Perioperative Care

Before, during and after surgery

Fundamentals

Before surgery

Informed consent: the surgeon explains risks, benefits and alternatives; the nurse witnesses the signature and confirms the patient understands. Get it before sedating medications. Use a qualified interpreter if needed.
Fasting (ASA): clear liquids up to 2 h before; breast milk 4 h; light meal, formula or non-human milk 6 h; fatty or fried food, meat ≥8 h.
Remove jewelry, dentures, nail polish as policy requires; void.
Check labs, allergies, H&P, pregnancy test as indicated, site marking by the surgeon.

Medications to ask about

Anticoagulants and antiplatelets: hold per the surgeon's plan (e.g., warfarin ~5 days; DOACs 1–3+ days depending on drug and kidney function). Never stop after a recent stent without the cardiologist.
SGLT2 inhibitors: hold ~3 days (ertugliflozin 4).
GLP-1 receptor agonists: most patients continue them (2024 multisociety guidance); higher-risk patients (dose recently increased, nausea, vomiting, bloating) may need a 24-h clear-liquid diet before surgery. Tell the anesthesia team (aspiration risk).
Insulin: basal dose usually reduced, not skipped; glucose checks.
Herbal supplements (garlic, ginkgo, ginseng, St. John's wort): stop ~1–2 weeks before.
Beta blockers usually continue; ACE inhibitors/ARBs often held the morning of surgery.

In the operating room

Universal Protocol: pre-procedure verification, site marking, and a time-out with the whole team before the incision.
Counts of sponges, sharps and instruments.
Positioning: pad pressure points; avoid nerve injury.
Circulating nurse (non-sterile) vs scrub nurse (sterile).

Malignant hyperthermia

Triggered by volatile anesthetic gases and succinylcholine. Earliest sign: unexplained rise in end-tidal CO₂, then tachycardia, muscle (jaw) rigidity, hyperkalemia; high fever is a late sign. Stop triggers, dantrolene IV, cool, treat high K⁺.

After surgery (PACU and unit)

Airway first (jaw thrust if obstructed), breathing, circulation; vital signs often every 15 min at first.
Pain and nausea control; level of consciousness; dressing and drains.
Should void within ~6–8 h; bladder scan if not.
Turn, cough, deep breathe; incentive spirometer 10 times/hour while awake.
Early ambulation; SCDs and anticoagulant prophylaxis as ordered.
Diet advanced as bowel function returns (flatus, bowel sounds).

Post-op complications: typical timing

When	Complication	Clues
First hours	Hemorrhage, hypovolemic shock	Tachycardia, ↓ BP, restlessness, saturated dressing, bleeding under the patient
Days 1–2	Atelectasis, pneumonia	↓ breath sounds, crackles, fever, ↓ SpO₂
Days 1–5	Paralytic ileus, urinary retention, UTI	Distension, no bowel sounds or flatus; not voiding; burning
Days 3–7	Wound infection	Red, warm, swollen, drainage, fever
Days 5–8	Dehiscence / evisceration	"Something gave way"; serosanguineous drainage gush
Any time (often day 5+)	DVT / PE	Calf swelling; sudden dyspnea and chest pain

Memory hook: post-op fever "5 Ws" Wind (lungs, days 1–2) · Water (urinary tract, days 3–5) · Wound (days 3–7) · Walking (DVT/PE, day 5+) · Wonder drugs (drug fever, any time).