perioperative management

Introduction

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

Diagnostic procedures

• avoid perioperative pulmonary artery catherization to monitor hemodynamic status
• preoperative spirometry not routinely indicated

Radiology

• chest X-ray not routinely indicated

Complications

• non-cardiac surgery
  • demand cardiac ischemia
  • stress-induced cardiomyopathy

Management

• perioperative music may reduce postoperative pain
• minimally invasive surgery is recommended for older patients
• enhanced recovery after surgery may improve outcomes for older patients

preoperative food & fluid management

• > 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
    • clear fluids within 2 hours before anticipated anesthesia should not postpone or cancel surgery
  • avoid prolonged fasting in children
  • do not delay surgery after confirming the removal of chewing gum
• fluid restriction if any cardiopulmonary compromise, especially heart failure
  • see perioperative fluid management

perioperative medication management

• see perioperative anticoagulation
• see perioperative antiplatelet therapy
• antihypertensive agents
  • continue beta-blockers, calcium channel blockers, nitrates
  • continue centrally-acting alpha-2 adrenergic receptor agonists
    • clonidine, brimonidine (ophthalmic)
    • do not initiate clonidine
  • withholding ACE inhibitors, angiotensin receptor blockers (ARBs) may diminish risk of intraoperative hypotension (23% vs 28%) but not 30 day risk of cardiovascular events or mortality
  • diuretics optional, usually withheld
  • patients with hypertension do not require urgent preoperative reduction in blood pressure unless evidence of end-organ damage
  • >= 2 antihypertensives on the morning of vascular surgery increases risk for postoperative renal failure
  • continue vasodilators
  • also see perioperative beta blockade
• perioperative beta-blocker to prevent atrial fibrillation
  • not necessary for patients with ventricular rate < 110/min
  • perioperative amiodarone 10 mg/kg 6 days prior to & 6 days post-op reduces postoperative atrial fibrillation after cardiac surgery by 50%
  • metoprolol as effective in preventing atrial fibrillation as amiodarone
• alpha-1 blockers & 5-alpha reductase inhibitors
  • may be taken morning of surgery
  • risk of intra-operative floppy iris syndrome in cataract surgery
• hypolipidemic agents:
  • continue statins
    • consider initiating statin in high-risk patients
    • perioperative statin in high-risk patients, several weeks prior to surgery results in less ischemia & fewer MIs in patients undergoing vascular surgery
  • hold cholestyramine, fibrates
• antiasthmatic agents
  • continue maintentance & rescue inhalers
  • probably continue leukotriene antagonists (monteleukast, zafirlikast) & lipoxygenase inhibitors (zileuton)
• gastrointestinal agents
  • antacids:
    • continue H2 receptor blockers & proton pump inhibitors
  • withhold hyoscyamine (risk of anticholinergic effects)
• immunosuppressive agents
  • continue hydroxychloroquine
  • continue/individualize methotrexate, (continue)
  • continue azathioprine, 6-mercaptopurine
    • mycophenolate, azathioprine, cyclosporine, tacrolimus should be withheld 1 week prior to surgery unless disease (lupus) severe
  • discontinue biologic immunosuppressive agents
    • hold adalimumab for 2 weeks before & after surgery
    • infliximab probably ok to continue
    • rituximab ok at end of dosing cycle
    • continue belimumab
  • continue glucocorticoids:
    • increase if stress dose indicated
    • 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
      • intravenous hydrocortisone for stress dose coverage (see below for dosing)
• hypoglycemic agents
  • discontinue oral hypoglycemics & non-insulin injectable hypoglycemics 12-72 hours prior to surgery, depending upon 1/2life of hypoglycemic agent
    • SGLT-2 inhibitors (flozins) should be stopped 3-4 days before surgery
    • GLP-1 agonists should be held the morning of surgery (agents dosed daily) or during the week prior surgery (agents dosed weekly)
      • GLP-1 agonists (glutides) generally do not need to be held prior to outpatient procedures or minor surgery
      • continue preoperatively for patients deemed at low risk
      • 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
    • metformin should not be given on the morning of surgery
    • DPP-4 inhibitors should not be given on the morning of surgery
  • on morning of surgery
    • give 60-80% usual AM dose or PM dose of intermediate-acting insulin or long-acting insulin
    • withhold short-acting insulin
  • a basal level of long-acting insulin with as needed short-acting insulin is the preferred method of glycemic control in the perioperative period
  • a target for serum glucose < 180 mg/dL (expert opinion)
    • perioperative hyperglycemia & hypoglycemia are common in patients managed with insulin
    • intensive glycemic control might be unnecessary in patients with diabetes undergoing major surgery
  • resume oral hypoglycemics at hospital discharge or when patient has resumed a full diet
• thyroid agents
  • continue antithyroid agent (propylthiouracil, methimazole, KI) for hyperthyroidism
  • hyperthyroidism does increase surgical risk & should be controlled preoperatively in non-emergent surgery
  • continue thyroid replacement for hypothyroidism
  • delay elective surgery for severe hypothyroidism
  • mild-moderate hypothyroidism does not increase surgical risk
• glucocortioids
  • usual dose of corticosteroid can be taken the morning of surgery
  • hydrocortisone stress-dosing
    • 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)
    • 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
• estrogen
  • discontinue hormone-replacement therapy several weeks before surgery
  • continue oral contraceptives if indicated & increase DVT prophylaxis
• bisphosphonates should be held the morning of surgery
• antidepressants
  • discontinue MAO inhibitors 10-14 days prior to surgery
  • consider withholding SSRIs 2-3 weeks prior to neurosurgery
  • tricyclic antidepressants (TCA) may be continued
  • lithium carbonate may be continued
• antipsychotics - continue antipsychotics
• neurologic agents
  • continue anticonvulsants
  • may continue parkinson agents
    • schedule surgery early in day to minimize missed doses
  • discontinue Alzheimer agents
  • continue benzodiazepines
• analgesics:
  • continue or reduce dose of long-acting opiates
  • NSAIDs & COX2 inhibitors generally discontinued 3-7 days prior to surgery
• anticholinergic medications should be held the morning of surgery
  • H2 blockers ok
• phosphodiesterase-5 inhibitors should be held 3 days prior to surgery due to concerns of hypotension
• 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
• perioperative antibiotics is a risk factor for C difficile colitis
• herbal medications: discontinue 1-2 weeks prior to surgery
• hold vitamins & supplements
• resume withheld medications after surgical wounds heal & sutures or staples have been removed (generally ~ 14 days)
• also see preoperative medication management guidelines from the Mayo Clinic

perioperative blood transfusions

• no clear cutoff for perioperative blood transfusion
• a threshold hemoglobin of 7-8 g/dL recommended for asymptomatic patients
• restrictive transfusion strategy may increase risk of ischemia
• a threshold hemoglobin of 10 g/dL recommended for patients with ischemic heart disease
• elderly orthopedic patients may benefit from a less restrictive transfusion strategy

pulmonary hygiene

• smoking cessation > 8 weeks prior to surgery improves pulmonary function & may decrease risk of complications
• routine preoperative & postoperative lung expansion maneuvers (incentive spirometry) to prevent postoperative pulmonary complications
  • may not be of benefit
• training in postoperative breathing exercises before upper abdominal surgery reduces postoperative pulmonary complications
• perioperative prophylactic respiratory physiotherapy includes increased mobility, sputum clearance, deep breathing exercise, & inspiratory muscle training consistently reduces postoperative pulmonary complications
• early mobilization
• delay or cancel elective surgery in patients with pulmonary hypertension

More general terms

• medical therapy; therapeutic intervention
• management

More specific terms

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

Additional terms

• perioperative risk assessment
• post-operative management
• preoperative evaluation & management