Perioperative Management Issues

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Perioperative Management Issues

• Karen Stierman, M.D.
• Francis Quinn, M.D.

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Perioperative Period

• Defined as the time before,during and after the
  operative procedure
• Preoperative testing should include
• Pregnancy testing, childbearing age
• Assessment of nutritional status
• Hemoglobin(female)
• Other tests as HP indicates

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Malnutrition

• Mild to moderate
• Weight loss 6-12 of normal, albumin 3.5g/dl,
  transferrin 200 mg/dl
• Severe - weight loss gt12, low protein
• NG versus TPN
• Protein levels
• Normal 0.8 g/kg/day
• Ill 1.2 to 2.0 g/kg/day

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TPN

• Requires monitoring avoid volume overload
• Multiple times a day VS, urine, glucose,acetone,
  fluids
• Daily Weight, Lytes, I/O, protein, calories
• Weekly Liver function tests, serum
  magnesium,protein, iron

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TABLE 20-1. Blood components Fraction Indicat
ion Packed red blood cells Acute
hemorrhage,symptomatic anemia Fresh frozen
plasma Coagulation abnormalities,
hemoglobinopathy Cryoprecipitate Low
fibrinogen levels, coagulation
abnormalities,and hemoglobinopathy Factor
concentrates Specific factor deficits
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Blood Transfusion

• Monitor hypersensitivity, volume overload,
  lytes, acid/base, thrombocytopenia, hypothermia
• Citrate toxicity low ionized calcium
• Autologous transfusion can give 1 unit/72 hours
  up to 72 hrs prior to surgery(HCTgt33)

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Anemia

• Hemoglobin lt7g/dl in case with moderate expected
  blood loss requires transfusion.
• Chronic anemia or low blood loss patient may be
  able to withstand

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Anemia

• Sickle cell
• Traitheterozygous, no tx
• Diseasehomozygous, transfuse to 50 HgS
• Glucose-6-phosphate dehydrogenase
• Men
• Oxidant damage to Hg lysis
• Avoid certain meds

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Thrombocytopenia

• Platelet countlt140,000/mL
• DDX sepsis, drug induced, dilutional, DIC
• Platelet countlt50,000/mL symptomatic
• Each unit increases count by 5-10K
• Half life 2- 3 days

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Qualitative platelet disorders

• Uremia, liver disease, previous bleeding d/o
• NSAIDS, ASA
• Correct underlying disorder
• Desmopressin acetate

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Coagulopathy

• PT/PTT
• Low risk aortic valve, afib,previous DVT
• D/C coumadin 1-2 days prior
• High risk mitral vave, cardiac emoboli,
• D/C coumadin, begin heparin
• Emergency
• FFP- coumadin Protamine sulfate heparin

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DVT

• Risk factors
• Obesity, cancer, immobilization, hypercoaguable
  states, age greater than 40 years old
• Diagnosis Homans, fever, edema, pain, cord,
  discoloration Duplex US
• Treatment Heparin

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P.E.

• Sudden onset tachypnea, dyspnea, chest pain,
  hemoptysis, hypoxia, arrhythmia
• V/Q scan
• Pulmonary angio
• Heparin/oral anticoags

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Diabetes

• Fasting BG in all - incidence 1 and rises to 5
  for those over 40 yrs. old
• In NPO patient, hold insulin or oral agent and
  monitor glucose
• Poor control hold off on elective case
• Goal 120-250 mg/dl

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TABLE 20-3. Insulin coverage during surgery
For patients on oral hypoglycemic agents Stop
oral agents 24 h before surgery. Insulin to
control hyperglycemia (see below). For
insulin-dependent patient Stop subcutaneous
insulin pump. On the morning of surgery, give
one-third to one- half of usual daily dose of
intermediate-acting insulin (NPH, Lente)
subcutaneously. Supplement with regular insulin
during surgery dependent on blood
glucose. Alternatively give regular insulin as a
separate constant infusion of 13 U/h, with
rate determined by the serum glucose
measurements.
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Ketoacidosis/Hyperosmolar coma

• Ketoacidosis- IV bolus of 12-20 U reg. insulin
  and constant infusion of 5-10u/hr
• Hyperosmolar nonketotic hyperglycemia lower
  insulin doses
• Fluids important
• Potassium

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Hypothyroid

• Slow replacement better than rapid with
  levothyroxine due to risk of adrenal
  insufficiency and angina
• Myxedema- Hydocortisone as well as synthroid
  because stress response decreased.

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Hyperthyroid

• Reschedule if elective
• Iodine Inhibits thyroid hormone production,
  decreases vascularity
• Steroid stress response
• Propanolol B blocker
• Antithyroid
• PTU blocks thyroid hormone production and
  inhibits conversion of T4-T3
• Methamazole

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TABLE 20-4. Medical control of thyrotoxic crisis
Propylthiouracil 300 mg p.o. every 6 h. Iodine
5 drops saturated solution of potassium iodide PO
every 68 h or sodium iodide 500 mg i.v.
Q12H. Propranolol 12 mg i.v. as needed to keep
pulse less than 100. Hydrocortisone 100 mg i.v.
Q8H. For congestive heart failure, digitalis and
diuretics are given and propranolol omitted.
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Adjunctive Measures Thyrotoxic crisis

• Temperature control
• O2
• IVF

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Hypocalcemia

• Thyroid/parathyroid surgery
• Ca levels Q12 hrs(8mg/dL) until stable
• Signs/Symptoms Chvosteks, Trousseaus,
  hyperreflexia, numbness/tingling in
  extremities/circumoral.
• Laryngeal stridor, overt tetany emergencies
• Calcium/ Vitamin D

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Adrenal insufficiency

• Suppressed hypothalmic/pituitary/adrenal axis
• Stress during surgery hypotension due to loss
  of vascular tone
• More than 5mg/day prednisone x 3 weeks in past
  year
• Currently on steroids, adrenal insuff., Cushings

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TABLE 20-5. Replacement hydrocortisone sodium
succinate for adrenal-suppressed patients
Minor surgical procedures usual daily cortisone
dose additional 100 mg i.m. before surgery Major
surgical procedures 100 mg i.v. or i.m. on call
to operating room 100 mg i.v. on induction 100 mg
i.v. q8h postoperatively 50 mg i.v. q8h on second
postoperative day Taper to maintenance over 35
days Maintain 200400 mg daily if ongoing
stresses or complications i.v., intravenous,
i.m., intramuscularly q8h, every 8 hours.
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DI/SIADH

• DI decreased ADH, decrease free water
  reabsorption, dilute urine, hyperosmolar serum.
  Tx with fluid intake, if severe-5 dextrose in
  water with minimal sodium, DDAVP
• SIADH hyponatremia, concentrated urine, Tx with
  fluid restriction, democlocyline(inhibits ADH on
  kidney)

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Cardiovascular

• Routine ECG men over 40 and women over 55.
• Full eval if symptomatic
• Med levels(digitalis) preop
• Take hypertensive and cardiac meds preop.
• No MAO or guanethidine 2 weeks prior to surgery

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Hypertension

• Anesthetic agents vasodilate
• Hypervolemia, hypoventilation,pain, meds,
  distended bladder/stomach, pre-existing
  hypertension.
• Correct underlying d/o
• Nitroprusside

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Hypotension

• Hypovolemia, anesthesia, meds, cardiac
  dysfunction,pulmonary d/o
• Fluid challenge
• Wedge pressure
• Sepsis
• Vasopressors

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Arrythmias

• Cardiac dz,hypoxia, hypotension,
  acid/base/electrolyte
• Supraventricular tachy adenosine, verapamil,
  propanolol, diltiazem
• Afib/flutter Digoxin
• Ventricular tach- lidocaine
• Cardiology consult

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Pulmonary considerations

• Mechanical vent alveolar hypovent with V/Q
  abnormalities
• History/Physical smoker, dyspnea
• ACS CXR greater than 40 yrs old, high risk for
  pulmonary disease
• Avoid fluid overload
• IS/Deep breath

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Pulmonary considerations

• Reactive airway nebs
• Brochoscopy mucous plug
• Wedge
• PAWP gt 25 mm HG- cardiogenic fluid
  restrict/diuretics
• ARDS normal PAWP, pulmonary edema, target
  cause, supportive measures

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GI

• Ulcers
• H2 blocker
• Massive GI bleed, NGT, GI consult
• Intestinal motility ileus, check for BS prior
  to feeding, Xray distended loops of bowel and
  diffuse gas, Tx with NGT
• Diarrhea Clostridium, clinda/amp most common
  but others can cause, Tx with fluids and Vanc.

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Renal

• Dialysis
• Platelet dysfunction, anemia, hypertension, lytes
• ATN ischemia or nephrotoxicity, urine casts,
  low urine/plasma creatinine, nephro consult

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Neuropsychiatric

• Seizures
• Heart, metabolic, drug/etoh, CNS
• Determine cause, airway/vent, Tx with benzos
  phenytoin,barbituates
• Myasthenia gravis continue anticholinesterase
  meds. Avoid quinidine, curare,lithium,B-blockers,p
  henytoin, aminoglycosides
• Delerium versus dementia

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TABLE 20-8. Pharmacologic management of status
epilepticus Agent Dosage Diazepam Adults i.v.
bolus of 510 mg at 12 mg/min to maximum of
2030 mg or continuous infusion 48 mg/h to total
daily dose of 14 mg/kg Children 1 mg/yr of age
to total dose of 510 mg Lorazepam 24 mg i.v.
slowly q510 min to total dose of 8
mg Phenytoin Adults Loading dose of 1520 mg/kg
at 3050 mg/min Children Loading dose of 1020
mg/kg at 0.51.5 mg/kg/min Phenobarbital Loading
dose of 1020 mg/kg i.v. (initial bolus 200300
mg), repeated in 20 min Supportive Glucose Adult
50 mL of a 50 solution Children 12 mL/kg of
a 25 solution Thiamine 100 mg i.v. Calcium
gluconate 12 amps for recent thyroid or
parathyroid surgery
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TABLE 20-9. Pharmacologic management of delirium
Hepatic encephalopathy Short-acting
benzodiazepines (e.g., oxazepam, 1530 mg
q6h) Alcohol withdrawal (i.v., Q12h) Chlordiazepo
xide, 2550 mg Diazepam, 510 mg Lorazepam, 2
mg Other forms of delirium Haloperidol Mild
agitation 215 mg p.o. twice daily (elderly
0.53.0 mg daily) More severe agitation 210 mg
i.m. hourly until sedation obtained (1060 mg/day
usually sufficient) Urgent 15 mg i.v. with
increases of 510 mg/h Chlorpromazine All
cases 2550 mg i.m. h if blood pressure adequate
i.v., intravenous, i.m., intramuscularly
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TABLE 20-10. Postoperative causes of fever
Noninfectious causes Hematoma and tissue trauma
Atelectasis Nonseptic phlebitis and deep venous
thrombosis Drug of anesthetic allergies
Transfusion reactions Presence of drains or
catheters Less common noninfectious causes
Activation of inflammatory disease
(lupus, rheumatoid arthritis) Endocrine excess
(thyroid storm) Hypothalamic abnormalities
Infectious sites Wound Urinary tract
Respiratory Intravenous line site Infected
prosthesis or foreign body Meningitis
(especially in skull-base surgery)
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TABLE 20-11. Treatment of malignant hyperthermia
Signs Sharp increase in core body
temperature Cardiac arrhythmias Excessive
bleeding Rise in end-tidal carbon dioxide
concentration Management Stop succinylcholine and
inhalation agent immediately 100
oxygen Dantrolene sodium, 2.5 mg/kg i.v. q510
min as necessary to maximum dose of 10
mg/kg Sodium bicarbonate, 12 mEq/kg i.v.
(monitor blood gases) Support therapy Remove
drapes Lower core temperature with iced saline
(i.v., rectally or intragastrically) Application
of ice to exposed body parts Watch for
hyperkalemia, acidosis, myoglobinuria,
arrhythmias, and posttreatment hypothermia
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TABLE 20-12. Pharmacologic management of
postoperative pain Drugs Dose Opioids Initial
dose Morphine 10 mg i.m. or 510 mg i.v. then 3
mg/h continuous i.v. infusion PCA Demand
0.53.0 mg, lock out 512 min Children
0.070.1 mg/kg/i.v. q2h Meperidine 75100 mg i.m.
or 2550 mg i.v., then 25 mg/hr infusion
PCA Demand 530 mg, lock out 512
min Buprenorphine 0.3 mg i.m. or i.v., q68h
Nonsteroidal antiinflammatory drugs Indomethacin
50100 mg q68h Ibuprofen 200400 mg
q46h Ketorolac 30 mg i.v. or i.m., q6h (maximum
5 days) i.m., intramuscularly i.v.,
intravenously q2h, every 2 hours q6-8h, every 6
to 8 hours PCA, patient controlled analgesia.
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