You are in: eMedicine Specialties > Perioperative Care > Perioperative Care Perioperative Management of the Female PatientArticle Last Updated: Jun 25, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Howard A Shaw, MD, Associate Professor of Obstetrics and Gynecology, University of Connecticut; Chairman/Director, Residency Program Director, Department of Obstetrics and Gynecology, St Francis Hospital and Medical Center Howard A Shaw is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American College of Physician Executives, American Medical Association, American Society for Colposcopy and Cervical Pathology, American Urogynecologic Society, Association of American Medical Colleges, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Connecticut State Medical Society, International Urogynaecology Association, and Southern Medical Association Coauthor(s): Julia A Shaw, MD, Associate Director, Yale-New Haven Hospital Women's Center, Department of Obstetrics and Gynecology, Yale-New Haven Hospital Editors: Thomas Michael Price, MD, Associate Professor of Reproductive Endocrinology, Director of Reproductive Fellowship Training Program, Duke University Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Donna Leco Mercado, MD, Director of Medical Consultation, Department of Internal Medicine, Baystate Medical Center; Assistant Professor, Tufts University School of Medicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center; William A Schwer, MD, Professor, Department of Family Medicine, Rush Medical College; Chairman, Department of Family Medicine, Rush-Presbyterian-St Luke's Medical Center Author and Editor Disclosure Synonyms and related keywords: preoperative management, pre-operative management, post-operative management, postoperative management, female surgical management, preoperative gynecologic management, pre-operative gynecologic management, post-operative gynecologic management, postoperative gynecologic management, gynecologic surgery, gynecological surgery, women's healthcare, women's health care, women's health, deep venous thrombosis, DVT, deep venous thromboembolism, venous thromboembolism, VTE, venous thrombosis INTRODUCTIONSection 2 of 10
  Caring for women who are about to undergo gynecologic surgery is challenging. The current climate in medicine is fraught with issues involving quality of care, professional liability, availability of information via the Internet, patient input into her care, and dwindling health care dollars. Technological advances in laparoscopy, urogynecology, and female pelvic medicine, and the rapid introduction of surgical devices have created conflict between the surgeon's desire to provide the most current care and rising health care costs. These issues in administering care in women are compounded by a change in this patient population, from a young healthy group to an increasingly larger group of geriatric patients, including many who have chronic diseases. Preoperative management is a dynamic process in which patients and physicians are interdependent. This process is aimed at enhancing the outcome from a surgical procedure and must be thorough, streamlined, educational, and cost-effective with physician and patient satisfaction as the final goal. For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems. PREOPERATIVE MANAGEMENTSection 3 of 10
The purpose of the preoperative workup is to assist the gynecologic surgeon in preparing their patient for surgery. In most cases, this workup includes patient evaluation, stratification of risk, and risk factor modification. The surgeon is thus able to reduce delays in the preparation phase, to enhance patient safety, to recognize and treat complex medical problems, to reduce evaluation costs, and to minimize case delays and cancellations. Goals of the preoperative examination
Preoperative evaluationThe purpose of the preoperative evaluation is not to provide a general screening examination. Normal healthy women undergoing minor procedures may be seen by both the surgeon and the anesthesia personnel on the day of surgery in the preoperative holding area. These patients should receive written and oral instructions and be allowed to ask questions while in the waiting area. However, women with significant medical conditions should be seen at least a week before surgery to allow time for risk assessment, specialty consultation, and patient preparation. Many medical conditions can change or occur within a few weeks, days, or hours after the preoperative evaluation. These complicated patients and their conditions require additional evaluation or treatment before surgery is performed. Other time restrictions on evaluation may be required by individual hospitals. HistoryA thorough medical and surgical history and review of systems regarding significant medical conditions is an important start to preoperative evaluation. By obtaining information from the patient and other sources, one may determine a woman's perioperative risk. A detailed medical history should consist of the elements outlined below. General medical history
Review of systems
Obstetric and gynecologic history
Social history
Family history
Health habits
A comprehensive review of a woman's history, as described above, is the first step in determining the depth of physical examination and laboratory and radiologic workup that is required. Our aging population may have subtle organ system deterioration. This requires the surgeon to more carefully review cardiac, pulmonary, and renal functioning. This review is in addition to the routine workup. The medical history obtained should review a patient's medication intake to look for effects of these medications on anesthesia. This search must also include over-the-counter, botanical, and other homeopathic medications. Also important is searching for allergic reactions to medications and the use of recreational drugs. Physical examinationThe goal of the preoperative physical examination is to identify physical findings consistent with medical disease states. This examination is not designed to document the condition for which the surgical procedure is indicated but only to confirm the patient's history. An appropriate examination consists of the following:
A thorough abdominal and pelvic examination is a major component of the physical examination. One must use these physical findings to determine if the disease process is stable, has improved, or has worsened. The surgeon should discuss with the patient the extent of the surgery, the incision planned, and any variations in technique or extent of surgery depending on the intraoperative findings. This discussion, and also a thorough examination, reassures the patient and her physician. PREOPERATIVE INDICATIONS FOR LABORATORY TESTSSection 4 of 10
The continued push for cost-effective medicine has resulted in questioning the need for routine preoperative laboratory tests. As described above, an appropriate history and physical examination determine the need for tests beyond a complete blood count (CBC). Prothrombin time (PT), platelet count, and activated partial thromboplastin time (aPTT) are not routinely indicated unless a bleeding disorder is suspected. Blood glucose determination is indicated only in the elderly population because of the high prevalence of diabetes mellitus. Blood urea nitrogen (BUN) determination only (ie, no creatinine) seems indicated in the absence of a history of urinary tract problems. Serum creatinine may be considered in gynecologic patients who are at high risk or who have ureteral injury. This provides a baseline to use for postoperative follow-up. A routine urinalysis is not indicated. Chest radiographs have been shown to be of minimal value in women younger than 30 years who are undergoing elective surgical procedures.1 Intravenous pyelogram (IVP) has been a standard study used when extensive pelvic surgery is indicated, but IVP is not indicated before routine gynecologic surgery. Electrocardiograms (ECGs) are not indicated in patients younger than 35 years who have a benign cardiac history and physical examination. When an ECG is deferred, review of exercise tolerance is an important part of the patient history. In summary, patient age, disease diagnosis, procedure risk class (see Anesthesia evaluation in Other Preoperative Considerations), and prevalence of associated disease states, coupled with a careful and detailed history and physical examination, determine the need for specific preoperative testing. Some of these specific tests and indications are listed below. Hemoglobin/hematocrit
White blood cell count
Platelet count
Blood glucose level
Electrolytes
Blood urea and nitrogen/creatinine
Liver function tests
Medication levels
Urinalysis
Pregnancy testing
Illicit drug screening
OTHER PREOPERATIVE CONSIDERATIONSSection 5 of 10
Chest radiographyApproximately 1.3% of routine chest radiographs have been shown to demonstrate pathology not expected by the patient's history. Less than 0.1% of these result in perioperative management changes.1 Respiratory complications have been shown to be predicted most accurately by evaluating the American Society of Anesthesiology (ASA) class, type of anesthesia, nutritional status, and type of surgery. (See Anesthesia evaluation below for the ASA prediction classes.) The most common use of a preoperative chest radiograph is for comparison purposes. It allows the surgeon to compare the preoperative chest radiograph with the postoperative film. Therefore, obtaining a preoperative chest radiograph, as identified by history and physical examination and as indicated by coexisting medical conditions, is important. ElectrocardiographyECGs are considered of help in the treatment of women with known cardiac disease. They also may be of assistance in patients who have signs or symptoms that suggest cardiac disease or in those with significant risk factors for cardiovascular disease. An ECG is useful to the surgeon only if it uncovers an abnormality or disease not discovered by other means. It also is important for risk stratification and/or reduction. Previous ECGs must be available at the preoperative evaluation. This decreases the need for unnecessary cardiac evaluation if abnormalities are found to be unchanged from previous studies. In addition, ECGs may not need to be repeated if a satisfactory study was performed within the past year and if no indication exists for reevaluation. The routine use of ECG based on age, in the absence of other indicators, is controversial. However, the incidence of ECG abnormalities has been shown to increase with age. Therefore, at this time, obtaining ECGs based on age criteria is recommended. In general, ECGs are not needed for women younger than 50 years who do not have diabetes. If the patient has diabetes, ECGs can be performed starting when the individual is aged 35 years. Preoperative consultationMedical consultation provides assistance with risk stratification, risk modification, and planning perioperative patient management. Ideally, the medical consultants who are part of the perioperative evaluation should be the same individuals who provide continuing care for the woman. The consultation should inquire about the following:
Anesthesia evaluationThe anesthesiologist's preoperative visit is key in preparing the patient for the operating room. The method of anesthesia; the agents available; and the use of epidural anesthesia, patient-controlled analgesia (PCA), or other modalities for postoperative pain relief are discussed. The assignment of surgical risk is made using the ASA physical status classification. The letter E is added to any of the classes when an emergency surgical procedure is performed. Anesthesia and surgical morbidity increase as the physical status increases from status I through status V, as follows:
Risk considerations by organ systemHematopoietic The history generally uncovers abnormalities in the clotting cascade. Symptoms such as easy bruising and episodes of prolonged bleeding require determining PT, platelet count, bleeding time, and aPTT. Almost all bleeding abnormalities are discovered by some combination of these 4 tests. A hemoglobin level of 10 g/dL is a widely accepted criterion that must be met before anesthesia is induced for elective surgical procedures. Obviously, this does not apply to patients with chronic conditions, such as renal disease or sickle cell anemia. Thus, if a patient has a hemoglobin level of less than 10 g/dL, performing an evaluation and treating her prior to surgery is prudent. In gynecology, heavy menstrual flow is often the culprit causing a woman's anemia. Suppression of menses with oral progestins, depomedroxyprogesterone acetate (DMPA), gonadotropin-releasing hormone (GnRH) agonists, or oral contraceptives is recommended prior to surgery. If the patient needs a blood transfusion, packed red blood cells are preferable. One unit should elevate the hematocrit by 3 points. In the more elective case, one should consider autologous transfusion as part of preoperative planning. The long-term use of aspirin may create bleeding problems at the time of surgery. Aspirin inactivates platelet function for as long as 10 days after ingestion. Similarly, nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and phenothiazines also interfere with platelet function. On occasion, one may see malnutrition or bowel sterilization that results in vitamin K deficiency. This vitamin K deficiency causes a decline in clotting factors and prolongs the PT, and increased bleeding ensues. Finally, elective surgery should be postponed if the platelet count is less than 50,000/mm3. Spontaneous bleeding is usually observed when the platelet count is close to 10,000/mm3. Platelet transfusion may be given to these patients before and during surgery to raise the count above 50,000/mm3. Electrolyte disturbances Vomiting, diarrhea, and the use of diuretics are the most common factors that result in electrolyte disturbances and intravascular volume depletion in gynecologic patients. Hemorrhage, starvation, and fluid restriction contribute to intravascular volume reduction. Patients with severe vomiting deplete their sodium and potassium secondary to the loss of these ions in the vomitus and resultant hypochloremic metabolic alkalosis, which is associated with renal sodium and potassium loss. Women with severe diarrhea also lose sodium and potassium and present with hyperchloremic acidosis. Electrolyte abnormalities, especially potassium, must be corrected before surgery. Hypokalemia potentiates neuromuscular blocking agents (eg, pancuronium bromide), creates cardiac arrhythmias, and leads to acid-base imbalance. In the early 1990s, medical journals reported young women developing hyponatremia following gynecological surgery. While this phenomenon is not readily found in the gynecology literature, it is highly noted in internal medicine references. Because severe hyponatremia can lead to the aforementioned complications, monitoring electrolyte levels in young women at risk, both preoperatively and postoperatively, may be important. Replacement of intravascular volume is difficult and depends on the contributing causes. For fluid replacement only, isotonic sodium chloride solution and lactated Ringer solution are commonly used. One liter of infused isotonic sodium chloride solution adds 250 mL to the intravascular compartment. Monitoring BUN, urine-specific gravity, hematocrit, blood pressure, pulse, and urine output is important. This allows the surgeon to judge the adequacy of fluid replacement. In complicated cases, using a Swan-Ganz catheter may be necessary to monitor fluid status adequately. Respiratory system Gynecologic patients rarely present with pulmonary problems. Most gynecologic patients are relatively young and healthy. However, young patients who do not have symptoms may have pulmonary diseases such as asthma, sarcoidosis, or others due to smoking, pollutants, or medication. Many factors predispose patients to pulmonary complications postoperatively, including advanced age, smoking, obesity, and known pulmonary disease. Any of these conditions may alert the surgeon that these patients require pulmonary function tests (PFTs) and an arterial blood gas (ABG) determination. If the ABG reveals a PaO2 less than 50 mm Hg and/or PaCO2 greater than 50 mm Hg, the elective surgery is postponed until the woman's pulmonary function is improved. Similarly, a mean breathing capacity less than 50% of predicted value and forced expiratory volume (FEV) less than 2 L in 1 second indicates a high risk for pulmonary morbidity. Patients with COPD require special attention. Using a preoperative management protocol is helpful prior to surgery. Using these protocols reduces postoperative complications. Features of the protocol may include an expectorant, a bronchodilator, adequate fluid volume, incentive spirometry, postural drainage, and antibiotics for purulent sputum. If fewer pulmonary problems are present, cessation of smoking, use of incentive spirometry, chest physiotherapy, and administration of a bronchodilator enhance pulmonary function before surgery. For asthma, patients should be wheeze-free at the time of surgery. Patients with suboptimal control of asthma should have their surgery postponed. For patients with persistent asthma, PFTs and an ABG determination may be helpful to guide therapy. If the FEV is greater than 2 L or greater than 50% of predicted value, the patient is allowed to have surgery with general anesthesia. If the patient is asymptomatic and if the PaO2 and PaCO2 values are normal or minimally decreased, no additional surgical risks should accrue from anesthesia. However, moderate or severe symptoms, changes in FEV more than 50% of predicted value, and depression of PaO2 or elevation of PaCO2 require intensive evaluation and treatment before elective surgery. Preoperative care of patients with bronchial asthma involves (1) hydration, which allows for clearance of secretions; (2) removal of bronchial irritants (eg, smoking); and (3) attention to premedication because drugs such as codeine, morphine, and cholinergic agonists can exacerbate asthma. Atelectasis and bronchitis remain the 2 most common complications postoperatively. These complications occur in approximately 10-20% of the healthy adult population. The incidence rate of atelectasis after lower abdominal surgery is commonly reported in the 10% range. Knowledge of these complications requires the surgeon to remember to instruct the patient to use deep breathing exercises postoperatively. The primary postsurgical risk is the development of bronchitis. In addition, at the time of endotracheal intubation, quiescent asthma can flare up, most likely secondary to irritation of airway receptors. Cardiovascular The cardiac evaluation of gynecologic patients should extend far beyond routine auscultation. A careful routine history and physical examination generally suffice in young, healthy, asymptomatic women with a benign cardiac history. The gynecologic surgeons should be more concerned when their patients are older or have significant history or physical findings that require a more detailed cardiac evaluation. Risk assessment is referenced differently depending on the specialty literature that is reviewed. The American Heart Association Task Force Report, perioperative cardiovascular evaluation for noncardiac surgery, is a commonly used modern reference for this type of assessment and is included in the References section (see also Hyperthyroidism is usually caused by the multinodular diffuse enlargement associated with When thyroid function is abnormal, the cardiovascular system is usually affected. The most concerning of these symptoms are tachycardia, irregular heart rhythm, atrial fibrillation, heart failure, and, occasionally, papillary muscle dysfunction. Diarrhea does occur and can cause dehydration, which must be corrected preoperatively. The prudent surgeon probably should operate on a woman with clinical hyperthyroidism only in a life-or-death situation. Otherwise, she should be made euthyroid prior to any surgical procedure. Antithyroid drugs are administered long-term and are continued on the morning of surgery. If emergency surgery becomes necessary before the euthyroid state is achieved or if hyperthyroidism gets out of control during surgery, IV administration of esmolol and/or propranolol is titrated to restore normal heart rate. Intravascular fluid volume and electrolyte balance is maintained. However, administering propranolol or esmolol may not prevent thyroid storm. Thyroid storm Thyroid storm is a clinical diagnosis of a life-threatening illness in a patient whose hyperthyroidism has been severely exacerbated by illness or operation. Patients experiencing thyroid storm have hyperpyrexia, tachycardia, and alterations in consciousness. The symptoms may appear similar to malignant hyperthermia, pheochromocytoma, or neuroleptic malignant syndrome. Therapy consists of administering antithyroid drugs, blocking the release of hormone with iodine, attending to hydration, and correcting the precipitating cause. Hypothyroidism Hypothyroidism is a common disease in women. It occurs in as many as 5% of women. It usually is subclinical, with serum thyroid hormones in the reference range and only serum TSH being elevated. Therefore, it may have little or no perioperative significance. In women with overt hypothyroidism, however, a relative lack of thyroid hormone results in slow mental functioning, slow movement, dry skin, periorbital edema, intolerance to cold, depression of the ventilatory responses to hypoxia and hypercarbia, impaired clearance of free water (with or without hyponatremia), slow gastric emptying, and bradycardia. In extreme cases, cardiomegaly, heart failure, and pericardial pleural effusions manifest as fatigue, dyspnea, and orthopnea. A rising TSH level is the most sensitive laboratory indicator of a failing thyroid. Preoperative management of hypothyroidism consists of restoring normal thyroid status. One gives the normal dose of triiodothyronine (T3) or thyroxine (T4) on a long-term basis and orally the morning of surgery. Syndrome of inappropriate secretion of antidiuretic hormone Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is secondary to dysregulation of the cells secreting antidiuretic hormone (ADH) and occurs when ADH secretion is sustained despite hyponatremia. This metabolic abnormality is extremely rare in gynecological surgical patients. However, in some patients with cancer, it occurs 1-2% of the time. Although it is most commonly observed in women with small-cell carcinoma of the lung, it also is observed in women with gynecologic and bladder cancers. The management of this disorder may be difficult. SIADH occurs in a state of euvolemic hyponatremia. The hyponatremia is caused by over-secretion of ADH. Because free water cannot be excreted normally, persistent ADH secretion causes water retention, hyponatremia, and progressive expansion of intracellular and extracellular fluid. This expansion of extracellular fluid stimulates natriuresis, with a resultant isotonic loss of extracellular fluid, bringing the extracellular compartment back to baseline. Among the known causes of this syndrome are the use of some anesthetic agents, positive-pressure ventilation, surgical stress, CNS neoplasms, meningitis, brain abscesses, and intracranial hemorrhage. Some drugs also are known to cause the syndrome. These drugs include vincristine, vinblastine, cyclophosphamide, phenothiazines, vasopressin, chlorpropamide, carbamazepine, oxytocin, tricyclic antidepressants, narcotics, and monoamine oxidase inhibitors (MAOIs). Both the surgeon and the anesthesiologist should not forget that stress, pain, or nausea can cause SIADH. Symptoms include anorexia, nausea, vomiting, mild-to-moderate mental status changes or lethargy, and rapid-onset seizures and coma. Presentation includes hyponatremia (<136 mmol/L), volume expansion without edema, natriuresis, hypouricemia, normal or reduced serum creatinine level, normal thyroid and adrenal function, normal blood pressure, no postural hypotension, and no evidence of peripheral edema. The hyponatremia of SIADH occurs in the setting of plasma volume expansion, which is considered the hallmark of SIADH. Laboratory evaluation should include serum sodium levels and urine and plasma osmolality determinations. The diagnosis of SIADH is made when hyponatremia coexists with serum hypoosmolality (<280 mOsm/kg water) and a urine osmolality of more than 100 mOsm/kg water. Therapy includes treating the underlying disease, restricting fluids to no more than 500-800 mL/d, and minimizing free water intake. Postoperative SIADH and its concomitant hyponatremia may be treated with isotonic or hypertonic (3%) sodium chloride solution combined with a loop diuretic. Torsemide or furosemide is usually added. This method of therapy targets increasing the serum sodium by 1 mmol/L/h or less, to a maximum increase of 10-12 mmol/d. In patients with chronic hyponatremia and minimal symptomatology, the surgeon should correct the sodium more slowly, at approximately 0.5 mmol/h, to avoid central pontine myelinolysis (a demyelinating lesion of the pons, with destruction of myelin sheaths but sparing of the axis cylinders and nerve cells), which can result from aggressive sodium replacement and result in permanent neurological impairment or death. Central pontine myelinolysis is a rare entity but has been reported to be more common in young women. Arieff has described this disease in a large number of healthy young women in whom symptomatic hyponatremia developed after elective surgery and who subsequently died or suffered permanent brain damage.2 Women are not necessarily at any greater risk of developing postoperative hyponatremia than men, but women have a 25-fold increased risk of death or permanent neurologic damage as a result of the hyponatremia. The manifestations include flaccid quadriplegia or paraplegia, dysphagia, dysarthria, facial weakness, and coma. It is imperative that the surgeon and the anesthesia team pay attention to hyponatremia in young women. The physician should correct the sodium concentration at a rate of 0.5 mmol/L/h until the serum sodium concentration reaches 120-125 mmol/L. Remember, however, that young women with acute symptomatic hyponatremia are at risk for severe neurologic sequelae, respiratory arrest, and death. These patients should be treated with hypertonic saline to raise the serum sodium concentration to 125 mmol/L at a rate of 1 mmol/L/h. At this serum sodium level, the patient should be asymptomatic and the serum sodium can then be returned to normal gradually over several days, along with water restriction. Gastrointestinal Assessing the patient's nutritional status and symptoms related to bowel function preoperatively is important. GI symptoms require evaluation because of their relationship to the pelvis, either by direct extension of pelvic disease or by extension of a generalized process. If these symptoms are chronic, one must perform a radiographic evaluation. Patients with nausea, vomiting, and diarrhea require an electrolyte assessment. Patients with a depleted intravascular volume need more aggressive preoperative fluid administration. Attention to fluid administration is important before surgery because dehydration can lead to hypotension and tachycardia at the time of anesthesia induction. Bowel preparation prior to surgery is a common preoperative routine. Emptying the bowel enhances surgical exposure, reduces the chances of bowel injury and contamination, and hastens bowel recovery in the postoperative period. Urinary Patients who are undergoing gynecological surgery usually do not present with symptoms referable to the bladder and kidneys. Symptoms that do occur are commonly due to pressure on the uterus or obstruction of function (usually ureter). A routine urinalysis is indicated in symptomatic patients. A baseline IVP is rarely necessary for routine gynecologic procedures. An IVP may be useful in such conditions as ovarian remnant disease, intraligamentous myomas, and severe endometriosis, in which the IVP may provide information about the anatomy of the urinary tract, the presence of anatomic distortion, the presence of anomalies of the tract, or the possibility of long-term urinary tract diseases. Patients under general anesthesia have a decrease in renal blood flow and a similar reduction in glomerular filtration rate. Thus, anesthesia personnel notice decreased urine output during surgery. The authors recommend routine cystoscopy to note patency of the ureters bilaterally after all major gynecologic cases. Psychologic considerationsSurgical procedures on the female genital tract stimulate all kinds of feelings regarding femininity. Although women are concerned about a successful outcome, they also express worries about physical rehabilitation, cosmetic results, impairment in sexual functioning, and a general return to well-being. The surgeon must address these issues in a realistic and positive way. The patient should be allowed an open candid discussion with her surgeon to allow her to have the most comprehensive understanding of the proposed procedure and postoperative course possible. Antimicrobial prophylaxisA wound infection develops as a result of a complex interaction between the bacteria inoculated into the wound during surgery and the local and systemic resistance of the host to infection. The size of the bacterial inoculum is correlated directly with the risk of a postoperative wound infection. Factors, such as prolonged preoperative hospital stay and the excessive use of antibiotics increase the risk of colonization with hospital-acquired pathogens. Alterations in the resistance of the host to infection may occur systemically or locally (ie, within the wound). Nutritional support and control of distant infection reduce the risk of wound infection. Achievement of optimal local resistance to infection is predominantly a surgical task. Various factors, such as the presence of blood, foreign bodies, ischemia, or necrotic tissue at the operative site, may impair local host defenses and increase the risk of infection. Meticulous surgical technique helps avoid many of these contributing factors. The primary benefit of antibiotics is a reduction of the inoculum of viable bacteria in the wound. Principles of antibiotic administration
DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM PROPHYLAXIS AND OTHER DRUG CONSIDERATIONSSection 6 of 10
Deep vein thrombosis/pulmonary embolism prophylaxis In the Classification of risk levels for deep venous thromboembolism among gynecologic surgery patients5, 4
Additional VTE risk factors
Effects of oral contraceptives on prevention of deep vein thrombosis No studies confirm the clinical benefit of stopping oral contraceptives preoperatively. The hypercoagulable changes induced by oral contraceptives do not return to normal levels for 4-6 weeks after discontinuation of therapy. The risk of postoperative thromboembolism has been reported to be 0.96% for those who use oral contraceptives and 0.5% for those who do not. The risk of stopping oral contraceptives 4-6 weeks before major surgery must be balanced against the risks of pregnancy. No randomized clinical trials have evaluated the discontinuation of hormone replacement therapy (HRT) before major gynecologic surgery to prevent DVT or pulmonary embolism. Three studies have been quoted by the American Risk screening for deep vein thrombosis prevention Because of its high prevalence in whites, patients with a history of DVT may be tested for the factor V Leiden mutation. Patients with a strong family history of thrombosis whose test findings are negative for the factor V Leiden mutation may benefit from testing for the prothrombin gene mutation G20210A, MTHFR gene, and deficiencies in the natural inhibitors, including protein C, protein S, and AT-III.4 Patients with a history of thrombosis, recurrent fetal loss, early or severe preeclampsia, severe unexplained intrauterine growth restriction, or unexplained thrombocytopenia may be tested for antiphospholipid antibodies. Fasting plasma homocystine levels may be assessed, especially in women of childbearing age who have had venous or arterial thrombosis, because elevated levels can be treated with vitamins (folic acid, vitamin B-2, vitamin B-6). Perioperative prophylactic heparin has been shown to decrease the incidence of DVT from approximately 30% to less than 10%, without any significant complications.4 General recommendations for VTE prophylaxis5, 4
Other considerations: medications for acute and chronic medical conditionsPatients on medications for acute and chronic medical conditions An increasing number of patients present to their surgeon's office taking medications used to treat multiple diseases. The average hospitalized patient receives more than 10 drugs. Many of these drugs have adverse effects that might make surgery more risky or patient management more difficult. One should always obtain a drug history, including vitamins, herbs, and alternative medicines. In general, unnecessary drugs should be discontinued for at least 3, preferably 5, half-lives of the drugs. For essential or beneficial drugs, the optimal dose should be determined and maximized. Monoamine oxidase inhibitors Patients presenting for surgery may be under treatment for various affective disorders, including depression. One class of antidepressant medications, MAOIs, presents the surgeon with a treatment dilemma. Should MAOIs be routinely discontinued preoperatively? If so, how long before surgery should withdrawal of the medication be undertaken? Monoamine oxidase (MAO) is the principal intraneuronal enzyme responsible for deamination of amine neurotransmitters, such as dopamine, norepinephrine, epinephrine, and serotonin. Therapy with MAOIs causes accumulation of neurotransmitters in presynaptic terminals in neuronal tissue. They also cause accumulation of a false neurotransmitter, octopamine, in presynaptic sympathetic nerve terminals, which is a far less potent vasoconstrictor than other neurotransmitters released from nerve terminals. Thus, patients on MAOIs may exhibit exaggerated orthostatic hypotension in response to stimuli that normally only cause a small decline in blood pressure. The inhibition of MAO is often irreversible, and the effects of MAOIs depend on regeneration of this enzyme. Enzyme regeneration can take as long as 2 weeks after discontinuance of MAOIs. Traditionally, recommendations have been to discontinue MAOIs 2-3 weeks prior to elective surgery, although no controlled studies support this recommendation. However, currently, several clinical reports indicate that continuing MAOIs in the perioperative period is safe, but the reports include only small numbers of patients. Current recommendations by many authors suggest that MAOIs should not be discontinued prior to surgery. General anesthesia may be preferable to regional techniques if hypotension cannot be controlled. Meperidine and other narcotics should be avoided in patients who are taking MAOIs because case reports document the occurrence of hyperpyrexic coma following administration of most narcotics. Anticoagulants The use of anticoagulants poses additional problems in the management of routine and complicated gynecological cases. A frequent concern is the risk of perioperative or postoperative hemorrhage. Perioperative management of patients being treated with anticoagulants requires weighing the risks of increased surgical bleeding from residual anticoagulation versus potential thrombotic or embolic events from stopping the anticoagulant. An effective and safe plan for preoperative weaning from anticoagulant therapy and confirming the return of normal anticoagulation function must be determined prior to surgery. This decision is based, at least in part, on the type of operation and the indications for anticoagulation.
POSTOPERATIVE CARESection 7 of 10
The care of the gynecologic surgical patient requires an accurate understanding of the pathophysiologic changes that occur perioperatively. During this period, the body attempts to maintain systemic homeostasis despite multiple iatrogenically induced alterations. Given the proper environment and appropriate interventions, the body eventually should correct for these derangements. The surgeon's goal during the postoperative period is twofold. The first goal is to provide appropriate support that allows for the maintenance of homeostasis and the prevention of potential complications. The second goal is to recognize unfavorable trends in the course of recovery and respond expeditiously to prevent further compromise. With diligent care, the surgical patient should eventually return to her preoperative level of function. SUPPORTIVE POSTOPERATIVE CARESection 8 of 10
Vital signsMuch information can be obtained by close monitoring of vital signs, including blood pressure, pulse, and respiratory rate. More importantly, the trend and changes of these measurements more accurately reflect the patient's ongoing condition. In the immediate postoperative period, the recovery room staff usually obtain frequent measurements. Selected parameters are more important during various stages of the recovery period. Initially, respiratory rate and blood pressure are of greater significance during recovery from anesthesia because these factors reflect hemodynamic stability and the level of anesthetic reversal. Later, after adequate analgesia and pulmonary function have been obtained, the pulse rate correlates better with intravascular volume status. After discharge from the recovery room, vital signs should be monitored every 4 hours until stable and then every 8 hours depending on the patient's progress. Postoperative activityEarly ambulation is extremely important after surgery. In addition to improving diaphragmatic excursion with its subsequent decrease in pulmonary atelectasis, early ambulation also prevents the development of DVT. To further decrease the incidence of pulmonary ventilating defects and to improve mobilization of mucous secretions, patients are encouraged to cough and breathe deeply. To assist with this respiratory exercise, an incentive spirometer is used at least every hour while the patient is awake. NutritionA low-residue diet 6 hours after major gynecologic surgery for benign indications is not associated with increased postoperative gastrointestinal complaints, including ileus.6 Healthy recovery from surgery may include transient loss of appetite and mild nausea. This is usually secondary to anesthetic agents and other perioperative medications. Symptoms can be treated easily with antiemetics, such as promethazine at 25 mg intramuscularly every 4 hours, as needed. After a major transperitoneal procedure, adynamic ileus may be responsible for continued nausea, abdominal distention, and absence of flatus. The return of small bowel function occurs within 6 hours of surgery and is highlighted by the return of bowel sounds. Gastric emptying and pyloric sphincter function require 2-3 days and coincide with decreased nausea and decreased nasogastric (NG) tube output. Finally, the return of colonic peristalsis that occurs in 3-5 days is signaled by the passage of flatus. Management of patients with gastrointestinal dysmotilityThe patient should take nothing by mouth for 48 hours or until nausea resolves. An NG tube is inserted if the patient is severely symptomatic with continued vomiting and distention. When NG output decreases and nausea resolves, the tube can be removed. The patient may then advance to a clear liquid diet. Progression to a regular diet should be withheld until full return of gastrointestinal motility. If prolonged dysfunction is noted or anticipated, early nutritional support is recommended (eg, enteral feeding either via a nasal feeding tube, surgically placed feeding jejunostomy). Hyperalimentation via a central venous catheter is used if the enteral route cannot be used to maintain adequate nitrogen balance. Fluid and electrolyte managementPostoperative fluid management is dependent on current deficits, maintenance requirements, and abnormal losses. The status of the patient's current conditions should be determined first. The patient's fluid status or deficits can be determined by preoperative vomiting, bowel distention, oral intake, intraoperative hemorrhage, extravascular fluid accumulation (third space), and previous fluid replacement. A physical examination, vital signs, recent weight change, and a record of fluid balance also can help determine the status of the intravascular volume and total body water. If uncertainty exists regarding the patient's actual fluid status, invasive monitoring using a Swan-Ganz catheter can be used to measure central venous pressure (CVP) or left ventricular filling pressure (ie, preload). The daily maintenance requirement for water in the healthy individual with normal renal function is approximately 1 L. In the surgical patient with a higher insensible loss and less than optimal renal concentrating ability, a daily maintenance requirement from 35-40 mL/kg/d is necessary. Electrolyte replacement after uncomplicated surgery rarely requires more than sodium chloride and potassium supplementation, both at 1 mEq/kg/d. This requirement is met easily by administering 0.25% normal saline with 20 mEq KCl/L at the volume predicted above for daily fluid needs. In consideration of the volume, electrolytes, and glucose requirements, one generally begins with 0.25% normal saline with 20 mEq KCl/L at 100-125 mL/h. Additional fluid requirements for low blood pressure, inadequate urine output, or decreased CVP/left ventricular filling volume can be supplemented with isotonic sodium chloride solution. Urine output is important because it is a direct reflection of tissue perfusion. The patient who voids less than 17 mL of urine per hour is, by definition, oliguric. For most patients, a urine flow of less than 30 mL/h should demand clinical attention. Oliguria can be prerenal, renal, or postrenal. To determine the cause of the low output, a variety of laboratory data, clinical measurements, and physical findings should be gathered to assist in the diagnosis. Heart rate, orthostatic changes, and daily weights are easily measurable and usually correlate with the intravascular volume status. More accurately, CVP or a Swan-Ganz catheter measuring pulmonary capillary wedge pressure (PCWP) can be used in diagnostically difficult situations. Laboratory data, including serum sodium, BUN-to-creatinine ratio, fractional excretion of sodium, and serum osmolality, are suggestive but often nondiagnostic in the acute situation. Physical examination noting jugular venous distention, mucous membrane turgor, pulmonary rales, S3 heart sounds, or pitting edema adds valuable data to the clinical evaluation. Once a working diagnosis is made, therapy should be provided. The patient's response is followed and her condition reevaluated, thus confirming the accuracy of the initial diagnosis. When corrected, potential complications, such as volume overload or acute tubular necrosis, can be avoided. Postoperative oliguria most commonly has a prerenal etiology. Intravascular volume is decreased most commonly due to operative blood loss and third-space sequestration of extracellular fluid. Cardiogenic failure may be present. Treatment consists of an initial bolus of isotonic solution at 300-500 mL, repeated, but not to exceed 1 L. Failure to respond may require invasive monitoring with a Swan-Ganz catheter. Cardiogenic failure requires diuretics and/or inotropic agents, depending on PCWP and cardiac output (CO). A postrenal etiology may be found with ureteral obstruction (ie, bilateral to produce anuria). Diagnosis is made with the assistance of renal ultrasound. If the ultrasound is inconclusive, ureteral catheters are diagnostic and therapeutic. A renal etiology should be suspected when prerenal and postrenal causes are excluded. The most common pathology in the immediate postoperative period is acute tubular necrosis. More specifically, this results from (1) ischemia due to hypoperfusion or (2) nephrotoxicity secondary to aminoglycoside or radiocontrast dye use. Laboratory data should include serum sodium, BUN-to-creatinine ratio, fractional excretion of sodium, serum osmolality, and microscopic examination of the urine. In treatment, close attention must be paid to fluid balance and electrolyte abnormalities. Fluid diuresis is initiated with an IV diuretic such as furosemide. Dosages are doubled until an adequate response (ie, approximately 100 mL/h) is achieved or a maximal dose of furosemide 600 mg/d is reached. If good urinary output cannot be achieved, maintenance fluid replacement should be adjusted to include only insensible losses and ongoing losses from the previous 24 hours. If conservative management fails to maintain homeostasis, hemodialysis should be employed. Pain controlPreemptive treatment of perioperative pain The traditional approach to postoperative analgesia is to begin therapy when surgery is completed and pain is experienced. Preemptive analgesia is defined as "antinociceptive treatment that prevents the establishment of altered central processing, which amplifies postoperative pain." Intense noxious stimulation (surgical incision) can sensitize the CNS to subsequent input. Such stimulation may lead to changes in the dorsal horn of the spinal cord that are later perceived as postoperative pain. This may be perceived as even more painful than it would otherwise have been. In addition to reducing acute perioperative pain arising from surgical wounds, preemptive analgesia may also offer prophylaxis against certain pathologic chronic pain states. One routine method of preemptive pain management is to use oral NSAIDs the day before surgery and the day of surgery. In addition, injection of the skin at the incision site with a few milliliters of 1% lidocaine or 0.25% Marcaine prior to incising adds to the analgesic effect. Anecdotally, patients require less narcotic overall for pain control and go home earlier. This effect is even greater for outpatient procedures, such as tubal fulguration. Patient-controlled analgesia Liberal use of postoperative analgesics is essential for recovery. Adequate pain control allows for early ambulation, improved pulmonary toilet, and decreased overall stress. The most effective regimen for pain control involves small frequent dosing, such as the use of a PCA pump. This system consists of a preprogrammed infusion pump that is controlled by a handheld button. An IV dose of premeasured narcotic is delivered when the button is depressed, providing a timely bolus of analgesia. Patients on PCA have decreased overall narcotic use and have improved pain control. The addition of an intramuscular or oral NSAID preoperatively provides added analgesia and quicker return to function than narcotics alone. With a healthy progression to recovery, patients usually can be switched to an oral narcotic within 2-4 days. For those who are difficult to wean from IV narcotics, intramuscular injection can be used, thus prolonging the half-life of the effective dose. Patient-controlled epidural analgesia Considerable interest has been raised in combining potent analgesic effects of drugs delivered into the epidural space with the advantages of the patient participation associated with the PCA concept. The epidural catheter is placed in standard fashion, a loading dose (opioid, local anesthetic, or both) is given, and the PCA pump is set to define the patient-activated bolus doses and lockout interval between doses. Usually, a continuous background epidural infusion rate is also provided. Morphine, fentanyl, and hydromorphone all have been used with success. Drug requirements have been reported to be 4- to 5-fold less than in patients receiving IV PCA hydromorphone. Patients also may have a more rapid return of bowel function and a shorter hospital stay. Incision careThe management of the incision is based on the normal biology of the healing process, which is conceptually divided into 3 phases.
Incision care is based on understanding these biological principles. With the attainment of epithelial closure, the operative dressing can be removed after 24-48 hours. If wound drainage is noted upon inspection, a sterile dressing must be replaced until the drainage ceases and closure is attained. The timing of suture removal is based on 2 opposing guidelines. Staples or sutures should be left in place until adequate tensile strength is obtained by collagen deposition and maturation. On the other hand, allowing sutures to stay in place for a long period increases scar formation at the sites of skin penetration. In healthy individuals with an abdominal incision, sutures or staples can generally be removed on the third postoperative day. This allows for maximal cosmetic benefit while providing adequate support for wound stability. The timing of the removal can be adjusted depending on the importance of each opposing factor. Types of incisions The surgeon may choose either a vertical skin incision or a transverse skin incision when performing gynecologic surgery. The ultimate choice hinges on such factors as presence of prior abdominal scars, desired exposure, expected and/or associated pathology, and risk for wound separation or dehiscence. To some degree, the decision also is based on the surgeon's experience and on consumer pressures favoring a low transverse incision. The midline vertical, transverse Maylard, and transverse Pfannenstiel incisions are the 3 most commonly employed types, while the transverse Cherney and paramedian vertical incisions are used on occasion. In general, vertical incisions allow greater access to the pelvis, result in less blood loss, provide greater feasibility for incisional extension around the umbilicus, and allow easier examination of the upper abdomen. Transverse incisions are preferred cosmetically, are generally less painful, have been associated with a lower risk of subsequent herniation, and provide approximately equal visualization of the pelvis. Some argue that the incidence of postoperative pulmonary complications is lower when a transverse incision is used, particularly in patients with preexisting pulmonary problems, such as obstructive lung disease. Historically, transverse incisions have been associated with fewer incidences of dehiscence and herniation. However, some recent data refute this dictum, and, thus, the controversy remains. ShockShock is a state of inadequate tissue perfusion and is directly proportional to blood pressure. Causes of postoperative hypotension include hypovolemia from decreased intravascular volume, decreased peripheral resistance from sepsis or neurogenic collapse, and cardiogenic failure. The clinical presentation can be very helpful in differentiating these types of shock and may direct subsequent management. Because the central problem is lack of perfusion to vital organs, oliguria and decreased mental status are objective signs of inadequate tissue perfusion. Because of its life-threatening potential, immediate therapy should be initiated before diagnostic evaluation. An IV fluid bolus should be given to those thought to have vascular collapse, and the patient should be placed in the Trendelenburg position (ie, head down and feet up). When the patient stabilizes and if the cause of the hypotension is still in doubt, invasive monitoring may be required. A central line placed in the superior vena cava can be used to measure the intravascular volume. The CVP normally ranges from 8-12 cm water. In patients with possible right heart failure, other cardiac dysfunction, sepsis, respiratory failure, or severe preeclampsia, CVP is inadequate to evaluate left heart filling pressure. A Swan-Ganz catheter allows for a more accurate measurement of left ventricular end-diastolic pressure (ie, left atrial pressure). PCWP, normally from 10-18 cm Hg, is a measurement of left heart filling volume, thus correlating with intravascular fluid status. HypovolemiaSigns and symptoms of hypovolemia include low CVP or PCWP. Treatment consists of replacement with isotonic sodium chloride solution until normal parameters are reached. Serial blood counts are taken, and a transfusion is initiated for a symptomatic drop in hematocrit. Monitor coagulation parameters if more than 4 U are transfused. Derangements in coagulation components require correction with fresh frozen plasma or platelets. Persistent blood loss requires surgical reexploration or intra-arterial embolization. Decreased peripheral resistanceSigns and symptoms of decreased peripheral resistance include fever, rigors, leukocytosis, and hypotension with normal intravascular volume. Cardiac output (CO) is high while systemic vascular resistance (SVR) is low. Treatment consists of measurement of CO and SVR, normalization of PCWP with fluid, and initiation of vasopressors. Dopamine is started at 2 mcg/kg/min and is titrated to maintain a mean arterial pressure greater than 60 mm Hg. Eliminate the source of sepsis and maintain appropriate antibiotic coverage, initially with broad-spectrum antibiotics; narrow according to culture results. Cardiogenic shockSigns and symptoms consist of a high PCWP and low CO. SVR is usually either high or in the reference range. Myocardial function is obtained by dividing CO by body surface area, yielding the cardiac index (CI). Treatment consists of dobutamine starting at 2 mcg/kg/min for inotropic support initially. Maintain a CI above 3 L/min/m2. Identify other treatable causes of cardiogenic dysfunction, such as arrhythmia, hypoxia, acidosis, pericardial tamponade, and massive pulmonary embolism. Continued myocardial decompensation may require an intra-arterial balloon pump and subsequent evaluation for mechanical cardiac support. Respiratory managementRespiratory care plays an important role in the care of the postoperative patient. Anesthesia, splinting, and immobilization lead to retention of pulmonary secretions and atelectasis. Turning, ambulation, coughing, and use of an incentive spirometer are integral parts of an aggressive pulmonary toilet program. Bronchodilators may be beneficial in patients who smoke or have underlying pulmonary disease. In the postoperative patient, acute hypoxia is likely due to a ventilation/perfusion (V/Q) mismatch. This may arise if alveoli are perfused but not ventilated, commonly observed with postoperative atelectasis. If alveoli are ventilated adequately but perfused poorly, as with pulmonary emboli or pulmonary edema, an alveolar dead space is present. Ventilation failure is often due to excessive sedation from anesthetics or narcotics. Treatment of respiratory dysfunction requires oxygen therapy when the PaO2 falls below 60 mm Hg. Oxygen can be administered by nasal cannula or face mask. A maximum of 4 L can be given by cannula, corresponding to a fraction of inspired oxygen (FIO2) of 35%. A non-rebreathing face mask is superior to nasal cannula because it can deliver up to 40-60% FIO2. Patients who cannot maintain a PO2 of 60 mm Hg, a PCO2 less than 50 mm Hg, or a respiratory rate of less than 45 require intubation and mechanical support. FIO2 should be kept below 50% to decrease the risk of oxygen toxicity from the production of free oxygen radicals. Use of positive end-expiratory pressure (PEEP) can support oxygenation by reducing functional reserve capacity (FRC), thus reducing the requirements of FIO2. PEEP should not be administered above 10 mm water without close hemodynamic monitoring because of the risk of barotrauma and pneumothorax. Postoperative feverTemperature elevation higher than 100°F (38°C) in the surgical patient should alert the surgeon of potential complications. Evaluation and subsequent therapy are dependent on how soon after surgery the fever develops. Postoperative fever may be broken down into the following 3 categories. First 24-48 hours
Postoperative days 2-4 UTI, an infected IV line, or pneumonia may be present. The workup should include |