Perioperative care
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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.

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Perioperative Care

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Perioperative care

Perioperative Care

Kimberly Ephgrave, MD, FACS

Professor of Surgery

University of Iowa Carver College of Medicine


Ms sedentary

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

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

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

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

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

Physical Exam

What would you look for?


Physical exam1

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?


What should be done about smoking1

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

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?


What about a cardiac workup1

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

Who qualifies for beta-blockade?

  • Two or more of the following risk factors:

    • Age > 65

    • Hypertension

    • Current smoker

    • Hypercholesterolemia

    • Diabetes


Perioperative care

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 pre admission testing

What might you order for Pre-admission testing?


Perioperative care

Possible Labs


Studies

Studies ?


Possible studies

Possible Studies


Is ms sedentary a candidate for any pre op prophylaxis

Is Ms. Sedentary a candidate for any pre-op prophylaxis?


Pre op prophylaxis

Pre-op prophylaxis

  • Bowel Prep ?

  • DVT ?

  • Antibiotic ?


Discuss risk factors for dvt

Discuss Risk Factors for DVT


Post op orders

POST-OP ORDERS


What should you do about her diabetes postoperatively

What should you do about her diabetes postoperatively?


What is your target blood sugar range

What is your target Blood Sugar range?


Icu studies

ICU Studies

  • Normoglycemia: Less mortality, less sepsis

  • Insulin administration:No protective effect per se.


Sliding scale vs insulin drip

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

Summary


Questions

QUESTIONS ??????


Perioperative care

Acknowledgment

The preceding educational materials were made available through theASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials wewelcome your comments/ suggestions at:

[email protected]


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