Professional Documents
Culture Documents
Management
Healthy Patient
The operative mortality for a healthy patient (ASA Class1) undergoing
elective surgery is approx. 1 in 10,000. The risk is minimized by paying
attention to 3 areas of the history: COAGULATION DISORDERS, DRUG
HISTORY AND PREVIOUS ANESTHETIC COMPLICATIONS - For local
anesthesia should do: CBC/Diff, UA and PT/PTT For general anesthesia
should do: CBC/Diff, PT/PTT, UA, SMA 6, pregnancy test, chest x-ray (if
over 40 years old or if HX of smoking)
12. For minor procedures in NIDDM (TYPE II) patients well controlled on oral agents
(other than chlorpropamide) d/c the drug one day before surgery and follow a NO
INSULIN-NO GLUCOSE protocol during surgery and reinstitute the regular oral
therapy when the patient begins eating
13. Well controlled IDDM patients undergoing short, minor procedures may also be
managed on a NO INSULIN-NO GLUCOSE protocol
14. For long, major procedures it is safer to utilize intravenous insulin therapy
during surgery
15. For IDDM (TYPE I) patients undergoing surgery, the regular insulin
administration can be done a couple of ways:
a. Administer 1 /3 to 1 /2 the patients usual AM dose and
b. Start D5W IV and cover with insulin as per fingerstick BS or
c. Start 500ml D5W for the first hour, followed by 125 ml/hr of D5W with 1-2 units
of regular insulin (1 unit is used in patients taking < 20 units pre-op)
d. Give usual dose of insulin plus 50 gm of carbohydrate for each missed meal
e. Subcu. insulin 6-10 units Q6h
1. Two types:
a. Essential hypertension (most common)
b. Secondary hypertension: due to renal disease, endocrine disease, oral
contraceptives, pregnancy and coarctation of the aorta.
Note * Take the initial reading in each arm. A significant difference shows certain
diseases.
3. Check the heart: there may be left ventricular hypertrophy with systolic aortic
ejection murmur.
4. Check the optic funds: they may show retinopathy (indicator of the severity
of the disease).
6. Types:
a. Diuretics: Thiazides: Dyazide, Maxide, Hydrodiuril
b. Beta-Adrenergic Blocker: Tenormin, Lopressor, Corgard, and Inderal
c. Loop Diuretics: Lasix
d. Potassium Retaining: Aldactone, Triamterene
e. Calcium-Entry Blocker: Cardizem, Procardia
f. Combination- Dyazide, Maxide
g. Central Sympatholytics: Clonidine (Catapres)
h. Angiotensin Converting Enzyme Inhibitor: Capoten, Vasotec
i. Arteriolar dilators: Hydralazine, Minoxidil
j. Alpha andrenergic blockers: Minipress, Hytrin
NOTE* Diuretics are first line drugs used to treat hypertension, CHF and
lymphedema. There is concern regarding diuretics because of the
hypercholesterolemic effect of thiazides linked to ASHD 9 ischemic heart disease.
Thiazides can cause hyperglycemia, hyperuricemia and hypokalemia (pre-op
patients taking thiazides should have potassium checked). Therefore these drugs
are going out of favor as a first line drug for hypertension, replaced by channel
blockers and ACE inhibitors. Loop. diuretics (Lasix) are used in hypertensive
patients with fluid retention refractory to thiazides and in patients with impaired
renal function.
Beta blockers are effective in treating hypertension because they decrease
the heart rate, cardiac output and decrease renin release. These drugs prevent
angina. Beta blockers can precipitate bronchial asthma, Raynaud's phenomenon
and aggravate existing peripheral vascular disease.
ACE inhibitors are often used as a first line drug in treating hypertension.
They work by inhibiting the renin-angiotensin-aldosterone system. They are
effective vasodilators for the treatment of CHF.
Clonidine is a second line drug in treating hypertension. A severe rebound in
blood pressure may occur if the drug is abruptly discontinued, therefore, should
be continued perioperatively (4-6 hr pre-op)
7. Secondary hypertension is treated with elimination of the etiological
factor, where possible
NOTE* Procardia given sublingually reduces blood pressure quickly, but does not
drop it below normal
NOTE* There will be suppression of the HPA axis if any patient has taken more
than 7.5mg/day of prednisone for longer than one week prior to surgery
2. Therefore if a patient has taken more than 7.5mg/day of prednisone
then exogenous steroids must be supplied during the perioperative
period otherwise there could be resulting HYPOTENSION AND
CARDIOVASCULAR COLLAPSE
3. For minor procedures the regimen of exogenous steroids Is:
Hydrocortisone IV or IM @ 100 mg the evening before surgery, 100 mg prior to the
start of the procedure, and 100 mg Q 8h for 24 hours (there have been
modifications of this utilizing 100mg hydrocortisone pre-op and 100mg post-op)
NOTE* For minor procedures done under local sedation the following can be done:
15 mg prednisone PO 6AM before the surgery, 15 mg prednisone PO that same
afternoon, and 15 mg prednisone the next afternoon following the surgery
4. For major procedures the dosing is the same as above except the
doses Q8h should continue until the stress of the postoperative period
has passed.
6. Special care must be taken with patients who have Addison's disease.
2. Heparin type:
a. Inhibits intrinsic clotting pathway
b. Used as short term therapy for prophylaxis against DVT's
3. Coumarin type:
a. Inhibits extrinsic clotting pathway
b. Used as long term therapy
c. DOSAGE REGULATED ACCORDING TO PT
d. EFFECTS CAN BE REVERSED BY VITAMIN K (delayed) OR FRESH FROZEN
PLASMA (immediate)
NOTE* There is no specific therapy presently available for this disease. Treatment
consists of symptomatic relief along with adequate hydration and analgesics.
Oxygen therapy, alkalizing measures, and vasodilators have been used in
attempts to shorten the crisis
4. Pre-op studies should include the studies for the normal patient
undergoing general anesthesia, plus EKG, chest x-ray
NOTE* Probably the best prophylaxis (when indicated) should be IV penicillin or 1st
generation cephalosporin
NOTE* Barbiturates are not generally recommended in infants as they can cause
paradoxic restlessness and excitement
3. Antibiotics:
a. Amoxicillin or clindamycin PO
b. First generation cephalosporin, Unisyn, or vancomycin IV
NOTE* Allopurinol rather than uricosuric drugs is indicated for patients excreting
more than 600 mg of uric acid in 24 hours
NOTE* Postoperative attacks of gout are managed as in any patient with acute
gouty arthritis