Ethics, preoperative considerations, anaesthesia and analgesia

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5 Ethics, preoperative considerations, anaesthesia and analgesia

This chapter encompasses the wide ranging area of perioperative care, from ethical issues surrounding consent, to preoperative preparation and optimization, as well as strategies for the management of postoperative pain. An overview of anaesthesia is included with particular emphasis on its impact on preoperative preparation and selection of patients for surgical intervention.

Ethical and legal principles for surgical patients

The level of trust invested in surgeons by patients when they submit to a surgical procedure is unique in society, as is the potential for harm and exploitation. It is paramount therefore that the practice of surgery is subject to ethical and legal principles that enshrine the rights of patients and the duties of surgeons within the context of varying societal expectations. Medical ethics is a complex area, particularly with the challenges that advances in bioethics and new technologies bring, and there should be sufficient latitude within the framework of medical ethics to accommodate differing views in resolving ethical dilemmas. In the United Kingdom, ethical standards are upheld by regulatory bodies such as the General Medical Council and the Surgical Royal Colleges (Table 5.1).

Table 5.1 The duties of a doctor registered with the General Medical Council

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:
Make the care of your patient your first concern  
Protect and promote the health of patients and the public  
Provide a good standard of practice and care Keep your professional knowledge and skills up-to-date
  Recognize and work within the limits of your competence
  Work with colleagues in the ways that best serve patients’ interests
Treat patients as individuals and respect their dignity Treat patients politely and considerately
  Respect patients’ right to confidentiality
Work in partnership with patients Listen to patients and respond to their concerns and preferences
  Give patients the information they want or need in a way they can understand
  Respect patients’ right to reach decisions with you about their treatment and care
  Support patients in caring for themselves to improve and maintain their health
Be honest and open and act with integrity Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk
  Never discriminate unfairly against patients or colleagues
  Never abuse your patients’ trust in you or the public’s trust in the profession
You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

Medical ethics is not just an abstract subject but a practical and rigorous discipline that applies on a daily basis to surgical practice. Its importance cannot be overestimated. This section seeks to give an overview of medical ethical and legal principles with the exception of the ethics surrounding transplantation which is discussed in the chapter on transplantation.

Principles in surgical ethics

Surgeons regularly need to make decisions that involve a broad understanding of medical ethics. Obtaining fully informed consent is probably the most common example, but surgeons are often involved in ethical dilemmas in acute situations involving unconscious and critically injured patients. Ethical issues are also encountered in surgical research and in the world of surgical publication. The information below cannot cover every prevailing philosophy relating to medical ethics, but is intended to provide guidance that can be applied to most situations that the surgeon is likely to encounter.

Principalism

Principalism is a widely adopted approach to medical ethics. Championed by Beauchamp and Childress, it judges all possible actions in a particular ethical dilemma against four principles. These are autonomy, beneficence, non-malfeasance and justice (Summary Box 5.1). Each is considered in more detail below and while addressed separately, it becomes apparent that the principles are linked and do not simply cover four unrelated issues. Protagonists of this approach to bioethics suggest that it provides a practical framework for working through ethical dilemmas, allowing identification of important issues and is universally applicable with its four principles widely acceptable irrespective of culture or religious beliefs. The principles can be applied to most surgical clinical scenarios and if each element is given due consideration it is unlikely that the resulting decision will be unethical.

Informed consent

General considerations

Informed consent is central to the practice of surgery, and has to be obtained for surgical procedures, other treatment modalities, investigations, screening tests and prior to patient participation in research. Informed consent is not only ethically correct but also a legal riht and should be respected even if the patient’s wishes are at variance with the surgeon’s opinion. Informed consent can only be obtained from patients with ‘capacity’. This should be assumed for all conscious adults unless there is evidence to the contrary. The patient’s views must be respected and upheld after an information sharing process that conveys all the information the patient needs and wants in order to make a decision. The surgeon must maximize the opportunity for patients to consent and facilitate the process wherever possible.

Capacity exists if a patient can:

Circumstances where the capacity to consent may not exist:

Other important considerations in obtaining consent relate to who should obtain consent and when, and what information should be shared/withheld and in what format. In general terms, the surgeon performing the procedure has responsibility to obtain consent but this can be delegated provided the person to whom it is delegated:

The information that should be shared with a patient to obtain consent should start from a mutual understanding by both doctor and patient of the medical condition, as well as the patient’s views, beliefs and prior knowledge. All treatment options should be detailed, including the option of no treatment alongside the risks, side effects, potential benefits and burdens and the risk that the treatment will be unsuccessful. All potential serious adverse outcomes, no matter how rare should be discussed, along with more frequent minor complications. Risks and benefits should, wherever possible be quantified in percentage terms. These figures should derive from audited local/personal practice and not simply plucked from the literature. It is acceptable for the surgeon to give the patient advice; but, in such circumstance, any conflict of interest must be declared.

If a patient expresses the wish that they do not want the information required for informed consent and understands the potential consequences, then information can be withheld on the basis of non-malfeasance, but only when serious psychological harm might ensue and not simply because the patient may be upset or refuse treatment. This is called ‘therapeutic privilege’. The provision of procedure specific patient information sheets can supplement the process of informed consent, but does not negate the doctor’s responsibility to ensure patient’s understanding of the procedure.

Consent may be implied or explicit. Implied consent is considered adequate for routine interventions with negligible risks where patient consent is implied by their cooperation (e.g. venepuncture). The majority of interventions require explicit consent; this may be oral or written. It is perhaps surprising that although written consent is obtained for the majority of procedures, it is only a legal requirement for organ donation and fertility treatment in the UK. Nevertheless, the existence of a written, dated form of consent provides evidence that a consultation covering specific issues was likely to have taken place.

Increasingly in the UK patients may not have sufficient English to enable the process of informed consent. In such circumstances it is tempting to conduct the consultation and consent process via a family member or friend acting as an informal interpreter. However, best practice is to use the services of an official translator. Similarly, written information should in the appropriate language; if this is not possible the translator should read it out to the patient who then has an opportunity to ask questions back through the translator. It goes without saying that the medical records should clearly document that this process has taken place.

Consent in specific circumstances

Confidentiality

Confidentiality is a central element in the doctor–patient relationship. There are exceptions where confidentiality can and should be breached for the protection of others (e.g. notifiable diseases such as tuberculosis). In the context of multidisciplinary team working, only information necessary to enable treatment by a third party should be divulged. When patients are discussed for the purposes of teaching or publication, patient identity must be concealed. Confidentiality is not just an important principle, it may be legally enforceable, for example by the Data Protection Act.

See Table 5.2 for important sources of information regarding ethics in medicine.

Table 5.2 Sources of further information on ethics

Publications

Websites

Specific topics

Negligence

In order for a surgeon to be found negligent three pre-requisites must be fulfilled. Firstly, it must be demonstrated that the surgeon owed the patient a duty of care (this is usually assumed), secondly, it must be shown that that the doctor breached that duty of care; and, thirdly that, on the balance of probabilities (more likely than not), the breach of duty resulted directly in harm (causation). Medical negligence can relate to diagnosis, treatment and the failure to warn a patient of risks that would have resulted in the patient refusing an intervention. The standard against which a doctor’s performance is measured was established in case law in 1957 (the Bolam case). This states that a doctor is not guilty of negligence if he has acted ‘in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular area’. In practice, Bolam defends a doctor’s practice if a body of medical opinion can be found to support that doctor’s actions. It facilitates the defence of minimal acceptable practice rather than ideal practice. A subsequent House of Lords ruling went further stating that, ‘the court has to be satisfied that the exponents of the body of opinion relied on can demonstrate that such an opinion has a logical basis … that the experts have directed their minds to the question of risks and benefits and have reached a defensible conclusion’. This updated ruling (Bolitho) provides the legal basis for most complaints that result in an allegation of negligence. Several professional organizations in the UK offer advice and support to doctors including the British Medical Association, the General Medical Council, and medical defence organizations.

Completion of a death certificate

Following the death of a patient, it is a legal requirement that a death certificate be completed before the body is released for cremation or burial. Death certification must be completed by the doctor who has attended the deceased during their last illness and includes a record of the patient’s name and age, as well as the date, time and place of death. The cause of death has to be recorded, as well as any contributing conditions that have led directly to the cause of death and significant conditions that contributed to the death but are unrelated to the disease causing it. In certain situations a death has to be referred as a legal requirement to the coroner’s office in England, Wales and Northern Ireland or to the Procurator Fiscal in Scotland for consideration of a post mortem examination to establish the cause of death. These include: recent surgery, where death may be due to abortion, accidental death, death in suspicious/violent/unnatural circumstances, death due to suspected poisoning, self neglect, negligence or suicide, death occurring in prison or police custody, where the death may be due to industrial disease or related to the deceased person’s employment, where the cause of death is unknown; and unexpected death.

Where cremation is requested, a separate cremation form has to be completed by a doctor who attended the deceased during their last illness and a second doctor who is at least five years full registration. Care must be taken to identify the presence of pacemakers and other potential explosive devices in the body. The cremation of foetal remains of less than 24 weeks gestation does not require a cremation certificate.

Ethics committees

Research on human subjects is necessary to advance medical knowledge and treatment. Ensuring that it is carried out in a safe and ethical way is the remit of the ethics committee. The Declaration of Helsinki sets out the principles of ethical research. All clinical trials involving human subjects or tissue must receive ethical approval prior to commencing recruitment. For information on how ethical approval is obtained in the UK see the National Research Ethics Service which is part of the National Patient Safety Agency (http://www.nres.npsa.nhs.uk/). The composition of ethics committees is important and should reflect societal diversity in terms of age, gender, ethnicity and disability and embody a broad range of experience and expertise so that the scientific, clinical and methodological aspects of a research proposal can be reconciled with the welfare of the research participants.

Ethics committees take into consideration a whole range of aspects of a research proposal before giving approval. Their primary consideration is to safeguard the rights, safety and wellbeing of research subjects. They examine the recruitment process, including informed consent, the quality of information given to subjects, payments to subjects, the risks of the research protocol including safety measures and information, compensation procedures and indemnity. The likelihood and capability of the trial design to answer the research questions is considered as well as adequacy of resources, plans for data processing, storage and protection.

Preoperative assessment

Careful preoperative assessment is fundamental to achieving good surgical outcomes. The same principles apply to both emergency and elective situations, the only difference usually being the extent to which preoperative assessment must be compromised when an emergency condition requires urgent intervention.

Assessment of operative fitness and perioperative risk

In the elective surgical setting, preoperative assessment takes place in several stages beginning at the point of referral. A good referral letter should include details not only of the presenting complaint but also of the patient’s general health, co-morbidities and current medication. The first contact with the surgical team is usually in the out-patient clinic and this consultation may lead to a decision to offer surgery. In reaching such a decision, the surgeon should consider not only the physical fitness of the patient to withstand the proposed surgery, but also the likely impact on their social and emotional wellbeing. When making the decision to operate, the risks and potential benefits of surgery should be weighed against those of alternative or no treatment. The purpose of preoperative assessment is to prepare the patient for surgery, identify co-morbid conditions, estimate and perioperative risk by optimizing the patient’s physical condition. The majority of preoperative assessment for elective surgery takes place in the preoperative assessment clinic one to two weeks before surgery, and culminates in the admission immediately prior to, increasingly in the UK on the morning of, surgery.

The first priority is to establish the severity and extent of the condition requiring surgery by employing appropriate imaging and other investigations. For example, it is important to know that both recurrent laryngeal nerves are functional prior to thyroid surgery as damage is a recognized complication of this type of operation, on the other hand malignant conditions require appropriate staging to establish the disease extent. The second objective is to identify co-morbid conditions through careful clinical assessment and through optimization, minimize perioperative risk. Figure 5.1 details the areas of potential perioperative risk and Figure 5.2 shows a logical sequence of preoperative assessment. Details of previous operations and anaesthetics should be sought, as well as drug, alcohol and smoking history, specific allergies and concerns. Investigations to assess the surgical condition, co-morbid conditions and general health should be arranged as soon as possible to minimize surgical delay. Thorough and timely preoperative assessment is essential to avoid the expense and delay of cancelled or delayed surgery. Good quality assessment and appropriate optimizations prior to admission mean that many patients can be admitted on the day of surgery.

An anaesthetic review should be requested prior to admission where there is increased risk, fitness for surgery is in doubt or there are specific anaesthetic issues requiring input. Other specialist input may be required, including cardiology, respiratory and haematology.

On the morning of surgery, both the surgeon and anaesthetist should reassess the patient and identify outstanding issues and any changes in their condition. Care should be taken to ensure that all investigation results are available as well as necessary blood products and special equipment. Details of the anaesthetic should be discussed, and postoperative analgesic strategies, taking into account patient preferences wherever possible.

In the emergency situation this process is condensed. Judging the timing of surgery is crucial. The surgeon must determine which interventions will optimize the patient’s condition while avoiding deterioration due to unnecessary delay progression of the acute surgical problem.

Oxygen delivery in minimizing operative risk

A number of important studies have demonstrated that postoperative morbidity and mortality are related to inadequate oxygen delivery to the tissues, resulting in hypoxia. Oxygen delivery (DO2) is dependent on cardiac output (CO) and the oxygen content of arterial blood (CaO2).

image

The arterial oxygen content in turn depends on the delivery of oxygen to the alveoli, its efficient transfer from alveoli into blood, adequately functioning haemoglobin, the arterial partial pressure of oxygen and arterial haemoglobin oxygen saturation. In an average resting adult an oxygen requirement of approximately 250 ml/min is exceeded by delivery of around 1000 ml/min, resulting in considerable reserve. When oxygen demand increases, cardiac output may rise and tissue oxygen extraction may increase to up to 50–60% in order to compensate. If this does not meet tissue oxygen demand, hypoxia with anaerobic metabolism ensues. If uncorrected this can cause local and remote organ damage, dysfunction, multiple organ failure and ultimately death. It has been shown that the duration of oxygen debt correlates with the presence and magnitude of postoperative complications and mortality. It therefore follows that patients with poor cardiovascular and respiratory reserve or anaemia, and who are less able to increase oxygen delivery, are at higher perioperative risk and that measures taken to optimize their condition and oxygen delivery will help to minimize that risk.

Goal directed measures to optimize cardiac index, oxygen delivery, mixed venous oxygen saturation and minimize anaerobic metabolism using intraoesophageal Doppler probes, pulmonary artery catheters, intravenous fluid loading, blood transfusion, supplemental oxygen and inotropes have all been shown to improve outcomes.

Systematic preoperative assessment

Smoking

All patients should be offered support to quit smoking, particularly once the decision to operate has been made. The benefits of preoperative smoking cessation are listed in Table 5.3 and should be explained to the patient. Some of the benefits occur within hours (reduced circulating nicotine and carboxyhaemoglobin) while others take weeks, months, or even years. Despite the significant advantages in the perioperative period, many patients are unable or unwilling to stop smoking prior to and after their surgery. Referral to specialist services that support patients to stop smoking may help.

Table 5.3 Benefits of preoperative smoking cessation

Surgical

Other

Drug therapy

A comprehensive drug history should be recorded prior to admission for surgery. In general patients should take their routine medication right up to the time of surgery. The perioperative management of diabetes mellitus and patients on anticoagulation is considered separately. Drugs that require special consideration in the perioperative period are discussed below.

Previous operations and anaesthetics

Details of previous anaesthetics including complications, side effects and reactions should be sought. Previous anaesthetic charts are a useful source of information and should alert the anaesthetist to potential anaesthetic challenges including a difficult endotracheal intubation. Previous major anaesthetic complications or a suspicious family history should alert to the possibility of a rare inherited abnormality. Pseudocholinesterase deficiency is an inherited enzyme abnormality also known as scoline apnoea and is characterized by prolonged apnoea requiring prolonged ventilation in response to short acting, depolarizing muscle relaxants such as suxamethonium chloride. Diagnosis is confirmed by demonstrating decreased plasma cholinesterase activity. Malignant hyperpyrexia is an inherited autosomal dominant condition characterized by life-threatening hyperpyrexia as a result of abnormal muscle metabolism after exposure to volatile anaesthetic agents or suxamethonium. Diagnosis is complex and investigations should be carried out in specialist centres.

The most common complaint after general anaesthesia is postoperative nausea and vomiting (PONV). This causes significant patient distress, delays recovery and discharge following day case procedures. Steps to minimize PONV include the use of short-acting anaesthetic agents and potent centrally-acting antiemetic drugs (e.g. ondansetron), as well opiate avoidance.

Preoperative investigations

Preoperative investigations are undertaken to assess fitness for anaesthetic and identify problems amenable to correction prior to surgery. Preoperative investigations commonly include haematological, biochemical, radiological, cardiovascular and respiratory tests. Most surgical units will have local protocols guiding the use of preoperative investigations.

Haematology

Full blood count

The majority of patients undergoing surgery will have a preoperative full blood count. The oxygen carrying capacity of blood (haemoglobin concentration) is of paramount

importance but the platelet and white cell count are also important considerations in terms of haemostatic capacity and where sepsis is suspected. Any patients undergoing surgery with the potential for significant blood loss should have a full blood count, as should those with signs or symptoms of anaemia, patients with significant cardiorespiratory disease that may compromise oxygen delivery to the tissues and those with overt or suspected blood loss (for example gastrointestinal tract symptoms).

Wherever possible, anaemia should be corrected preoperatively to optimize oxygen delivery to the tissues. Preoperative blood transfusion should only be considered for haemoglobin concentrations below 8 g/dl unless the patient is at increased risk of tissue hypoxia due to significant cardiorespiratory disease, especially severe ischaemic heart disease or severe intraoperative bleeding (EBM 5.1). (http://www.transfusionguidelines.org.uk) The threshold for transfusion should be higher (because lower haemoglobin concentrations are tolerated) in patients with chronic anaemia (such as renal failure patients) where compensatory mechanisms such as increased red blood cell 2,3-diphosphoglycerol and reduced blood viscosity increase oxygen delivery.

An abnormally elevated white cell count may indicate infection or haematological disease and should be investigated preoperatively. Thrombocythaemia increases the risk of thromboembolism and prophylactic measures should be taken. Thrombocytopenia may need to be corrected to reduce the risk of bleeding. The UK blood transfusion service recommends transfusing to a platelet count of 50 × 109/l for lumbar puncture, epidural anaesthesia, endoscopy with biopsies and surgery in non-critical sites and to 100 × 109/l for more major surgery including critical sites such as neurosurgery or ophthalmic surgery. Advice from a haematologist may be helpful.

Biochemistry

Cardiac investigations

Electrocardiography (ECG) is of very limited value in predicting the risk of ischaemic events and generally should only be performed in the elderly (over 65 years), to detect occult rhythm disorders or signs of previous cardiac events. In younger patients ECG should be restricted to those with signs of, or known, cardiovascular disease and those with risk factors for ischaemic heart disease. Routine chest X-ray should only be performed in the context of cardiovascular assessment where congestive cardiac failure is suspected. Echocardiography is used to assess cardiac function (left ventricular ejection fraction in particular) and may be indicated prior to major surgery and in patients with suspected valvular disease and heart failure. A 24-hour ECG is useful in patients with a history suggestive of paroxysmal arrhythmias or heart block – usually syncopal attacks. Tests of cardiovascular physiological reserve include exercise ECG, thallium scan, stress echocardiography and cardiopulmonary exercise tests (CPEX). CPEX is a dynamic test of cardiopulmonary reserve that is used selectively to help select patients for high risk surgery such as thoracic, vascular and cardiac surgery. This measures VO2 max (maximum oxygen consumption) and carbon dioxide excretion under exercise conditions, which is related to overall fitness, as well as the anaerobic threshold (the point at which respiration switches from aerobic to anaerobic metabolism). There is some controversy regarding its value in predicting the risk of an adverse outcome for an individual patient or for specific operations, but it may aid the decision-making process.

In general, the involvement of a cardiologist is advisable if anything more than basic cardiac evaluation is required. The significance of common arrhythmias is listed in Table 5.7. The perioperative management of patients with pacemakers is discussed below.

Table 5.7 Significance of common arrhythmias in the perioperative period.

Arrhythmia Significance
Uncontrolled atrial fibrillation May compromise cardiac output
Exclude metabolic causes, e.g. electrolyte abnormality, and thyrotoxicosis
Ventricular rate should be controlled prior to surgery
Controlled atrial fibrillation Rarely causes severe perioperative problems unless associated with other significant heart disease
Patient may be on anticoagulants; if not, consider thromboprophylaxis
Ventricular extrasystoles Usually of little significance
  May indicate ischaemia in patients with ischaemic heart disease
First-degree heart block, asymptomatic bi- or trifascicular block or asymptomatic second-degree heart block Little significance.
Previously considered an indication for temporary pacemaker insertion
Now usually managed by careful monitoring in the perioperative period
Third-degree heart block Requires pacemaker insertion prior to anaesthesia

Respiratory investigations

Patients with purulent sputum suspected of having a chest infection should have sputum culture and antibiotic sensitivity performed. Preoperative chest X-ray is a useful baseline in patients with known or suspected pulmonary disease, and may demonstrate consolidation, atelectasis and pleural effusions. Routine chest X-ray is not indicated, having poor sensitivity to detect new respiratory disease.

Pulmonary function tests are useful to gauge severity and reversibility of the obstructive component of respiratory disease and may help guide therapy to optimize function. Pulmonary function tests are indicated in pre-existing significant pulmonary disease, patients with significant respiratory symptoms, and in patients undergoing thoracic surgery. Table 5.8 lists the commonly performed pulmonary function tests. Although commonly used, the evidence that preoperative pulmonary function tests are predictive of postoperative complications is not convincing. Indications for preoperative arterial blood gas analysis are given in Table 5.9.

Table 5.8 Respiratory function tests commonly carried out preoperatively

Respiratory function test Significance
FEV1 Forced expire volume. Volume of air forcibly expelled in one second
FVC Forced vital capacity. Volume of air forcibly expelled from full inspiration to maximal expiration.
FEV1/FVC ratio Restrictive lung disease (fibrosing alveolitis or scoliosis): the FEV1 and FVC are reduced proportionately with an unchanged FEV1/FVC ratio
Obstructive pulmonary disease (asthma and COPD): the FEV1 is reduced by a greater extent than the FVC resulting in a reduced FEV1/FVC ratio
A ratio of < 70% indicates obstructive pulmonary disease and bronchodilator therapy is indicated.
PEFR Peak expiratory flow rate. Maximum speed of expiration. PEFR < 70% of expected indicates poorly controlled obstructive lung disease.
Gas transfer factor An estimate of the lungs’ ability to transfer gases. Usually performed by inhaling a gas mixture containing a small amount of carbon monoxide
Reduced in conditions that reduce the surface area available for gas transfer (emphysema), conditions that thicken the alveolar membrane (fibrosis), interstitial lung disease, asbestosis and anaemia
Increased in polycythaemia (some laboratories adjust for haemoglobin concentration)

Table 5.9 Indications for blood gas analysis in the preoperative period

Surgical presentation Useful features
Elective surgery  
Chronic respiratory disease:
Moderate to severe COPD
Fibrotic lung disease
Bronchectasis and cystic fibrosis
Severe chest wall deformity e.g. ankylosing spondylitis
Lung malignancy
Degree of hypoxaemia (respiratory failure)
Distinguish type I (characterized by normocapnia) from type II (characterized by hypercapnia) respiratory failure
Detect degree of compensation of hypercapnia (uncompensated, acute hypercapnia results in respiratory acidosis)
Emergency surgery  
As above.
Acute respiratory disease: pneumonia, pleural effusion, ARDS, pneumo- or haemothorax, suspected pulmonary embolism Dyspnoea, decreased SaO2
Shock
As above
Document acid–base disturbance including the presence and degree of metabolic acidosis indicating inadequate tissue perfusion and to guide resuscitation

COPD = chronic obstructive pulmonary disease; ARDS = acute respiratory distress syndrome

The high risk patient

Blood borne viruses (hepatitis B, C and HIV) all pose risk to the surgical team and precautions should be taken to minimize the risk of inoculation. Similar precautions are also recommended for patients with a known or suspected diagnosis of Creutzfeldt–Jacob Disease (CJD) or vCJD (variant CJD) and patients at increased risk of hepatitis B, C or HIV where their viral status is not known. High risk patients include intravenous drug users (IVDUs), recipients of multiple blood transfusions and blood products, including haemophiliacs and those from HIV endemic areas, particularly sub-Saharan Africa. The adoption of universal precautions for all patients is recommended and helps minimize the risk of inoculation injury to the surgical team.

All members of the surgical team should be immunized against hepatitis B. All blood exposure incidents should be reported to occupational health according to local protocol for assessment and consideration of post-procedure prophylaxis. Theatre staff should be notified of high risk patients. Precautions include wearing goggles, waterproof gowns and protective footwear, double gloving and the use of disposable surgical and anaesthetic equipment where possible. Meticulous surgical technique is important with minimal sharps handling and avoidance of direct tissue contact with hands. Stapling devices should replace sutures where possible and sharp needles replaced by blunt ones where practicable. Specimens from high risk patients should be appropriately labelled and transported separately.

Where patient testing for blood borne viruses is indicated, i.e. post blood exposure incident or in high risk patients where viral status is not known, it should be performed only after appropriate consent and counselling.

Preoperative MRSA screening

Infection with methicillin resistant Staphylococcus aureus (MRSA) can have devastating clinical consequences, causing significant in-hospital morbidity and mortality, prolonging hospital stay and increasing cost. Preoperative MRSA screening has been shown to be an effective strategy to decrease MRSA infection rates by identifying asymptomatic carriers and allowing decolonization treatment prior to hospital admission which reduces the risk of transmission and clinical infection (see chapter 4). Preoperative MRSA screening involves swabbing the areas (nostrils, perineum and axillae) regularly colonized by Staphylococcus aureus. MRSA carriers should then undergo preoperative decolonisation using daily antibacterial shampoo, body wash and nasal cream three times daily for five days. Although this regime is only 50–60% effective, in the remainder, reduced bacterial shedding reduces the risk of transmission and infection. Where possible, MRSA positive emergency admissions should be nursed in single room isolation until decolonization is complete.

The preoperative ward round

The purpose of the preoperative ward round is to ensure that the patient has been adequately assessed and prepared for surgery and involves both surgeon and anaesthetist. Consideration should be given to the appropriate administration of drugs in the perioperative period as well as a comprehensive, multidisciplinary approach to the perioperative period. Patient questions should be addressed and full explanations of the surgical procedure, anaesthesia, post-operative analgesia, as well as the use of catheters, drains and postoperative monitoring should be given.

Venous thromboembolism prophylaxis

In the United Kingdom, 25 000 people die each year from venous thromboembolism (VTE): many of these deaths are preventable (EBM 5.2). A substantial proportion of these are surgical patients. In addition to death from pulmonary embolism (PE), deep vein thrombosis (DVT) causes substantial morbidity which may persist to cause the chronic health problems of post-thrombotic syndrome with leg ulceration and swelling with huge health care costs.

All patients should have their risk of VTE assessed prior to, or on, admission to hospital to enable prophylactic measures to be taken. The patient’s risk of bleeding should be taken into consideration and balanced against the risk of DVT when deciding on thromboprophylaxis. The magnitude of the risk of DVT relates to patient and operative factors as shown in Table 5.10. Measures should be taken to reduce the risk of VTE, in addition to thromboprophylaxis; these include maintaining hydration, encouraging mobility and in patients at very high risk of VTE the use of an inferior vena caval filter. Women should consider stopping oestrogen-containing contraceptives and hormone replacement therapy four weeks prior to surgery.

Table 5.10 Patients at risk of venous thromboembolism

Medical patients

Surgical patients

VTE risk factors

Pregnancy

Adapted from: Venous thromboembolism: reducing the risk. NICE clinical guideline 92, 2010.

Mechanical and pharmacological thromboprophylaxis is available (Table 5.11). All surgical patients with increased risk of VTE should be offered mechanical VTE prophylaxis at admission and pharmacological VTE prophylaxis if the risk of bleeding is low. Thromboprophylaxis should be continued until mobility is not significantly reduced, usually for 5–7 days with the exception of orthopaedic lower limb surgery where it should be continued for 2–4 weeks after surgery.

Table 5.11 Thromboprophylaxis

Mechanical

Pharmacological

Antibiotic prophylaxis

Antibiotic prophylaxis refers to the use of antibiotics peri-operatively to reduce the incidence of surgical site infections (EBM 5.3). Surgical site infections (SSI) refer to infections of the wound, tissues involved in the surgery or devices where surgery involves the insertion of implants or surgical devices (see Chapter 4). Prevention of SSI is important because they are responsible for approximately 16% of hospital acquired infections and cause considerable morbidity, prolonged hospital stay and increased costs. Every surgical patient should be assessed for the risk of SSI and its potential severity and appropriate prophylactic antibiotics selected. The risk of SSI depends on patient and operative risk factors, including the wound class (Table 5.12), SSI risk should be balanced against the risks of antibiotic prophylaxis such as allergy and increasing the prevalence of resistant bacteria and infection with organisms like Clostridium difficile. In general a single dose of intravenous antibiotics is adequate provided the half-life permits activity throughout the operation.

Table5.12 Degree of contamination

Class Definition
Clean Operations in which no inflammation is encountered and which do not breach the respiratory, alimentary or genitourinary tracts. Operating theatre technique is continuously aseptic
Clean–contaminated Operations which breach the respiratory, alimentary or genitourinary tracts but without significant spillage
Contaminated Operations where acute inflammation is encountered or where the wound is visibly contaminated, e.g. gross spillage from a hollow viscus or compound injuries less than 4 hours old
Dirty Operations in the presence of pus, a perforated hollow viscus or a compound injury more than 4 hours old

Perioperative implications of chronic disease

Some of the more important and common chronic diseases are discussed below.

Cardiovascular disease

Ischaemic heart disease

Ischaemic heart disease is common; increases with age; and significant number of patients with significant coronary artery disease are asymptomatic. Preoperative assessment therefore should focus not only on documented ischaemic heart disease but also on the diagnosis and investigation of occult or undiagnosed disease, especially in high-risk groups (Table 5.13).

Table 5.13 Factors indicating increased risk of ischaemic heart disease

Myocardial infarction

In patients with previous myocardial infarction (MI), the risk of a perioperative MI decreases with time from infarction (Table 5.14), but overall is approximately 6%. This contrasts with patients without a history of MI whose risk is around 0.2%. The mortality of perioperative MI is approximately 50% greater than that of non-perioperative MI. In general, a delay of six months for elective surgery is recommended with three months delay for more urgent surgery, although individual patient factors need to be considered, taking the risks of delayed surgery into account. Post-infarction coronary artery angioplasty, stenting and bypass surgery may reduce the risk of perioperative MI meaning that surgery may be safely carried out sooner. Advice from cardiologists may be helpful in planning the timing of surgery following MI to minimize risk and optimise medical treatment.

Table 5.14 Risk of postoperative myocardial infarction according to time elapsed after previous myocardial infarction.

Time elapsed after MI Incidence of postoperative MI (%)
> 6 months 5
4–6 months 10–20
< 3 months 20–30

Postoperative MI may be difficult to diagnose due to atypical or silent presentations, particularly in diabetics. In addition, thrombolysis is often contraindicated because of the risk of postoperative bleeding. Advice from a cardiologist should be sought early once the diagnosis is suspected.

Congestive cardiac failure

The commonest cause of congestive cardiac failure is ischaemic heart disease but the exact cause should be determined where possible as it may influence treatment. Cardiac failure is associated with a number of complications as a result of either poor pump function or underlying cardiac disease (Table 5.15). Uncontrolled heart failure indicated by peripheral oedema, paroxysmal nocturnal dyspnoea or orthopnoea is associated with very high perioperative risk and should be controlled prior to elective surgery.

Table 5.15 Increased perioperative risk in patients with cardiac failure.

Mechanism Complication
Poor ‘pump function’ Pulmonary oedema
Cardiogenic shock
Renal failure
Organ ischaemia, e.g. bowel ischaemia
Deep venous thrombosis
Cardiac disease Arrhythmias
Myocardial infarction
Venous thromboembolism

Perioperative management of patients with cardiovascular disease

Cardiovascular management

The principle of perioperative cardiovascular management is to protect against myocardial ischaemia by:

Maximizing myocardial oxygen supply

Blood supply to the left ventricle occurs during diastole and depends on the coronary perfusion pressure (diastolic blood pressure minus left ventricular end diastolic pressure). Left ventricular blood supply is therefore optimal when tachycardia is avoided, the duration of diastole is maximal and diastolic blood pressure high.

In order to optimize and monitor myocardial oxygen supply and demand closely, patients with significant cardiovascular and respiratory disease may benefit from invasive perioperative monitoring (Table 5.16 and EBM 5.5).

Table 5.16 Monitors of cardiovascular status during the perioperative period.

Monitor Information given
Arterial catheter Continuous measurement of blood pressure
Central venous catheter Central venous pressure (estimate of cardiac preload with important exceptions)
Pulmonary artery catheter Pulmonary capillary wedge pressure (a measure of left atrial pressure) and cardiac output (by thermodilution)
Oesophageal Doppler Cardiac output

Respiratory disease

Patients with significant respiratory disease require close monitoring, preferably in a high dependency or intensive care unit, particularly after thoracic or major abdominal surgery where hypoventilation, atelectasis and pneumonia are common. It is essential that adequate analgesia is provided to enable the clearance of secretions and avoid atelectasis by coughing to avoid hypoxia and pneumonia. It is also important to remember that a small proportion of patients with chronic hypercarbia rely on hypoxic drive for ventilation and that high concentrations of inspired oxygen may cause hypoventilation and respiratory failure. These patients walk a tightrope between the increased postoperative complications associated with hypoxia and respiratory failure where hypoventilation ensues from excess supplemental oxygen therapy. They are particularly vulnerable to postoperative complications such as respiratory failure and pneumonia requiring respiratory support including ventilation. The perioperative management of patients with respiratory disease is discussed below.

Diabetes mellitus

The increased perioperative risk associated with diabetes mellitus is attributable to related co-morbidities and poor glycaemic control which is exacerbated by surgical stress.

Principles of perioperative diabetes management

The aim of perioperative diabetic management is to maintain stable circulating glucose levels, ensuring an adequate supply to the cells. A circulating glucose concentration of 6–10 mmol/l is a reasonable target range. As hypoglycaemia is more dangerous to the patient than hyperglycaemia, moderate hyperglycaemia is acceptable. Care should be taken to administer sufficient potassium when insulin is administered as insulin increases cellular potassium uptake, with a tendency towards hypokalaemia. The approach used to achieve perioperative glycaemic control depends on a number of factors including:

In practice, many units have protocols for the perioperative management of diabetes, which can be tailored to the individual patient. Table 5.17 gives examples of the typical approach to diabetic control.

Table 5.17 Typical scenarios for diabetic patients presenting for surgery.

Patient Procedure Management
Diet-controlled diabetic Elective laparoscopic cholecystectomy (moderate stress response) Monitor blood glucose until eating
Patient on oral hypoglycaemics Hernia repair (minor stress response) Omit oral hypoglycaemic on morning of surgery
Monitor preoperatively for hypoglycaemia
Monitor postoperatively until eating normally
Restart oral hypoglycaemics when on normal diet
Normally well-controlled Elective aortofemoral bypass (major stress response) Omit oral hypoglycaemic on morning of surgery
Monitor perioperatively for hypo- or hyperglycaemia
If blood glucose > 10 mmol/l, commence glucose/insulin/potassium infusion
Normally poorly controlled blood sugar > 10 mmol/l Emergency aortofemoral bypass (major stress response) Commence glucose/insulin/potassium infusion prior to surgery Stop oral hypoglycaemics perioperatively
Insulin-dependent diabetic
Well-controlled Cataract surgery (minor stress response) Omit morning insulin
Monitor blood sugar for hypoglycaemia
Restart regular insulin when eating
Normally well-controlled Elective coronary artery bypass graft (major stress response) Convert to glucose/insulin/dextrose prior to surgery
Monitor blood sugar perioperatively
Convert to subcutaneous short-acting insulin and then regular insulin as diet reintroduced
Blood sugar > 20 mmol/l or ketones in urine Emergency laparotomy for diverticular abscess (major stress response) Treat as diabetic ketoacidosis and stabilize prior to surgery
Ensure adequate volume resuscitation
Continue glucose/insulin/potassium infusion perioperatively
Convert to intermittent short-acting and then normal insulin as diet reintroduced

Gastrointestinal

Biochemical

Haematological

Miscellaneous

Jaundice

Preoperative diagnosis of the cause of jaundice is important because it will impact management. Pre-hepatic jaundice is usually due to haemolysis (e.g. massive transfusion and burns) or a defect in bilirubin conjugation (e.g. Gilbert’s disease). Intrahepatic jaundice covers all of the abnormalities that may occur in the bilirubin conjugation process as well as its uptake by and secretion from the hepatocyte. Post-hepatic (surgical) jaundice is caused by posthepatic biliary obstruction. The risks of surgery in jaundiced patients relate to the following factors:

Abnormal coagulation

Patients with abnormal coagulation fall into three categories.

Anticoagulant therapy

Patients receiving oral anticoagulants may require reversal of anticoagulation, bridging anticoagulation to cover the perioperative period and re-anticoagulation. Advice from a haematologist or cardiologist may be helpful. In general, warfarin should be stopped 4–5 days before surgery to achieve an INR < 2 for minor surgery and < 1.5 for major surgery. The risk of thromboembolism during the perioperative period without anticoagulation should be assessed (Table 5.20). Where the risk is high or medium, bridging anticoagulation with intravenous unfractionated heparin or low molecular weight heparin should be administered. Bridging anticoagulation is not required for patients at low risk of thromboembolism. Oral anticoagulation should be reintroduced as soon as the risk of haemorrhage has subsided and the patient is tolerating oral medication. Bridging anticoagulation should only be stopped once the INR is therapeutic.

Table 5.20 Risk stratification of conditions requiring consideration of continuous perioperative anticoagulation

High risk Intermediate risk Low risk

Bridging anticoagulation required Bridging anticoagulation may be required Bridging anticoagulation not required

Vitamin K can be used to reverse warfarin anticoagulation in patients requiring urgent surgery; it takes 24–48 hours to reverse anticoagulation. Where more rapid correction of coagulation is required, fresh frozen plasma and prothrombin complex concentrates are indicated. The use of prothrombin complex concentrates usually requires the approval of a haematologist. Protamine can be used to reverse the effects of heparin if urgent reversal is required (coagulation normalizes without treatment 4–6 hours after heparin cessation).

Miscellaneous conditions

There are many other diseases with particular considerations in the perioperative period that are beyond the scope of this chapter for detailed discussion, Table 5.21 gives an overview of some of these.

Table 5.21 Relevance of some medical conditions in the perioperative period.

Condition Considerations
Rheumatoid arthritis Neck may be ‘unstable’, careful positioning necessary, complex drug therapy, associated chronic diseases, e.g. renal failure, lung disease
Multiple sclerosis Reduced respiratory reserve; stress of surgery can cause relapse or worsening of disease
Epilepsy Drugs may interact with anaesthetics; surgical stress and some drugs may precipitate seizures
Scoliosis or spondylitis Can significantly reduce respiratory reserve; difficult endotracheal intubation
Myasthenia gravis Risk of respiratory failure or aspiration; anaesthetic technique needs modifying
Sickle-cell anaemia Stress of surgery, hypoxia, hypothermia can all precipitate sickle-cell crisis

Anaesthesia and the operation

Prior to the induction of anaesthesia a preoperative check should be completed by the ward nursing and theatre staff, anaesthetist and surgeon. This is to guard against incorrect and wrong site surgery, prevent poor planning and adverse events.

Recent introduction of the World Health Organization (WHO) Surgical Safety Checklist has formalized this process. The preoperative check covers patient identity, proposed surgery and site (including marking), availability of clinical records, investigation results, consent and patient allergies, as well as equipment availability and anaesthetic concerns.

Local anaesthetic agents

Local anaesthetic agents such as lignocaine and bupivacaine exert their effect by causing a local, reversible blockade of nerve conduction by reducing nerve membrane sodium permeability. They are non-specific and act on autonomic, motor and sensory nerves equally. Their duration of action depends on the local anaesthetic agent used, dose, whether adrenaline has been co-administered and the proximity of local anaesthetic to the nerve.

Maximum local anaesthetic doses are shown in Table 5.22. A patient receiving large doses of local anaesthetic should be monitored with ECG, pulse oximetry and non-invasive blood pressure measurement. Local anaesthetic toxicity as a result of inadvertent injection into the blood stream or overdose may be heralded by perioral tingling and can result in arrhythmias and convulsions (Table 5.23). Intravascular injection should be avoided by aspirating on the needle prior to injection. Treatment of toxicity is supportive; the airway should be secured, ensuring adequate ventilation and the circulation supported with intravenous fluid and antiarrhythmics if necessary. Seizures should be controlled with small increments of intravenous benzodiazepines.

Table 5.22 Safe maximum doses of commonly used local anaesthetics

Drug With adrenaline (epinephrine) (mg/kg) Without adrenaline (epinephrine) (mg/kg)
Lidocaine 6 2
Bupivacaine 2 2
Prilocaine Maximum 600 mg  

Table 5.23 Signs of local anaesthetic toxicity

Early

Late

Local anaesthetics can be used to provide surgical anaesthesia and postoperative analgesia in a variety of techniques which are discussed in more detail below. Patients undergoing major surgery under regional anaesthesia should always be fasted as for a general anaesthetic in case sedation is required or conversion to general anaesthetic.

Spinal and epidural anaesthesia

Spinal anaesthesia

Spinal anaesthetic is defined by the introduction of local anaesthetic, usually lidocaine or bupivacaine into the subarachnoid space to block the spinal nerves before they exit the intervertebral foramina (Fig. 5.4). To protect against damage to the spinal cord, spinal anaesthesia is administered below L2, either at the L3/4 or L4/5 level. At this level, the cauda equina nerves acquire their perineural coverings and myelin sheath as they exit the dura making them exquisitely sensitive to the effect of local anaesthetic. As a result, 2–4 ml of local anaesthetic produces a dense block up to T6 level, with a rapid onset of action, giving 2–3 hours of surgical anaesthesia. The addition of 6–8% glucose increases the density of the spinal anaesthetic solution making it easier to control the level of the block using gravity. Aspiration of subarachnoid fluid confirms the correct site of the spinal needle.

Epidural anaesthesia

Both spinal and epidural anaesthesia block spinal cord sympathetic outflow. Rapid vasomotor paralysis with peripheral vasodilatation is an early sign of a successful spinal or epidural anaesthetic due to the rapid onset of blockade in these small unmyelinated fibres. Conversely, the resulting peripheral vasodilatation can be a nuisance with unwanted hypotension requiring treatment with intravenous fluids, vasoconstrictors, or reduction in the rate of the epidural infusion.

Epidural anaesthesia involves the injection of local anaesthetic into the epidural space which extends along the entire vertebral canal between the ligamentum flavum and dura mater (Fig. 5.5). Local anaesthetic spreads cranio-caudally penetrating the meningeal sheaths containing the nerve roots causing an anaesthetic block affecting several dermatomes. The level of epidural anaesthetic is therefore dictated by the proposed site of surgery and the dematomes involved. The nerve roots are fully covered and myelinated as they traverse the epidural space and therefore a larger volume (10–20 ml) of local anaesthetic, compared to spinal anaesthesia, is required to achieve anaesthesia. The technique by which a needle is introduced into the epidural space depends on sensing a loss of resistance as the needle passes through the ligamentum flavum; aspiration ensures that the needle is not advanced too far into the subarachnoid space, termed a ‘dural tap’. An ongoing CSF leak following a dural tap can lead to loss of CSF volume and headache. As well as adequate hydration, the CSF leak may be managed by the use of a blood patch. This involves using the patient’s own blood injected into the epidural space to seal the leak. If a dural tap goes undetected with the injection of local anaesthetic into the subarachnoid space, a profound block of all spinal nerves will result, with the potential of respiratory arrest and profound hypotension. A catheter is often left in the epidural space to provide access for ongoing analgesia. Table 5.24 details some common complications of epidural anaesthesia. Both spinal and epidural anaesthesia block spinal cord sympathetic outflow. Rapid vasomotor paralysis with peripheral vasodilatation is an early sign of a successful spinal or epidural anaesthetic due to the rapid onset of blockade in these small unmyelinated fibres. Conversely, the resulting peripheral vasodilatation can be a nuisance with unwanted hypotension requiring treatment with intravenous fluids, vasoconstrictors, or reduction in the rate of the epidural infusion.

Table 5.24 Complications of epidural anaesthesia and analgesia

Complication Steps to avoid complication
Epidural abscess (0.015–0.05%) Avoid if skin or systemic sepsis
Epidural haematoma (0.01%) Correct coagulopathy, reverse anticoagulation and avoid in patients who have received recent heparin
Respiratory depression Avoid high epidural block, (C3–5 innervate diaphragm)
Cardiac depression Avoid mid-thoracic epidural, blocking cardiac sympathetic outflow. The loss of positive chrontropic and inotropic innervation results in cardiovascular instability and hypotension

Postoperative analgesic strategy

There is good evidence to guide postoperative analgesia. Multimodal analgesia, utilizing several analgesics that act at different parts of the pain pathway is more effective than the use of single agents and reduces the dose required of individual analgesics, minimizing side effects. Epidural analgesia and patient controlled parenteral opiate analgesia are commonly used for major surgery. Limb surgery lends itself to the use of postoperative peripheral nerve blocks. Subcutaneous or oral morphine regimens may be sufficient for less major surgery. In all cases paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), where appropriate, should be used alongside opiate analgesia. A step-down regimen should be in place to minimize the use of potent opioid analgesia as the requirement for them lessens as time elapses from surgery. Individual analgesic techniques are discussed below.

Paracetamol, NSAIDs and selective Cox-2 inhibitors

Paracetamol is effective in the management of post- operative pain and can be administered by the oral, intravenous and rectal routes. Regular use has been shown to reduce opioid requirements by 20–30% and in combination with NSAIDs, the combination is more effective than NSAIDs alone. Paracetamol should therefore be prescribed to all postoperative patients except in the rare instance of contraindications.

NSAIDs are also an important component of multimodal postoperative analgesia. In combination with opioids, NSAIDs increase analgesia and have an opioid sparing effect, reducing consumption, postoperative nausea and vomiting and sedation. Their use is limited by their side effect profile, including renal impairment, impaired platelet function with the potential for increased postoperative bleeding, peptic ulceration and bronchospasm in individuals at risk. Asthma is not an absolute contraindication and previous use without adverse effects permits their use.

Selective cyclo-oxygenase (COX)-2 inhibitors such as celecoxib, parecoxib and etoricoxib are as effective as NSAIDs in the management of postoperative pain and have an opioid sparing effect. Their potential advantage is an improved side effect profile compared with NSAIDs, with no impairment of platelet function, reduced gastrointestinal complications and no associated bronchospasm. The use of COX-2 inhibitors is limited by their association with a small increased risk of thrombotic events (myocardial infarction and stroke) and therefore they should not be used except where NSAIDs are contraindicated and after assessing cardiovascular risk. COX-2 inhibitors are contraindicated in ischaemic heart disease, cerebrovascular and peripheral arterial disease and moderate to severe cardiac failure. They should also be used with caution in patients with risk factors for these conditions.