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Peri-Operative Management

Mortality Risks Pacemaker
Alcoholics Pre-op Evaluation / Management
Chest Pain Perioperative Antibiotics
Coumadin Perioperative Medications
IV Fluids Post-op Ileus
Obesity  Closed Head Injury

Alcoholics

  • Add Thiamine 100mg IV/PO QD (prevents Wernicke's encphalopathy) and Folate 1mg IV QD
  • Consider DT prophylaxis with benzodiazepines: Lorazepam(Ativan) 1.5-2mg IV/IM/PO Q6hours; diazepam(Valium) 2-10mgPO TID; Oxazepam(Serax) 15mg PO TID.

Risk factors associated with postoperative mortality

  • Five "critical" risk factors: chronic renal failure, congestive heart failure, chronic obstructive pulmonary disease, hip fracture, and age of older than 70 years. There is a linear increase in mortality  with each increased risk factor. (Bhattacharyya T, JBJSurg 2002;84-A(4):562-72)
  • Diabetes, gender, fracture pattern, coronary artery disease, peripheral vascular disease, septic arthritis, and rheumatoid arthritis did not demonstrate increased risk of mortality  (Bhattacharyya T, JBJSurg 2002;84-A(4):562-72).

Chest Pain (post-operative)

  • Angina and MI are most common cause
  • Consider: PE, aortic dissection, pericarditis, endocarditis, pneumonia, pneumothorax, esophageal rupture, cholecystitis, pancreatitis, dyspepsia, GERD, vertebral fracture, rib fractrue, constochondritis, herpes zoster
  • IF Cardiac:
    2liters Oxygen via nasal cannula
    Stat EKG
    SL nitroglycerin after EKG
    Nitropaste 1-2"
    Aspirin
    Cardiac enzymes
    Medicine consult

Coumadin (Perioperative managment of patients on coumadin / oral anticoagulants)

  • 10mg given the night of surgery.
    None the following night.
    Then coumadin dose = 20-PT.
    Also coumadin dose = 10(2.1 - INR)
    Other dosing schedules: UK, AUS, AAFP,
  • Patients on coumadin at high risk of thromboembolic event who undergo invasive procedures need the coumadin withheld and perioperative intravenous heparin, LMWH, or carry out the invasive procedure on sub-therapeutic anticoagulation at INR range of 1.5 to 2.0
  • Discontinue warfarin 4-7 days prior to surgery. Start LMWH 36hours after warfarin discontinued. Surgery perform 12-24hours after last LMWH dose. Check INR 24hours prior to surgery; If INR >1.5 but less than 2, give a 1 or 2 mg oral dose of vitamin K. If INR > 2, postpone the procedure.
  • INR must be <1.5 before surgery.
  • If INR is between 2.0 and 3.0, usually 4 doses of warfarin must be withheld for INR to fall below 1.5; 5 days for < 1.3.
  • Postoperatively restart heparin and warfarin as soon as is possible, ideally post-op day 0 or 1, depending on risks for bleeding.
  • (Dunn A, Arch Intern Med 2003;163:901).
  • Rapid Coumadin reversal: best studied in the intracranial hemorrhage literature:
    -Options: FFP, vitamin K, Factor VII, Prothrombin complex concentrate
    -Fresh Frozen Plasma (FFP): If the initial INR is between 2-4, then 2 units of FFP. If the initial INR is >4, then 4 units of FFP.
    -Vitamin K (1.0–2.0 mg orally or 0.5–1.0 mg intravenously). Measure INR within 24 hours
    -Activated Factor VII: Experimental: rFVIIa 1mg IV, INR checked 20 minutes post-rFVIIa administration. Consider additional rFVIIa 1mg if INR is still elevated.
    -Prothrombin Complex Concentrate (PCC): Experimental: 30 i.u./kg ideal body weight as is rounded to the nearest dispensed vial size. Vials are dispensed as 5mL (500 i.u.), 10mL (1000 i.u.), or 10mL (1500i.u.). INR checked 20 post administration.
    -Vitamin K:

IV Fluids

  • 100cc/Kg for the first 10Kg
  • 50cc/Kg for the second 10Kg
  • 20cc/Kg > 20Kg
  • Average person: D5 1/2 NS + 20meQ KCL/L @ 100cc/hr

Pacemaker

  • Systemss can be unipolar or bipolar. Unipolar = pulse generator acts as the anode while the leads represent the cathode. Bipolar = anode and cathode electrodes are in the heart.
  • Pacemakers generally implanted to treat symptomatic bradycardia
  • implantable cardiac defibrillators (ICD) implanted to manage tachycardia and defibrillate.
  • Magnets placed over ICD's or pacemakers alter their function. Never place a magnet over the device without first knowing the specific device, manufacture and devices programed responce to magnets.
  • Pacemaker / defibrillator is a relative contraindication to MRI. Some recently manufactured devices are MRI-compatible.
  • Cautery: can cause interference and affect the function of pacemakers/ICD's. Unipolar systems should be used as little as possible and the cautery tool and grounding pad should be placed so that the current path avoids the pacemaker/ICD system, use short irregular bursts at the lowest settings. Bipolar cautery is better and required for arthroscopic shoulder cases. The device can also be set to asynchronous pacing at a rate greater than the patient's underlying rate.
  • Interrogation of the device with manufacturer and cardiologist within 6 months of surgery
  • Contact manufacturer for pacemaker interrogation for the day of surgery
  • Have pacing and defibrillation devices in the operating room
  • Avoid swelling and fluid extravasation in the area of the pacemaker as this can dislodge the leads.
  • Have pacemaker interrogated postoperatively with full telemetric check
  • Wellman, DS, JSES 2010:19:1204

Pre-Operative Evaluation

  • Order: EKG, U/A, Chest xray,
  • see list from pre-op nurses.

Post-Operative Ileus

  • Work-up: check lytes, Mg, C. Dif toxin x 3, flat and upright abdominal xrays

Closed Head Injury

  • Must avoid hypotension, hypoxia and elevated intracranial pressure
  • If early fracture fixation is necessary, the intracranial pressure should be monitored and the cerebral perfusion pressure maintained.
  • Hemodynamically stable; cerebral perfusion pressure is maintained = Immediate reamed intramedullary nailing
  • Hemodynamically unstable or cerebral perfusion pressure labile = external fixation or temporary skeletal traction.
  • REFERENCES: Anglen JO, J Trauma. 2003;54(6):1166-70.  Pietropaoli JA, J Trauma. 1992;33(3):403-7. McKee MD, J Trauma. 1997;42(6):1041-5.