From the Guidelines
Managing surgical patients as a PGY1 requires a systematic approach that prioritizes effective communication with the surgical team, nursing staff, and patients, as well as a thorough pre-operative, intra-operative, and post-operative care plan. This approach should include assessing key clinical and anatomic variables, considering alternative therapies, and ensuring formalized surgical standby and periprocedural hemodynamic support are available, as outlined in the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention 1.
When developing a management plan, it is crucial to effectively communicate with other specialty services, including intensive care and surgical teams, as well as counsel patients' families regarding immediate and long-term management, as emphasized by the task force on pediatric cardiology fellowship training in general cardiology 1.
Key components of the care plan should include:
- Pre-operative preparation: reviewing medical history, current medications, allergies, and previous surgical experiences
- Pre-operative orders: appropriate NPO status, necessary labs (e.g., CBC, basic metabolic panel, coagulation studies), and imaging
- Prophylactic measures: antibiotics based on procedure type (e.g., cefazolin 2g IV for most clean procedures) and DVT prophylaxis with sequential compression devices and/or pharmacologic prophylaxis (e.g., enoxaparin 40mg daily or heparin 5000 units TID)
- Post-operative care: pain management using a multimodal approach, fluid management, early ambulation, respiratory care, and wound management
- Monitoring for common complications: surgical site infections, urinary retention, ileus, and VTE
It is also important to remember that guidelines provide an evidence-based framework, but management of individual patients must be flexible, taking into account the patient's preference, other medical or psychosocial conditions, evolution in knowledge over time, and the provider's experience 1.
From the Research
Preoperative Care
- A thorough preoperative evaluation is mandatory for all patients undergoing any surgical procedure to identify correctable medical abnormalities and understand the residual risk 2.
- The preoperative evaluation should vary among patients, depending on age and general health 2.
- Preoperative care includes preparation of the patient and awareness of complications associated with perioperative care 3.
Management of Surgical Patients
- As a PGY1, managing surgical patients requires understanding of the patient's needs and risk factors that may be affected by the surgical experience 4.
- The nurse's role in the preoperative assessment is to identify patient vulnerabilities, facilitate multidimensional communication, manage patients' expectations, and compensate for gaps in care 4.
- Enoxaparin can be used for prophylaxis and treatment of thrombosis in surgical patients, with the convenience of less frequent administration than unfractionated heparin and a possible lesser propensity for bleeding complications 5, 6.
Thrombosis Prevention
- Enoxaparin has demonstrated prophylactic efficacy against venographically confirmed deep venous thrombosis (DVT) in surgical patients at high risk of DVT 5.
- A once-daily regimen of enoxaparin is at least as effective and safe as conventional treatment with a continuous intravenous infusion of unfractionated heparin for the treatment of proximal lower limb DVT 6.
- The use of enoxaparin can lead to a reduced number of hospital admissions and a shorter hospital stay 6.