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perioperative management

Also see: - preoperative evaluation & management - perioperative risk assessment - postoperative management Laboratory: - for patients at elevated risk, post-operative troponin-I in serum/plasma may be reasonable [47] Special laboratory: 1) avoid perioperative pulmonary artery catherization to monitor hemodynamic status 2) preoperative spirometry not routinely indicated [17] Radiology: - chest X-ray not routinely indicated [17] Complications: - non-cardiac surgery [30] - demand cardiac ischemia - stress-induced cardiomyopathy [30] Management: - perioperative music may reduce postoperative pain [26] - minimally invasive surgery is recommended for older patients [46] - enhanced recovery after surgery may improve outcomes for older patients [46] === preoperative food & fluid management === 1) > 8 hours fasting prudent before general anesthesia - a light meal or nonhuman milk may be ingested for up to 6 hours before elective procedures - breast milk up to 4 hours prior to elective procedure - carbohydrate-containing clear liquids (simple or complex, not alcohol) for up to 2 hours prior to elective procedure [37] - clear fluids within 2 hours before anticipated anesthesia should not postpone or cancel surgery [39] - avoid prolonged fasting in children [37] - do not delay surgery after confirming the removal of chewing gum [37] 2) fluid restriction if any cardiopulmonary compromise, especially heart failure - see perioperative fluid management === perioperative medication management === 1) see perioperative anticoagulation 2) see perioperative antiplatelet therapy 3) antihypertensive agents a) continue beta-blockers, calcium channel blockers, nitrates b) continue centrally-acting alpha-2 adrenergic receptor agonists - clonidine, brimonidine (ophthalmic) - do not initiate clonidine [17] c) withholding ACE inhibitors, angiotensin receptor blockers (ARBs) may diminish risk of intraoperative hypotension [28,41,45] (23% vs 28%) [41] but not 30 day risk of cardiovascular events or mortality [41,45] d) diuretics optional, usually withheld e) patients with hypertension do not require urgent preoperative reduction in blood pressure unless evidence of end-organ damage [17] f) >= 2 antihypertensives on the morning of vascular surgery increases risk for postoperative renal failure [31] g) continue vasodilators h) also see perioperative beta blockade [3,4,5,7,10,15,17,19] 4) perioperative beta-blocker to prevent atrial fibrillation a) not necessary for patients with ventricular rate < 110/min [38] b) perioperative amiodarone 10 mg/kg 6 days prior to & 6 days post-op reduces postoperative atrial fibrillation after cardiac surgery by 50% c) metoprolol as effective in preventing atrial fibrillation as amiodarone [21] 5) alpha-1 blockers & 5-alpha reductase inhibitors - may be taken morning of surgery - risk of intra-operative floppy iris syndrome in cataract surgery 6) hypolipidemic agents: a) continue statins 1] consider initiating statin in high-risk patients [17] 2] perioperative statin in high-risk patients, several weeks prior to surgery results in less ischemia & fewer MIs in patients undergoing vascular surgery [18] b) hold cholestyramine, fibrates [17] 7) antiasthmatic agents a) continue maintentance & rescue inhalers b) probably continue leukotriene antagonists (monteleukast, zafirlikast) & lipoxygenase inhibitors (zileuton) 8) gastrointestinal agents - antacids: - continue H2 receptor blockers & proton pump inhibitors - withhold hyoscyamine (risk of anticholinergic effects) 9) immunosuppressive agents a) continue hydroxychloroquine b) continue/individualize methotrexate [17], (continue) [17] c) continue azathioprine, 6-mercaptopurine - mycophenolate, azathioprine, cyclosporine, tacrolimus should be withheld 1 week prior to surgery unless disease (lupus) severe [17] d) discontinue biologic immunosuppressive agents - hold adalimumab for 2 weeks before & after surgery [43] - infliximab probably ok to continue - rituximab ok at end of dosing cycle - continue belimumab e) continue glucocorticoids: 1] increase if stress dose indicated 2] consider stress dose coverage if patient took the equivalent of >= 10-20 mg prednisone per day for at least 3 weeks in the past 6-12 months [17] - intravenous hydrocortisone for stress dose coverage (see below for dosing) 10) hypoglycemic agents a) discontinue oral hypoglycemics & non-insulin injectable hypoglycemics 12-72 hours prior to surgery, depending upon 1/2life of hypoglycemic agent [17] - SGLT-2 inhibitors (flozins) should be stopped 3-4 days before surgery [34,47] - GLP-1 agonists should be held the morning of surgery (agents dosed daily) or during the week prior surgery (agents dosed weekly) [34] - GLP-1 agonists (glutides) generally do not need to be held prior to outpatient procedures or minor surgery [42] - continue preoperatively for patients deemed at low risk [48] - if high risk: escalation phase, on highest dose, GI symptoms (nausea, vomiting, dyspepsia, gastroparesis, Parkinson disease, hold for 1 week prior to procedure or preoperative liquid diet for 24 hours [48] - metformin should not be given on the morning of surgery [34] - DPP-4 inhibitors should not be given on the morning of surgery [34] b) on morning of surgery - give 60-80% usual AM dose or PM dose of intermediate-acting insulin or long-acting insulin [34] - withhold short-acting insulin c) a basal level of long-acting insulin with as needed short-acting insulin is the preferred method of glycemic control in the perioperative period d) a target for serum glucose < 180 mg/dL (expert opinion) [17,23] - perioperative hyperglycemia & hypoglycemia are common in patients managed with insulin [40] - intensive glycemic control might be unnecessary in patients with diabetes undergoing major surgery [44] e) resume oral hypoglycemics at hospital discharge or when patient has resumed a full diet [17] 11) thyroid agents a) continue antithyroid agent (propylthiouracil, methimazole, KI) for hyperthyroidism b) hyperthyroidism does increase surgical risk & should be controlled preoperatively in non-emergent surgery [17] c) continue thyroid replacement for hypothyroidism d) delay elective surgery for severe hypothyroidism e) mild-moderate hypothyroidism does not increase surgical risk 12) glucocortioids a) usual dose of corticosteroid can be taken the morning of surgery [34] b) hydrocortisone stress-dosing 1] indications - primary adrenal insufficiency - Cushingoid features - prednisone equivalent of > 5 mg/day for 3 weeks in past 3 months - high-dose inhaled glucocorticoid - high-dose topical glucocorticoid (may be indicated) - parenteral glucocorticoid in past 3 months (may be indicated) 2] dosage of hydrocortisone - minor procedures: 25 mg (once) - orthopedic procedures: 50-75 mg QD for 1-2 days - cardiac surgery (CABG): 100 mg QD for 2-3 days 13) estrogen a) discontinue hormone-replacement therapy several weeks before surgery b) continue oral contraceptives if indicated & increase DVT prophylaxis 14) bisphosphonates should be held the morning of surgery [34] 15) antidepressants a) discontinue MAO inhibitors 10-14 days prior to surgery b) consider withholding SSRIs 2-3 weeks prior to neurosurgery c) tricyclic antidepressants (TCA) may be continued d) lithium carbonate may be continued 16) antipsychotics - continue antipsychotics [17] 17) neurologic agents a) continue anticonvulsants b) may continue parkinson agents - schedule surgery early in day to minimize missed doses [17] c) discontinue Alzheimer agents d) continue benzodiazepines 18) analgesics: - continue or reduce dose of long-acting opiates - NSAIDs & COX2 inhibitors generally discontinued 3-7 days prior to surgery [17] 19) anticholinergic medications should be held the morning of surgery - H2 blockers ok 20) phosphodiesterase-5 inhibitors should be held 3 days prior to surgery due to concerns of hypotension [34] 21) biologic-response modifiers - discontinue sirolimus - transplantation patients: - continue all biologic-response modifiers (except sirolimus) - non-transplantation patients: - discontinue all biologic-response modifiers at least 4 1/2lifes prior to surgery & for 2 weeks after surgery [17] 22) perioperative antibiotics is a risk factor for C difficile colitis 23) herbal medications: discontinue 1-2 weeks prior to surgery 24) hold vitamins & supplements 25) resume withheld medications after surgical wounds heal & sutures or staples have been removed (generally ~ 14 days) [17] 26) also see preoperative medication management guidelines from the Mayo Clinic [36] === perioperative blood transfusions === 1) no clear cutoff for perioperative blood transfusion [9] 2) a threshold hemoglobin of 7-8 g/dL recommended for asymptomatic patients [17] 3) restrictive transfusion strategy may increase risk of ischemia [27] 4) a threshold hemoglobin of 10 g/dL recommended for patients with ischemic heart disease 5) elderly orthopedic patients may benefit from a less restrictive transfusion strategy [27] === pulmonary hygiene === 1) smoking cessation > 8 weeks prior to surgery improves pulmonary function & may decrease risk of complications 2) routine preoperative & postoperative lung expansion maneuvers (incentive spirometry) to prevent postoperative pulmonary complications [8,17] - may not be of benefit [17] 3) training in postoperative breathing exercises before upper abdominal surgery reduces postoperative pulmonary complications [29] 4) perioperative prophylactic respiratory physiotherapy includes increased mobility, sputum clearance, deep breathing exercise, & inspiratory muscle training consistently reduces postoperative pulmonary complications [17,35] 5) early mobilization [17] 6) delay or cancel elective surgery in patients with pulmonary hypertension [17]

Related

perioperative risk assessment post-operative management preoperative evaluation & management

Specific

perioperative anticoagulation perioperative antiplatelet therapy perioperative beta blockade perioperative fluid management perioperative revascularization preoperative placement of needle localization wire, breast

General

medical therapy; therapeutic intervention management

References

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