Perioperative Care


The student can perform a complete history and physical examination. The student will review pharmacology of common anesthetic medications, antibiotics, and pain control agents. The student can integrate the physiology of cardiovascular, pulmonary, gastrointestinal, renal, hepatic, endocrine and nervous system function. The student is familiar with carbohydrate, protein and fat metabolism and the role of vitamins / minerals in health and disease

Knowledge Objectives

Through their reading and patient care experiences, at the end of the rotation students should be able to:

Preoperative Assessment

Describe features of a patients clinical history that influence surgical decision making. Consider: known diseases, risk factors, urgency of operation, medications etc.
Discuss tools that may assist in preoperative risk assessment. Consider laboratory studies, imaging studies etc. Include the following:
Pulmonary (example: exercise tolerance, pulmonary function testing)
Cardiovascular (ASA classification, Goldman criteria, echocardiography, thallium studies, Doppler)
Renal (Bun/Cr, dialysis history)
Metabolic (nutritional assessment, thyroid function)
Compare and contrast anesthetic risk factors. Consider the following variables:
Age: neonates to geriatrics
Urgency of intervention:
emergent versus elective surgery
associated conditions: pregnancy, diabetes, COPD, valvular or ischemic heart disease, cerebral/peripheral vascular disease, renal insufficiency etc.
Discuss history, physical and laboratory findings utilized in nutritional assessment. Be familiar with the most common forms of nutritional & deficiency disorders. Consider: protein-calorie malnutrition, chronic alcoholism, iron & B12 deficiencies, malabsorption syndromes and requirements of the morbidly obese.
Discuss disease states and surgical interventions at high risk for nutritional impairment.
Discuss the advantages and disadvantages of nutritional support.
compare and contrast enteral vs. parenteral administration
methods of determining requirements and assessing response
Perioperative Assessment

Discuss the components of informed consent as it applies to surgical interventions (procedures, transfusions etc.)
Demonstrate documentation of consent in the medical record.
Discuss the rationale for documentation in the medical record.
Describe the components and demonstrate the ability to formulate an operative or procedure note, postoperative orders, a postoperative note.
Describe the indications and efficacy of various monitoring techniques.
Compare & contrast invasive vs. noninvasive.
Consider the following: vital signs, I&O, arterial lines, pulse oxymetry, ABG, ECG, Swan Ganz,
CVP, ICP etc.
Discuss conditions that potentially interfere with fluid and electrolyte homeostasis in the peri-operative period, and describe strategies for replacement / monitoring.
Example: effects of bowel preparation, NPO status, NG drainage, dialysis, operative losses, etc.
Describe factors that might impair coagulation or increase risk of bleeding.
Describe the various blood component therapies available.
Discuss the indications, risks and benefits of transfusion therapy.
Compare the use of packed cells vs. whole blood , FFP, platelets, cryoprecipitate, albumin.
Discuss alternatives to allogeneic blood transfusion and their appropriate use. Include: autologous donation, hemodilution, , iron / erythropoetin therapy, and modification of transfusion trigger.
Discuss risk factors for alcohol withdrawal syndromes. Consider prevention strategies.
Postoperative Assessment

List the conditions necessary for discharge of a patient to home or to the floor following a general or spinal anesthetic
Discuss the pharmacological action, benefits, risks, and side effects of various pain control agents.
Compare and contrast : parenteral vs. enteral agents and describe the role of epidural and nerve blocks in pain management
Describe the expected outcome of an uncomplicated surgical procedure. Discuss a normal post-operative course for various common operations. Consider:
Time to recovery, order of recovery of digestive function (stomach, small bowel, colon) etc.
Characteristics of a healing surgical wound.
Impact of various incisions on recovery.
Functional abilities and disabilities acutely and chronically.
Nutritional and fluid needs and options for replacement.
Potential complications : prevention strategies.
Patient support systems and options for post hospital care.
Describe criteria for admission of a patient to an ICU or special care unit following surgery.
Compare and contrast post-operative courses of patients undergoing Whipple procedure, coronary artery bypass, multiple trauma with craniotomy, laparotomy and orthopedic injuries.
List criteria for weaning a patient from the ventilator post-operatively.
Calculate the nutritional needs and describe preferred routes of administration of nutritional therapy for patients with various surgical problems. Consider patients with:
inflammatory bowel disease
50% TBSA burn
intestinal fistula
major esophageal resection for tumor
Describe what is meant by the term prophylaxis and discuss its rationale in preventing infectious and pulmonary complications.
Discuss alternatives, including their appropriate uses and risks, for prophylaxis of DVT and PE.
Discuss the indications for antibiotic prophylaxis; include commonly utilized agents, timing and duration of prophylaxis. Consider alternatives in patients with known drug allergies.
Discuss the rationale for bowel preps in patient undergoing various abdominal surgeries.
Describe modifications in diet, chronic medications, behavior (smoking, alcohol) that might be indicated in patients undergoing major surgery.