MEDICAL DISEASES IN

THE SURGICAL PATIENTS

Diabetes Mellitus:
 Diabetes Mellitus:
• Most common medical disease encounted
during surgical practice management of
the Diabetic is essential to enable a
successful outcome. Blood glucose
concentrations maybe elevated in the pre-
op period due to physical trauma,
emotional and physiological stress leads to
increase in epinephrine and cortisol.
Infections may increase, blood glucose
concentrations Hypokalaemia –
• cells from secreting adequate amounts of
insulin, which causes rise in blood glucose
levels in non-insulin dependent diabetes.
Pre-op workup includes – Through
physical examination, rule out occult
infection, ECG r/o M.I, IHD Chest X-ray r/o
pneumonia and pulmonary oedema.
Complete urinalysis r/o U.T.I. and
proteinuria Ideally glucose 5.5 –
11.0mmol.litre.
Pre-operative and Intra operative
management of Diabetic patient
• Non-insulin dependent (type 2) Diabetes
Mellitus
• 85% of diabetes over age 50yrs have a
moderately decreased ability to produce and
secrete insulin and control at home is usually by
diet and sulfonyl ureas eg. Glipizide, glyburide
and chlorpropamide. The day before surgery all
oral hypoglyceamics should be discontinued and
5% Dextrose given 100mls/hr when the patient
is being starved. Intra-op blood glucometer
readings should be done every 3hrs to ensure
adequate glucose control.
• Insulin dependent (Type 1) Diabetes
Mellitus – may require insulin during
surgery
(1) Subcutaneous insulin
• (2) Constant infusion of mixture of
glucose and insulin
• (3) Separate infusion of glucose and
insulin
 Post-operative Care
• Blood glucose level should be monitored
every 2-4hrs to monitor signs and
symptoms of hypoglycaemia (eg. Anxiety,
tremors, profuse sweating without fever).
Use of sliding scale insulin regimes should
be based on blood glucose determinations
and not urine glucose determinations due
to many variables eg. Renal threshold
dehydration, etc.
 Hyperosmolar coma
• severe dehydration and if large amounts of
dextrose is given during surgery, resulting
in osmotic diuresis with water loss,
dehydration, hyperosmolarity occurs if
glucose reading 22-44 mmol/litre. A
marked increase in glucose and insulin
requirements are seen post-op in presence
of occult infection eg. Wound infection,
cellulitis, U.T.I and aspiration pneumonia or
stress response to trauma.
 Thyroid disease-
• Hyper and hypothyroidism represent
serious problems for surgical patients.
Large goiters may distort the airway by
compression and make airway intubation
difficult.
 In Hyperthyroidism –
• may develop hypertension, severe cardiac dysrhythmia,
C.C.F, Hyperventilation and hyperthermia. Life
threatening Thyrotoxicosis (Thyroid storm) may be
precipitated by thyroidectomy which causes increase
release of thyroxine, therefore it is best to bring the
patient to a Euthyroid state before surgery, usually 1-6
weeks treatment by propylthiouracil 800-1000mg/d for 7
days and maintenance 200-400mg /d. If emergency
surgery is required, adequate sedation, potassium iodide
plus B adrenergic blocking agent eg. Propranolol in
addition to propylthiouracil.
 Hypothyroid patient –
• are at risk for acute hypotension, shock and hypothermia
may result from Hypoventilation. Myxoedema coma may
occur – if patient fail to awaken promptly from
anaesthesia with co2 retention, co2 narcosis with
hypothermia. Increased tissue friability, poor wound
healing and wound dehiscence may occur. Treatment L-
thyroxine before elective surgery. In emergency give L-
thyroxine 0.5mg I.V or by NG tube or orally or for elective
surgery give 25ug/d and increased to 150 – 200ug/d to
establish Euthryroid state. Always do cortisol levels to
r/o coexistent addisons disease since L-Thyroxine may
precipitate addisonian crisis.
 Adrenal insufficiency:
• Patients with adrenal insufficiency undergoing
stress of operation may increase risk for
addisonian crisis manifested by salt wastage,
decreased blood volume, hypotension, shock
and death. Treatment 2-3days pre-op 1-3 litres
NACL (normal saline) cortisol therapy 20mg a.m.
and 10 mg p.m. On day of surgery 100mg of
cortisol I.M./I.V just before surgery and 50 –
100mg every 6hrs during surgery up to 300mg
/d. Saline – post-op 2-3 litres/day and care
monitoring of blood pressure serum electrolyte,
urine output.
• Gradual reduction of cortisol by 50% and to
maintain 30mg/day. Patients with chronic
corticosteroid therapy may have severe
hypokalaemia and serious hypertension and
must be corrected before surgery. Cortisol
300mg/d given during surgery if diabetic, insulin
is given 3units/hr and monitoring of intra-op
blood sugar
• Post-op slow wound healing, and predisposition
to infections without fever
 Pituitary Insufficiency: eg.
Sheehan’s Syndrome
• Pan hypopituitarism must be treated for
thyroid and adrenocorticosteroid for
insufficiency with levothyroxine and
cortisol.
• Cardiac Disease
• Preexisting heart disease whether
clinically apparent and undiagnosed may
lead to major cause of non surgical
perioperative deaths
– cardiac disease may be exacerbated by
physiologic changes accompanying surgery
H.R., B.P blood vol., 02, ph and coagulability
fluctuations
– may lead to myocardial Ischaemia due to
increase myocardial 02 demand or reduced
coronary blood flow, impaired myocardial
contractibility and altered cardiac
performance due to changes in pre-load and
afterload.
– Increased catecholamines circulating or
symptomatic nervous system may precipitate
arrhythmias increase HR and increase BP
– Anaesthetic medications such as vagolytics
and muscle relaxants have direct effects on
myocardial contractility, automaticity and
conduction operative period – most stressful
period.
– Greatest risk first 72hrs – perioperative
period.
– Due to increase monitoring of patients and
understanding of haemodynamic alterations
reduction of risks have occurred
– Fluid shifts, H.R. and B.P fluctuations
– Mininmize cardiac complications by being
aware of presence and severity of preexisting
heart disease and risk of asymptomatic and
unrecognized disease.
– Coordination between medical Consultant,
Anaesthetist and Surgeon is essential.
 Differential Diagnosis.
• (1) Myocardial infaraction M.I or Angina Pectoris
may present with epigastric pain P.U.D gall
bladder disease or surgical abdomen
• (2) Right Heart Failure RHF may have RUQ pain
mimicking gall bladder disease
(3)Nausea, early satiety, weight loss maybe due
to severe heart failure and not
abdominal carcinoma
• (4) Ascites due to Heart failure or pericardial
disease
• (5) Dyspagia due to left atrial enlargement or
disease of aorta
• (6) Back and abdominal pain due to aortic
dissection
• (7) Abdominal pain due to splenic, renal or
mesenteric emboli from infective endo carditis,
emboli of cardiac origin or atrial myxoma
• (8) Upper abdominal pain and even jaundice due
to pulmonary infaraction
• Proper evaluation, thorough examination, ECG,
Chest X-ray and echocardiogram maybe
essential.

• Respiratory Disease
• Risk Factors:- most common perioperative
complications involve pulmonary system high
incidence of pulmonary complications eg.
Thoracotomy, upper abdomen. Low indidence
of pulmonary complications eg. Lower abdomen
and peripheral surgery.
Factors which contribute to perioperative
pulmonary complications
• (a) pulmonary aspirations
(b) retention of tracheobronchial secretions
• © respiratory depression from drugs
(d) atelectasis
(e) Immobility eg. Elderly, traction
orthopaedic
• (f) upper abdominal surgery affects
diaphragmatic function
• Secondary factors:
• Age, Obesity, smoking and
cooperativeness of patient in post-op
period
• Effects of obesity – obesity defined as
body weight greater than increase 1.2 x N
massive obesity increase 2 x N
Acute upper Respiratory Tract
Infections
– presence of cold, pharyngitis or tonsillitis relative
contraindication to elective surgery, since viral
infections decrease defence mechanisims against
bacterial infections.
– give perioperative antibiotics
– Acute Lower Respiratory Tract infection (Tracheitis,
Bronchitis, pneumonia)
• absolute contra indication to elective surgery.
– In emergency cases – humidified oxygen, and gases,
suctioning and use of bronchodilations and antibiotics
 Chronic obstructive Pulmonary
Disease COPD
• (Bronchitis, Emphysema, Bronchiectasis)
• Pre-op 2-7 days – stop smoking, antibiotics for
purulent sputum, bronchodilators, physical
therapy
• Bronchial Asthma
• same at COPD except if on conticosteroids will
require corticosteroid therapy inperioperative
period. Pulmonary function test maybe
necessary FEV, and FVC and residual lung
capcity RLC
– Spirometry measurement – least expensive
screeningtest if FEV1, - less than 50% serious
lung complications post-op
– Patients may require post-operative
mechanical ventilation and special monitoring
 Renal Disease:
• Acute and chronic renal failure
• Complete urinalysis, serum, creatinine,
albumin, BUN r/o haematuria, protienuria,
hypoalbuminea, elevated BUN and serum
creatinine. Chronic renal failure do not
require maintenance dialysis (GFR.>
15ml/min serum creatinine .< 6mg/dl. Pre-
op hydration and blood transfusion to raise
increase PCV 32.
• If GFR > 5mls/min intermittent dialysis
maybe necessary and transfusion to
haematocrit above 32% maybe necessary.
• patients with renal insuffiency due to
Diabetes Mellitus are more susceptible to
infection, cardiovascular complications
such as strokes, acute M.I and poor
wound healing.
 Surgery and Anaemia
• In general, moderate anaemia (hematocrit
> 30%) does not increase the hazards
associated with surgery. Deficiencies of
Fe, Folic acid and Vit B12 should be
resolved before surgery. Megaloblasitc
Anaemia (pernicious anaemia and folic
acid deficicency) – must be corrected
before elective surgery.
 Sickle Cell Disease
• Sickling precipitated by anoxia and
acidosis, therefore avoid or prevent these
conditions, painful crises, intraabdominal
acute pain.
• The decision to transfuse a patient prior to
surgery will depend on
• (a) duration of anaemia
(b) extent of operation
© intravascular volume
(d) probability of blood loss
(e) presence of coexisting condition –
impaired pulmonary function,
• Inadequate cardiac output myocardial
ischaemia, cerebrovascular or Peripheral
circulatory disease
• Good clinical judgement is essential.
Studies have shown haemoglobin values
of 10g/dl or greater rarely require
perioperative transfusion. HB 7g/dl or less
require RBC transfusion. Other
perimeters used are arterial oxygenation
mixed venous oxygen tension, C.O and
oxygen extraction ratio, blood volume
 Pregnancy
• Prevalence
• Acute appendicitis occurs in 1:2000
pregnancies
• Acute cholecystitis occurs in 1:3500 –
6500 pregnancies
• Cancer of Breast occurs in 1:3000
pregnancies
 Special considerations
• (a) Patients on steroids or Cushings
syndrome pose a particular challenge to
the surgical patient. Poor wound healing
and wound dehiscence and infection
susceptibility
• (b) Patient on Immunosuppressive drugs
also pose a similar dilemma Doxyrubicin,
cyclophosphamide, Vincristine etc.
• © Immunocompromised patients eg. H.I.V and AIDS
pose a significant challenge to the Surgeon eg. Risk of
transmission infection to health care workers (as in
Hepatitis) and the patient susceptibility to infection, poor
wound healing due to wasting disease.
• Serious Respiratory Infection and opportunistic infections
eg. Cryptococcus, Toxoplasmosis and Tuberculosis.
• d) Malnutrition – mild moderate severe
• 10% 15% 20%
• Body weight loss correction of malnutrition with T.P.N or
enteral nutrition.