Essential Keys To Managing The High-Risk Patient Undergoing Elective Surgery

Valerie L. Schade, DPM, AACFAS

   Discuss the reasons and importance for continued recovery at nursing or rehabilitation facilities with the patient and his or her support network. This is so both the patient and his or her supporters will “buy in” to the necessity of spending a period of time there to aid in the patient’s safe return home. One should also discuss the importance of involvement of the patient’s support network during the patient’s stay at these facilities.

   When one does not assess these needs preoperatively but expects a patient to be able to perform these tasks postoperatively, the physician may be setting the patient up for complications that could have been prevented by assessing and addressing these needs upfront.3

Emphasizing The Value Of OR Preparation

If you are planning on using specific equipment for the surgery, prior to the day of surgery, review this equipment in detail and review the process in which this equipment works. Consider having the representative of the equipment manufacturer allow you and your surgical team to review use of the equipment prior to the day of surgery with a “hands-on” cadaveric or sawbones lab. This prior planning can minimize potential complications as the surgical team will be familiar with the use of the equipment and the steps of the procedure they will be performing.

   Delegate specific tasks to each member of the surgical team to ensure each person knows his or her specific role on the day of surgery. This is particularly important when working with medical students, residents or assisting surgeons.

   Several simple additions to the setup of the operating room can enhance the working space of the operative field. Prepping and draping of the operative extremity to expose the limb from above the knee to the toes allows increased space on the surgical field as exposure is not limited to the foot and ankle. This also allows for assessment of the positional relationship of the foot to the lower leg, which is essential during procedures involving realignment of the foot and ankle.

   Be cautious in assessing this positional relationship if you are using an ipsilateral hip bolster to limit external rotation of the lower leg. Adding an arm board to the foot of the bed on the side of the non-operative limb also increases the working surgical space. This gives one the ability to move the non-operative extremity off to the side and creates a large working area between the lower legs. If intraoperative image intensification is necessary, place the imaging unit on the side of the non-operative extremity. This allows the surgeon to work without having the arm of the unit blocking him or her from the ideal portion of the operative field.

Other Pertinent Insights On Post-Op Strategies To Minimize Complications

One can minimize postoperative complications with the postoperative dressing, immobilization and activity restriction. Studies have found that postoperative use of a bulky, well padded, Jones-type compressive dressing aids in edema control and immobilization of the foot and ankle, and limits hematoma formation that could lead to infection or delayed healing.5,6

   The addition of a sugar tong splint, with or without an anterior bolster, also helps limit motion about the foot and ankle, reducing tension and stress to incisions, which could lead to delayed healing or dehiscence. The surgeon should use a sugar tong splint as opposed to a posterior splint in order to avoid pressure-induced wounds to the posterior heel and plantar forefoot.6

   The surgeon should cleanse the entire extremity at each postoperative visit and apply a new sterile dressing to limit the potential for infection and improve hygiene.7 Instruct patients to perform daily sponge baths while the dressings are in place in order to avoid the inner dressing from becoming wet from condensation or failed attempts to cover the dressing to take a shower. Moisture within the dressing can lead to maceration, skin breakdown and infection.

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