Preoperative Medical Management of the Surgical Patient

1
Preoperative Medical Management of the Surgical
Patient

• Sepein Chiang, DO

2
Preoperative Medical Evaluation

• Elective procedures ideally an outpatient office
  based activity
• Emergency procedures rapid inpatient medical
  evaluation
• Elderly often have multiple preexisting medical
  problems
• Often are the healthiest when they arrive

3
Cardiac

• Increased risk CAD, unstable angina, recent MI,
  decompensated CHF, severe aortic stenosis,
  uncontrolled HTN
• No increased risk chronic stable angina,
  controlled HTN, nonspecific EKG changes
• Echocardiograms stress tests

4
Pulmonary

• Increased risk heavy smokers, asthma, obesity,
  COPD
• Respiratory infections should be aggressively
  treated
• Identify patients at increased risk of pulmonary
  embolus

5
Renal

• Increased risk chronic renal insufficiency, end
  stage renal disease
• Susceptible to stresses of volume and electrolyte
  changes, rhabdomyolysis
• Increased risk for infection and bleeding
• Careful of renally excreted medications

6
Hepatic

• Increased risk acute viral alcoholic hepatitis
  cirrhosis with decompensation
• Hypoalbuminemia, coagulopathy, ascities and
  encephalopathy
• Routine pre-op LFTs not recommended unless HP
  raise suspicion

7
Diabetes Mellitus

• Often have co-existing cardiac, renal and
  vascular problems
• Increased risk for infection poor wound healing

8
Rheumatic Diseases

• Obtain pre-op cervical spine films
• Increased risk for atlantoaxial subluxation
• Cautious of hyperextension during endotracheal
  intubation
• Often on steroids and may have suppression of the
  hypothalamic-pituitary-adrenal axis with
  decreased responsiveness to stress
• Daily prednisone of 7.5 mg or greater

9
Tests Labs

• EKG
• CXR
• UA
• CBC, lytes, BUN, Cr, RBS, coags, type screen
• Appropriate xrays
• Check skin over fracture site for cellulitis or
  pressure sores

10
Basic Orders

• Neurovascular checks
• Allergies
• Bedrest
• Elevate heels
• TED, SCDs
• NPO

• IV hydration
• Foley
• Pain control
• Pre-operative IV antibiotics

11
Conclusion

• Consult internal medicine but watch over
  everything yourself!!