perioperative care kimberly ephgrave, md, facs professor of surgery university of iowa carver...
TRANSCRIPT
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 should you do Next ?
What might you order for Pre-admission testing?
CBC: CEA
Electrolytes : ABG
LFT’s: Lipid Panel
Amylase/Lipase: Cardiac Enzymes
PT/PTT: Other:
U/A:
Possible Labs
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 ??????
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