Transcript Association for Surgical Education: Perioperative Care

Perioperative Care
Kimberly Ephgrave, MD, FACS
Professor of Surgery
University of Iowa Carver College of Medicine
Ms. Sedentary
 Your patient is a 63 y/o woman who needs an
elective subtotal colectomy.
 She has multiple lesions in right, left, and
transverse colon but no invasion on biopsies.
 You agree that it is not urgent, and it would be
wise to optimize her health status.
History
 What co-morbid conditions affect
surgical risk?
 Which can be altered if we are willing to
delay surgery a few months?
Risk Factors that Might be Changed
 Malnutrition: Decreases wound healing, increases
infectious complications
 Chronic obstructive lung disease: Pulmonary
complications
 Current Smoking: Wound complications.
 Hyperglycemia: Sepsis and mortality in ICU’s
 Coronary Artery Disease: Cardiac morbidity
Risk Factors I: Ms. Sedentary
 Malnutrition not present: Ms. Sedentary has an albumin
of 4.5 and pre-albumin of 30; she is obese.
 Chronic obstructive lung disease: She has a ‘smoker’s
cough’ productive of colored sputum.
 Smoking status: Ms. Sedentary smokes about 1 ppd,
down from a peak of > 2 ppd.
Risk Factors II: Ms. Sedentary
 Hyperglycemia: Ms. Sedentary is an obese
diabetic, on two oral medications, with a
hemoglobin A 1C of 7.8%.
 Coronary Artery Disease: Ms. Sedentary is
hypertensive. She does not have angina, but her
ability to exercise is limited by claudication.
Physical Exam
What would you look for?
Physical Exam




BMI 32
Diminished pedal pulses
Harsh upper airway noises; clear with cough
Afebrile, BP 154/88, HR 84 and regular with no
murmurs or gallops
What should be done about
smoking?
What should be done about
smoking?
 Early papers suggested recent cessation worse than no
cessation.
 Recent studies: Lower wound and pulmonary
complications if cessation for > 3-4 weeks.
 Elective cosmetic surgery probably not indicated in
current smokers due to doubling wound healing
complication rates.
 Close follow-up and bupropion both helpful.
What about ‘smoker’s cough’?




Rule out pneumonia
Treat active bronchitis with antibiotics.
Treat bronchospasm with bronchodilators.
Add steroids if needed for persistent
bronchospasm.
What about a cardiac workup?
What about a cardiac workup?
 Good studies of non-cardiac surgery in patients
with peripheral vascular disease suggest
invasive testing not indicated in the absence of
symptoms.
 However, beta blockade IS indicated
perioperatively.
 Titrate to HR < 70 as long as BP is not
hypotensive.
Who qualifies for beta-blockade?
 Two or more of the following risk factors:
• Age > 65
• Hypertension
• Current smoker
• Hypercholesterolemia
• Diabetes
Pre-Operative Course:
You successfully treat her bronchitis, begin
bronchodilators, and help her to quit smoking pre-operatively. You
also place her on atenolol, and maintain a heart rate less than 70
peri-operatively.
What should you do Next ?
What might you order for Preadmission testing?
Possible Labs
CBC:
CEA
Electrolytes :
ABG
LFT’s :
Lipid Panel
Amylase/Lipase:
Cardiac Enzymes
PT/PTT:
Other:
U/A:
Studies ?
Possible Studies
Chest X-Ray
EKG
Pulmonary Function
Testing
Echocardiogram
Other:
Stress Test
Is Ms. Sedentary a candidate for any
pre-op prophylaxis?
Pre-op prophylaxis
 Bowel Prep ?
 DVT ?
 Antibiotic ?
Discuss Risk Factors for DVT
POST-OP ORDERS
Bed/Floor
Monitoring
Medications
IV Fluids
Vitals
BP Meds
Incentive Spirometry
Foley Catheter
Insulin
Resp. Tx
I&O
Pain Meds
Activity
Tubes
Anti-nauseants
Diet/ Nutrition
Blood Sugars
DVT prophylaxis
SCD’s
Wound Care
Other:
What should you do about her
diabetes postoperatively?
What is your target Blood Sugar range?
ICU Studies
 Normoglycemia: Less mortality, less sepsis
 Insulin administration:
No protective effect per se.
Sliding Scale vs. Insulin drip
 Sliding scales generally allow more time spent in
higher (> 200) ranges.
 Insulin drip potentially more dangerous outside of
ICU’s because staffing may be low and checks for
hypoglycemia infrequent.
 Blood sugars above 150-200 range interfere with white
blood cell function, affecting wound healing and
resistance to infection.
Summary
QUESTIONS ??????
Acknowledgment
The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
[email protected]