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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

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.
  • 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 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 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
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 ?

pre op prophylaxis
Pre-op prophylaxis
  • Bowel Prep ?
  • DVT ?
  • Antibiotic ?
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.

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