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 Pre-admission 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 Monitoring Medications IV Fluids Vitals BP Meds 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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