15.1 Preoperative Phase

15.1.1 Risk Stratification

  • Patient-related surgical risk depending on the patient’s state of health and the invasiveness of the operation.

15.1.1.1 Identification of Patient-Related Risks

  • Careful anamnesis, thorough examination.

  • Presentation in the anaesthesia department (ideally max. 6 weeks before surgery).

  • Initiate further diagnosis.

  • General condition of the patient according to ASA classification:

    • Description of preoperative health status, 1 (healthy patient) to 6 (brain-dead patient at organ removal ◘ Table 15.1).

Table 15.1 ASA (American Society of Anesthesiologists) classification
Full size table

15.1.1.2 Systemic Diseases with High Postoperative Risk

  • Cardiovascular System:

    • Various scores: RCR (Revised Cardiac Risk) index according to Lee (Lee et al. 1999), NYHA (New York Heart Association) classification, MET (metabolic equivalent).

    • Risk factors for cardiovascular complications: Coronary artery disease (CAD), heart failure, fresh myocardial infarction, chronic venous insufficiency (CVI), insulin-dependent diabetes mellitus (IDDM), chronic renal failure, cardiac arrhythmia (CAr), fresh insult.

    • Diagnosis: 12-lead ECG, echocardiography, exercise ECG, coronary angiography, carotid Doppler, chest X-ray.

  • Pulmonary disease:

    • Different scores for the prediction of postoperative ventilation risk and re-intubation.

    • Increased risk in chronic obstructive pulmonary disease (COPD), asthma, obesity, obstructive sleep apnoea syndrome (OSAS) and smokers.

    • Diagnosis: chest X-ray, blood gas analysis BGA, lung function test.

  • Diabetes mellitus:

    • Perioperative normoglycemic setting: blood glucose (BG) = 140–180 mg/dl and close-meshed BG controls.

15.1.1.3 Perioperative Risk (◘ Table 15.2)

  • Depending on invasiveness, duration and possible blood loss.

    • Mild: minor endoscopic and outpatient procedures, breast surgery.

    • Moderate: intraperitoneal, intrathoracic surgery, orthopedics.

    • High: Aortic surgery, vascular surgery.

Table 15.2 Risk of perioperative myocardial infarction or death within 30 days after surgery
Full size table

15.1.1.4 Intubation Conditions

  • To estimate a possible difficult airway.

  • Mallampati score (relation of tongue size to pharynx).

  • Head reclination.

  • Mouth opening.

  • 3-3-2 rule (mouth opening >3 fingers, os hyoideum chin distance ≥3 fingers, thyromental distance >2 fingers).

  • Aspiration risk.

15.1.2 Laboratory and Blood Products

15.1.2.1 Blood Management

  • Preoperative anemia prevalence: approx. 30%.

  • Risk factor for perioperative morbidity and mortality.

  • Preoperative improvement through “patient blood management” by increasing erythropoiesis (erythropoietin, iron substitution).

  • Preoperative blood transfusion.

  • Preparation of packed red blood cells (PRBCs) depending on the planned procedure.

  • Caution: PRBCs administration: increased morbidity, mortality and risk of complications.

15.1.2.2 Laboratory Diagnosis

  • Blood tests dependent on:

    • Age.

    • ASA classification (see above).

    • Operation.

    • Risk profile of the patient.

  • Small blood count, electrolytes, coagulation, BG, creatinine, transaminases.

  • No routine screening.

15.1.3 Additional Investigations

15.1.3.1 ECG

  • Preoperative ECG not necessary in asymptomatic and anamnestically unremarkable patients.

  • ECG recommended for

    • Patients with cardiac symptoms and/or

    • Abnormal cardiac history.

15.1.3.2 Chest X-Ray

  • Indicated for new onset or acutely symptomatic respiratory symptoms.

15.1.3.3 Pulmonary Function Diagnosis

  • Indicated for severity assessment in new-onset or acutely symptomatic pulmonary disease, lung surgery.

15.1.4 Perioperative Anticoagulation

15.1.4.1 Coronary Artery Disease and Stent Implantation

  • Metal stents: dual platelet aggregation inhibition up to 3 months.

  • DES (Drug Eluting Stent): Time interval up to 12 months.

  • If possible, no elective operations during this period.

  • Commonly used: Acetylsalicylic acid (ASA), dipyridamole, clopidogrel, prasugrel, ticagrelor.

  • Perioperative discontinuation: Increased rate of cardiovascular events due to rebound phenomenon = continue ASA.

  • Bleeding risk:

    • ASA only moderate bleeding risk, exceptions: NCH (neurosurgery), prostate resection…

    • Dual platelet aggregation = high risk of bleeding: discontinue 7–10 days prior to major procedures, procedures in closed body cavities, and spinal anesthesia close to the spinal cord.

15.1.4.2 Perioperative Thrombosis Prophylaxis

  • Venous thromboembolism = still clinically relevant complication.

  • The more morbid the patient, the higher the risk of thrombosis.

  • Incidence can be reduced by 50% through prophylaxis.

  • Parenteral: Unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), Fondaparinux.

Caution

Heparin-induced thrombocytopenia type II (HIT II) in UFH and LMWH.

  • Alternative anticoagulants:

    • Argatroban (Agarta): for HIT II.

    • Bivalirudin (Angiox): Alternative to UFH for coronary intervention.

    • Phenprocoumon.

15.1.4.3 New Oral Anticoagulants (NOACs/DOACs)

  • Pradaxa (dagibatran etexilate) and Xarelto (rivaroxaban) for:

    • Knee and hip joint replacement.

    • Stroke prophylaxis in atrial fibrillation.

    • Therapy for venous thromboembolism.

  • Eliquis (apixaban) approved for knee and hip replacements.

15.1.5 Medication Management

15.1.5.1 Continue

  • Antianginal, antihypertensive and antiarrhythmic medication:

    • Beta-blockers: otherwise increase in mortality due to rebound phenomenon; preoperative new medication can be considered with sufficient distance to surgery and high-risk patients.

    • Calcium antagonists: Otherwise possible preoperative blood pressure increase.

    • Nitrates: risk of myocardial ischemia.

    • Antiarrhythmic drugs: risk of arrhythmias.

  • Corticosteroids:

    • Continue substitution for longer than 5 days if substitution is already in place.

    • In addition, 50–200 mg hydrocortisone perioperatively over 48 h in patients with long-term medication above the Cushing’s threshold, depending on the severity of the procedure.

  • Statins:

    • Continue perioperatively.

    • New prescription after vascular surgery.

    • Reduce perioperative risk of infarction.

  • Anticonvulsants: triggering seizures.

  • Parkinson’s drugs: enhancement of extrapyramidal symptoms.

  • Thyroid hormones.

  • Psychotropic drugs:

    • Tricyclic antidepressants.

    • Neuroleptics.

    • Selective serotonin reuptake inhibitors.

    • Third generation MAO (monoamine oxidase) inhibitors.

Caution

Perioperative drug interaction.

15.1.5.2 Convert

  • Phenprocoumon: convert to heparin 3–5 days before surgery.

  • MAO inhibitors: Switch to reversible and selective third generation MAO inhibitors 2 weeks prior to surgery.

15.1.5.3 Discontinue

  • Diuretics

    • Otherwise risk of hypovolaemia with hypotension.

    • Immediate restart after surgery in stable patients.

  • ACE (angiotensin converting enzyme) inhibitors and AT II (angiotensin II) blockers

    • Danger of perioperative hypotension in operations with high volume shifts, otherwise due not discontinue.

  • Digitalis

    • Controversially discussed.

    • Long half-life, short-term discontinuation associated with little benefit.

    • Continue in patients with normofrequency absolute arrhythmia.

  • OAD (oral antidiabetic drugs)

    • Risk of hypoglycaemia: Regular perioperative BG measurements.

    • Metformin: Risk of lactic acidosis, discontinue 48 h before surgery.

15.1.5.4 Endocarditis Prophylaxis

  • Depends on operation and patient-related risk

    • Patients with valve replacements (mechanical and biological prostheses), patients with reconstructed valves using grafts for 6 months after surgery.

    • Patients after endocarditis.

    • Patients with congenital heart defects (cyanotic, postoperative).

    • Patients after heart transplant, with cardiac valvulopathy.

  • For interventions in the gastrointestinal tract or urinary tract

    • Prophylaxis only in cases of an infection of these organs.

    • Amoxicillin: 2 g single dose 60 min before surgery.

    • In case of penicillin or ampicillin allergy: Clindamycin 600 mg.

15.1.6 Information from the Anaesthetist’s Point of View

15.1.6.1 Legal Situation (Germany)

  • Any medical interference with bodily integrity: criminal offence of bodily harm.

  • Consent of the patient only legal after detailed explanation and documentation.

  • If possible, 24 h before planned surgical intervention.

15.1.6.2 Prerequisite

  • The patient has to understand and decide, voluntariness.

  • Patients who have reached the age of majority and have the capacity to consent and make decisions.

  • In the case of minors and persons incapable of giving consent: Parents, legal guardians.

15.1.6.3 Requirement

  • Explanation of the relevant information.

  • Procedure with risks typical of procedures and anaesthesia.

  • Various therapy options with risk-reward consideration.

  • Understanding the patient.

  • 3 phases of enlightenment according to hick:

    • Comprehensive information.

    • Summary.

    • Decision of the patient.

15.1.6.4 Elements of Consent

  • Decision for a course of action (alternatives).

  • Placement of the treatment order.

  • Caution: Documentation is obligatory (in writing).

15.1.6.5 Outpatient Interventions

  • For minor surgery: Consent is possible directly prior to surgery (without premedication).

15.1.6.6 Living Will or Health Care Proxy

  • For major procedures or anticipated intensive care stays, inquire about.

15.2 Intraoperative Phase

15.2.1 Intraoperative Monitoring According to AAGBI and BDA Guidelines

  • WHO checklist, team time-out before start of surgery.

  • Essential Equipment:

    • Ventilation system with CO2 –, O2 – and ventilation pressure measurement.

    • Pulse oximetry.

    • NIBD (non-invasive blood pressure measurement).

    • ECG.

    • Relaxometry.

    • Temperature measurement.

    • Defibrillator and cardiopulmonary resuscitation equipment.

    • Infusion pumps.

  • In addition, according to the severity of the intervention and the morbidity of the patient:

    • Invasive blood pressure measurement and haemodynamic monitoring.

    • Transesophageal Doppler.

    • Cerebral measurement of oxygen saturation.

    • Blood glucose meter.

    • BIS (Bispectral Index) Monitor.

15.2.2 Volume Management

  • Avoid preoperative exsiccosis and malnutrition.

  • Hemostasis and coagulation management.

  • Surgical technique and careful haemostasis decisive.

  • Implementation of an evidence-based perioperative transfusion regime.

  • Measures to save foreign blood.

  • Normothermia and avoidance of acidosis.

  • if necessary, use of hemostatic drugs (tranexamic acid, Minirin).

15.2.3 Hemodynamics

15.2.3.1 Pathophysiology

  • MAP (mean arterial pressure) <60 mmHg: decrease in cerebral and renal blood flow.

  • Critical perfusion pressure of the coronaries dependent on cardiac output (CO).

15.2.3.2 Risk Factors for Hypotension

  • Age.

  • ASA classification.

  • Duration of the operation.

  • Combined regional and general anaesthesia.

  • Premedication.

  • Storage.

  • Intraoperative hypotension associated with increased 1-year mortality.

15.2.3.3 Principles/Goals

  • MAP >60 mmHg, in hypertensive patients >80 mmHg.

  • Early initiation of volume and catecholamine therapy, if necessary with hemodynamic monitoring.

15.2.4 Heat Retention

  • Perioperative hypothermia = risk factor for

    • Worsened outcome.

    • Wound healing disorder.

    • Extended length of stay in hospital.

15.2.5 Perioperative Antibiotic Therapy

15.2.5.1 Incidence of SSI (“Surgical Site Infection”)

  • Wound healing disorders in approx. 10% of all operations.

  • 16% of all nosocomial infections.

  • Up to 24.5% after gastrointestinal surgery.

  • Lead to longer hospital stays.

  • Additional costs.

15.2.5.2 Risk Factors

  • Patient-Related:

    • Diabetes mellitus.

    • Obesity.

    • Clotting disorder.

    • Age.

    • Malnutrition.

    • Medication.

  • Patient-independent:

    • Hygiene standards.

    • Operating time.

    • Inadequate perioperative antibiotic therapy.

15.2.5.3 Pathogen Spectrum

  • According to the type and location of the intervention

    • Frequently mixed infections with enterobacteria, approx. 2/3 of all infections by: E. coli, Enterococcus spp., Bacteroides spp., Pseudomonas aeruginosa.

  • Multi-resistant germs:

    • MRSA (methicillin-resistant Staphylococcus aureus).

    • MRSE (coagulase-negative staphylococci with methicillin/oxacillin resistance).

    • VRE (vancomycin-resistant enterococci).

    • ESBL (extended spectrum beta-lactamases).

15.2.5.4 Prevention

  • Avoid preoperative medications: NSAIDs (non-steroidal anti-inflammatory drugs), chemotherapy, phenprocoumon.

  • Optimize concomitant diseases.

  • Perioperative antibiotic administration.

  • Hygiene measures: Hand disinfection, area clothing, asepsis.

  • Wound closure without impairment of local blood circulation.

  • Drains as short as possible in situ.

Caution

No recommendation for irrigation of the abdominal cavity before wound closure.

15.2.5.5 Perioperative Antibiotic Prophylaxis (PAP)

  • Requirement: bactericidal, i.v. application, tolerable

  • Two goals:

    • Reduction of bacteria introduced into the surgical area.

    • Prevention of systemic germ introduction.

  • Antibiotic of choice: aminopenicillins plus beta-lactam inhibitor or first or second generation cephalosporins.

  • Second choice antibiotic: third or fourth generation cephalosporins in combination with metronidazole or carbapenem.

  • Time of application: 1 h before to 2 h after skin incision.

Caution

Vancomycin or fluoroquinolones have a longer infusion duration (60 min).

  • In case of bacteriological sample collection (e.g. blood culture), administration after sample collection.

  • 1–2 doses only for 24 h after surgery, if necessary only single dose.

  • For long operations second dose intraoperatively.

15.3 Postoperative Phase

15.3.1 Analgesia

15.3.1.1 Pathophysiology

  • Prevention:

    • Delirium.

    • Chronification.

    • Cardiorespiratory problems.

    • Delayed mobilization.

15.3.1.2 Evidence-Based Analgesia

  • Evidence-based analgesia positive for:

    • Earlier hospital discharge.

    • Reduce morbidity.

15.3.1.3 Pain Measurement

  • Measurement of pain by:

    • VAS (visual analogue scale).

    • NRS (numerical rating scale).

    • If possible 2-hourly in the first 24 h.

Caution

Increase in pain or new onset of increased analgesic consumption: indication of complications.

15.3.1.4 Principles

  • Individual adaptation to patient, comorbidity.

  • Stepwise therapy according to WHO analgesic ladder.

  • Administration of opioids as sparingly as possible.

  • Use coanalgesics such as clonidine, spasmolytics.

  • Prefer perioperative epidural anesthesia.

15.3.2 Postoperative Nausea and Vomiting (PONV)

15.3.2.1 Forecasting Systems

  • For the assessment of postoperative nausea and vomiting.

  • E.g. Apfel Score:

    • Female.

    • History of PONV/kinetosis.

    • Non-smoker.

    • Opiate administration.

15.3.2.2 Prophylaxis

  • Regional anaesthesia, no volatile anaesthetics, avoid opiates.

    • Medications:

      • Corticosteroids (dexamethasone).

      • 5-HT3 antagonists: administration at the end of surgery.

      • No butyrophenones or benzamines because of possible extrapyramidal motor effects.

  • Adjuvants: Acupuncture/acupressure on the wrist, aromatherapy, ginger.

15.3.2.3 Therapy

  • Quick action.

  • 5-HT3 antagonists as first-choice drugs.

  • Dexamethasone only slow onset of action, only in combination.

  • Alternative: haloperidol, dimenhydrinate, promethazine.

15.3.3 Delirium/Postoperative Cognitive Deficit (POCD)

15.3.3.1 Epidemiology

  • Prevalence 15–50%, ventilated patients up to 80%.

  • Longer hospital stay, increased mortality, and cognitive late effects on long-term follow-up.

15.3.3.2 Division

  • Three types:

    • Hyperactive.

    • Hypoactive.

    • Mixed type.

  • Three forms of postoperative cognitive deficit:

    • Emergence Delirium: at discharge.

    • Postoperative delirium.

    • Transient cognitive impairment.

15.3.3.3 Preoperative Evaluation of Risk Factors

  • Age.

  • Morbidity.

  • Cognitive skills.

  • Severity of the surgical procedure.

  • Hypoxia.

  • Infection.

15.3.3.4 Prevention

  • Avoid preoperative food restriction and fluid deficit.

  • Stress avoidance (isolation, lack of daylight, restraint).

  • Communication aids (glasses, hearing aid).

  • Early mobilization.

  • Avoid prodelirant drugs (e.g. benzodiazepines, opiates, sedative hypnotics).

15.3.3.5 Early Screening

  • CAM-ICU (Confusion Assessment Method/Intensive Care Unit), ICU:

    • Acute onset or fluctuating course.

    • Attention Deficit Disorder.

    • Changes in awareness.

    • Disorganized thinking.

  • Nu-DESC (Nursing Delirium Screening Scale), PACU.

15.3.3.6 Therapy

  • Most important tool: Recognition of delirium.

  • Reduce risk factors.

  • Strengthen reorientation.

  • Drug therapy:

    • Haloperidol.

    • Atypical neuroleptics.

    • Dexmedetomidine.

  • Caution: Haloperidol: QT time, extrapyramidal symptoms at more than 4.5 mg/day.

15.3.4 Recovery Room (PACU)

  • Regular documentation of vital parameters.

  • Surveillance:

    • State of alertness according to AVPU (“alert, voice, pain, unresponsive”) scheme, protective reflexes present.

    • Circulatory situation: blood pressure, heart rate, ECG.

    • Airway: pulse oximetry, oxygen supply and if necessary airway protection e.g. by Wendl tube.

  • Assessment of dressings and drains.

  • Recognize and Treat:

    • PONV.

    • Shivering.

    • Restlessness.

    • Postoperative pain.

  • Transfer if:

    • Patient awake, cooperative, preserved protective reflexes.

    • No more risk from anaesthesia and perioperative respiratory or circulatory problems.

    • Discharge criteria met.

    • Responsibility for discharge lies with anaesthetist.

    • Transfer to another ward/home.

15.3.5 Intensive Care Unit (ICU)/Intermediate Care (IMC)

  • In addition to the tasks of the PACU listed above:

    • Ward with monitoring and treatment of patients after extensive operations.

    • Monitoring and treatment of patients with high morbidity/mortality after minor surgery.

    • Circulatory the rapy.

    • Weaning.

    • Pre-operative stabilisation and preparation for surgery.

    • Organ-specific support.

15.4 Fast Track Surgery

15.4.1 Definition

  • Multimodal interdisciplinary perioperative treatment concept according to defined clinical treatment algorithms.

  • Objectives

    • Shortening the duration of treatment.

    • Reduction of perioperative complications.

15.4.2 Preoperative Management

  • Short preoperative food abstinence.

  • Premedication with short-acting substances.

15.4.3 Intraoperative Management

  • Atraumatic surgical technique.

  • Anaesthetic guidance with short-acting substances.

  • PONV prophylaxis.

  • Peridural analgesia: Improves perioperative mortality and reduces tumor recurrence rate.

  • Balanced volume therapy.

  • Caution: Intestinal edema.

  • Avoid hypothermia.

  • Periopertiave antibiotic prophylaxis.

15.4.4 Postoperative Management

15.4.4.1 Analgesia

  • Peridual anesthesia instead of systemic opiate administration.

  • Analgesia according to WHO stage scheme.

Caution

Gastrointestinal bleeding is possible with NSAIDs.

15.4.4.2 Early Mobilization

15.4.4.2.1 Optimized Diet

  • Epidemiology: mortality rate in ICU patients with gastrointestinal failure 43.7% vs. 5.3% without gastrointestinal failure.

  • Pathophysiology:

    • Operation = motility disorder.

    • Motility disorder = passage disorder (bacterial density increased) + barrier function impaired.

    • Causes of motility disorder:

      • Drugs (opiates).

      • Immobilization.

      • Electrolyte derailments.

      • Shock.

      • Inflammation of the intestinal wall due to cytokine release also during surgical interventions.

      • Bowel wall edema.

      • Increased sympathetic tone with vasoconstriction in the splanchnic area.

  • Fast track therapy.

    • Keep alimentation interruption as short as possible.

    • Start enteral nutrition early.

    • Laxatives (lactulose, macrogol).

    • Prokinetics (metoclopramide, erythromycin, neostigmine).

    • Opiate receptor antagonist (Relistor).

15.4.5 Guidelines

ESC/ESA (2014) Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J 35:2383–2243.