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Surgical Patient Care

1 Contact Hour including 1 Advanced Pharmacology Hour
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Tuesday, August 20, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥ 92% of participants will know how to care for surgical patients.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Explain the components of a perioperative evaluation.
  2. Identify the concerns in conducting a perioperative cardiac risk assessment.
  3. Compare and contrast the categories of the American Society of Anesthesiologist’s physical status classification system.
  4. Describe the purpose of the Mallampati Score.
  5. List the common postoperative complications.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Author:    Berthina Coleman (MD, BSN,RN)

Introduction

According to the Center for Medicare and Medicaid Services (CMS) (2022), national health spending decreased from 9.7% in 2020 to 4.2% in 2021. This percentage corresponds to $4.3 trillion in healthcare spending (Center for Medicare and Medicaid Services [CMS], 2022). The decrease in spending from 2020 to 2021 is theorized to be related to lower levels of federal supplemental funding, according to the CMS. However, national health expenditure is expected to grow by 5.1% per year between 2021 and 2030 (CMS, 2022). As such, the projected national health expenditure share of gross domestic product in 2030 is 19.6% (CMS, 2022).

According to the Health Cost Institute, the cost of health care has progressively increased over the past decade including the cost of surgical care. In 2019, the per-person cost of health care in the United States reached $6,001 per person, corresponding to 21.8% over the past five years (Health Cost Institute, 2019; Ning et al., 2021).

Perioperative Evaluation

Perioperative mortality and morbidity have fortunately continued to decrease over the past decade. This decrease is likely related to improved anesthetic and surgical techniques with corresponding improved perioperative care. Typically, primary care providers are consulted to assess the risk of perioperative complications in the preoperative setting (McIsaac et al., 2018; Marwell et al., 2018).

Anesthetic Agents

The decision around the type of anesthetic technique to be utilized intraoperatively is left to the anesthesiologist. General anesthesia, spinal, or epidural agents can be used depending on the patient and the type of surgery, but it is important to know that all of these agents can cause vasodilation and decrease myocardial contractility (McIsaac et al., 2018; Marwell et al., 2018). Often these agents lead to mild hypotension but occasionally can lead to more severe and more prolonged episodes of hypotension (McIsaac et al., 2018).

Anesthetic agents lead to decreased tidal volume and impaired gas exchange. Stress hormones can remain elevated for days. In fact, serum antidiuretic hormone levels can remain elevated for up to 1 week. The surgical procedure itself and the anesthetic can lead to increased inflammation and hypercoagulability (McIsaac et al., 2018).

Evaluating Asymptomatic Patients

Patients less than age 50 without any medical problems are at a very low risk for sustaining perioperative complications. A typical preoperative evaluation should include a history and physical examination, a documented functional status, and an assessment of the patient’s cardiopulmonary status or exercise tolerance. All of these components will provide the clinical team with insight into how the patient will tolerate the actual surgery and the perioperative period. In addition, it is important to obtain a bleeding disorder history or other causes of coagulopathy which would increase blood loss during surgery (Marwell et al., 2018; Martin & Cifu, 2017).

Common symptom-specific questions which should be asked to elicit a history of coagulopathy include (Papadakis et al., 2022; Martin & Cifu, 2017; Stone & Humphries, 2017):

  • Iron deficiency
  • Unprovoked epistaxis or gingival bleeding
  • Abnormally heavy menstrual cycles
  • Hemarthrosis with mild trauma
  • Family history of abnormal bleeding
  • Severe kidney or severe liver disease
  • Use of medications that impair coagulation, including herbs or supplements 
  • Unproved bruising measuring more than 5 cm on the trunk

Note that routine laboratory tests are currently not recommended in asymptomatic patients. Usually, elderly patients who are undergoing minor procedures may not benefit from preoperative screening labs (Martin & Cifu, 2017).

Cardiac Risk Assessment

Myocardial infarction and cardiac arrest are the 2 most important perioperative complications directly linked to increased mortality. Arrhythmias, unstable angina, and heart failure are additional cardiac complications which can occur during the perioperative period (Papadakis et al., 2022; McPhee et al, 2022).

End-organ cardiovascular disease is the most compelling risk factor for cardiac complications in the perioperative setting. Examples of end-organ cardiovascular disease include cerebrovascular disease, chronic kidney disease, coronary artery disease, and heart failure. Insulin-dependent diabetes is considered a cardiovascular disease equivalent. An elevated serum creatinine level greater than 2 mg/dL is considered a risk factor for cardiovascular complications as well (McPhee et al., 2022).

Certain surgical procedures increase the risk of cardiac complications, such as vascular procedures, including intrathoracic or intra-abdominal vascular procedures. Several risk factors have been identified and are outlined in the revised cardiac risk index (RCRI). 

The number of predictors present corresponds to a certain risk percentage (McPhee et al., 2022):

  • None: 0.4%
  • One: 1%
  • Two: 2.4%
  • More than two: 5.4%

Patients with limited exercise capacity have increased cardiovascular risk in the perioperative setting. Emergency procedures should not be delayed to perform an extensive cardiovascular assessment.

Most patients with cardiovascular risk factors can be correctly stratified based on their clinical history and physical exam. In patients with at least one revised cardiovascular risk index predictor prior to a major surgical procedure, these patients should have a preoperative electrocardiogram (ECG). Typically, patients scheduled for minor procedures do not need to undergo preoperative cardiovascular screening or testing.

Cardiovascular stress testing is usually reserved for patients with elevated cardiovascular risk scores. Inducible ischemia indicates a high risk of cardiac complications, especially when related to vascular procedures. Preoperative B-type natriuretic peptide (BNP) or N-terminal fragment of proBNP correlates with an increased risk of perioperative cardiac complications. A BNP value greater than 92 mg/L or proBNP value greater than or equal to 300 ng/L in the preoperative setting is associated with a 4X increase in 30-day mortality and myocardial infarction (McPhee et al., 2022).

Preoperative medications such as nitrates, beta-blockers, or calcium channel blockers should be continued in the perioperative period. The initiation of beta-blockers prior to major cardiovascular procedures has been associated with reduced risk of nonfatal myocardial infarction. On the other hand, the use of a high fixed dose of beta-blockers increased the risk of total mortality and stroke. As such, beta-blockers should be started well ahead of the scheduled surgery.

American Society of Anesthesiologists

The American Society of Anesthesiologists (ASA) has developed a physical status classification system. It is used to describe the illness severity category for each patient, which ranges from I to VI (Doyle et al., 2022; Papadakis et al., 2022):

  • ASA I: Normal healthy patient
  • ASA II: A patient with mild systemic disease
  • ASA III: A patient with severe systemic disease
  • ASA IV: A patient with severe disease that is a constant threat to life
  • ASA V: A moribund patient who is not expected to survive without the operation
  • ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes

Patients who are categorized as ASA I and II can be sedated without the assistance of the anesthesia staff (Doyle et al., 2022). However, patients who are more ill, that is, ASA category III and IV, should have anesthesia consulting for elective procedures (Doyle et al., 2022). ASA III classification is an independent risk factor for adverse outcomes in general anesthesia (Doyle et al., 2022).

Surgical patients should be screened for their comorbidities, including coronary artery disease, chronic obstructive pulmonary hypertension, or hypertension. Patients using supplemental oxygen are rated as an ASA class III or IV (Doyle et al., 2022). It is important to document a history of allergies because this may become critical information in the perioperative setting. For example, an allergy to eggs will prevent the use of propofol. Decreased renal and liver function will affect the clearance of anesthetics and their metabolites.

Airway

Mallampati Score

The Mallampati score is a 4-point scale created to predict difficult airways during intubation (Green & Roback, 2019). Airway assessment is important in the perioperative setting. The Mallampati score is used in both the operative and procedural sedation settings. Airway choice is typically affected by the type of sedation. Several factors affect intubation failure, including the inability to open the mouth for more than 4 cm, a history of cervical spine inflexibility, a Mallampati core greater than III, and a large tongue (Green & Roback, 2019).

Image 1: Mallampati Score

graphic showing mallampati score classifications

Nutritional Status in Perioperative Patients

The nutritional status of patients can impact their ability to recover from surgical procedures. Patients who are overfed or underfed may each face serious challenges in the perioperative setting which could lead to increased morbidity and mortality. It is crucial that malnutrition be recognized and documented in the medical record prior to surgery.

Common factors that may affect a patient's nutritional status include prior gastrointestinal surgery, geographic location, poverty, and other socio-economic factors. Malnutrition can be classified into the type of deficiency such as overall caloric deficiency, micronutrient deficiency or protein deficiency. Note that malnutrition can be disease related, injury related, or starvation related.

Postoperative Evaluation

Postoperative Pain

Patients in the post-anesthesia care unit (PACU) are not always able to communicate their pain to the clinical team due to the somnolent effects of anesthesia. Clinicians have to rely on blood pressure, heart rate, respiratory rate, signs of agitation, and nonverbal signs of pain to correctly assess the patient’s pain.

Postoperative Hypertension and Hypotension

Hypotension in the PACU is usually caused by hypovolemia or medication side effects. Hypovolemia symptoms include altered mental status and low urine output. If the patient remains hypotensive in spite of the resuscitative efforts, then invasive blood pressure monitoring becomes necessary using an arterial line. Note that epidural anesthesia can blunt sympathetic system response, which is exacerbated in the setting of hypovolemia. Note that urine output less than 0.5 cc/kg/hour should prompt immediate evaluation for hypovolemia (McKean et al., 2017).

Pain can lead to increases in the patient’s blood pressure and heart rate. Beta-blockers should be used in patients who were taking them prior to surgery. Hypertension management in the PACU should be treated aggressively in certain procedures, such as carotid endarterectomy, in order to avoid debilitating consequences, including neurologic damage (McKean et al., 2017). In patients who were hypertensive prior to surgery, most antihypertensives can be used in the PACU, with the exception of diuretics (McKean et al., 2017).

Postoperative Respiratory Insufficiency

Dyspnea, tachypnea, and wheezing in the postoperative setting should raise responses and should raise suspicion that the patient may be in respiratory distress. Most patients do need oxygen in the postoperative setting, and clinicians must remain vigilant in case there is a need for immediate reintubation (McKean et al., 2017). Multiple factors contribute to postoperative respiratory insufficiency, such as longer duration of surgeries, endotracheal intubation, use of narcotics, and upper abdominal and thoracic surgeries.

Poor pain control also leads to an increased chance of respiratory insufficiency (McKean et al., 2017). Pulmonary edema is a sign of respiratory distress in the postoperative period, and a chest x-ray can be used to evaluate the patient in the postoperative setting. Patients who had a central line placed intraoperatively, who become short of breath suddenly, should be re-evaluated for a pneumothorax (McKean et al., 2017).

Postoperative Delirium

Delirium is a common occurrence in patients in the postoperative setting, especially in patients with a history of alcohol and drug abuse, patients with dementia, or elderly patients (McKean et al., 2017). Symptoms of delirium usually wax and wane in intensity over time. Confusion, hallucination, and agitation are commonly seen among this patient population.

Postoperative Nausea and Vomiting

Nausea and vomiting are common complaints in the PACU setting, and their etiology is multifactorial (McKean et al., 2017). Factors that can contribute to nausea and vomiting include the use of volatile anesthetics, procedures involving the eyes or ears, and patients who had surgeries performed lasting more than 3 hours. Prophylactic antiemetics have been shown to alleviate the effects of postoperative nausea and vomiting (McKean et al., 2017).

Postoperative Fever

Within the first 48 hours postoperative, a low-grade fever is considered normal. Generally, it could be caused by atelectasis (lung collapse) or inflammatory changes (McKean et al., 2017). It is usually not from an infectious cause. After 48 hours, any fever over 100.4 degrees Fahrenheit should be evaluated for a potential source of infection. The first sources that should be evaluated include the surgical site, central lines, urinary catheters, and the lungs.

Postoperative Urinary Tract Infection

Urinary tract infections (UTIs) are more common in women compared to men and generally occur after vaginal or urologic surgery, particularly those that require the use of an indwelling catheter in the postoperative setting. The 3 most common causative bacteria are Escherichia coli, Staphylococcus aureus, and Proteus mirabilis. Common clinical practice is to remove indwelling catheters postoperatively within the first 48 hours. If that is not possible, the patient should be assessed daily for the further need for an indwelling Foley catheter. In general, most patients in a procedure lasting longer than 3 hours should have a Foley catheter placed. If a patient has not voided in over 8 hours, they should be evaluated with a bladder ultrasound at the bedside. If bladder retention is greater than 500 cc, the patient requires intermittent catheterization.

Case Study: Mr. Bona

You are a nurse working in a post-anesthesia care unit. 

You are caring for Mr. Bona who is status post appendectomy.

Mr. Bona is a 34-year-old male. He is an ASA class 1 who presented in the ED with acute abdominal pain. He was eventually diagnosed with appendicitis. During the procedure, the case was extremely difficult to complete laparoscopically, and eventually, it was converted to an open procedure. He is now recovering in the PACU with no complaints.

A few hours later, it was noted that Mr. Bona had a low-grade fever of 100.2 on post-op day #1. A low-grade fever on postoperative day #1 is considered normal. The patient should be closely monitored for increased temperature after 48 hours. Specifically, watch for temperatures above 100.4 degrees Fahrenheit.

At this time, the patient should be encouraged to ambulate and use their incentive spirometer. The patient ambulated several times during your shift, consistently used the incentive spirometer, and met the targets you set for him. The fever resolves 4 hours after onset. The remainder of his stay was uneventful, and he was discharged on day #3 with no complications.

Summary

Caring for patients in the postoperative setting can be challenging given the increasing medical complexity of our patient populations. However, it is imperative that clinicians participating in the care of these patients are kept up to date on principles governing the management of patients in the perioperative setting. It is of utmost importance that everyone in the health care team understand the underlying principles governing perioperative care and be able to aptly apply them as the need arises.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • Centers for Medicare & Medicaid Services. (CMS). (2022). National health expenditure projections 2021-2030: Forecast summary. Visit Source.
  • Doyle, D., Goyal, A., & Garmon, E. (2022). American society of anesthesiologists classification. National Library of Medicine. StatPearls. Visit Source.
  • Green, S., & Roback, M. (2019). Is the Mallampati score useful for emergency department airway management or procedural sedation? Annals of Emergency Medicine, 74 (2), 251–259. Visit Source.
  • Health Cost Institute. (2019). 2019 Health care cost and utilization report. Health Cost Institute. Visit Source.
  • Martin, S., & Cifu, A. (2017). Routine preoperative laboratory tests for elective surgery. Journal of the American Medical Association (JAMA), 318 (6), 567. Visit Source.
  • Marwell, J., Helfin, M., & McDonald, S. (2018). Preoperative Screening. Clinics in Geriatric Medicine, 34 (1), 95–105. Visit Source.
  • McIsaac, D., Wijeysundera, D., Huang, A., Bryson, G., & van Walraven, C. (2018). Association of hospital-level neuraxial anesthesia use for hip fracture surgery with outcomes. Anesthesiology, 128 (3), 480–491. Visit Source.
  • McKean, S., Ross, J., Dressler, D., & Scheurer, D. (2017). Principles and practice of hospital medicine (2nd ed.). McGraw-Hill Education, New York, NY. Visit Source.
  • Ning, N., Haynes, A., & Romley, J. (2021). Trends in the quality and cost of inpatient surgical procedures in the United States, 2002–2015. PLOS ONE, 16 (11). Visit Source.
  • Papadakis, M., McPhee, S., Rabow, M, & McQuaid, K. (2022). Current medical diagnosis & treatment 2022. McGraw-Hill Medical, New York, NY. Visit Source.
  • Stone, K., & Humphries, R., (2017). Current diagnosis & treatment: Emergency medicine (8th ed.). McGraw-Hill Education LLC., New York, NY. Visit Source.