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Surgery - Improved recuperation after surgery
Enhanced recovery after surgery (ERAS) aims to minimize perioperative physiological and stress responses, optimize recovery pace, and limit complications. It is typically used for healthy patients who do not require specific preoperative corrections.
The following are the important areas to consider.
Nutrition • Oral carbohydrate loading 24 hours before surgery, including up to 4 hours before anesthesia, is believed to minimize the early catabolic reaction to major surgery.
• Early reintroduction of full nutrition, including carbohydrate-rich drinks from 6 hours post-surgery, nutritional supplements, and a light food from 48 hours post-surgery, to promote immediate GI tract function. Anaesthetic Technique • Avoiding opiate use, such as morphine in PCA and epidurals, to minimize nausea and reduced GI motility.
• Avoiding epidurals to facilitate early mobilization and minimize the effects of autonomic spinal blocking on the heart, lungs, and gastrointestinal system. • Using regional LA-based treatments, such as transversus abdominis plane (TAP) block, regional LA infiltration, or infusional catheters, can reduce central nociceptor input and improve systemic stress response during surgery.
Surgical method
• Minimally invasive procedures, such as laparoscopic surgery, aim to lessen metabolic reaction, improve early mobilization, and minimize GI tract exposure during abdominal surgery. Avoiding bowel preparation during abdominal surgery minimizes the risk of fluid and electrolyte imbalances, disrupts GI tract flora, and leads to fewer GI problems (e.g., anastomotic leaks). Physiotherapy involves early mobilization with particular exercises, sitting out within 12 hours, and walking within 48 hours of surgery.
Perioperative respiratory exercises. Nursing:
• Intensive patient preparation, including preoperative teaching on expected outcomes. Intensive perioperative and post-operative nursing include promoting early re-establishment of food, movement, and self-care. Although intense and demanding, ERAS-type treatments are equally successful in the elderly and young. They are not recommended for insulin-dependent diabetics, people with pre-existing nutritional issues, or those with cognitive impairment.
Enhanced recovery after surgery (ERAS) aims to minimize perioperative physiological and stress responses, optimize recovery pace, and limit complications. It is typically used for healthy patients who do not require specific preoperative corrections.
The following are the important areas to consider.
Nutrition • Oral carbohydrate loading 24 hours before surgery, including up to 4 hours before anesthesia, is believed to minimize the early catabolic reaction to major surgery.
• Early reintroduction of full nutrition, including carbohydrate-rich drinks from 6 hours post-surgery, nutritional supplements, and a light food from 48 hours post-surgery, to promote immediate GI tract function. Anaesthetic Technique • Avoiding opiate use, such as morphine in PCA and epidurals, to minimize nausea and reduced GI motility.
• Avoiding epidurals to facilitate early mobilization and minimize the effects of autonomic spinal blocking on the heart, lungs, and gastrointestinal system. • Using regional LA-based treatments, such as transversus abdominis plane (TAP) block, regional LA infiltration, or infusional catheters, can reduce central nociceptor input and improve systemic stress response during surgery.
Surgical method
• Minimally invasive procedures, such as laparoscopic surgery, aim to lessen metabolic reaction, improve early mobilization, and minimize GI tract exposure during abdominal surgery. Avoiding bowel preparation during abdominal surgery minimizes the risk of fluid and electrolyte imbalances, disrupts GI tract flora, and leads to fewer GI problems (e.g., anastomotic leaks). Physiotherapy involves early mobilization with particular exercises, sitting out within 12 hours, and walking within 48 hours of surgery.
Perioperative respiratory exercises. Nursing:
• Intensive patient preparation, including preoperative teaching on expected outcomes. Intensive perioperative and post-operative nursing include promoting early re-establishment of food, movement, and self-care. Although intense and demanding, ERAS-type treatments are equally successful in the elderly and young. They are not recommended for insulin-dependent diabetics, people with pre-existing nutritional issues, or those with cognitive impairment.
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Surgery - Getting the patient to theatre
Organizing and following a routine are crucial when preparing patients for surgical procedures. Inadequate preparedness can lead to serious implications for patients. Background papers Prepare the theatre or endoscopic list ahead of time to ensure accuracy. The list should include the patient's name, hospital number, location, surgery information, surgeon, and anesthesiologist. Patient paperwork
• Ensure current medical notes are available for this admission, including a complete history and examination.
• \tMonitor blood results for specific conditions, such as K+ in renal failure, clotting function in anticoagulated patients, and calcium (Ca2+) in parathyroidectomy patients.
• Ensure patients have access to blood and blood products from the transfusion department. (Most hospitals have protocols for determining the appropriate quantity of units of blood.)
• Ensure necessary imaging results are available. Ensure the consent form is completed and included in the medical notes.
• Complete the medication chart.
Patient preparation • Ensure the patient's procedure side/site is clearly indicated (if applicable). This should be done with the patient awake and validated by nursing staff. Check if the patient has been marked by any relevant professionals, such as a stoma care provider or a prosthetist for amputees.
• Determine any necessary preparations, such as bowel preparation, ahead of time. Bowel preparation This device is used to empty the big bowel prior to surgery. Preparation options include a stimulant mechanical bowel preparation, such as sodium picosulfate, which should be given with plenty of drink at least 8 hours before surgery. Avoid any potential obstructions.
• Use an osmotic mechanical bowel preparation, such as magnesium citrate or Klean Prep®, with 2-4 sachets diluted in water up to 8 hours before operation. Suitable for bowel preparation during colonic surgeries, including colonoscopy and CT colonography.
• Stimulant left colon preparation, such as phosphate enema. Suitable for rectum/anus surgery or flexible sigmoidoscopy procedures.
• Mechanical bowel preparation is now less common than it was previously. Bowel surgery may increase the risk of septic complications and has known adverse effects such as electrolyte imbalances, hypovolaemia in the elderly, and nausea and vomiting (especially with large-volume osmotic preparations). Getting The Patient to Theatre 97 Anaesthetic premedication. Reduces anxiety during anaesthesia preparation and reduces the need for anesthetic agents during induction. Benzodiazepines, such as diazepam (PO) or midazolam (5mg IV), are commonly utilized as preoperative agents. Hyoscine butylbromide is occasionally used to reduce upper aerodigestive tract secretions.
Organizing and following a routine are crucial when preparing patients for surgical procedures. Inadequate preparedness can lead to serious implications for patients. Background papers Prepare the theatre or endoscopic list ahead of time to ensure accuracy. The list should include the patient's name, hospital number, location, surgery information, surgeon, and anesthesiologist. Patient paperwork
• Ensure current medical notes are available for this admission, including a complete history and examination.
• \tMonitor blood results for specific conditions, such as K+ in renal failure, clotting function in anticoagulated patients, and calcium (Ca2+) in parathyroidectomy patients.
• Ensure patients have access to blood and blood products from the transfusion department. (Most hospitals have protocols for determining the appropriate quantity of units of blood.)
• Ensure necessary imaging results are available. Ensure the consent form is completed and included in the medical notes.
• Complete the medication chart.
Patient preparation • Ensure the patient's procedure side/site is clearly indicated (if applicable). This should be done with the patient awake and validated by nursing staff. Check if the patient has been marked by any relevant professionals, such as a stoma care provider or a prosthetist for amputees.
• Determine any necessary preparations, such as bowel preparation, ahead of time. Bowel preparation This device is used to empty the big bowel prior to surgery. Preparation options include a stimulant mechanical bowel preparation, such as sodium picosulfate, which should be given with plenty of drink at least 8 hours before surgery. Avoid any potential obstructions.
• Use an osmotic mechanical bowel preparation, such as magnesium citrate or Klean Prep®, with 2-4 sachets diluted in water up to 8 hours before operation. Suitable for bowel preparation during colonic surgeries, including colonoscopy and CT colonography.
• Stimulant left colon preparation, such as phosphate enema. Suitable for rectum/anus surgery or flexible sigmoidoscopy procedures.
• Mechanical bowel preparation is now less common than it was previously. Bowel surgery may increase the risk of septic complications and has known adverse effects such as electrolyte imbalances, hypovolaemia in the elderly, and nausea and vomiting (especially with large-volume osmotic preparations). Getting The Patient to Theatre 97 Anaesthetic premedication. Reduces anxiety during anaesthesia preparation and reduces the need for anesthetic agents during induction. Benzodiazepines, such as diazepam (PO) or midazolam (5mg IV), are commonly utilized as preoperative agents. Hyoscine butylbromide is occasionally used to reduce upper aerodigestive tract secretions.
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Pathology - Prophylaxis: antibiotics and thromboprophylaxis.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
Surgery - In-theater preparation
Poor preparation and checking in the operating room can lead to risks for patients, such as wrong side surgery (e.g., removing a healthy kidney), incorrect site surgery (e.g., inguinal, not femoral, hernia repaired), allergic reactions to medication, insufficient vital materials (e.g., blood), insufficient equipment (e.g., image intensifier, specialist joint replacement jig), and retained swabs or instruments. Strict adherence to a checklist can reduce the probability of 'never occurrences' in high-risk industries, such as aviation. The WHO suggests a standardized checklist approach.
WHO Checklist
The WHO checklist is a customizable form with four essential checkpoints that can be tailored to specific organizations.
Before the start of the operational list.
• Ensure surgical, anaesthetic, and nursing teams are present and identifiable. • Confirm patient list, procedure order, and address any unique issues
. • Verify that anesthetic equipment, medicine, and monitoring are in working order
. • Confirm imaging and equipment requirements for the list. Before inducing anesthesia, ensure patient identity and permission are valid. Check the site and side markers, if applicable. Check that the anesthetic needs are correct and functional. Check for allergies and predicted blood loss. Before skin incision, ensure all team members are present and known. Check the procedure that will be conducted. Confirm any surgical, anesthetic, or nursing concerns. Confirm that critical imaging/equipment are available. Before leaving the theatre, ensure the correct name for the procedure conducted is known and recorded.
• Verify the swab and instrument counts are accurate. Confirm that any surgical specimens were properly collected and labeled. Confirm any specific postoperative instructions.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
Surgery - In-theater preparation
Poor preparation and checking in the operating room can lead to risks for patients, such as wrong side surgery (e.g., removing a healthy kidney), incorrect site surgery (e.g., inguinal, not femoral, hernia repaired), allergic reactions to medication, insufficient vital materials (e.g., blood), insufficient equipment (e.g., image intensifier, specialist joint replacement jig), and retained swabs or instruments. Strict adherence to a checklist can reduce the probability of 'never occurrences' in high-risk industries, such as aviation. The WHO suggests a standardized checklist approach.
WHO Checklist
The WHO checklist is a customizable form with four essential checkpoints that can be tailored to specific organizations.
Before the start of the operational list.
• Ensure surgical, anaesthetic, and nursing teams are present and identifiable. • Confirm patient list, procedure order, and address any unique issues
. • Verify that anesthetic equipment, medicine, and monitoring are in working order
. • Confirm imaging and equipment requirements for the list. Before inducing anesthesia, ensure patient identity and permission are valid. Check the site and side markers, if applicable. Check that the anesthetic needs are correct and functional. Check for allergies and predicted blood loss. Before skin incision, ensure all team members are present and known. Check the procedure that will be conducted. Confirm any surgical, anesthetic, or nursing concerns. Confirm that critical imaging/equipment are available. Before leaving the theatre, ensure the correct name for the procedure conducted is known and recorded.
• Verify the swab and instrument counts are accurate. Confirm that any surgical specimens were properly collected and labeled. Confirm any specific postoperative instructions.
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Surgery - Positioning the Patient
Getting the patient to the surgical table • The surgical team plays a role in ensuring patient safety during and after surgery. Ensure compliance with basic safety guidelines.
• The anaesthetist is responsible for maintaining the patient's airway by coordinating all movements. • Avoid dislodging IV cannulae, epidural sites, or existing drains. • Use approved manual handling techniques, such as a 'Patslide' or comparable device, instead of lifting patients. • Take special precautions with prosthetic joints that may dislocate during relaxation, unstable fractures, Rheumatoid arthritis related instability, ulcers, or skin sores.
Once in position. • Prevent diathermy exit point burns by ensuring no patient points come into contact with the operating table's metal surface. • Properly pad bony prominences and thin skin areas, such as the neck of the fibula in leg stirrups. • Ensure diathermy pads are properly applied and not impacted by skin preparations. • Provide adequate patient support, especially if the table is likely to shift, tilt, or rotate throughout the procedure (e.g., arm, thoracic, and abdominal supports for lateral positions, shoulder bolsters for head down positions). • When doing procedures that need access to the perineum, ensure sufficient pelvic support while exposing the perineum over the end of the operating table.
• Plan the placement of ancillary equipment. For instance, where will video stacks be located? Is more than one energy source needed, and where will the generators be located? Is there access to mobile imaging equipment or on-table radiography? Position all equipment to offer the surgical team enough access to the patient.
Getting the patient to the surgical table • The surgical team plays a role in ensuring patient safety during and after surgery. Ensure compliance with basic safety guidelines.
• The anaesthetist is responsible for maintaining the patient's airway by coordinating all movements. • Avoid dislodging IV cannulae, epidural sites, or existing drains. • Use approved manual handling techniques, such as a 'Patslide' or comparable device, instead of lifting patients. • Take special precautions with prosthetic joints that may dislocate during relaxation, unstable fractures, Rheumatoid arthritis related instability, ulcers, or skin sores.
Once in position. • Prevent diathermy exit point burns by ensuring no patient points come into contact with the operating table's metal surface. • Properly pad bony prominences and thin skin areas, such as the neck of the fibula in leg stirrups. • Ensure diathermy pads are properly applied and not impacted by skin preparations. • Provide adequate patient support, especially if the table is likely to shift, tilt, or rotate throughout the procedure (e.g., arm, thoracic, and abdominal supports for lateral positions, shoulder bolsters for head down positions). • When doing procedures that need access to the perineum, ensure sufficient pelvic support while exposing the perineum over the end of the operating table.
• Plan the placement of ancillary equipment. For instance, where will video stacks be located? Is more than one energy source needed, and where will the generators be located? Is there access to mobile imaging equipment or on-table radiography? Position all equipment to offer the surgical team enough access to the patient.
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Surgery - Sterilization, disinfection, and antiseptic
Definitions • Sterilization involves removing all living germs, vegetative organisms, and spores.
• Disinfection removes dividing vegetative germs.
• Antisepsis reduces the danger of medical cross-infection from germs. Sterilization
Heat: • Dry heat (e.g. incineration, blazing, red hot) is effective but rarely useful. Dry heat necessitates temperatures of 160°C for at least 60 minutes. • Moist heat, such as autoclave heating with pressurized steam at 121°C and 15lb/in2 for 15 minutes, is effective and useful for operating theaters.
Irradiation involves gamma radiation. Effective with inorganic materials. Ultrafine membrane filters can disinfect air and fluids, although they are not commonly used in hospitals.
Disinfection methods include using acids or alkalis, such as bleach. Effective for non-human contact applications. Examples of alcohols and phenols include ethyl alcohol for skin swabs, alcohol solutions for hand disinfection, carbolic chloroxylenols, and phenol (Clearsol®). • Oxidizers include povidone-iodine for skin disinfection and surgical washing, hydrogen peroxide (H2O2) for superficial wound cleansing, and aldehydes for surgical tools like endoscopes. •
Cationic solutions, such as chlorhexidine, can be used for antiseptic wash. • Organic dyes, such as Proflavine.
Antisepsis
Antisepsis concepts include: • Remove gross contamination first with plain soap. • Use high-potency acid/alkali disinfectants on inert surfaces. • Apply less corrosive oxidizers to fragile inert materials. • Use weak alcohols and oxidizers to cleanse the skin.
Definitions • Sterilization involves removing all living germs, vegetative organisms, and spores.
• Disinfection removes dividing vegetative germs.
• Antisepsis reduces the danger of medical cross-infection from germs. Sterilization
Heat: • Dry heat (e.g. incineration, blazing, red hot) is effective but rarely useful. Dry heat necessitates temperatures of 160°C for at least 60 minutes. • Moist heat, such as autoclave heating with pressurized steam at 121°C and 15lb/in2 for 15 minutes, is effective and useful for operating theaters.
Irradiation involves gamma radiation. Effective with inorganic materials. Ultrafine membrane filters can disinfect air and fluids, although they are not commonly used in hospitals.
Disinfection methods include using acids or alkalis, such as bleach. Effective for non-human contact applications. Examples of alcohols and phenols include ethyl alcohol for skin swabs, alcohol solutions for hand disinfection, carbolic chloroxylenols, and phenol (Clearsol®). • Oxidizers include povidone-iodine for skin disinfection and surgical washing, hydrogen peroxide (H2O2) for superficial wound cleansing, and aldehydes for surgical tools like endoscopes. •
Cationic solutions, such as chlorhexidine, can be used for antiseptic wash. • Organic dyes, such as Proflavine.
Antisepsis
Antisepsis concepts include: • Remove gross contamination first with plain soap. • Use high-potency acid/alkali disinfectants on inert surfaces. • Apply less corrosive oxidizers to fragile inert materials. • Use weak alcohols and oxidizers to cleanse the skin.
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Surgery - Operative procedures in renal and hepatic disorders
Renal dysfunction
Renal impairment encompasses a continuum, from individuals with subclinical dysfunction (normal serum creatinine and urea levels, although borderline creatinine clearance) to those with end-stage renal failure. It is beneficial to categorize these patients into two primary groups: those with chronic renal impairment and those who are dialysis-dependent.
Chronic kidney dysfunction
Surgery may induce acute renal failure in patients with chronic renal insufficiency. Avoid hypovolemia and hypotension. Ensure that these patients obtain sufficient intravenous hydration if they are to remain nil by mouth for an extended duration. Avoid nephrotoxic agents wherever feasible, including non-steroidal anti-inflammatory medications (NSAIDs), aminoglycosides, ACE inhibitors, and radiographic contrast media. Decrease dosages of medications eliminated by the kidneys, such as morphine, low-molecular-weight heparin (LMWH), and digoxin, and regularly seek relevant levels.
Patients with diagnosed renal insufficiency undergoing dialysis
For patients undergoing major surgery, consult with the anesthesiologist and ICU regarding their post-operative management at the earliest opportunity. Dialysis must be conducted the day before to surgery. Patients are required to undergo a complete blood count (FBC) and urea and electrolytes (U&Es) upon admission, as well as pre- and post-dialysis assessments. Additionally, U&Es should be conducted twice day following major surgery until the patient is stabilized on their standard dialysis regimen.
Decrease dosages of medications eliminated by the kidneys, such as morphine, low molecular weight heparin (LMWH), and digoxin, and regularly seek relevant serum values. If the patient is typically anuric, the insertion of a urine catheter is unwarranted, as it poses an unnecessary risk of infection.
Identify the locations of arteriovenous fistulae. Avoid utilizing them for phlebotomy or cannulation, and refrain from applying blood pressure cuffs on that side.
These patients are susceptible to several complications:
Hyperkalemia, acidosis, and pulmonary edema are potential life-threatening situations (% Renal complications, pp. 136–8). Infection. Anemia with coagulopathy. Disruptions in fluid and electrolyte balance.
Metabolic acidosis. Systemic hypertension, pericarditis.
Hepatic dysfunction
The risk associated with liver disease in patients undergoing general surgery was assessed by Child and Turcotte (refer to Box 2.3). Child grade C correlates with elevated perioperative mortality. Liver failure results in the subsequent complications: Hypoglycemia; hepatic encephalopathy; coagulopathy (international normalized ratio); ascites; and infection.
Multiple variables can precipitate abrupt decompensation of mild hepatic impairment and should be avoided or managed vigorously in this population: • Infection, particularly bacterial peritonitis; drowsiness; diuretics; constipation; electrolyte imbalance; dehydration; and hypotension.
• Preoperatively: assess hepatitis serology, order liver ultrasound for newly detected hepatic impairment; consult with haematology on additional blood product requests; confer with a specialist about normal drug dosages. Jaundice Patients with obstructive jaundice are susceptible to post-operative renal failure (hepatorenal syndrome). This is believed to result from the nephrotoxic impact of toxins typically excreted by the liver, along with alterations in circulation. • Maintain sufficient hydrated. For a patient who is NBM, administer IV normal saline 1L over a duration of 6 to 8 hours. • Insert a urine catheter and initiate an hourly fluid balance chart. • Conduct daily assessments of urea and electrolytes (U&E) and liver function tests (LFTs). Coagulopathy in chronic cholestatic jaundice may be ameliorated with 1 mg of intravenous vitamin K—consult with hematology. Avoid or minimize the dosages of hepatotoxic medications and those eliminated by the liver.
Renal dysfunction
Renal impairment encompasses a continuum, from individuals with subclinical dysfunction (normal serum creatinine and urea levels, although borderline creatinine clearance) to those with end-stage renal failure. It is beneficial to categorize these patients into two primary groups: those with chronic renal impairment and those who are dialysis-dependent.
Chronic kidney dysfunction
Surgery may induce acute renal failure in patients with chronic renal insufficiency. Avoid hypovolemia and hypotension. Ensure that these patients obtain sufficient intravenous hydration if they are to remain nil by mouth for an extended duration. Avoid nephrotoxic agents wherever feasible, including non-steroidal anti-inflammatory medications (NSAIDs), aminoglycosides, ACE inhibitors, and radiographic contrast media. Decrease dosages of medications eliminated by the kidneys, such as morphine, low-molecular-weight heparin (LMWH), and digoxin, and regularly seek relevant levels.
Patients with diagnosed renal insufficiency undergoing dialysis
For patients undergoing major surgery, consult with the anesthesiologist and ICU regarding their post-operative management at the earliest opportunity. Dialysis must be conducted the day before to surgery. Patients are required to undergo a complete blood count (FBC) and urea and electrolytes (U&Es) upon admission, as well as pre- and post-dialysis assessments. Additionally, U&Es should be conducted twice day following major surgery until the patient is stabilized on their standard dialysis regimen.
Decrease dosages of medications eliminated by the kidneys, such as morphine, low molecular weight heparin (LMWH), and digoxin, and regularly seek relevant serum values. If the patient is typically anuric, the insertion of a urine catheter is unwarranted, as it poses an unnecessary risk of infection.
Identify the locations of arteriovenous fistulae. Avoid utilizing them for phlebotomy or cannulation, and refrain from applying blood pressure cuffs on that side.
These patients are susceptible to several complications:
Hyperkalemia, acidosis, and pulmonary edema are potential life-threatening situations (% Renal complications, pp. 136–8). Infection. Anemia with coagulopathy. Disruptions in fluid and electrolyte balance.
Metabolic acidosis. Systemic hypertension, pericarditis.
Hepatic dysfunction
The risk associated with liver disease in patients undergoing general surgery was assessed by Child and Turcotte (refer to Box 2.3). Child grade C correlates with elevated perioperative mortality. Liver failure results in the subsequent complications: Hypoglycemia; hepatic encephalopathy; coagulopathy (international normalized ratio); ascites; and infection.
Multiple variables can precipitate abrupt decompensation of mild hepatic impairment and should be avoided or managed vigorously in this population: • Infection, particularly bacterial peritonitis; drowsiness; diuretics; constipation; electrolyte imbalance; dehydration; and hypotension.
• Preoperatively: assess hepatitis serology, order liver ultrasound for newly detected hepatic impairment; consult with haematology on additional blood product requests; confer with a specialist about normal drug dosages. Jaundice Patients with obstructive jaundice are susceptible to post-operative renal failure (hepatorenal syndrome). This is believed to result from the nephrotoxic impact of toxins typically excreted by the liver, along with alterations in circulation. • Maintain sufficient hydrated. For a patient who is NBM, administer IV normal saline 1L over a duration of 6 to 8 hours. • Insert a urine catheter and initiate an hourly fluid balance chart. • Conduct daily assessments of urea and electrolytes (U&E) and liver function tests (LFTs). Coagulopathy in chronic cholestatic jaundice may be ameliorated with 1 mg of intravenous vitamin K—consult with hematology. Avoid or minimize the dosages of hepatotoxic medications and those eliminated by the liver.
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Surgery - Operative procedures during gestation
Pregnancy testing: Urinary dipstick for β-human chorionic gonadotrophin (HCG) exhibits a sensitivity of 91%, which is notably lower for women conducting self-tests. Specificity varies from 61% to 100% when assessed from the initial day of the first missed menstrual cycle, which occurs two weeks post-ovulation. Blood β-HCG exhibits nearly 100% sensitivity and specificity, capable of detecting pregnancy 6 to 8 days post-ovulation. False negatives and positives primarily result from user error. Alterations in anatomical and physiological structures Pregnancy induces several alterations pertinent to surgical procedures.
First trimester: Drugs may have teratogenic effects Decreased lower oesophageal sphincter (LOS) tone elevates the risk of gastro-oesophageal reflux and aspiration in the supine position.
Second trimester: • Pharmacological agents may adversely impact fetal growth or metabolism without resulting in overt malformations. • Increased vulnerability to urinary tract infections (UTIs), especially ascending kidney infections and pyelonephritis. The risk of venous thromboembolism (VTE) increases throughout the second trimester and is consistently elevated in the third trimester. • Increased susceptibility to superficial infections.
Third trimester: Drugs may initiate labor. Superior and posterior displacement of the movable abdominal viscera due to the expanding uterus. The appendix is positioned higher in the right upper quadrant (RUQ).
• The risk of hypotension in the supine position arises from inferior vena cava compression by the gravid uterus; this can be mitigated by placing the drugged or unconscious patient in a mild lateral decubitus position. Potential risks of miscarriage The risk of miscarriage associated with surgical pathology and surgery fluctuates by trimester. It is at its peak in the initial instance. The likelihood of viable premature labor increases during the third trimester. The risk of miscarriage associated with GA is consistently weighed against the danger of sepsis resulting from untreated surgical conditions, especially acute appendicitis. This is a prevalent problem in surgical practice. Ultrasound imaging may be ineffective due to inadequate visualization, and CT scanning is contraindicated because of radiation exposure. MRI is frequently utilized post-first trimester. Diagnostic laparoscopy is contraindicated because of the impact of pneumoperitoneum on pregnancy. The sole method for obtaining a diagnosis may necessitate surgery when significant differential diagnoses have been ruled out.
Common differential diagnoses of appendicitis during pregnancy include ectopic pregnancy problems. Pyelonephritis. Imminent miscarriage/placental abruption.
Pharmaceutical prescription during gestation
Screening pharmaceuticals for detrimental effects on the human embryo is unequivocally immoral; hence, numerous novel and frequently utilized medications have not been administered during pregnancy. Certain older medications have been utilized during pregnancy and are considered 'safe' due to the lack of data indicating fetal harm. An essential equilibrium must be preserved between addressing the mother's significant sickness and mitigating any danger to the fetus. In general, refrain from providing medications whenever feasible. Be aware of the pregnant stage; numerous medications are sanctioned only during specific trimesters. Two Verify any medication you prescribe in the BNF (or its equivalent). • If uncertain, see a professional for guidance. • Significant teratogens comprise: • Thalidomide (an antiemetic). • Carbamazepine with sodium valproate. • Isotretinoin. Tetracycline. • Warfarin. • Angiotensin-converting enzyme (ACE) inhibitors. Lithium. • Methotrexate, cyclophosphamide
Pregnancy testing: Urinary dipstick for β-human chorionic gonadotrophin (HCG) exhibits a sensitivity of 91%, which is notably lower for women conducting self-tests. Specificity varies from 61% to 100% when assessed from the initial day of the first missed menstrual cycle, which occurs two weeks post-ovulation. Blood β-HCG exhibits nearly 100% sensitivity and specificity, capable of detecting pregnancy 6 to 8 days post-ovulation. False negatives and positives primarily result from user error. Alterations in anatomical and physiological structures Pregnancy induces several alterations pertinent to surgical procedures.
First trimester: Drugs may have teratogenic effects Decreased lower oesophageal sphincter (LOS) tone elevates the risk of gastro-oesophageal reflux and aspiration in the supine position.
Second trimester: • Pharmacological agents may adversely impact fetal growth or metabolism without resulting in overt malformations. • Increased vulnerability to urinary tract infections (UTIs), especially ascending kidney infections and pyelonephritis. The risk of venous thromboembolism (VTE) increases throughout the second trimester and is consistently elevated in the third trimester. • Increased susceptibility to superficial infections.
Third trimester: Drugs may initiate labor. Superior and posterior displacement of the movable abdominal viscera due to the expanding uterus. The appendix is positioned higher in the right upper quadrant (RUQ).
• The risk of hypotension in the supine position arises from inferior vena cava compression by the gravid uterus; this can be mitigated by placing the drugged or unconscious patient in a mild lateral decubitus position. Potential risks of miscarriage The risk of miscarriage associated with surgical pathology and surgery fluctuates by trimester. It is at its peak in the initial instance. The likelihood of viable premature labor increases during the third trimester. The risk of miscarriage associated with GA is consistently weighed against the danger of sepsis resulting from untreated surgical conditions, especially acute appendicitis. This is a prevalent problem in surgical practice. Ultrasound imaging may be ineffective due to inadequate visualization, and CT scanning is contraindicated because of radiation exposure. MRI is frequently utilized post-first trimester. Diagnostic laparoscopy is contraindicated because of the impact of pneumoperitoneum on pregnancy. The sole method for obtaining a diagnosis may necessitate surgery when significant differential diagnoses have been ruled out.
Common differential diagnoses of appendicitis during pregnancy include ectopic pregnancy problems. Pyelonephritis. Imminent miscarriage/placental abruption.
Pharmaceutical prescription during gestation
Screening pharmaceuticals for detrimental effects on the human embryo is unequivocally immoral; hence, numerous novel and frequently utilized medications have not been administered during pregnancy. Certain older medications have been utilized during pregnancy and are considered 'safe' due to the lack of data indicating fetal harm. An essential equilibrium must be preserved between addressing the mother's significant sickness and mitigating any danger to the fetus. In general, refrain from providing medications whenever feasible. Be aware of the pregnant stage; numerous medications are sanctioned only during specific trimesters. Two Verify any medication you prescribe in the BNF (or its equivalent). • If uncertain, see a professional for guidance. • Significant teratogens comprise: • Thalidomide (an antiemetic). • Carbamazepine with sodium valproate. • Isotretinoin. Tetracycline. • Warfarin. • Angiotensin-converting enzyme (ACE) inhibitors. Lithium. • Methotrexate, cyclophosphamide
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Surgery - Cardiac surgery and cardiovascular disease
Ischemic heart disease
Risk factors encompass male individuals over 45 years, female individuals over 55 years, a familial history of early myocardial infarction, current or treated hypertension, smoking, diabetes mellitus, and elevated cholesterol levels.
Evaluate severity—measure exercise tolerance; inquire about palpitations, orthopnea, utilization of anti-anginals, history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting. The ECG is the primary regular screening test; yet, it appears normal in approximately one-third of individuals with confirmed ischaemia.
Symptomatic patients scheduled for major surgery should be consulted with a cardiologist to optimize their meds.
Myocardial infarction
The likelihood of a perioperative myocardial infarction is associated with previous medical history and risk factors. • Overall population incidence following abdominal surgery: 0.5%. • Incidence of pre-existing cardiovascular symptoms: 2%. • Incidence of prior myocardial infarction (MI): 5–10%. • Incidence following recent myocardial infarction: 25% (70% will succumb to reinfarction).
Methods for mitigating risk
Non-urgent surgery should be postponed for a minimum of six months after an acute myocardial infarction and potentially after acute ischemia.
Cancer surgery may be performed if the likelihood of disease progression is deemed to surpass the perioperative mortality rate.
Continue all standard cardiovascular medications up to and during surgery. Manage any emergent angina symptoms if surgery is required.
Continue antiplatelet therapy if not contraindicated.
Consider engaging critical care services (HDU) during the perioperative phase.
Valvular cardiac pathology
Cardiac murmurs are prevalent.
Solicit a transthoracic echocardiography (TTE) to assess the lesion and confer with a cardiologist on the anomalies.
Severe aortic stenosis presents a significant mortality risk; elective surgery should be deferred. High-gradient aortic stenosis is related with a 10% mortality rate during non-cardiac surgery.
Severe mitral stenosis may result in pulmonary edema and cardiac failure; hence, significant elective surgery should be deferred until the defect is rectified.
Aortic regurgitation (AR) necessitates management of fluid balance and heart rate. Antibiotic prophylaxis is indicated, however the procedure may proceed. Mitral regurgitation (MR) ought to be treated with diuretics and vasodilators. Left ventricular (LV) function is often exaggerated in.
Prosthetic valves present numerous complications. Mechanical valves necessitate anticoagulation. Discontinue warfarin five days before to surgery and initiate heparin bridging once the international normalized ratio (INR) falls below therapeutic levels.
Cease IV heparin 2 to 6 hours before to surgery and reinstate it as soon as postoperative bleeding is adequately controlled, until the INR reaches therapeutic levels.
Thrombosis is more probable in the presence of mechanical valves, compromised left ventricular (LV) function, a history of thromboembolic disease, and to a lesser extent in rate-controlled atrial fibrillation (AF).
In surgical procedures addressing life-threatening hemorrhage, such as from a bleeding peptic ulcer or intracranial hemorrhage, it may be essential to reverse anticoagulation for multiple days. Collaborate closely with cardiology. Prosthetic valves no longer necessitate antibiotic prophylaxis for procedures that induce bacteraemias; if uncertain, consult with cardiology.
Hypertension arterial
Preoperative management of blood pressure may diminish the propensity for perioperative ischemia. If hypertension is severe (>180 mmHg), surgical intervention should be postponed until adequate control is achieved. • Evaluate current antihypertensive management or initiate treatment: consult with the anaesthetist.
Examine for indications of end-organ damage (renal, neurological) and concomitant cardiovascular disease. • Investigate uncommon yet significant etiologies: phaeochromocytoma, hyperaldosteronism, coarctation of the aorta, renal artery stenosis.
Congestive heart failure
Heart failure correlates with adverse outcomes in non-cardiac surgery. Risk factors encompass ischemic and valvular heart disease.
• Identify: S3, pedal edema, elevated jugular venous pressure (JVP), bibasal crepitations. Request a chest X-ray (CXR) if suspicion is present.
Cardiac arrhythmias
Arrhythmias and conduction abnormalities are prevalent. Asymptomatic arrhythmias do not correlate with an elevated risk of cardiac problems; however, it is essential to investigate potential underlying diseases, such as ischemic heart disease, medication toxicity, and metabolic disturbances. High-grade conduction problems, such as total heart block, necessitate consultation with a cardiologist. Pacing may be warranted. Patients with a history of atrial fibrillation, especially those with a prior embolic stroke or structural heart abnormality, typically receive warfarin therapy. Solicit a cardiology evaluation preoperatively if rate control is inadequate.
• Permanent pacemakers or implantable cardioverter-defibrillators (ICDs). Diathermy may induce a pacemaker reset, entirely block pacing, and activate ICD discharge. Pacemakers and implantable cardioverter-defibrillators (ICDs) must be assessed by a cardiac technician both preoperatively and postoperatively. Pacemakers must be adjusted to fixed-rate pacing during surgery and subsequently reset postoperatively. ICDs must be deactivated to avert discharge, and external defibrillator pads should be placed on the patient.
When defibrillation or synchronized cardioversion is necessary, position the paddles as far as feasible from the pacemaker or ICD. The specific sort of diathermy employed must be taken into account. Monopolar is not unequivocally contraindicated; nevertheless, bipolar may be more advantageous.
Ischemic heart disease
Risk factors encompass male individuals over 45 years, female individuals over 55 years, a familial history of early myocardial infarction, current or treated hypertension, smoking, diabetes mellitus, and elevated cholesterol levels.
Evaluate severity—measure exercise tolerance; inquire about palpitations, orthopnea, utilization of anti-anginals, history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting. The ECG is the primary regular screening test; yet, it appears normal in approximately one-third of individuals with confirmed ischaemia.
Symptomatic patients scheduled for major surgery should be consulted with a cardiologist to optimize their meds.
Myocardial infarction
The likelihood of a perioperative myocardial infarction is associated with previous medical history and risk factors. • Overall population incidence following abdominal surgery: 0.5%. • Incidence of pre-existing cardiovascular symptoms: 2%. • Incidence of prior myocardial infarction (MI): 5–10%. • Incidence following recent myocardial infarction: 25% (70% will succumb to reinfarction).
Methods for mitigating risk
Non-urgent surgery should be postponed for a minimum of six months after an acute myocardial infarction and potentially after acute ischemia.
Cancer surgery may be performed if the likelihood of disease progression is deemed to surpass the perioperative mortality rate.
Continue all standard cardiovascular medications up to and during surgery. Manage any emergent angina symptoms if surgery is required.
Continue antiplatelet therapy if not contraindicated.
Consider engaging critical care services (HDU) during the perioperative phase.
Valvular cardiac pathology
Cardiac murmurs are prevalent.
Solicit a transthoracic echocardiography (TTE) to assess the lesion and confer with a cardiologist on the anomalies.
Severe aortic stenosis presents a significant mortality risk; elective surgery should be deferred. High-gradient aortic stenosis is related with a 10% mortality rate during non-cardiac surgery.
Severe mitral stenosis may result in pulmonary edema and cardiac failure; hence, significant elective surgery should be deferred until the defect is rectified.
Aortic regurgitation (AR) necessitates management of fluid balance and heart rate. Antibiotic prophylaxis is indicated, however the procedure may proceed. Mitral regurgitation (MR) ought to be treated with diuretics and vasodilators. Left ventricular (LV) function is often exaggerated in.
Prosthetic valves present numerous complications. Mechanical valves necessitate anticoagulation. Discontinue warfarin five days before to surgery and initiate heparin bridging once the international normalized ratio (INR) falls below therapeutic levels.
Cease IV heparin 2 to 6 hours before to surgery and reinstate it as soon as postoperative bleeding is adequately controlled, until the INR reaches therapeutic levels.
Thrombosis is more probable in the presence of mechanical valves, compromised left ventricular (LV) function, a history of thromboembolic disease, and to a lesser extent in rate-controlled atrial fibrillation (AF).
In surgical procedures addressing life-threatening hemorrhage, such as from a bleeding peptic ulcer or intracranial hemorrhage, it may be essential to reverse anticoagulation for multiple days. Collaborate closely with cardiology. Prosthetic valves no longer necessitate antibiotic prophylaxis for procedures that induce bacteraemias; if uncertain, consult with cardiology.
Hypertension arterial
Preoperative management of blood pressure may diminish the propensity for perioperative ischemia. If hypertension is severe (>180 mmHg), surgical intervention should be postponed until adequate control is achieved. • Evaluate current antihypertensive management or initiate treatment: consult with the anaesthetist.
Examine for indications of end-organ damage (renal, neurological) and concomitant cardiovascular disease. • Investigate uncommon yet significant etiologies: phaeochromocytoma, hyperaldosteronism, coarctation of the aorta, renal artery stenosis.
Congestive heart failure
Heart failure correlates with adverse outcomes in non-cardiac surgery. Risk factors encompass ischemic and valvular heart disease.
• Identify: S3, pedal edema, elevated jugular venous pressure (JVP), bibasal crepitations. Request a chest X-ray (CXR) if suspicion is present.
Cardiac arrhythmias
Arrhythmias and conduction abnormalities are prevalent. Asymptomatic arrhythmias do not correlate with an elevated risk of cardiac problems; however, it is essential to investigate potential underlying diseases, such as ischemic heart disease, medication toxicity, and metabolic disturbances. High-grade conduction problems, such as total heart block, necessitate consultation with a cardiologist. Pacing may be warranted. Patients with a history of atrial fibrillation, especially those with a prior embolic stroke or structural heart abnormality, typically receive warfarin therapy. Solicit a cardiology evaluation preoperatively if rate control is inadequate.
• Permanent pacemakers or implantable cardioverter-defibrillators (ICDs). Diathermy may induce a pacemaker reset, entirely block pacing, and activate ICD discharge. Pacemakers and implantable cardioverter-defibrillators (ICDs) must be assessed by a cardiac technician both preoperatively and postoperatively. Pacemakers must be adjusted to fixed-rate pacing during surgery and subsequently reset postoperatively. ICDs must be deactivated to avert discharge, and external defibrillator pads should be placed on the patient.
When defibrillation or synchronized cardioversion is necessary, position the paddles as far as feasible from the pacemaker or ICD. The specific sort of diathermy employed must be taken into account. Monopolar is not unequivocally contraindicated; nevertheless, bipolar may be more advantageous.
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Surgery - OCP (oral Contraceptive Pills)
Estrogen-containing contraceptive pills (OCPs) elevate the risk of thromboembolic illness in women who use them before undergoing surgery. Progesterone-only contraceptives seem to present minimal or no supplementary risk and may be maintained throughout surgical procedures. The elevation in risk correlates with the magnitude of the surgical procedure and the presence of comorbidities; recommendations are modified accordingly. •
Low-risk procedures, such as dentistry, day case, and minor laparoscopic surgeries. • Oral contraceptive pills may be resumed. • Moderate risk procedures include abdominal, orthopedic, and major breast surgeries. • Oral contraceptive pills should be ceased at least one month before elective surgery. • Urgent or emergency surgeries must be performed with comprehensive thromboprophylaxis (see to % Prophylaxis—antibiotics and thromboprophylaxis, pp. 98–9). • High-risk procedures include pelvic and lower limb orthopaedic surgeries, as well as cancer surgeries. • Oral contraceptive pills (oCP) should be ceased at least one month before elective surgery. • Urgent or emergency surgeries necessitate the implementation of prolonged thromboprophylaxis, which includes both antibiotics and thromboprophylaxis.
Estrogen-containing contraceptive pills (OCPs) elevate the risk of thromboembolic illness in women who use them before undergoing surgery. Progesterone-only contraceptives seem to present minimal or no supplementary risk and may be maintained throughout surgical procedures. The elevation in risk correlates with the magnitude of the surgical procedure and the presence of comorbidities; recommendations are modified accordingly. •
Low-risk procedures, such as dentistry, day case, and minor laparoscopic surgeries. • Oral contraceptive pills may be resumed. • Moderate risk procedures include abdominal, orthopedic, and major breast surgeries. • Oral contraceptive pills should be ceased at least one month before elective surgery. • Urgent or emergency surgeries must be performed with comprehensive thromboprophylaxis (see to % Prophylaxis—antibiotics and thromboprophylaxis, pp. 98–9). • High-risk procedures include pelvic and lower limb orthopaedic surgeries, as well as cancer surgeries. • Oral contraceptive pills (oCP) should be ceased at least one month before elective surgery. • Urgent or emergency surgeries necessitate the implementation of prolonged thromboprophylaxis, which includes both antibiotics and thromboprophylaxis.
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Surgery - Operative intervention in endocrine disorders
Diabetes: Specific Perioperative Risks
• Hypoglycemia, hyperglycemia, or ketoacidosis.
• Underlying diabetes mellitus-related comorbidities are frequently unrecognized (e.g., mild renal impairment, small-vessel coronary and cerebrovascular disease, mild autonomic neuropathy with concomitant diminished cardiovascular homeostatic responses).
• Susceptibility to infection and impaired wound healing. Increased sensitivity to pressure-induced skin necrosis.
Management of the diabetic patient
• Notify the anaesthetist, diabetologist, and any specialists engaged in the patient's continuous care, such as nephrologists.
• Determine whether the patient is orally managed, insulin-dependent (low or high demand), or brittle insulin-dependent, as the risk of perioperative complications escalates with each category. Diabetics should be prioritized on surgical schedules to facilitate predictable blood sugar management. Examine preoperative assessments for indications of further comorbidities. Ketoacidosis during the perioperative period is linked to significantly elevated morbidity and mortality and must be prevented at all costs.
Minor surgical procedure
• Administer oral medication as per standard regimen. • Insulin-controlled: discontinue preoperative insulin on the day of surgery; test blood sugar every 4 hours; resume regular insulin once the oral diet is reinstated.
Minor surgical procedure
• For oral administration, discontinue long-acting hypoglycemics prior to surgery. Assess blood sugar levels every four hours. Initiate intravenous insulin therapy if blood sugar levels surpass 15 mmol/L. • Insulin-controlled—initiate intravenous insulin sliding scale preoperatively once the patient is nil per os (NBM) and maintain until a normal diet is reinstated. Verify blood sugar levels every four hours. Reinitiate the standard insulin regimen (initially at fifty percent dosage) once the oral diet is established.
Urgent surgical intervention
• Verify the presence of pre-existing ketoacidosis. Utilize the medical treatment protocol to manage blood sugar levels and defer surgery until blood sugar is below 20 mmol/L, unless the situation is life-threatening. Utilize an intravenous insulin sliding scale for all patients to enhance blood sugar regulation. A standard IV sliding scale (soluble insulin with 5% glucose) is as follows: • Blood Sugar <4mmol />: administer infusion of 0.5U/h and consider medical evaluation.
• Blood Sugar 4–15 mmol/L: infusion 2.0 U/h
. • Blood sugar 15–20 mmol/L: provide infusion at 4.0 U/h.
• Blood sugar above 20 mmol/L: administer infusion of 4.0 U/h, consult the diabetology team, and contemplate treatment analogous to that for ketoacidosis.
Steroids: Specific Perioperative Risks
Oral steroids are utilized to manage various prevalent conditions, such as rheumatoid arthritis (RA), severe asthma, and chronic obstructive pulmonary disease (COPD). Steroids diminish neutrophil and fibroblast activity, impair immunological response, and induce lasting alterations in connective tissue. Prolonged administration of systemic steroids leads to adrenal suppression. Chronic steroid use is connected with the following issues. Addisonian (hypoadrenal) crisis
• Increased vulnerability to infection. • Inadequate wound healing, encompassing anastomotic leakage. • Osteoporosis. Patients utilizing long-term inhaled corticosteroids, such as for asthma and COPD, are not considered high risk due to negligible systemic absorption. Management of the patient receiving steroids: • If feasible, the steroid dosage should be reduced prior to surgery. Administer IV hydrocortisone 25–100 mg four times daily, approximately equivalent to 2.5–20 mg of prednisolone once daily, commencing on the morning before surgery and continuing until the patient can resume oral steroids.
Diabetes: Specific Perioperative Risks
• Hypoglycemia, hyperglycemia, or ketoacidosis.
• Underlying diabetes mellitus-related comorbidities are frequently unrecognized (e.g., mild renal impairment, small-vessel coronary and cerebrovascular disease, mild autonomic neuropathy with concomitant diminished cardiovascular homeostatic responses).
• Susceptibility to infection and impaired wound healing. Increased sensitivity to pressure-induced skin necrosis.
Management of the diabetic patient
• Notify the anaesthetist, diabetologist, and any specialists engaged in the patient's continuous care, such as nephrologists.
• Determine whether the patient is orally managed, insulin-dependent (low or high demand), or brittle insulin-dependent, as the risk of perioperative complications escalates with each category. Diabetics should be prioritized on surgical schedules to facilitate predictable blood sugar management. Examine preoperative assessments for indications of further comorbidities. Ketoacidosis during the perioperative period is linked to significantly elevated morbidity and mortality and must be prevented at all costs.
Minor surgical procedure
• Administer oral medication as per standard regimen. • Insulin-controlled: discontinue preoperative insulin on the day of surgery; test blood sugar every 4 hours; resume regular insulin once the oral diet is reinstated.
Minor surgical procedure
• For oral administration, discontinue long-acting hypoglycemics prior to surgery. Assess blood sugar levels every four hours. Initiate intravenous insulin therapy if blood sugar levels surpass 15 mmol/L. • Insulin-controlled—initiate intravenous insulin sliding scale preoperatively once the patient is nil per os (NBM) and maintain until a normal diet is reinstated. Verify blood sugar levels every four hours. Reinitiate the standard insulin regimen (initially at fifty percent dosage) once the oral diet is established.
Urgent surgical intervention
• Verify the presence of pre-existing ketoacidosis. Utilize the medical treatment protocol to manage blood sugar levels and defer surgery until blood sugar is below 20 mmol/L, unless the situation is life-threatening. Utilize an intravenous insulin sliding scale for all patients to enhance blood sugar regulation. A standard IV sliding scale (soluble insulin with 5% glucose) is as follows: • Blood Sugar <4mmol />: administer infusion of 0.5U/h and consider medical evaluation.
• Blood Sugar 4–15 mmol/L: infusion 2.0 U/h
. • Blood sugar 15–20 mmol/L: provide infusion at 4.0 U/h.
• Blood sugar above 20 mmol/L: administer infusion of 4.0 U/h, consult the diabetology team, and contemplate treatment analogous to that for ketoacidosis.
Steroids: Specific Perioperative Risks
Oral steroids are utilized to manage various prevalent conditions, such as rheumatoid arthritis (RA), severe asthma, and chronic obstructive pulmonary disease (COPD). Steroids diminish neutrophil and fibroblast activity, impair immunological response, and induce lasting alterations in connective tissue. Prolonged administration of systemic steroids leads to adrenal suppression. Chronic steroid use is connected with the following issues. Addisonian (hypoadrenal) crisis
• Increased vulnerability to infection. • Inadequate wound healing, encompassing anastomotic leakage. • Osteoporosis. Patients utilizing long-term inhaled corticosteroids, such as for asthma and COPD, are not considered high risk due to negligible systemic absorption. Management of the patient receiving steroids: • If feasible, the steroid dosage should be reduced prior to surgery. Administer IV hydrocortisone 25–100 mg four times daily, approximately equivalent to 2.5–20 mg of prednisolone once daily, commencing on the morning before surgery and continuing until the patient can resume oral steroids.
