Makindo Medical Notes.com

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• There is a big difference in elective surgery and emergency surgery and a whole world of other procedures in between and it is for the team to decide what the overall balance in risks and benefits are and to act in the best interests of the patient.

General

• Surgery is a cardiorespiratory and coagulation and would healing stress event and the physician's jobs is to help anaesthetists and surgeon by identifying risks and issues and helping to correct as much pathology as possible. Ultimately the decision to operate is between the surgeon and anaesthetist and patient.

Cardiac disease

• IHD remains a major risk and symptoms of angina or equivalents should raise red flags and will need cardiology assessment.
• Breathlessness and exercise tolerance are useful guides to a cardiorespiratory reserve that needs investigation. If there is uncertainty then cardiology assessment recommended.
• This is also important for the management of antithrombotics in those with stents and valve replacement. Patients should have an ECG to look for Ischaemia, AF, Hypertension and suggestions of structural heart disease and conduction defects.
• Elective surgery is usually delayed post recent MI for at least 6 months. Risks highest in first 6 weeks.
• Hypertension: may be diagnosed or poor control spotted at assessment when BP is likely to be up anyhow. Needs a long term strategy of control. Urgent assessment if unstable - chest pain, encephalopathy, LVF etc. See GP next day for most.
• Arrhythmias should be detected e.g. AF and managed pre-surgery. Chronic or complex arrhythmias should be discussed with a cardiologist.
• Those with cardiac failure should have their therapy optimised prior to surgery and require special attention to perioperative fluid balance.
• Patients with abnormal or prosthetic heart valves, PDA or septal defects, and patients with a history of bacterial endocarditis should have prophylactic oral or intravenous antibiotic cover for any surgical procedures.

Respiratory medicine

• Smoking should be identified and patients should stop smoking at least 6 weeks before surgery.
• Routine CXR will not exclude all lung disease and functional assessment and history is needed e.g. Early COPD or Asthma
• Those with significant lung disease may benefit from a preoperative respiratory opinion and formal respiratory function testing.
• Perioperative management and early sitting out and mobilisation to prevent hypostatic pneumonia as well as good pain control
• Effective VTE prophylaxis to prevent PE

Diabetes mellitus

• Patients with diabetes are at increased risk of hypoglycaemia and ketoacidosis. This is on top of ongoing risks of ischaemic heart disease, vascular insufficiency, renal failure and increased risk of infection).
• Diet-controlled diabetics often require no specific intervention, but should have perioperative blood glucose monitoring and oral hypoglycaemic agents should be omitted on the morning of surgery (unless undergoing a short day-case procedure) and restart when oral diet recommences. Perioperative blood sugar levels should be monitored.
• For Major surgery, or if NBM for a prolonged period, a variable rate insulin infusion should be commenced.
• Those with Insulin-controlled diabetics will have a variable rate Insulin infusion with close monitoring of blood sugar and urine for ketones is essential. Once the oral diet is recommenced the patient should convert back to regular subcutaneous Insulin therapy.

Coagulation disorders

• Increased risk of DVT/PE is a significant postoperative risk. Risk factors include previous DVT/PE and inherited thrombophilic disorders as well as modifiable risks as smoking, obesity, prolonged postoperative immobility, malignancy and drugs such as the combined oral contraceptive pill.
• Risk factors should be identified and modified (including stopping the combined oral contraceptive pill 4 weeks prior to major surgery).
• Specific prophylaxis includes subcutaneous LMWH injections and compression stockings, and intermittent calf compression which should be considered for at-risk patients.
• Bleeding disorders such as haemophilia, use of anticoagulant or antiplatelet medication and chronic liver disease may cause perioperative bleeding. Patients with known coagulation factor or Vitamin K deficiencies may require perioperative replacement therapy. Anti-coagulant medication may be reduced, changed or stopped depending on the underlying indication for anticoagulation.

Liver disease

• Those with liver disease can have impaired coagulation (Vitamin K and coagulation factor deficiencies)
• Impaired metabolism of drugs, increased susceptibility to infection and low albumin
• Correct coagulation deficiencies with Vitamin K which may help if Vit K deficiency.
• Careful fluid balance is essential.
• Alcohol intake should be elicited to predict the likelihood of a withdrawal syndrome

Renal disease

• Identify those at increased risk - vascular disease, HTN, Diabetes
• Avoid Hypotension and urinary output should be monitored
• Oliguria/anuria recognised early and treated.
• Ensure hydration is continued post-op
• Avoid NSAIDs as much as possible

Emergency surgery

• In patients requiring emergency surgery time is short and information may be limited and so there may not be enough time to identify and correct all coexistent diseases.
• Assess significant cardiac, respiratory, metabolic or endocrine disease, which may affect anaesthesia.
• An ECG, CXR, Bloods and Coagulation study can help as well as ABG where needed.
• Any anaemia, fluid and electrolyte imbalance or cardiac failure should be corrected prior to surgery wherever possible.
• Assess for VTE risk and manage