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The care of the patient with a major surgical problem commonly involves distinct phases of management that occur in the following sequence:

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  1. 1. Preoperative care

    Diagnostic workup

    Preoperative evaluation

    Preoperative preparation

    2. Anesthesia and operation

    3. Postoperative care

    Postanesthetic observation

    Intensive care

    Intermediate care

    Convalescent care

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Preoperative Care

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The diagnostic workup is concerned primarily with determining the cause and extent of the present illness. Preoperative evaluation consists of an overall assessment of the patient’s general health in order to identify significant abnormalities that might increase operative risk or adversely influence recovery. Preoperative preparation includes interventions dictated by the findings on diagnostic workup and preoperative evaluation and by the nature of the expected operation. This includes interventions specifically imposed to modify the risk of perioperative complications.

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Postoperative Care

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The postanesthetic observation phase of management is the few hours immediately after operation during which the acute reaction to operation and the residual effects of anesthesia subside. A postanesthetic recovery unit with special staff and equipment is usually provided for this purpose. Patients who need continued cardiopulmonary support or continued invasive monitoring to avoid major morbidity and death should be transferred to an intensive care unit.

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Intermediate care is usually provided on an inpatient nursing unit until the patient’s recovery can continue at home during the convalescent phase.

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The Continuum of Surgical Care

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The continuum of surgical care is represented above as progressing through a series of preoperative and postoperative phases. In practice, these phases merge, overlap, and vary in relative importance from patient to patient. Complications, death, and the therapeutic end result in the surgical patient depend upon the competence with which each succeeding phase is managed. The rapid progression and severe episodic stress of major surgical illness leave small margin for errors in management. The care immediately preceding and following operation, which includes preoperative evaluation and preparation and postanesthetic observation and intensive care, is especially critical. The increased complexity of surgical critical care has resulted in a team approach to the ICU patient, with management directed by the primary surgeon and the critical care specialists in the ICU, whose role it is to maintain optimum care.

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General Health Assessment

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The initial diagnostic workup of the surgical patient is focused on the cause of the presenting complaints. Except in strictly minor surgical illness, this initial workup should be supplemented by a complete assessment of the patient’s general health. This evaluation, which should be completed prior to all major operations, seeks to identify abnormalities that may influence operative risk or may have a bearing on the patient’s future well-being. Preoperative evaluation includes at least a complete history and physical examination. The evaluation should initially focus on the clinical assessment of risk based on the patient’s history and current symptoms. This assessment should guide the remainder of ...

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