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Chapter 3: Perioperative

Management

The Healthy Patient


The Diabetic Patient
The Hypertensive Patient
The Patient on Steroid Therapy
The Asthmatic Patient
The Alcoholic Patient
The Patient on Anticoagulant Therapy
The Patient With Clotting Abnormalities
The Rheumatoid. Patient
The Sickle-Cell Patient
The Cardiac Patient
The Pulmonary Disease Patient
Perioperative Management of the Infant and Child
Mitral Valve Prolapse Patient
The Gouty Arthritis Patient
PERIOPERATIVE 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)

The Diabetic Patient


1. Given early morning surgical preference

2. If surgery Is delayed start IV with D5W to avoid hypoglycemia from


remaining insulin or oral hypoglycemics from the day before

NOTE* Remember the phrase," BETTER SWEET THAN SOUR".


3. Consult family physician for Insulin requirements

4. Chlorpropamide has a half-life of 60 hours and thus should be stopped


more than 24 hours prior to surgery (best stopped 2-3 days before)

5. Diabetics with a propensity towards ketoacidosis require IV glucose


and insulin

6. It is recommended that that regular insulin be used during the


perloperative period

7. Check pre-op potassium levels (the administration of Insulin reduces


the serum potassium levels and therefore in patients with hypokalemia,
potassium replacement is needed when insulin is to be administered)

8. Patients with severe diabetic autonomic neuropathy have an increased


incidence of gastroparesis and aspiration (increased chances for sudden
death). Autonomic neuropathy can result in a resting tachycardia and
orthostatic hypotension (BP drops 20mm Hg from a lying to a sitting
position)

9. Preop blood sugar levels (mg/dl):


a. If hypoglycemia present pre-op consider postponing the case
b. If BS in diet controlled diabetic pre-op, is below 200: no meds needed
c. If BS in diet controlled diabetic is about 200 (some say 300): consider
regular insulin
d. If BS in Type II diabetic is < 150: stop the drug on the morning of the
surgery
e. If BS in Type II diabetic is between 150-250: take AM dose of oral agent
f. If BS in Type II diabetic is > 250: start regular insulin

10. Monitor long term glucose levels by measuring glycosylated hemoglobin


(HbA1C): should be between 3 and 6% (realistically between 7-10)

11. Avoid post-op hyperglycemia: Since a BS greater than 250 inhibits


phagocytosis, leading to an increase in post-op infections esp. gram negative

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

16. Post-op BS levels can managed as follows:


a. 150-199 2 units
b. 200 -249 4 units
c. 250-299 6 units
d. 300-349 8 units
e. 350-399 10 units
f. >400 12 units

The Hypertensive Patient

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.

2. Evaluate by taking BP 3 different times to eliminate other factors such


as stress.

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.

NOTE* An S4 gallop is the most common finding in hypertension

4. Check the optic funds: they may show retinopathy (indicator of the severity
of the disease).

5. Primary treated by step-care approach:


a. Step 1- Start with a diuretic (or start with a calcium channel blocker) b. Step 2-
Add a beta blocker
c. Step. 3- Add a vasodilator
d. Step 4- Add a combination drug

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

8. For severely hypertensive patients (BP of 160/90 or higher), elective


surgery should be postponed until adequate control achieved

9. All antihypertensive medications should not be discontinued


preoperatively EXCEPT GUANETHIDINE and should be taken at 6 AM (FOR
AM SURGERY) if medication is normally taken in the morning

10. Acute elevations of BP are usually seen postoperatively which can be


due to: PAIN, REACTION TO ENDOTRACHIAL TUBE, VOLUME OVERLOAD, AND
EMERGENCE EXCITEMENT

11. Post-op hypertensive episodes are treated by eliminating the cause


and if necessary giving the following: sub-lingual Procardia or can give
diuretics IV or nitropatch, sublingual nitroglycerine, or nitroprusside

NOTE* Procardia given sublingually reduces blood pressure quickly, but does not
drop it below normal

12. These patients are very sensitive to vasopressors: DON'T USE


EPINEPHRINE!!!!

13. Potassium levels in all patients taking diuretics must be measured


pre-op and adequately replaced prior to surgery to prevent hypokalemia
associated cardiac arrhythmias

The Patient on Steroid Therapy


1. Steroids are utilized for the following: asthma, COPD (chronic obstructive
pulmonary disease), autoimmune diseases (RA) and malignancy. They have an
effect on three major areas of importance in the perioperative setting:

a. Suppression of the hypothalamus/pituitary adrenal axis (HPA) b. Poor wound


healing
c. Predisposition to infection

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.

5. Tapering of steroids is only necessary if coverage lasts longer than 3


days

6. Special care must be taken with patients who have Addison's disease.

The Asthmatic Patient


1. Consider local or spinal anesthesia

2. Continue asthma medication up until 1 & 1 /2 hours before surgery


(take with a sip of water)
3. Inhalant medications are used as prescribed by the M.D. and can be
used up to 1 & 1 /2 hours prior to surgery

4. Aminophylline via continuous infusion of 800 mg In 500 cc D5W at 20cc


per hour (5cc per hour for children). You can adjust the rate according to
the theophylline level

The Alcoholic Patient


1. Should have 3-4 days of rehydration (to make sure no DT's), vitamins,
proper diet, and no alcohol intake prior to coming to surgery

2. Nutritional status should be evaluated. This is done via measurement of


serum albumin and total lymphocytes
a. Serum albumin (<2.3 gm/dl): A measurement of nutritional status for the
previous week. Not a good indicator for. nutrition for the day of surgery
b. Total lymphocytes (<900): A good indicator of nutritional status for the day of
surgery. This measures the response to stress

Patients on Anticoagulant Therapy


1. Indications for anticoagulants:
a. PERIOPERATIVE PROPHYLAXIS FOR PREVENTION OF DVT's b. ISCHEMIC HEART
DISEASE,
c. ATRIAL FIBRILLATION
d. MITRAL STENOSIS
e. TIA's (transient ischemic attacks)
f. Prosthetic heart valves

2. Heparin type:
a. Inhibits intrinsic clotting pathway
b. Used as short term therapy for prophylaxis against DVT's

5,000u subcu 2h before surgery & 5,000u subcu Q 12 h until pt ambulatory


c.
DOSAGE REGULATED ACCORDING TO PTT (that's when you are treating, and not
prophylaxing)
d. EFFECTS REVERSED WITH PROTAMINE

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)

4. For patients undergoing surgery, stop anticoagulants 3-6 days prior to


surgery and reinstate therapy postoperatively 24 hours after the
procedure. If you are worried about your patient not being on
anticoagulants, you can stop coumadin 3 days prior to surgery and start
a heparin drip and stop that 2-4 hours preoperatively

The Patient With Clotting Abnormalities


1. History Is essential. Ask about: previous surgical bleeding problems,
bruising easily, frequent nose bleeds

2. Drugs that alter platelet function: ASPIRIN, NONSTEROIDALS, STEROIDS,


ANTIHISTAMINES, HIGH DOSES OF IV PENICILLIN (ESPECIALLY CARBENICILLIN), and
HEPARIN

3. Tests to determine bleeding diathesis: PLATELET COUNT, BLEEDING TIME


(Lee-White), PT, AND PTT

NOTE* Bleeding time is especially useful if the patient is on aspirin, as aspirin


stops platelet aggregation (must stop aspirin 1 week prior to surgery)
4. Bleeding diseases:
a. Von Willebrand's Disease
i. Abnormal factor VIII, PROLONGED PTT & BLEEDING TIME
ii. Treat with fresh frozen plasma
b. Hemophilia
i. Type a: factor VIII deficiency ii. Type b: factor IX deficiency iii. Type c: factor XI
deficiency
iv. ALL 3 TYPES HAVE NORMAL BLEEDING TIME AND PROLONGED PTT
v. Treat with:
• Factor replacement
• Fresh frozen plasma
• Whole blood
• Cryoprecipitate (4-6 units preoperatively and the same postoperatively
• Lyophilized concentrate

NOTE The hemophiliac patient must achieve a level of 70-100% prior to


surgery, with a minimum of 40% being attained for 10 days
c. Vitamin K Deficiency
i. Vit K NOTE* Due to the increased incidence of Hepatitis C and HIV with these
effects patients, use caution
both
intrinsic and extrinsic clotting pathway
ii. PTT & PT are prolonged
iii. Treat with 10 mg of vit K subcu: normalizes pt in 8 hrs.

The Rheumatoid Patient


1. DO CERVICAL SPINE X-RAYS PRE-OP (predisposition for atlas/axis
dislocation)

2. If patient on steroids, you must supplement as per the previous


recommendations (see The Patient on Steroid Therapy)

3. If patient on nonsteroidals, discontinue perioperatively as it will alter


bleeding times

4. If the patient is on antimalarials (chloroquine) for RA therapy, since a


frequent complication is eye problems the patient should consider a
preoperative consultation with an ophthalmologist.

5. If the patient is receiving gold salts for RA therapy, their potential


toxic side effects should be looked for (urticaria, skin eruptions, mouth
ulcers, eosinophilia, albuminuria, and leukopenia), especially In the
urinalysis which can document substantial protein loss. If the drugs are
not withdrawn after the onset of the side effects, patients can experience
life threatening exfoliative dermatitis, nephritis, and thrombocytopenia

6. If the patient Is on penicillamine for RA therapy, one can possibly


expect potential decreased or slowed wound healing as this drug affects
collagen synthesis. Vitamin C supplementation is useful in these patients

7. If the RA patient is on immunosuppressive drugs (methotrexate,


captopurine, azothioprine, and cyclophosphamide), due to the side
effects of these drugs (increased bleeding time, bone marrow
suppression leukopenia, thrombocytopenia), makes the patient more
prone to infection. You should consider preoperative antibiotics in these
patients

Note* These patients have been therapeutically immunosuppressed to decrease


the severity of their autoimmnune response, and are therefore, prone to
infections

The Sickle Cell Patient


1. LOCAL ANESTHETICS A PRIORITY

2. Avoid respiratory depression with narcotics and sedatives- avoid


hypoxia with general anesthesia

3. Avoid using a tourniquet in patients with sickle-cell disease

4. Avoid hypoxia, dehydration, and acidosis intraoperatively and


postoperatively

5. Complications of surgery can Include: delayed healing, increased


incidence of wound dehiscence, leg ulcerations, bone Infection
(osteomyelitis usually caused by Salmonella), and aseptic necrosis

NOTE* In the preoperative evaluation of the patient suspected of having sicklecell


disease or trait the following tests are indicated:
a. Sickle-cell prep
b. Hemoglobin electrophoresis (for those with uncertain hemoglobinopathies)

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

The Cardiac Patient


1. The cardiac patient is at a higher risk during the perioperative period,
and the factors which give the most post-op cardiac complications are:
a. S3 GALLOP WITH JUGULAR VEIN DISTENTION
b. M.I. WITHIN 6 MONTHS
c. Greater than 5 PVC's PER MINUTE
d. AGE GREATER THAN 70 YEARS OLD
e. PREMATURE ATRIAL CONTRACTIONS

2. Elective surgery should be postponed until 6 MONTHS postmyocardial


infarct and In patients with uncompensated congenital heart failure
3. All risk factors such as unstable angina and cardiac failure should be
stabilized preoperatively

4. Pre-op studies should include the studies for the normal patient
undergoing general anesthesia, plus EKG, chest x-ray

5. Nitrates and Beta blockers should be continued during the


perioperative period

6. Echocardiography should be considered in any patient with a


pathological heart murmur

7. Endocarditis prophylaxis should be given for patients with acquired


and congenital valvular heart disease with a rheumatic murmur and
prosthetic valves with
a. Amoxicillin: 3GMS PRE-OP AND 1.5 GM POST-OP (TAKEN 1 HR PRE-OP AND 6HR
POST-OP)
b. IF PENICILLIN ALLERGY, CLINDAMYCIN 300MG PRE-OP AND 150 MG POST-OP

NOTE* Probably the best prophylaxis (when indicated) should be IV penicillin or 1st
generation cephalosporin

NOTE* DRUG ADDICTS ARE PRONE TO SUBACUTE BACTERIAL ENDOCARDITIS WITH


TRICUSPID VALVE INFECTION SO ADMINISTER AN ANTISTAPH/STREP ANTIBIOTIC
PRE-OP (DICLOXICILLIN)

The Pulmonary Disease Patient:


1. The major post-op complications are atelectasis and infection

2. Smoking and obesity increase pulmonary risk

3. Use incentive spirometry post-op to prevent problems (start preop)

4. D/C smoking at least 1 week prior to surgery

5. Treat all respiratory infections prior to surgery

6. Administer Heparin 5,000u subcu in selected cases for prophylaxis for


venous thromboembolic disease. These patients are the ones with
previous history of
a. IDIOPATHIC THROMBOPHLEBITIS
b. CHF
c. OTHER DISEASES WHERE VENOUS STASIS MAY OCCUR

7. Consider the use of preoperative incentive spirometry (prevents


atelectesis which can lead to pneumonia)

8. Consider arterial blood gas in patient with pulmonary history


a. If pCO2>45 mmHg and P02<55 mmHg then the patient will require
pulmonary function studies and possible use of bronchodilators (theophylline)

9. Consider the use of sequential compression devices in the pulmonary


patient (stockings) preop, postop, and intraoperatively

Perioperative Management of the Infant and Child


1. Preoperative evaluation:
a. Laboratory evaluation:
i. CBC
ii. ESR
iii. PT/PTT
iv. FBS
v. Sickle-cell test (in young blacks)
vi. Urinalysis

2. History and physical:


a. Examination via the pediatrician
b. Vital signs should be recorded. Temperature should be taken rectally in children
under 3. Rectal temps may run 1 ° higher than oral temps. Pulse rates and
respiration rates may be higher in children, and corresponding systolic blood
pressure readings may be much lower than for adults
3. Preoperative medications: Drug administration in the hospital must be
individualized for the child's level of growth and development, the form of the
drug, and the reason for medication
a. Proper dosage can be calculated via Young's Rule, Cowling's Rule, or Clark's
Rule
i. Young: Divide the child's age by the age plus 12= The child's dose
ii. Cowling: Divide the age at the next birthday by 24
iii. Divide the weight (in lbs) by 150 to give the appropriate fraction.of
the adult dose
b. Sedatives: Used as a preanesthetic agent to decrease apprehension and provide
ease of induction
i. Barbiturates: secobarbital, pentobarbital, and amobarbital). The sedative dose of
barbiturates it 2 mg per kg orally TO

NOTE* Barbiturates are not generally recommended in infants as they can cause
paradoxic restlessness and excitement

ii. Chloral hydrate: A nonbarbiturate sedative-hypnotic, safe for infants and


children. Can be administered in juice or soft drinks to decrease the unpleasant
taste and minimize gastric irritation. The dosage ranges from 250 mg to 500 mg
orally, up to three times daily. It may be given at 50 mg per kg at bedtime, up to 1
gm per dose
4. Fluids: Intraoperative fluid replacement is especially important in infants and
children because their reserve available to compensate for fluid loss is small (have
a large surface area for their mass). You must assess the fluid loss carefully. The
estimated fluid loss can be satisfactorily replaced with Ringer's lactate

5. NPO: The routine order of NPO should be avoided


a. No solid food or milk should be given for 12 hours prior to surgery, but fluid
intake should have a minimal interruption
b. Infants younger than 6 months are not placed on NPO status until 4 hours prior
to induction and those from 6 months to 3 years are placed on NPO status 6 hours
prior to surgery. For children over 3 years, NPO status should be 8 hours prior to
induction

6. Postoperative pain: Avoid injections if at all possible (fear)


a. Pentobarbital suppository: Dosage Is 30 mg for children 1-5 years, 60 mg for
those 6-10 years, and 90 mg for those 11-14 years b. Chloral Hydrate
c. Codeine (3 mg per kg) for mild pain
d. Meperidine (1-1.5 mg per kg) for moderate pain

7. Antinauseants: Should be used sparingly, and doses should be adjusted


a. Promethazine: Dosage 12-5-25 mg rectally or orally
b. Vistaril®: Dosage 50 mg daily in divided doses for those under 6, and 50-100 mg
daily in divided doses for those over 6
c. Emetrol®: OTC antinauseant, free of toxicity and side effects, and works
immediately to control vomiting (1-2 tsp for infants and young children at 15
minute intervals until vomiting ceases)

Mitral Valve Prolapse Patient


The majority of these patients are asymptomatic, so when is there the
necessity of preoperative antibiotic prophylaxis to prevent bacterial
endocarditis? Those individuals with evidence of mitral valve
regurgitation (seen on echocardiogram) are at risk for life threatening
complications and are given antibiotic prophylaxis. Asymptomatic
patients are not usually given antibiotic prophylaxis unless it is for a high
risk procedure producing a bacteremia (dental procedures, tonsillectomy
and adenoidectomy, bronchoscopies, I & D of infected tissues, and GI
and GU procedures). Podiatric procedures on low risk patients, are not
usually prophylaxed unless there is infected tissue.
1. Clinical Symptoms:
a. Chest pain
b. Palpitations
c. Syncope
d. Dyspnea
e. Arrhythmias (tachycardia)
f. High levels of anxiety
2. Cardiogenic findings:
a. Late or holosystolic murmur with or without a midsystolic click
b. ST wave changes
c. T wave inversions
d. Q-T elongation

3. Antibiotics:
a. Amoxicillin or clindamycin PO
b. First generation cephalosporin, Unisyn, or vancomycin IV

Gouty Arthritis Patient


The trauma of of surgical procedure can precipitate an acute attack of gouty
arthritis, but the perioperative management of patients with gout has not been
standardized. High-risk patients may include those with attacks in the past year,
marked relief after a test course of colchicine, and a documented need for
antihyperuricemic medication. Moderate-risk patients are those with past episodes
of acute monarthritis resembling gout clinically and hyperuricemia during the
acute episode (no joint aspiration for documentation). Low-risk patients are those
with asymptomatic primary hyperuricemia, asymptomatic hyperuricemia
associated with drugs, or some primary medical state (leukemia or other
myeloproliferative disorders or solid tumors)
1. Treatment:
a. High-risk patients: Should receive colchicine in a dose of 0.5 mg 3 times daily for
2-3 days prior to the operation and 4-5 days postoperatively (colchicine or
indomethacin should be used when antihyperuricemic therapy is instituted)

NOTE* Allopurinol rather than uricosuric drugs is indicated for patients excreting
more than 600 mg of uric acid in 24 hours

b. Moderate-risk patients: Given colchicine prophylactically as in high risk patients


c. Low-risk patients: Need not be treated

NOTE* Postoperative attacks of gout are managed as in any patient with acute
gouty arthritis

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