Perioperative Management

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1 Perioperative Management LISA JEWELL, MD, FACS SOUTH BAY PLASTIC SURGEONS

2 South Bay Plastic Surgeons 3640 Lomita Blvd. Ste. 306 The Spa at South Bay Plastic Surgeons 3440 Lomita Blvd. Ste. 100 The Aesthetic Institute 3640 Lomita Blvd. Ste. 302 Torrance, CA (310) Drs. Whitney Burrell, Charles Spenler, Michael Newman, and Lisa Jewell

3 Surgery would be easy if you didn t have to worry about: Infection Nausea/Vomiting Bleeding/hematoma Pressure Ulcers Nerve Compression/Traction Injuries Hypothermia DVT/PE Wound healing delay Poor scarring Pain management Patient dissatisfaction

4 Perioperative Management Patient Surgeon Communication Anesthesia Considerations Infection Control Nutrition Smoking Cessation Glucose Control Homeopathic Medications OR Safety Pain Control Venous Thromboembolism Prevention Post Operative Care Evidence Based Strategies to Reduce PostoperativeComplications in Plastic Surgery Harrison, Bridget MD; Khansa, Ibrahim MD; Janis, Jeffrey E. MD Plastic & Reconstructive Surgery: September Volume Issue 3S - p 51S 60S

Patient-Surgeon Communication Starts at consultation Sit down Do not act rushed Use humor Explain all options Tell patient what to expect Under promise -> Over Deliver Benefits: More satisfied

5 Patient-Surgeon Communication Starts at consultation Sit down Do not act rushed Use humor Explain all options Tell patient what to expect Under promise -> Over Deliver Benefits: More satisfied patients Fewer malpractice claims Evidence Based Strategies to Reduce PostoperativeComplications in Plastic Surgery Harrison, Bridget MD; Khansa, Ibrahim MD; Janis, Jeffrey E. MD Plastic & Reconstructive Surgery: September Volume Issue 3S - p 51S 60S

6 Anesthesia Considerations Consider performing surgery in the hospital for cases longer than 4h ASA class 3 do in the hospital Obese patients do in the hospital Use MAC and local when possible Less PONV Shorter hospital stays Lower risk of DVT Lower cost Minimize Hypothermia Minimize PONV Patient positioning Good communication with anesthesia team Outpatient Surgery Evans, Gregory R. D., et al. Plastic & Reconstructive Surgery. 136(1):89e-95e, July 2015.

7 Hypothermia What is it? Hypothermia = Core Temp 36 C or 96.8 F How do you measure it: Esophageal Temp Probe Tympanic Membrane Nasopharynx Why do we care? Hypothermia Increase Risk of: Major cardiac events Causes delays in digital pulse ox response time Coagulation disorders -> Bleeding -> Blood loss Wound complications Post op shivering Longer hospital Stays Increased surgical costs Prevention of Hypothermia in Plastic Surgery Young, V. Leroy, MD, et al. Aesthetic Surgery Journal, Volume 26, Issue 5, 1 September 2006, Pages ,

8 Hypothermia Prevention Pre Warm Patient Warming blanket in pre op Start warming 1 hour prior to surgery Fluid Warming IVF Irrigation OR Temp Keep areas of body that are out of surgical field covered Cover areas that are in field if not in use Monitor Core Temp Esophageal temp probe PACU Warming blanket Prevention of Hypothermia in Plastic Surgery Young, V. Leroy, MD, et al. Aesthetic Surgery Journal, Volume 26, Issue 5, 1 September 2006, Pages ,

9 Patient Positioning Pressure Ulcer and Nerve Injury Prevention Incidence of Surgery Acquired PU % Risk factors Case longer than 3h Obesity Advanced Age Poor nutrition Mobility limitations Extremes of Height Position Specific Risks Patient Safety in the Operating Room: I. Preoperative Poore, Samuel O. M.D., et al. Plastic & Reconstructive Surgery: November Volume Issue 5 - p

10 Patient Positioning Pressure Ulcer and Nerve Injury Prevention Head in secure, padded position No braids or pony tails Tube is secure Anesthesiologist wiggles tube throughout case No oral airway until the end of case Neck neutral If arms abducted, keep to 90 Maintain supination when arms abducted Arms positioned on arm boards parallel to trunk Add thicker padding for thinner patients to avoid extension Remove padding for heavier patients to avoid extension Pad tops of arms Wrists in slight extension Remove IV tubing and monitor cords from bony prominences Pad cords that you cannot move Knees Flexed Supported on pillow Heels padded Not floating Have RN check patient after each position change Patient Safety in the Operating Room: I. Preoperative Poore, Samuel O. M.D., et al. Plastic & Reconstructive Surgery: November Volume Issue 5 - p

Pre operative anti emetics Scopolomine patch Multimodal Analgesia IV Tylenol Toradol Gabapentin Foley for cases longer than 4h PONV Management Hydration Post operative Zofran Take on a schedule

12 Pre operative anti emetics Scopolomine patch Multimodal Analgesia IV Tylenol Toradol Gabapentin Foley for cases longer than 4h PONV Management Hydration Post operative Zofran Take on a schedule Minimize narcotics Gum Ginger lozenges Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model Dumestre, Danielle O. M.D.; Webb, Carmen E. M.A.; Temple-Oberle, Claire M.D., M.Sc. Plastic & Reconstructive Surgery: March Volume Issue 3 - p

Infection Control IV antibiotics Within 1 hour of incision Re-dose Q4h intra-operatively Ancef Vanco if Pen Allergic Appropriate Skin Prep Betadine vs ChloraPrep vs DuraPrep Dura Prep has lowest

13 Infection Control IV antibiotics Within 1 hour of incision Re-dose Q4h intra-operatively Ancef Vanco if Pen Allergic Appropriate Skin Prep Betadine vs ChloraPrep vs DuraPrep Dura Prep has lowest surgical site infection rate Antibiotic Irrigation? Not shown to effectively reduce risk of infection May reduce risk of cap con Reduce exposure of implantable devices to: Air Surgical Gloves Patient skin Duration of Antibiotics? For non-implant surgery 24h is enough For implant surgery 24h is probably enough For implant surgery with drains?? Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence? Phillips, Brett T. M.D., M.B.A.; Halvorson, Eric G. M.D. Plastic & Reconstructive Surgery: October Volume Issue 4 - p

Infection Control: Drains What the literature tells us to do: Consider

Remove drains at a specific post op date regardless of output Remove

Remove drains when 30cc/24h output for 2 consecutive days Drain

14 Infection Control: Drains What the literature tells us to do: Consider Biopatch Use prophylactic antibiotics Don t use prophylactic antibiotics Remove drains at a specific post op date regardless of output Remove drains when output less than 30cc/24h for two consecutive days Don t use drains Use drains What Dr. Jewell Does: Non-braided drain suture Keflex until drains come out Remove drains when 30cc/24h output for 2 consecutive days Drain dressings a progression: Nothing Bacitracin and gauze Cover with Tegaderm in shower Mepilex Ag Cover with Tegaderm in the shower Aquacel Ag

15 Infection Control: Drains

16 Nutrition Pay special attention to post bariatric surgery patients They are at increased risk of: Low pre-albumin Low Vit A Low Hgb Increased infection Wound healing delay Correct nutritional deficiencies prior to surgery Evidence Based Strategies to Reduce PostoperativeComplications in Plastic Surgery Harrison, Bridget MD; Khansa, Ibrahim MD; Janis, Jeffrey E. MD Plastic & Reconstructive Surgery: September Volume Issue 3S - p 51S 60S

17 Obesity Increased risk of: Donor site morbidity Higher flap loss rates Wound healing delay Consider oncoplastic surgery rather than total breast reconstruction in obese patients Counsel patients that they are at increased risk for complications Encourage weight loss prior to surgery Important to set goal weight Regular check-ins Provide resources for patients Evidence Based Strategies to Reduce PostoperativeComplications in Plastic Surgery Harrison, Bridget MD; Khansa, Ibrahim MD; Janis, Jeffrey E. MD Plastic & Reconstructive Surgery: September Volume Issue 3S - p 51S 60S

Smoking Cessation Stop smoking 4 weeks prior to surgery Provide smoking cessation resources Don t resume smoking until 4 weeks after surgery Cancel surgery if patient does not quit Urine cotinine at

18 Smoking Cessation Stop smoking 4 weeks prior to surgery Provide smoking cessation resources Don t resume smoking until 4 weeks after surgery Cancel surgery if patient does not quit Urine cotinine at pre op visit Nicotine patches Vaping Marijuana Evidence Based Strategies to Reduce PostoperativeComplications in Plastic Surgery Harrison, Bridget MD; Khansa, Ibrahim MD; Janis, Jeffrey E. MD Plastic & Reconstructive Surgery: September Volume Issue 3S - p 51S 60S

19 Glycemic Control Any fasting glucose of >125mg/dL repeat If still >125mg/dL get endocrine consult Any random glucose of >200mg/dL get endocrine consult Pre op A1C should be 8% Intra op diabetics check FS Q2 hours and give sliding scale insulin Post op check FS AC and HS Goal is <140mg/dL fasting or <180 random Ask for help from Endocrinologist Perioperative Glycemic Control in Plastic Surgery: Review and Discussion of an Institutional Protocol John D. Dortch, MD, Dustin L. Eck, MD, Beth Ladlie, MD, Sarvam P. TerKonda, MD Aesthetic Surgery Journal, Volume 36, Issue 7, 1 July 2016, Pages ,

20 Homeopathic Medications and Vitamins Stop taking all supplements 4 weeks prior to surgery Unless deficient

21 Other Medications To Stop Taking Medication to Stop Taking ASA two weeks prior Ibuprofen One week prior Coumadin Per hematologist transition to heparin/lovenox Tamoxifen/Anti-Estrogens Per oncologist usually 3-5 days pre op Oral contraceptives?

22 OR Safety Use only outpatient facilities accredited by one or more of the following: American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) Accreditation Association for Ambulatory Health Care (AAAHC) Joint Commission on Accreditation of Health Care Organizations Certified to participate in the Medicare program under title XVIII A License by the state in which the facility operates. American Society of Plastic Surgeons REQUIRES members to use only outpatient facilities accredited by one or more of the above Good team communication Surgical Time Out Evidence Based Strategies to Reduce PostoperativeComplications in Plastic Surgery Harrison, Bridget MD; Khansa, Ibrahim MD; Janis, Jeffrey E. MD Plastic & Reconstructive Surgery: September Volume Issue 3S - p 51S 60S

23 Pain Control Poor pain control Patient won t move -> DVT Patient won t breathe -> Atelectasis and pneumonia Multimodal Analgesia Local Epidural Regional blocks OnQ catheter Liposomal Bupivicaine Exparel Abdominal Binders Use with caution in patients at high risk for DVT Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations Temple-Oberle, Claire M.D., et al.; for the ERAS Society Plastic & Reconstructive Surgery: May Volume Issue 5 - p 1056e 1071e

24 Pain Control-Jewell Recipe IV Tylenol at the beginning of the case Re-dose q8 during surgery for long cases Q8h for 24h post op in NPO patients Local used on all incision sites 50:50 mixture of 1% lidocaine with 1:100,000 epi and 0.5% Marcaine Plain Do not use in any free tissue transfer Do not use in immediate breast reconstruction OnQ in all open abdominal surgeries and subpectoral TE breast reconstruction Catheters placed in linea semilunaris or subpectoral Primed with 10cc 0.5% marcaine prior to emergence from anesthesia Exparel Use in Latissimus flaps donor site Use in pre-pectoral TE breast reconstruction Cannot use with Lidocaine mixture Toradol 30mg IV at the end of surgery Given at division of DIE vessels during free TRAM/ DEIP surgery Re-dose q6h up to 5 days in patient Norco 10/ tab q6 hours PRN pain post op Alternate with 400mg Ibuprofen q6 hours post op

25 Pain Control-Jewell Recipe

DVT Prophylaxis-Risk Assessment 2005 Caprini Risk Factor Assessment Other factors Recent car or air travel Head and neck cancer Abdominoplasty Abdominal flap breast reconstruction Combined procedures

26 DVT Prophylaxis-Risk Assessment 2005 Caprini Risk Factor Assessment Other factors Recent car or air travel Head and neck cancer Abdominoplasty Abdominal flap breast reconstruction Combined procedures Risk may be increased for up to 12 weeks post op Peak is 3 weeks post op Evidence-Based Recipes for Venous Thromboembolism Prophylaxis: A Practical Safety Guide Pannucci, Christopher J. M.D., M.S. Plastic & Reconstructive Surgery: February Volume Issue 2 - p 520e 532e

27 DVT Prophylaxis Risk Modification Obesity Recent Surgery Oral Contraceptive use Central venous access Type of anesthesia Combined procedures Mechanical Compression stockings Pneumatic compression devices Positioning Chemoprophylaxis Indicated in patients with score 8 Lovenox and Heparin have equal efficacy Lovenox greater bioavailability Once daily dosing Decreased risk of heparin induced thrombocytopenia Timing Give within 6 hours post op No indication to give pre-operatively Duration Entire inpatient stay Until fully ambulatory Evidence-Based Recipes for Venous Thromboembolism Prophylaxis: A Practical Safety Guide Pannucci, Christopher J. M.D., M.S. Plastic & Reconstructive Surgery: February Volume Issue 2 - p 520e 532e

28 Post operative care Pain control Control of PONV Incentive spirometry Should start in recovery room Early ambulation Early PT Wound care instructions Drain care instructions Garment instructions Hygiene instructions Activity instructions Scar care Evidence Based Strategies to Reduce PostoperativeComplications in Plastic Surgery Harrison, Bridget MD; Khansa, Ibrahim MD; Janis, Jeffrey E. MD Plastic & Reconstructive Surgery: September Volume Issue 3S - p 51S 60S

29 Scar Care Massage 10 minutes daily Moderate to firm pressure Sunscreen Scars are more sensitive to UV radiation Paper tape Silicone Compression

30 Congratulations! Bilateral DIEP Pre-Op Bilateral DIEP Post-Op

31 Thank you!

Patient Safety in Postbariatric Body Contouring. Karol A Gutowski, MD, FACS

Patient Safety in Postbariatric Body Contouring Karol A Gutowski, MD, FACS Disclosures The Doctors Company - Advisory Board Angiotech/Quill - Advisory Board Suneva Medical Instructor Viora - Speaker Will