What are the guidelines for preoperative and postoperative care?

Guidelines for Perioperative Care

Perioperative care should follow Enhanced Recovery After Surgery (ERAS) principles to optimize patient outcomes, focusing on preoperative optimization, appropriate intraoperative management, and structured postoperative care.

Preoperative Care

Patient Education and Counseling

• Patients should receive dedicated preoperative counseling about surgical and anesthetic procedures to reduce anxiety, enhance recovery, and improve outcomes 1
• Information should be provided in multiple formats (oral, written, multimedia) to improve perioperative feeding, early mobilization, pain control, and respiratory physiotherapy 1, 2

Preoperative Optimization

• Smoking cessation should be implemented at least 4 weeks before surgery to reduce respiratory and wound-healing complications 1
• Alcohol consumption should be stopped 4 weeks before surgery in patients who consume more than two units daily 1
• Preoperative carbohydrate loading up to 2 hours before surgery is safe and can decrease insulin resistance, particularly in major abdominal surgery 1
• Patients should be allowed clear fluids until 2 hours before anesthesia induction and solid food until 6 hours before surgery 1

Medication Management

• Long-acting anxiolytic drugs should be avoided, particularly in elderly patients (aged 65 years and older) 1
• Short-acting anxiolytics (such as 1-2 mg midazolam) can be used in selected cases to ease anxiety before anesthesia induction 1
• Anticoagulants should be managed based on thrombotic and bleeding risk:
  • Warfarin should be stopped at least 5 days preoperatively 3
  • Xa inhibitors like Apixaban should be stopped 2 days before surgery and Rivaroxaban 3 days before surgery 3
  • Antiplatelet medications like Aspirin/Clopidogrel should be stopped >7-10 days preoperatively except in high-risk cardiac patients 3, 4
• NSAIDs should be discontinued at varying intervals (1-10 days) depending on the specific medication 3

Risk Assessment

• Cardiac risk should be evaluated using validated tools like the revised Lee cardiac risk index 2
• Preoperative hemoglobin A1c should be measured for risk stratification, aiming for levels <7% 2
• Serum albumin levels should be assessed as hypoalbuminemia correlates with increased complications 1, 2

Intraoperative Care

Thromboprophylaxis

• Patients should wear well-fitting compression stockings and receive pharmacological prophylaxis with low molecular weight heparin (LMWH) 1
• Extended prophylaxis for 28 days should be considered in patients with colorectal cancer or others with increased VTE risk 1

Anesthetic Protocol

• A standardized anesthetic protocol should be used, with consideration for the specific surgical approach (laparoscopic vs. open) 1
• Intraoperative hypotension should be avoided as it increases perioperative cardiac and renal complications 2
• Fluid shifts should be managed carefully, especially in patients with heart failure or cardiomyopathy 2

Postoperative Care

Pain Management

• Multimodal analgesia should include acetaminophen and NSAIDs if not contraindicated 1
• Wound catheters and/or local abdominal wall blocks should be considered to reduce opioid demand 1
• Thoracic epidural analgesia should be used only after assessment for sepsis and abnormal coagulation 1

Respiratory Care

• Patients with hypoxemia should receive continuous positive airway pressure or noninvasive positive pressure ventilation rather than standard oxygen therapy if aspiration risk is low 1
• Respiratory physiotherapy involving sputum clearance, inspiratory muscle strength training, and deep breathing exercises should be implemented 1

Delirium Prevention

• Patients over 65 years of age should receive regular postoperative delirium screening 1
• At-risk patients should be managed with non-pharmaceutical interventions such as regular orientation, sleep hygiene approaches, and cognitive stimulation 1

Venous Thromboembolism (VTE) Prevention

• Patients should be assessed with a validated tool for VTE risk on admission and throughout their hospital stay 1
• For very high-risk patients, pharmacological combined with mechanical prophylaxis should be given 1
• Daily reassessment of VTE risk should occur postoperatively 1

Level of Care

• Appropriate postoperative care location should be determined based on validated preoperative risk scores, impact of the surgical procedure, ongoing physiological instability, and continuing supportive requirements 1
• High-risk patients should be considered for ICU admission to allow for close monitoring and rapid intervention if needed 1

Common Pitfalls to Avoid

• Viewing preoperative evaluation as simply "giving medical clearance" rather than a comprehensive risk assessment 2
• Performing tests that will not influence perioperative management 2
• Failing to communicate findings and recommendations to all members of the perioperative team 2
• Withdrawing antiplatelet drugs in high-risk cardiac patients when the bleeding risk is lower than the thrombotic risk 4