Preoperative Evaluation and Postoperative Management
CHAP .19 Preoperative Evaluation and Postoperative Management
99. 5 .4
1st year resident, Noh Jae Hong
Management of Medical Problems
ENDOCRINE DISEASE
1. Diabetes Mellitus
most common endocrine disease
-- uncontrolled DM : morbidity : 2times
mortality : 3 times
-- MI risk of females with NIDDM : 4times
-- DM duration more than 20yrs, nephropathy : 50%
hypertension : 70%
-- increased risk of acute renal failure, after iv contrast
s-Cr >2.0
vascular disease
onset of DM < 40yrs
-- autonomic neuropathy --> increased risk of MI,(intraoperative hypotension, cardiac arrythmia)
sudden death
decreased esophageal and intestinal motility
delayed gastric emptying
increased risk of aspiration pneumonitis
-- infection --> G(-), staphylococcal pneumonia
G(-) & Group B Streptococcus sepsis 7% (1% of normal population)
sepsis is mc caused by E.coli from urinary tract
-- wound dehiscence, infection, decreased amounts of collagen formation, fibroblast growth
capillary growth : 10.7% : 1.8%
-- Goal of treatment : avoiding ketosis, hyperglycemia, hypoglycemia
-- admit pts 2days prior to surgery
begin insulin drip at 1-3U/hr
initially, glucose monitored every 1-2hrs
after 100-200mg/dl range, monitor every 4hrs
-- Type 2 DM
controlled with hypoglycemics or diet : iv fluid containing no dextrose should not given insulin
RI : BST>250mg/dl
pts taking long acting sulfonylurea ---> discontinued 3days prior to surgery
" short " ---> " 1days "
-- Type 1 DM
1/3~1/2 of pts usual daily dose of NPH is given subcutaneously the morning of surgery
intra- or postop insulin should be delivered iv, as a continuous drip or intermittent (q6hrs)
sc bolus of RI with 5% dextrose
-- periop hypoglycemia : coma
periop hyperglycemia (250mg/dl): infection, poor wound healing, electrolyte abnomalities, hyperosmolar coma,
ketoacidosis
-- postop BST q 6hrs until eating
maintain BST<250mg/dl , RI should be given on a sliding scale
-- regional anesthesia : lower stress-induced hyperglycemia
-- thrombotic complication : enhanced plt aggregation and TXA2 production
improved glycemic control and low-dose aspirin may correct the plt function
2. HYPERTHYROIDISM
Graves' ds is mc cause of hyperthyroidism
F:M = 10:1
[ Preoperative management ]
* PTU : at least 2wks before surgery
100-200mg q6hrs along with beta blocker
--> inhibit tyroglobulin iodination and iodotyrosine couling recuce extrathyroidal conversion of T4 to T3
* SSKI(saturated solution of potassium iodide) : 6-12 drops *2/d for 10-14days prior to surgery
* hydrocortisone : 100mg q8hrs --> decrease extrathroidal conversion of T4 to T3
* propranolol : 10-80mg q6-8hrs
[ Treatment of tyroid storms ]
1) PTU
2) invasive hemodynamic monitoring and crystalloid therapy
3) O2
4) mechanical cooling devices
5) avoidance of aspirin, atropine, methoxyflurame, cyclopropane
3. HYPOTHROIDSIM
over 50% of all cases are caused by previous thyroid surgery or RI therapy
* symptoms : lethargy, dry skin, memory impairment, apathy, hoarseness,
periorbital edma, goiter, brittle hair, increased relaxation phase of DTR
constipation, cardiomegaly, pleural effusion, pericardial effusion, ascites
* preop preparation : slow replacement with levothyroxine
if given too quickly, may cause cardiovascular collapse
* tyroid replacement therapy : 0.025mg of tyroxin daily, doubled every 2weeks until the patients
taking a dose of 0.15mg daily
TSH level will determine the daily dose
in severe myxedematous pts : 0.3-0.5mg tyroxin given in iv
hydrocortisone (100-300mg q8hrs)
Cx: hypoglycemia, anemia, hypothermia, hyponatremia
increased incidence of intraop hypotension, increased rates of CRF, ileus after abdominal surgery
4. ADRENAL INSUFFICIENCY/IATROGENIC STEROID USE
should be DDX for periop hypertension
ACTH stimulation test : ACTH 25u given
normal : cortisol level : absolute rise >7ug or total >18ug doubling of the basal line
Empirical coverage with a "stress" dose of hydrodortisone is recommended 100-300mg q8hrs
pts on chronic steroid supression or Addison's ds
¨ç hydrocortisone : 100mgIM in OR
" : 50mg IM/IV in recovery room q6hrs for 3 dose
" : 25mg IM/IV q6hrs for 4doses if pts hemodynamically stable
¨è taper to maintenance dosage over next 3-5days
havles the dose of hydrocortisone until a dose of 25mg is reached
eliminating one daily dose each day until the drug has been stopped
¨é increase cortisol dosage to 200-400mg over 24hrs if hypotension
CADIOVASCULAR DISEASE
Preoperative Evaluation
* History : known heart ds, DM, hyperlipidemia, hypertension, smoking, strong family history of heart ds
* P/E : hypertension , JVE, lateral displaced point of maximal impulse, irregular pulse, S3,
pulmonay rales, murmurs, peripheral edema, bruits
* LAB : anemia,
K, Na : important in taking diuretics and digitalis
BUN/Cr : renal fx, hydration status
Glucose : duciagnosed DM
CXR, ECG
1. CORONARY ARTERY DISEASE
-- incidence of MI after surgery : 0.15%
-- prior MI, reinfarction rate : 5%
after 3mo : 30%, 3-6mo : 12%, 6mo = no prior history of IHD
-- postop MI mortality : 50%
Table 19.8
-- degree of LV dysfucntion is more critical
Exercise stress test : pts who has IHD not manifested when at rest
ischemic ECG + < 75% of maximal predicted HR ---> MI :25% mortality : 18.5%
---> selectively apply to a high risk population
Dipyridamole-thallium scan
-- high degree of sensitivity and specificity
-- dipyridamole to dilate normal vs but not stenotic vs
hypoperfused myocardium does not uptake 5min after injection
reperfusion and uptake of thalium 3hrs after injection : viable but high risk myocardium
-- periop MI risk 20-33% in pts with reperfusion
Resting gated blood pool
-- postop MI : 19% in EF>35%
-- postop MI : 75% in EF<35%
-- 2/3 of postop MI occur during first 3days
-- chest pain : 90% of nonsurgical pts with MI
50% of surgical pts with MI d/t coexisting pain and analgesia
suspision for postop MI is extremely important
-- CK-MB isoenzyme level is most sensitive and specific indicator of MI
-- routine postop ECG on all pts with cardiovascular ds is controversial
if routine screening of asymptomatic pts is desired, ECG should be obtained 24hrs following surgery
-- supplemental O2
-- beta blocker : decrease HR, contractility, systemic BP
pts receiving therapy prior to surgery continue to perioperative period
labetelol : reflex tachycardia is limited
osmolal : if asthma is present
-- prophylactic nitrates: controvetial
-- nifedipine : decrease BP in 5min, plateau in 30min
2. Congestive Heart Failure
Table 19.10
-- aggresive diuretics --> hypokalemia --> increase digitalis toxicity
--> dehyration --> hypotension during induction of anesthesia
-- MI,infection, pulmonary embolism, arrythmia
-- severe CHF place with Swan-Ganz cath helpful to guide perioperative fluid management
postoperative CHF results most frequently from excessive administration of iv fluids and blood
Treatment of pulmonary edema
--> iv furosemide, O2, iv morphine sulfate, elevation of head, iv aminophylline
3. Arryhthmia
with heart ds --> VT
without heart ds --> SVT
-- taking antiarrhthmic drugs prior to surgery should be continue
initiation of antiarrhymic medications is rarely indicated preoperatively
-- asymptomatic Morbitz I second-degree AV block : require no therapy
symptomatic Morbitz II, third degree AV block : permanent pacemaker before surgery
in emergency, pacing pulmonary artery cath
-- electrocautery units may interfere with demand type pacemaker
if demand type in place , pacemaker should be converted preoperativelu to the fixed-rate mode
-- surgery is not contraindicated in pts with budle branch block or hemiblock
4. Vavular heart disease
AS : great risk
sx : exertional dyspnea, angina, syncope
severe AS < 1cm2
significant AS : sinus rhythm be maintained during postoperative period
tachyarrythmia : digitalis
sinus tachycardia : propranolol
bradycardia below 45beats/min should be treated with atropine
SVT : verapamil
MS : mitral stenosis often have AF, if presents, digitalis should be used to reduce rapid ventrcular response
warfarin is withheld 1-3 days prior to surgery
anticoagulation is obtained by iv heparination, heparin is discontinued 6-8hrs prior to
surgery and resumed several days postoperatively
5. Hypertension
-- hypertension alone are no greater perioperative risk of cardiac morbidity or mortality
-- hypertension + heart ds : 13% perioperative mortality rate
diastolic BP >110mmHg, systolic BP>180mmHg should controlled prior to surgery
-- pts with beta blocker shouldbe maintained to prevent rebound tachycardia, hypercontractality, hypertension
-- Lab : ECG, chest X-ray, CBC, UA, E, Cr
-- hypertensive pts with sweating, palpitations, headache evaluated for coexisting pheochromocytoma
99. 5 .4
1st year resident, Noh Jae Hong
Management of Medical Problems
ENDOCRINE DISEASE
1. Diabetes Mellitus
most common endocrine disease
-- uncontrolled DM : morbidity : 2times
mortality : 3 times
-- MI risk of females with NIDDM : 4times
-- DM duration more than 20yrs, nephropathy : 50%
hypertension : 70%
-- increased risk of acute renal failure, after iv contrast
s-Cr >2.0
vascular disease
onset of DM < 40yrs
-- autonomic neuropathy --> increased risk of MI,(intraoperative hypotension, cardiac arrythmia)
sudden death
decreased esophageal and intestinal motility
delayed gastric emptying
increased risk of aspiration pneumonitis
-- infection --> G(-), staphylococcal pneumonia
G(-) & Group B Streptococcus sepsis 7% (1% of normal population)
sepsis is mc caused by E.coli from urinary tract
-- wound dehiscence, infection, decreased amounts of collagen formation, fibroblast growth
capillary growth : 10.7% : 1.8%
-- Goal of treatment : avoiding ketosis, hyperglycemia, hypoglycemia
-- admit pts 2days prior to surgery
begin insulin drip at 1-3U/hr
initially, glucose monitored every 1-2hrs
after 100-200mg/dl range, monitor every 4hrs
-- Type 2 DM
controlled with hypoglycemics or diet : iv fluid containing no dextrose should not given insulin
RI : BST>250mg/dl
pts taking long acting sulfonylurea ---> discontinued 3days prior to surgery
" short " ---> " 1days "
-- Type 1 DM
1/3~1/2 of pts usual daily dose of NPH is given subcutaneously the morning of surgery
intra- or postop insulin should be delivered iv, as a continuous drip or intermittent (q6hrs)
sc bolus of RI with 5% dextrose
-- periop hypoglycemia : coma
periop hyperglycemia (250mg/dl): infection, poor wound healing, electrolyte abnomalities, hyperosmolar coma,
ketoacidosis
-- postop BST q 6hrs until eating
maintain BST<250mg/dl , RI should be given on a sliding scale
-- regional anesthesia : lower stress-induced hyperglycemia
-- thrombotic complication : enhanced plt aggregation and TXA2 production
improved glycemic control and low-dose aspirin may correct the plt function
2. HYPERTHYROIDISM
Graves' ds is mc cause of hyperthyroidism
F:M = 10:1
[ Preoperative management ]
* PTU : at least 2wks before surgery
100-200mg q6hrs along with beta blocker
--> inhibit tyroglobulin iodination and iodotyrosine couling recuce extrathyroidal conversion of T4 to T3
* SSKI(saturated solution of potassium iodide) : 6-12 drops *2/d for 10-14days prior to surgery
* hydrocortisone : 100mg q8hrs --> decrease extrathroidal conversion of T4 to T3
* propranolol : 10-80mg q6-8hrs
[ Treatment of tyroid storms ]
1) PTU
2) invasive hemodynamic monitoring and crystalloid therapy
3) O2
4) mechanical cooling devices
5) avoidance of aspirin, atropine, methoxyflurame, cyclopropane
3. HYPOTHROIDSIM
over 50% of all cases are caused by previous thyroid surgery or RI therapy
* symptoms : lethargy, dry skin, memory impairment, apathy, hoarseness,
periorbital edma, goiter, brittle hair, increased relaxation phase of DTR
constipation, cardiomegaly, pleural effusion, pericardial effusion, ascites
* preop preparation : slow replacement with levothyroxine
if given too quickly, may cause cardiovascular collapse
* tyroid replacement therapy : 0.025mg of tyroxin daily, doubled every 2weeks until the patients
taking a dose of 0.15mg daily
TSH level will determine the daily dose
in severe myxedematous pts : 0.3-0.5mg tyroxin given in iv
hydrocortisone (100-300mg q8hrs)
Cx: hypoglycemia, anemia, hypothermia, hyponatremia
increased incidence of intraop hypotension, increased rates of CRF, ileus after abdominal surgery
4. ADRENAL INSUFFICIENCY/IATROGENIC STEROID USE
should be DDX for periop hypertension
ACTH stimulation test : ACTH 25u given
normal : cortisol level : absolute rise >7ug or total >18ug doubling of the basal line
Empirical coverage with a "stress" dose of hydrodortisone is recommended 100-300mg q8hrs
pts on chronic steroid supression or Addison's ds
¨ç hydrocortisone : 100mgIM in OR
" : 50mg IM/IV in recovery room q6hrs for 3 dose
" : 25mg IM/IV q6hrs for 4doses if pts hemodynamically stable
¨è taper to maintenance dosage over next 3-5days
havles the dose of hydrocortisone until a dose of 25mg is reached
eliminating one daily dose each day until the drug has been stopped
¨é increase cortisol dosage to 200-400mg over 24hrs if hypotension
CADIOVASCULAR DISEASE
Preoperative Evaluation
* History : known heart ds, DM, hyperlipidemia, hypertension, smoking, strong family history of heart ds
* P/E : hypertension , JVE, lateral displaced point of maximal impulse, irregular pulse, S3,
pulmonay rales, murmurs, peripheral edema, bruits
* LAB : anemia,
K, Na : important in taking diuretics and digitalis
BUN/Cr : renal fx, hydration status
Glucose : duciagnosed DM
CXR, ECG
1. CORONARY ARTERY DISEASE
-- incidence of MI after surgery : 0.15%
-- prior MI, reinfarction rate : 5%
after 3mo : 30%, 3-6mo : 12%, 6mo = no prior history of IHD
-- postop MI mortality : 50%
Table 19.8
-- degree of LV dysfucntion is more critical
Exercise stress test : pts who has IHD not manifested when at rest
ischemic ECG + < 75% of maximal predicted HR ---> MI :25% mortality : 18.5%
---> selectively apply to a high risk population
Dipyridamole-thallium scan
-- high degree of sensitivity and specificity
-- dipyridamole to dilate normal vs but not stenotic vs
hypoperfused myocardium does not uptake 5min after injection
reperfusion and uptake of thalium 3hrs after injection : viable but high risk myocardium
-- periop MI risk 20-33% in pts with reperfusion
Resting gated blood pool
-- postop MI : 19% in EF>35%
-- postop MI : 75% in EF<35%
-- 2/3 of postop MI occur during first 3days
-- chest pain : 90% of nonsurgical pts with MI
50% of surgical pts with MI d/t coexisting pain and analgesia
suspision for postop MI is extremely important
-- CK-MB isoenzyme level is most sensitive and specific indicator of MI
-- routine postop ECG on all pts with cardiovascular ds is controversial
if routine screening of asymptomatic pts is desired, ECG should be obtained 24hrs following surgery
-- supplemental O2
-- beta blocker : decrease HR, contractility, systemic BP
pts receiving therapy prior to surgery continue to perioperative period
labetelol : reflex tachycardia is limited
osmolal : if asthma is present
-- prophylactic nitrates: controvetial
-- nifedipine : decrease BP in 5min, plateau in 30min
2. Congestive Heart Failure
Table 19.10
-- aggresive diuretics --> hypokalemia --> increase digitalis toxicity
--> dehyration --> hypotension during induction of anesthesia
-- MI,infection, pulmonary embolism, arrythmia
-- severe CHF place with Swan-Ganz cath helpful to guide perioperative fluid management
postoperative CHF results most frequently from excessive administration of iv fluids and blood
Treatment of pulmonary edema
--> iv furosemide, O2, iv morphine sulfate, elevation of head, iv aminophylline
3. Arryhthmia
with heart ds --> VT
without heart ds --> SVT
-- taking antiarrhthmic drugs prior to surgery should be continue
initiation of antiarrhymic medications is rarely indicated preoperatively
-- asymptomatic Morbitz I second-degree AV block : require no therapy
symptomatic Morbitz II, third degree AV block : permanent pacemaker before surgery
in emergency, pacing pulmonary artery cath
-- electrocautery units may interfere with demand type pacemaker
if demand type in place , pacemaker should be converted preoperativelu to the fixed-rate mode
-- surgery is not contraindicated in pts with budle branch block or hemiblock
4. Vavular heart disease
AS : great risk
sx : exertional dyspnea, angina, syncope
severe AS < 1cm2
significant AS : sinus rhythm be maintained during postoperative period
tachyarrythmia : digitalis
sinus tachycardia : propranolol
bradycardia below 45beats/min should be treated with atropine
SVT : verapamil
MS : mitral stenosis often have AF, if presents, digitalis should be used to reduce rapid ventrcular response
warfarin is withheld 1-3 days prior to surgery
anticoagulation is obtained by iv heparination, heparin is discontinued 6-8hrs prior to
surgery and resumed several days postoperatively
5. Hypertension
-- hypertension alone are no greater perioperative risk of cardiac morbidity or mortality
-- hypertension + heart ds : 13% perioperative mortality rate
diastolic BP >110mmHg, systolic BP>180mmHg should controlled prior to surgery
-- pts with beta blocker shouldbe maintained to prevent rebound tachycardia, hypercontractality, hypertension
-- Lab : ECG, chest X-ray, CBC, UA, E, Cr
-- hypertensive pts with sweating, palpitations, headache evaluated for coexisting pheochromocytoma