Perioperative Management Issues Karen Stierman, M.D.

Faculty Advisor: Francis B. Quinn, M.D.

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

May 30, 2001

Perioperative Period

Defined as the time before,during and after the

operative procedure

Preoperative testing should include:

Pregnancy testing, childbearing age

Assessment of nutritional status

Hemoglobin(female)

Other tests as H&P indicates

Malnutrition

Mild to moderate

Weight loss 6-12% of normal, albumin 3.5g/dl, transferrin 200 mg/dl

Severe - weight loss >12%, low protein

NG versus TPN

Protein levels

Normal 0.8 g/kg/day

Ill 1.2 to 2.0 g/kg/day

TPN

Requires monitoring – avoid volume overload

Multiple times a day –VS, urine, glucose,acetone,

fluids

Daily – Weight, Lytes, I/O, protein, calories

Weekly – Liver function tests, serum

magnesium,protein, iron

TABLE 20-1. Blood components

Fraction Indication

Packed red blood cells Acute hemorrhage,symptomatic anemia

Fresh frozen plasma Coagulation abnormalities, hemoglobinopathy

Cryoprecipitate Low fibrinogen levels, coagulation

abnormalities,and hemoglobinopathy

Factor concentrates Specific factor deficits

Blood Transfusion

Monitor – hypersensitivity, volume overload, lytes,

acid/base, thrombocytopenia, hypothermia

Citrate toxicity – low ionized calcium

Autologous transfusion – can give 1 unit/72 hours

up to 72 hrs prior to surgery(HCT>33%)

Anemia

Hemoglobin <7g/dl in case with moderate

expected blood loss requires transfusion.

Chronic anemia or low blood loss patient may be

able to withstand

Anemia

Sickle cell

Trait;heterozygous, no tx

Disease;homozygous, transfuse to 50% HgS

Glucose-6-phosphate dehydrogenase

Men

Oxidant damage to Hg – lysis

Avoid certain meds

Thrombocytopenia

Platelet count<140,000/mL

DDX sepsis, drug induced, dilutional, DIC

Platelet count<50,000/mL – symptomatic

Each unit increases count by 5-10K

Half life 2- 3 days

Qualitative platelet disorders

Uremia, liver disease, previous bleeding d/o

NSAIDS, ASA

Correct underlying disorder

Desmopressin acetate

Coagulopathy

PT/PTT

Low risk – aortic valve, afib,previous DVT

D/C coumadin 1-2 days prior

High risk – mitral vave, cardiac emoboli,

D/C coumadin, begin heparin

Emergency

FFP- coumadin; Protamine sulfate – heparin

DVT

Risk factors

Obesity, cancer, immobilization, hypercoaguable states,

age greater than 40 years old

Diagnosis – Homan’s, fever, edema, pain, cord,

discoloration; Duplex US

Treatment – Heparin

P.E.

Sudden onset tachypnea, dyspnea, chest pain,

hemoptysis, hypoxia, arrhythmia

V/Q scan

Pulmonary angio

Heparin/oral anticoags

Diabetes

Fasting BG in all - incidence 1% and rises to 5%

for those over 40 yrs. old

In NPO patient, hold insulin or oral agent and

monitor glucose

Poor control – hold off on elective case

Goal 120-250 mg/dl

TABLE 20-3. Insulin coverage during surgery

For patients on oral hypoglycemic agents

Stop oral agents 24 h before surgery.

Insulin to control hyperglycemia (see below).

For insulin-dependent patient

Stop subcutaneous insulin pump.

On the morning of surgery, give one-third to one-

half of usual daily dose of intermediate-acting

insulin (NPH, Lente) subcutaneously. Supplement

with regular insulin during surgery dependent

on blood glucose.

Alternatively give regular insulin as a separate

constant infusion of 1–3 U/h, with rate

determined by the serum glucose measurements.

Ketoacidosis/Hyperosmolar coma

Ketoacidosis- IV bolus of 12-20 U reg. insulin and

constant infusion of 5-10u/hr

Hyperosmolar nonketotic hyperglycemia – lower

insulin doses

Fluids important

Potassium

Hypothyroid

Slow replacement better than rapid with

levothyroxine due to risk of adrenal insufficiency

and angina

Myxedema- Hydocortisone as well as synthroid

because stress response decreased.

Hyperthyroid

Reschedule if elective

Iodine – Inhibits thyroid hormone production, decreases vascularity

Steroid – stress response

Propanolol – B blocker

Antithyroid –

PTU blocks thyroid hormone production and inhibits conversion of T4-T3

Methamazole

TABLE 20-4. Medical control of thyrotoxic crisis

Propylthiouracil 300 mg p.o. every 6 h.

Iodine 5 drops saturated solution of potassium iodide

PO every 6–8 h or sodium iodide 500 mg i.v. Q12H.

Propranolol 1–2 mg i.v. as needed to keep pulse less

than 100.

Hydrocortisone 100 mg i.v. Q8H.

For congestive heart failure, digitalis and diuretics are

given and propranolol omitted.

Adjunctive Measures – Thyrotoxic

crisis Temperature control

O2

IVF

Hypocalcemia

Thyroid/parathyroid surgery

Ca levels Q12 hrs(8mg/dL) until stable

Signs/Symptoms – Chvostek’s, Trousseau’s,

hyperreflexia, numbness/tingling in

extremities/circumoral.

Laryngeal stridor, overt tetany – emergencies

Calcium/ Vitamin D

Adrenal insufficiency

Suppressed hypothalmic/pituitary/adrenal axis

Stress during surgery – hypotension due to loss of

vascular tone

More than 5mg/day prednisone x 3 weeks in past

year

Currently on steroids, adrenal insuff., Cushings

TABLE 20-5. Replacement hydrocortisone sodium succinate

for adrenal-suppressed patients

Minor surgical procedures

usual daily cortisone dose

additional 100 mg i.m. before surgery

Major surgical procedures

100 mg i.v. or i.m. on call to operating room

100 mg i.v. on induction

100 mg i.v. q8h postoperatively

50 mg i.v. q8h on second postoperative day

Taper to maintenance over 3–5 days

Maintain 200–400 mg daily if ongoing stresses or

complications

i.v., intravenous, i.m., intramuscularly; q8h, every 8 hours.

DI/SIADH

DI – decreased ADH, decrease free water

reabsorption, dilute urine, hyperosmolar serum. Tx

with fluid intake, if severe-5% dextrose in water

with minimal sodium, DDAVP

SIADH – hyponatremia, concentrated urine, Tx

with fluid restriction, democlocyline(inhibits ADH

on kidney)

Cardiovascular

Routine ECG – men over 40 and women over 55.

Full eval if symptomatic

Med levels(digitalis) preop

Take hypertensive and cardiac meds preop.

No MAO or guanethidine 2 weeks prior to surgery

Hypertension

Anesthetic agents vasodilate

Hypervolemia, hypoventilation,pain, meds,

distended bladder/stomach, pre-existing

hypertension.

Correct underlying d/o

Nitroprusside

Hypotension

Hypovolemia, anesthesia, meds, cardiac

dysfunction,pulmonary d/o

Fluid challenge

Wedge pressure

Sepsis

Vasopressors

Arrythmias

Cardiac dz,hypoxia, hypotension,

acid/base/electrolyte

Supraventricular tachy – adenosine, verapamil,

propanolol, diltiazem

Afib/flutter – Digoxin

Ventricular tach- lidocaine

Cardiology consult

Pulmonary considerations

Mechanical vent – alveolar hypovent with V/Q

abnormalities

History/Physical – smoker, dyspnea

ACS – CXR greater than 40 yrs old, high risk for

pulmonary disease

Avoid fluid overload

IS/Deep breath

Pulmonary considerations

Reactive airway – nebs

Brochoscopy – mucous plug

Wedge

PAWP > 25 mm HG- cardiogenic – fluid

restrict/diuretics

ARDS – normal PAWP, pulmonary edema, target

cause, supportive measures

GI

Ulcers

H2 blocker

Massive GI bleed, NGT, GI consult

Intestinal motility – ileus, check for BS prior to feeding, Xray – distended loops of bowel and diffuse gas, Tx with NGT

Diarrhea – Clostridium, clinda/amp most common but others can cause, Tx with fluids and Vanc.

Renal

Dialysis

Platelet dysfunction, anemia, hypertension, lytes

ATN – ischemia or nephrotoxicity, urine casts, low

urine/plasma creatinine, nephro consult

Neuropsychiatric

Seizures

Heart, metabolic, drug/etoh, CNS

Determine cause, airway/vent, Tx with benzo’s phenytoin,barbituates

Myasthenia gravis – continue anticholinesterase meds. Avoid quinidine, curare,lithium,B-blockers,phenytoin, aminoglycosides

Delerium versus dementia

TABLE 20-8. Pharmacologic management of status epilepticus

Agent Dosage

Diazepam

Adults i.v. bolus of 5–10 mg at 1–2 mg/min to maximum of 20–

30 mg or continuous infusion 4–8 mg/h to total daily dose of 1–4

mg/kg

Children 1 mg/yr of age to total dose of 5–10 mg

Lorazepam 2–4 mg i.v. slowly q5–10 min to total dose of 8 mg

Phenytoin

Adults Loading dose of 15–20 mg/kg at 30–50 mg/min

Children Loading dose of 10–20 mg/kg at 0.5–1.5 mg/kg/min

Phenobarbital Loading dose of 10–20 mg/kg i.v. (initial bolus 200–300

mg), repeated in 20 min

Supportive

Glucose

Adult: 50 mL of a 50% solution

Children: 1–2 mL/kg of a 25% solution

Thiamine 100 mg i.v.

Calcium gluconate 1–2 amps for recent thyroid or

parathyroid surgery

TABLE 20-9. Pharmacologic management of delirium

Hepatic encephalopathy

Short-acting benzodiazepines (e.g., oxazepam,

15–30 mg q6h)

Alcohol withdrawal (i.v., Q1–2h)

Chlordiazepoxide, 25–50 mg

Diazepam, 5–10 mg

Lorazepam, 2 mg

Other forms of delirium

Haloperidol

Mild agitation 2–15 mg p.o. twice daily (elderly 0.5–3.0 mg daily)

More severe agitation 2–10 mg i.m. hourly until sedation

obtained (10–60 mg/day usually sufficient)

Urgent 1–5 mg i.v. with increases of 5–10 mg/h

Chlorpromazine

All cases 25–50 mg i.m. h if blood pressure adequate

i.v., intravenous, i.m., intramuscularly

TABLE 20-10. Postoperative causes of fever

Noninfectious causes

Hematoma and tissue trauma

Atelectasis

Nonseptic phlebitis and deep venous thrombosis

Drug of anesthetic allergies

Transfusion reactions

Presence of drains or catheters

Less common noninfectious causes

Activation of inflammatory disease (lupus,

rheumatoid arthritis)

Endocrine excess (thyroid storm)

Hypothalamic abnormalities

Infectious sites

Wound

Urinary tract

Respiratory

Intravenous line site

Infected prosthesis or foreign body

Meningitis (especially in skull-base surgery)

TABLE 20-11. Treatment of malignant hyperthermia

Signs

Sharp increase in core body temperature

Cardiac arrhythmias

Excessive bleeding

Rise in end-tidal carbon dioxide concentration

Management

Stop succinylcholine and inhalation agent

immediately

100% oxygen

Dantrolene sodium, 2.5 mg/kg i.v. q5–10 min as

necessary to maximum dose of 10 mg/kg

Sodium bicarbonate, 1–2 mEq/kg i.v. (monitor blood

gases)

Support therapy

Remove drapes

Lower core temperature with iced saline (i.v.,

rectally or intragastrically)

Application of ice to exposed body parts

Watch for hyperkalemia, acidosis, myoglobinuria,

arrhythmias, and posttreatment hypothermia

TABLE 20-12. Pharmacologic management of postoperative pain

Drugs Dose

Opioids Initial dose

Morphine 10 mg i.m. or 5–10 mg i.v. then 3

mg/h continuous i.v. infusion

PCA: Demand 0.5–3.0 mg, lock

out 5–12 min

Children: 0.07–0.1 mg/kg/i.v. q2h

Meperidine 75–100 mg i.m. or 25–50 mg i.v.,

then 25 mg/hr infusion

PCA: Demand 5–30 mg, lock out

5–12 min

Buprenorphine 0.3 mg i.m. or i.v., q6–8h

Nonsteroidal antiinflammatory drugs

Indomethacin 50–100 mg q6–8h

Ibuprofen 200–400 mg q4–6h

Ketorolac 30 mg i.v. or i.m., q6h (maximum

5 days)

i.m., intramuscularly; i.v., intravenously; q2h, every 2 hours; q6-8h,

every 6 to 8 hours; PCA, patient controlled analgesia.