. N Engl J Med 2014;
the postoperative plan. The discharge letter should include 370(16): 1504–13.
details of the final diagnosis, the treatment and any com- Gan TJ, Meyer TA, Apfel CC et al. Society for ambulatory anesthesia
guidelines for the management of postoperative nausea and vomit-
plications that may have occurred. There should be advice
ing. Anesth Analg 2007; 105(6): 1615–28.
for referring the patient back to hospital and indications for Gupta PK, Gupta H, Sundaram A et al. Development and validation of a
readmission if specific problems do occur. The general practi- risk calculator for prediction of cardiac risk after surgery. Circulation
tioner (GP) should be informed of the subsequent care plan, 2011; 124: 381.
including follow-up, physiotherapy and other support needed. http://riskcalculator.facs.org/RiskCalculator/
Pathology results should be included if available, and the basis http://www.aagbi.org/publications/guidelines/immediate-post-anaes
of these in the subsequent care plan should be described along thesia-recovery-2013
Intensive care society website: http://www.ics.ac.uk/intensive_care_
with the prognosis if appropriate. professional/standards_and_guidelines/levels_of_critical_care_for_
adult_patients
National Institute for Health and Care Excellence. Venous thrombo-
Summary box 20.11 embolic diseases: diagnosis, management and thrombophilia testing.
Clinical guideline (CG144), June 2012, updated November 2015.
Discharge letter National Institute for Health and Care Excellence. Acute kidney
Diagnosis injury: prevention, detection and management. Clinical guideline
(CG169), August 2013.
Treatment
Laboratory results
Complications
Discharge plan
Support needed
Follow-up
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ve Bailey & Love Bailey & Love Bailey & Love
21
ve Bailey & Love Bailey & Love Bailey & Love Chapter
Day case surgery
Learning objectives
To understand: • The spectrum of surgical procedures suitable for day
• The concept of the day surgery pathway surgery
• The importance of patient selection and preoperative • Postoperative management and discharge
assessment arrangements
• Basic principles of anaesthesia for day surgery
DAY SURGERY Summary box 21.1

The delivery of a surgical procedure on a day case basis offers
advantages in providing significant benefits for both patient Definition of terms used in ambulatory surgery
and healthcare providers. The removal of an overnight stay ●● Outpatient surgery: not admitted to a ward facility
causes less disruption to the patient’s domestic and social ●● Procedure room surgery: surgery not requiring full sterile
theatre facilities
situation, and provides significant financial savings to the
●● Day or same-day surgery: admitted and discharged within the
hospital. In resource-rich countries, day surgery is now an 12-hour day
integral component of healthcare delivery, while in resource- ●● Overnight stay: 23-hour admission with early morning
poor countries, day surgery is increasing in popularity due to discharge
patient preference and healthcare reorganisation. ●● Short-stay surgery: admission of up to 72 hours
Day surgery is defined as the admission and discharge of a
patient for a specific procedure within the 12-hour working ● the procedure is scheduled early on the operating list to
day. Where a patient requires an overnight admission, then allow safe recovery and discharge; and
the term ‘23 hour stay’ should be used. ● the home environment can support a postoperative ambu-
Day surgery is a patient pathway, not a surgical procedure, latory patient.
and extends from first patient contact to final discharge (Fig-
ure 21.1). Success in day surgery requires each component of
the pathway to be safe and efficient and to be performed in
sequence. Unplanned overnight admissions are minimised by
MODELS OF CARE
ensuring that: Office-based care
● the patient is informed and fit for the procedure; This model, common in North America and Europe, where
● the procedure itself is achievable as a day case; diagnostics and ambulatory interventions are performed in
Diagnostics
Successful
+
discharge
optimisation
Schedule
Referring Specialist Preoperative
& Surgery Recovery
doctor consultation assessment
admission
Unplanned
Method to return patients overnight
unsuitable for surgical or medical reasons admission
Figure 21.1 Elective day surgery pathway.
James H Nicoll, 1864–1921, paediatric surgeon, Glasgow, Scotland, specialised in pyloric stenosis and spina bifida and pioneered the ‘Glasgow dispensary’, where
his work earned him the title of ‘father of Day Surgery’. He was made Legion of Honour France.
03_21-B&L27_Pt3_Ch21.indd 301 25/10/2017 08:09

302 CHAPTER 21 Day case surgery
consultation premises, allows patients ready access to ‘high SELECTION CRITERIA

street’ care. The downside is that the practice is usually lim-
ited to procedures under local anaesthesia, with or without Medical criteria
conscious sedation. The use of general anaesthesia is limited,
as this requires additional equipment and personnel, and Age
raises safety issues in an isolated facility. There is no upper age limit. The physiological health of the
patient is a superior determinant of day surgery success.
Stand-alone day surgery facilities

Summary box 21.2
Where day case procedures are performed in isolated facili-
ties, either on a remote site, or in the campus of the parent Selection criteria for day surgery
hospital, the workload is free from interference by emergency ●● Medical: use physiological rather than chronological age
admissions. The spectrum of procedures performed is, by ASA status over 2 requires careful review
necessity, limited to those under local or regional anaesthesia Provided that the BMI is under 40, this alone is not a
or minor to intermediate procedures under general anaesthe- contraindication
sia, to avoid unplanned overnight admissions and the require- ●● Social: a responsible adult carer must be available for the first
ment to transfer the patient to the parent hospital, which may 24 hours, for the elderly and patients at risk of covert
be some distance away. bleeding
home conditions need to be suitable
ability to contact hospital in an emergency
Self-contained integrated day ●● Surgical: operations up to 2 hours
surgery facilities recognised day surgery procedures
ability to eat and drink within a reasonable timescale
Though structurally part of a hospital, self-contained units
have their own reception, ward, theatre and recovery areas
and are functionally separate from the main hospital and
potential disruption by emergency admissions. The back-up Comorbidity
facilities of the main hospital are readily available if required, Day surgery units traditionally use the American Society of
so these units can undertake a full spectrum of day surgery Anaesthesiologists (ASA) Classification, which is a crude
procedures. The growing demand for day surgery can lead to evaluation of chronic health (Table 21.1). Stand-alone units
capacity issues and there may be duplication of costly capi- often confine their criteria to ASA 1 and 2 patients, while
tal equipment where procedures are performed on both a day ASA 3 patients are more suitable for hospital-integrated
case and inpatient basis. units. Patients with significant respiratory or cardiovascular
disease should be reviewed by an anaesthetist before being
Integrated day and short-stay accepted for day surgery (see Chapter 17). Many patients who
are fit but hypertensive are incorrectly excluded from day
surgery facilities surgery. There is no evidence to support cancellation when
This type of unit allows complete flexibility in the delivery of blood pressure is below 180/110 mmHg.
day and short-stay surgery, with the ability to embark on more
challenging day surgery procedures or consider day surgery Diabetes
on less fit patients. The availability of overnight beds has its The incidence of diabetes is increasing worldwide. Patients
downside: the preassessment team may convert fewer patients with well-controlled Type 1 and Type 2 diabetes are good can-
from overnight stay to day surgery by adopting the easy option didates for the well-managed day surgery pathway. Control
of keeping the more challenging patient in overnight. More- can be assessed by measuring their HBA1c, with a level of
over, the availability of beds rather than day surgery recovery below 8.5% indicating good control. Diabetes is associated
trolleys, puts these ambulatory beds at risk from emergency with potentially severe comorbidities, such as renal disease,
admissions.
While dedicated day surgery facilities are welcome,
regardless of model, they are not mandatory for the success- TABLE 21.1 The American Society of Anaesthesiologists
ful delivery of the day surgery pathway. Success does require a (ASA) Physical Status Classification (American Society of
dedicated day ward facility, where the staff can concentrate Anaesthesiologists 1963).
on the timely recovery and discharge of the day case patient. ASA 1 A normal healthy patient
In mixed wards of day cases and inpatients, nursing and medi-
ASA 2 A patient with mild systemic disease
cal staff naturally prioritise the care of the less fit patient, and
it may be easier to keep the day case patient overnight, rather ASA 3 A patient with severe systemic disease
than ensuring an optimum discharge process. ASA 4 A patient with severe systemic disease that is a
constant threat to life
ASA 5 A moribund patient who is not expected to
survive without the operation
03_21-B&L27_Pt3_Ch21.indd 302 25/10/2017 08:09

Selection criteria 303
autonomic neuropathy and cardiovascular disease, and so Epilepsy

these patients must be assessed carefully preoperatively and A diagnosis of epilepsy does not contraindicate day surgery.
managed by an experienced team. It is important to have pro- Patients who have well-controlled epilepsy should be man-
tocols for the care of diabetic patients that have been agreed aged as normal patients, though it is important to ensure that
with the local diabetic team and to involve them in the care their regular medication is not omitted in the preoperative
of more complex patients. Success depends on ensuring these period. Patients who are on medication but remain poorly
patients return to normal eating and drinking and managing controlled need careful review and discussion with their med-
their own diabetes as quickly as possible in the postoperative ical and anaesthetic teams. However, if they have suitable
period. home support and the proposed surgery does not put them at
Traditional care, with placing the patient first on the list risk, then they too are suitable for day surgery.
and providing them with instructions on management of their
medication preoperatively, works well. Those on morning Obesity
lists can simply miss their morning dose of oral hypoglycae- The body mass index (BMI) is calculated as weight in kilo-
mic medication or insulin, though they must be instructed to grams divided by the square of height in metres (kg/m2) and
bring their medications with them and to manage any hypo- obesity is defined as a BMI >30 (Figure 21.2). Traditional
glycaemia as they would normally. Those on afternoon lists guidelines are conservative about obesity due to fears of
and those patients who are on more complex therapy, such as intra- and postoperative complications. Although there is an
continuous subcutaneous infusions, can still be managed with increased incidence of non-serious respiratory complications
input from the anaesthetic or diabetic team. intraoperatively and in the immediate postoperative recovery
Weight in kilograms
40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140
1.92 11 12 14 15 16 18 19 20 22 23 24 26 27 28 30 31 33 34 35 37 38 1.92 21 BMI 20–25
1.90 11 12 14 15 17 18 19 21 22 24 25 26 28 29 30 32 33 35 36 37 39 1.90 25 BMI 25–30
1.88 11 13 14 16 17 18 20 21 23 24 25 27 28 30 31 33 34 35 37 38 40 1.88 32 BMI 30–35
1.86 12 13 14 16 17 19 20 22 23 25 26 27 29 30 32 33 35 36 38 39 40 1.86 37 BMI 35–40
1.84 12 13 15 16 18 19 21 22 24 25 27 28 30 31 32 34 35 37 38 40 41 1.84 41 BMI >40
1.82 12 14 15 17 18 20 21 23 24 26 27 29 30 32 33 35 36 38 39 41 42 1.82
1.80 12 14 15 17 19 20 22 23 25 26 28 29 31 32 34 35 37 39 40 42 43 1.80
1.78 13 14 16 17 19 21 22 24 25 27 28 30 32 33 35 36 38 39 41 43 44 1.78
1.76 13 15 16 18 19 21 23 24 26 27 29 31 32 34 36 37 39 40 42 44 45 1.76
1.74 13 15 17 18 20 21 23 25 26 28 30 31 33 35 36 38 40 41 43 45 46 1.74
1.72 14 15 17 19 20 22 24 25 27 29 30 32 34 35 37 39 41 42 44 46 47 1.72
1.70 14 16 17 19 21 22 24 26 28 29 31 33 35 36 38 40 42 43 45 47 48 1.70
1.68 14 16 18 19 21 23 25 27 28 30 32 34 35 37 39 41 43 44 46 48 50 1.68
1.66 15 16 18 20 22 24 25 27 29 31 33 34 36 38 40 42 44 45 47 49 51 1.66
1.64 15 17 19 20 22 24 26 28 30 32 33 35 37 39 41 43 45 46 48 50 52 1.64
1.62 15 17 19 21 23 25 27 29 30 32 34 36 38 40 42 44 46 48 50 51 53 1.62
1.60 16 18 20 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 1.60
1.58 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 1.58
1.56 16 18 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 58 1.56
Height in metres
Height in metres
1.54 17 19 21 23 25 27 30 32 34 36 38 40 42 44 46 48 51 53 55 57 59 1.54
1.52 17 19 22 24 26 28 30 32 35 37 39 41 43 45 48 50 52 54 56 58 61 1.52
1.50 18 20 22 24 27 29 31 33 36 38 40 42 44 47 49 51 53 56 58 60 62 1.50
1.48 18 21 23 25 27 30 32 34 37 39 41 43 46 48 50 53 55 57 59 62 64 1.48
40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140
Weight in kilograms
Figure 21.2 Body mass index calculator.
Adolphe Quetelet, 1796–1874, Belgian mathematician, astronomer and statistician, the pioneer in establishing the criteria of obesity that became known as the
Quetelet Index. In 1972 Ancel Keys (1904–2004), an American scientist from the University of Minnesota and an expert on human nutrition, public health and
epidemiology, named it the body mass index.
03_21-B&L27_Pt3_Ch21.indd 303 25/10/2017 08:09

period, the course of these patients is otherwise uneventful.

They should however, be managed by experienced medical Summary box 21.3
and nursing staff. Hypertension, congestive cardiac failure and Preoperative assessment
sleep apnoea are all more common in patients with morbid ●● On all day surgery patients
obesity, but in selected and optimised patients, a BMI up to 40 ●● Early in the patient pathway
for surface procedures and 38 for laparoscopic procedures are ●● By a specialist nursing team with anaesthetic support
acceptable and achievable in advanced units. Patients estab-
lished on nasal positive airway pressure for obstructive sleep
apnoea can be managed successfully.
Anticoagulants
PERIOPERATIVE MANAGEMENT
Patients are generally on oral anticoagulants due to atrial Scheduling
fibrillation, previous thromboembolism or because they have With dedicated day surgery lists, major procedures should be
a metal heart valve. It is therefore important to review these scheduled early on morning lists to allow maximum recovery
patients carefully before deciding to discontinue their antico- time. When the list is in the afternoon, the allocation of local
agulant for their operation. When it is felt that surgery will or regional anaesthetic cases later in the day helps reduce
require its discontinuation, this should be discussed with their unplanned overnight admissions. When mixed lists of day
cardiologist and the risks involved explained to the patient. and inpatient cases are planned, then day cases are scheduled
first. The mixing of day and complex inpatient cases is not
Social criteria advisable. The complex case may be inappropriately delayed
Safe and comfortable discharge home requires the patient to if the day case is scheduled first and, conversely, if the day
be accompanied by a responsible and physically able adult. case patient is scheduled later, there is a risk of cancellation
A journey time to home of 1 hour or less is advocated, but or unplanned overnight admission for the day case.
the comfort of the journey rather than the time involved is
more relevant. Home circumstances require appropriate toi- Anaesthesia and analgesia
let facilities and the means of contacting the hospital should
complications occur. Successful day surgery anaesthesia requires a multimodal
approach to analgesia, while ensuring patients are given
optimal dosages of anaesthetic agent (see Chapter 18). The
Surgical criteria agents used matter less than the skill of the person providing
Patients undergoing procedures up to 2 hours in duration anaesthesia.
can safely undergo day surgery with modern anaesthetic Multimodal analgesia starts in the preoperative period and
techniques. The degree of surgical trauma is an important unless contraindicated, patients should receive full oral doses
determinant of success, with entry to abdominal and thoracic of paracetamol and a non-steroidal anti-inflammatory drug,
cavities confined to minimal access techniques. Whatever the such as ibuprofen. Intraoperative anaesthesia can be main-
procedure, the main requirement is that there is suitable contained by any of the traditional inhalational agents. Total
trol of pain and the ability to drink and eat in a reasonable intravenous anaesthesia (TIVA) techniques using propofol
timescale. With day surgery now applicable to more major are also popular and offer the advantage of reduced postop-
and prolonged procedures, patients should undergo a venous erative nausea and vomiting (PONV). The use of intraopera-
thromboembolism risk assessment and have prophylaxis tive analgesia will depend on the procedure being performed.
provided if required. When available, the anaesthetist should use short-acting
opioids (fentanyl, alfentanil). Careful use of these agents
can minimise the incidence of PONV. Where the choice
PREOPERATIVE ASSESSMENT is limited to morphine, this should be used in small doses
The evaluation and optimisation of a patient’s fitness for sur- (<0.1 mg/kg) to minimise sedation and PONV. Wherever
gery is known as preoperative assessment (see Chapter 17) possible, a long-acting local anaesthetic agent such as bupiva-
and is best performed by a specialist nursing team with support caine should be injected into wounds by the surgeon.
from an anaesthetist with an interest in day surgery. All elec- Pain levels should be routinely assessed in the postopera-
tive surgical patients should be initially regarded as suitable tive recovery area. Further doses of paracetamol, fentanyl or
for day surgery until proved otherwise. The assessment should low doses of morphine can be used to ensure that patients are
be performed early in the pathway to allow time to optimise comfortable prior to return to the ward.
health problems before surgery The consultation consists of
a basic health screen to include the measurement of BMI,
blood pressure and an assessment of past medical history with
Postoperative complications
current medication recorded. Appropriate investigations are The range of postoperative complications is no different
performed to ensure the patient is fit for surgery. The patient from inpatient surgery. However, the fact that the patient is
and/or their carer should be given verbal and written informa- discharged home within a few hours of surgery requires proac-
tion regarding admission, operation and discharge. tive monitoring in the immediate postoperative period.
03_21-B&L27_Pt3_Ch21.indd 304 25/10/2017 08:09

Elective day surgery 305
Summary box 21.4 Patient with PONV
Optimal analgesia and anaesthesia

Give intravenous fluids to hydrate the patient
●● Multimodal analgesia with paracetamol and NSAIDs (if not (10–15 mL/kg over 1 hour) and intravenous antiemetic,
contraindicated) should be given preoperatively e.g. cyclizine, prochlorperazine
●● Use long-acting local anaesthetic infiltration of the surgical
wound
●● Careful dosing of inhalational or intravenous agents should be Review after 1 hour
used to maintain anaesthesia
●● Avoid long-acting opiates such as morphine, to reduce the
incidence of sedation and PONV If still a problem then give a second antiemetic of
different type, e.g. ondansetron, dexamethasone
Reactionary haemorrhage is uncommon but requires care- Patient is hydrated and can be reassured that
ful consideration following tonsillectomy and laparoscopic no further active management is possible
procedures. Reactionary haemorrhage following tonsillec- Offer choice if admission or to be discharged home
tomy occurs within the first 6 hours and these patients should
Figure 21.3 Active management of postoperative nausea and
be monitored for this period. The danger in laparoscopic sur- vomiting (PONV).
gery is covert haemorrhage, especially in young fit patients
who can lose over 15% of their blood volume before showing
any cardiovascular signs of hypovolaemia (tachycardia and Summary box 21.5
hypotension). These patients require a high index of suspi-
cion as the first signs can often be as subtle as slow recov- Surgical haemorrhage
ery and mobilisation or uncontrolled abdominal pain. When ●● Reactionary: occurs 4–6 hours after surgery and is caused
problems do occur, there should be clear escalation policies to by ligature slippage, clot displacement or cessation of
ensure the patient is reviewed by the surgical team as soon as vasospasm after mobilisation or coughing
possible. Nausea and vomiting is not uncommon and should ●● Secondary: occurs more than 24 hours after surgery and is
be managed actively to maximise successful discharge (Figure due to infection eroding a vessel
21.3).
Good surgical technique requires minimal tissue traction
ELECTIVE DAY SURGERY or tension and good haemostasis. In day surgery these attri-
For some surgical specialties, over 90% of their elective work- butes are even more important. The number and variety of
load can be achieved in day surgery. As a result, teaching and surgical procedures performed on a day case basis is increasing
training now routinely occurs on day surgery lists but requires year on year. Volume procedures in general surgery where the
structure and close supervision. As the spectrum of proce- British Association of Day Surgery considers at least 40% of
dures has increased and become more challenging, many sur- procedures can be performed on a day case basis, are shown
geons have increased their involvement in day surgery. This is in Table 21.2.
important because safe and efficient day surgery demands the
competence and skill of an experienced surgeon. Some sur- TABLE 21.2 Volume procedures where 40% or more
geons have concerns regarding patient safety after discharge. should be performed on a day case basis.
The risk of postoperative haemorrhage occurring once the
Abdominal Excisional/treatment of anal lesions,
patient has returned home is often stated as a major reason to
haemorrhoidectomy, primary and recurrent
keep the patient in hospital overnight, especially where the inguinal/femoral herniae, laparoscopic
abdominal or thoracic cavities have been entered. Reaction- cholecystectomy, laparoscopic fundoplication,
ary haemorrhage commonly occurs in the first 4–6 hours after pilonidal sinus surgery
surgery, but the patient is unlikely to have been discharged Breast Excision/biopsy breast lesion, sentinel node
home within this time period. It may be caused by slippage of excision
a ligature or displacement of blood clot, precipitated by a rise Genitourinary Laser prostatectomy, orchidectomy,
in blood pressure, coughing or increased mobility. Postopera- circumcision, excision of hydrocoele/varicocoele/
tive monitoring of vital signs should alert the recovery team epididymis
to any underlying bleed. Secondary haemorrhage is defined Orthopaedic Dupuytren’s fasciectomy, carpal tunnel release,
as occurring at least 24 hours after surgery but usually pres- therapeutic arthroscopy of knee or shoulder,
ents several days later, as it is due to postoperative infection. bunion operations, removal of metalwork
Thus, even if the patient had stayed overnight, these post- Vascular Varicose vein procedures, thoracoscopic
operative bleeds are still likely to occur once the patient has sympathectomy
returned home. British Association of Day Surgery 2012.
03_21-B&L27_Pt3_Ch21.indd 305 25/10/2017 08:09

Summary box 21.6 TABLE 21.3 Common procedures suitable for the
emergency day surgery pathway.
Successful day surgery requirements Arthroscopy
●● Minimal access techniques
Biopsy (temporal, lymph node)
●● Good haemostasis
Evacuation retained products of conception
●● Avoidance of unnecessary tissue handling or tension
Irreducible or strangulated hernia (inguinal, femoral, paraumbilical)
Incision and drainage of abscess (axillary, groin, neck, perianal,
pilonidal)
EMERGENCY DAY SURGERY K-wiring (finger or wrist)
Many emergency surgical procedures are minor and non- Laparoscopic appendicectomy
life threatening, and traditionally have been considered low Laparoscopic ovarian cystectomy
priority for surgical intervention. The prioritisation of more
Reduction and internal fixation
urgent cases to restricted emergency theatre slots may result
in extensive delays for minor cases, with unnecessary bed stays Tendon repair
and preoperative starvation. Many of these cases, such as inci-
sion and drainage of abscesses, can be safely discharged home
after their initial evaluation in the emergency department. patient to operation. This allows the ambulatory patient to be
They are provided with adequate analgesia and scheduled to discharged on the day of surgery, provided discharge protocols
return to the hospital at an appointed time the following day, are in place. This balance between clinical and managerial
suitably starved for their operation. This allows same-day dis- priority can be difficult to achieve without surgical experi-
charge for minor emergency procedures. ence, but forethought can permit a positive outcome for the
If performed early in the day, the surgery rather than the quality of emergency patient care and the managerial require-
pathway, may be defined as ‘day case’. Some patients may, ment to shorten duration of stay.
by chance, achieve a true day case pathway with admission, When designing an emergency day surgery pathway, tradi-
operation and discharge in the same day, provided they are tional day surgery selection criteria are ignored, with clinical
admitted early in the day, there is no diagnostic delay and a judgement used to determine whether patients are appropri-
theatre slot is available. Others may only achieve day case ate for day surgery. The only absolute contraindications are
surgery, but not a day case pathway, if there has been diagnos- systemic sepsis, unstable diabetes, major comorbidities and if
tic or clinical delay on admission (Figure 21.4). Common parenteral, rather than oral, analgesia is required.
procedures suitable for the emergency day surgery pathways
are shown in Table 21.3.
The success of an emergency day surgery pathway is depen- DISCHARGE
dent on the identification of unallocated theatre slots. These The assessment of when a patient is fit for discharge is best
may be planned where there is reasonable predictability of performed by trained day surgery nurses using strict discharge
emergency cases or may arise on elective lists, either day case criteria (Table 21.4). While postoperative review by the sur-
or inpatient, due to patient cancellations. Emergency facili- gical team is encouraged, the discharge should not be delayed
ties may also be underutilised when there are delays in getting by failure of their timely attendance. A suitable supply of
the more seriously ill patient to surgery. There is therefore an analgesics for the management of pain should be provided.
opportunity, providing staff are available, to utilise the empty Paracetamol, NSAIDs and codeine form the basis of the drugs
theatre for a minor case before bringing the optimised sick available in many countries.
A A
Home and planned
Same day
readmission
Emergency B B
admission Operation Discharge
Clinical or
Same day
diagnostic delay
C C
Figure 21.4 Emergency day surgery pathways. A, Planned preoperative discharge home with imminent return for day surgery. B, ‘True’
emergency day surgery with the entire pathway of admission, surgery and discharge on the same day. C, Preoperative delay, but surgery and
discharge on a day case basis.
03_21-B&L27_Pt3_Ch21.indd 306 25/10/2017 08:09

Further reading 307
TABLE 21.4 Discharge criteria. FURTHER READING

Vital signs stable for at least 1 hour McWhinnie D, Jackson I, Smith I, Skues M. Patient safety in the ambula-
tory pathway. British Association of Day Surgery Handbook Series.
Correct orientation as to time, place and person London: BADS, 2013.
Adequate pain control with supply of oral analgesia McWhinnie D, Skues M, Thompson D, Richards S, Connolly V. Ambu-
Understands how to use oral analgesia supplied latory emergency care. British Association of Day Surgery Handbook
Series. London: BADS, 2016.
Ability to dress and walk where appropriate Smith I, McWhinnie D, Jackson I. Day case surgery. Oxford Handbook
Minimal nausea, vomiting or dizziness Series. Oxford: Oxford Medical Publications, 2012.
Has taken oral fluids
Minimal bleeding or wound drainage
Has passed urine (if appropriate)
Has a responsible adult to take them home
Written and verbal instructions given about postoperative care
Knows when to come back for follow-up (if appropriate)
Emergency contact number supplied
03_21-B&L27_Pt3_Ch21.indd 307 25/10/2017 08:09

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Bailey & Love Bailey & Love Bailey & Love

Bailey & Love Bailey & Love Bailey & Love

03_17A-B&L27_Pt3.indd 253 25/10/2017 08:03

Preoperative care including the high-risk

INTRODUCTION Summary box 17.1

03_17B-B&L27_Pt5_Ch17.indd 254 25/10/2017 08:05

Genitourinary tract Examination

03_17B-B&L27_Pt5_Ch17.indd 255 25/10/2017 08:05

03_17B-B&L27_Pt5_Ch17.indd 256 25/10/2017 08:05

Summary box 17.5 Hypertension, ischaemic heart

03_17B-B&L27_Pt5_Ch17.indd 257 25/10/2017 08:05

If surgery cannot be postponed and the risk of significant

Implanted pacemakers and cardiac Figure 17.3 Atrial flutter.

03_17B-B&L27_Pt5_Ch17.indd 258 25/10/2017 08:05

03_17B-B&L27_Pt5_Ch17.indd 259 25/10/2017 08:05

03_17B-B&L27_Pt5_Ch17.indd 260 25/10/2017 08:05

platelet agents or anticoagulants. If it is felt that the neurolog-

03_17B-B&L27_Pt5_Ch17.indd 261 25/10/2017 08:05

anxiety result in increased demands for oxygen delivery to the

Factors contributing to risk

Consent. May not be possible in life-saving emergencies

Organisational efforts. For example, local/national algorithms

for treatment of the patient with multiple injuries

03_17B-B&L27_Pt5_Ch17.indd 262 25/10/2017 08:05

American Society of Anaesthesiologists

03_17B-B&L27_Pt5_Ch17.indd 263 25/10/2017 08:05

03_17B-B&L27_Pt5_Ch17.indd 264 25/10/2017 08:05

hypotension, tachycardia and procoagulant states (of which

Minimising myocardial ischaemia

03_17B-B&L27_Pt5_Ch17.indd 265 25/10/2017 08:05

Figure 17.8 Non-invasive ventilation. Figure 17.9 Robotic surgery.

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Furthermore, the guide explains that consent:

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FURTHER READING Mental Capacity Act (2005) UK.

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Anaesthesia and pain relief

HISTORY The use of a set of safety checklists in the operating theatre

03_18-B&L27_Pt3_Ch18.indd 269 25/10/2017 08:06

Summary box 18.1

Ground rules for anaesthesia

The general anaesthetic triad

Induction of general anaesthesia is most frequently done by

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Maintenance of anaesthesia, on the other hand, can be

Management of airway during

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Summary box 18.5

Muscle relaxation and artificial

Summary box 18.4

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TABLE 18.2 Properties of commonly used muscle relaxants.

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Regional anaesthesia (a)

Regional anaesthesia involves central neuroaxial or periph-

Summary box 18.7

● EMLA (eutectic mixture of local anesthetics). This is a

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INTRAVENOUS REGIONAL ANAESTHESIA (BIER’S