1. Medical Problems In The Surgical Patient
Dr Osama Bawazir
FRCSI, FRCS(Ed), FRCS (glas), FRCSC.

2. Introduction “A chance to cut is a chance to cure”
“Nothing heals like cold, hard steel”
Surgery = stress and insults
Physiology of surgery
Maximize pre-operative condition of patient
Preoperative evaluation: H&P
Perioperative care: think of what can kill first...

4. Perioperative medical care:
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

5. Perioperative medical care:
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

6. Pulmonary disease Patient-related risks Procedure related risks
Chronic lung dz – wheeze, productive cough
Smoking
General health
Obesity
Age?
separate from others?
Procedure related risks
Type of anesthesia
GETA alone  FRC 11%
inhibited coughing peri-op
Surgical site
Duration of surgery

7. Modifiable pulmonary risks
Obesity physiology
 lung capacity, FRC, VC
 WOB
hypoxemia
Tobacco
Definition of “stopped smoking”....
“When was your last cigarette?”

8. Pre-operative risk assessment: pulmonary function
Patient history
unexplained dyspnea, cough, reduced exercise tolerance, OSA
Physical exam:
wheeze, rales, rhonchi,  exp time,  BS
5.8x more likely to develop pulmonary complications*
Pre-operative CXR is mandatory over 40 yo
ABG
no role for routine use
result should not prohibit surgery
caution if  PaCO2
* Lawrence et al Chest 110:744, 1996

9. Respiratory problems
second only to cardiovascular events as a cause of perioperative death.
Several risk factors ↑pulmonary complications, including
age
male gender
emergency surgery
ASA status
length of the surgery.
The main two specific factors
pre-existing respiratory disease
surgery of the chest or upper abdomen.
Clinically:
Atelectasis
bronchospasm
retained secretions
infectious complications

10. EFFECT OF SURGERY AND ANAESTHESIA ON RESPIRATORY FUNCTION
Ventilation
Opioids can produce profound respiratory depression.
The inhalational anaesthetics halothane, enflurane, and isoflurane also depress respiratory drive.
Lung volumes
functional residual capacity is reduced during general anaesthesia by about 20 per cent below the value measured in the awake, supine position.
the diaphragm ascended into the chest by about 2 cm during anaesthesia with or without paralysis
Gas exchange
V/ Q mismatch
Elimination of CO (changes in the ratio of dead space to tidal volume )

11. Host defences dryness tends to damage the respiratory epithelium.
The cough mechanism is depressed during anaesthesia
the immune system is altered in the immediate postoperative period

12. 1.The alveolar/arterial Po2 gradient is increased during anaesthesia, and this change is markedly affected by age.
2.The decrease in Po2 is secondary to an increased distribution of flow to areas of decreased ventilation, most commonly the dependent areas.
3.The increase in VD/ VT seems to be secondary to increased distribution of ventilation to areas of lesser perfusion.
4.The major differences are between the awake and anaesthetized state; paralysis and controlled ventilation do not greatly alter overall gas exchange.

14. Management Optimization of pulmonary function Chest physical therapy
Estimate function:
Clinical and Specialist opinion.
ABG
CXR
Spirometry: FEV1/FVC, PEFR
Chest infection:
Postpone for 2 weeks
Antibiotics & Physio.
COPD
Leis with specialist
Reschedule surgery.
Plan to transfer to ICU for mechanical ventilation pending:
Lung function, type & duration of surgery.
Optimization of pulmonary function
Chest physical therapy
Pharmacological therapy
NON-INVASIVE RESPIRATORY MONITORING
ANAESTHETIC TECHNIQUE

15. Smoking 10 cigr.=6 fold increase in post-op respiratory complications.
Respiratory and CVS effects
Carbon monoxide has higher affinity for O2 than Hb.
Nicotine increases heart rate and BP.
Hypersecretion of thick mucus
Immunosuppressive
Stop 3 months= improve pulmonary functions
Stop 1-2 days= Decreases CO levels.

16. “Surgeons as medical doctors” Smoking cessation
83% of patients think MD’s are against smoking
55% think THEIR DOCTOR is against it
55% say their MD has never advised to quit smoking
despite that 22% say MD inquired of smoking hx
MD can make a difference
81% have tried to quit if MD says to
61% have tried to quit if MD says nothing
Pts less likely to try to quit if advised to “cut down”
* Mullins and Borland, Aust Fam Physician 22(7):1146, 1993.

17. Age
Distinction must be made between physiological state and chronological age.
Are less mobile, intercurrent disease, less physiological reserve.
Caution with regards to:
IVF & Narcotic analgesia.
More likely to have wound infection.
In 65 CVA 1%, In 80 CVA 3%

18. Obesity BMI> 30 Increased risk in: Relative risk of mortality 3-5
DVT,
Wound infections & Dehiscence
Respiratory complications & sleep apnoea.
Intercurrent diseases.
Operative difficulty
Relative risk of mortality 3-5
Advise controlled wt reduction
Arrange ICU post-op

19. Cardiovascular Diseases
Predictors
Major:
Unstable coronary syndrome.
Decompensated CCF.
Significant Arrhythmias
Severe valvular disease
Intermediate:
Mild angina
PMH MI
Compensated CCF DM
Minor
Age, abnormal ECG..etc

20. CARDIOVASCULAR DISEASES
Recent infarction
EF< 40%
left ventricular failure
Persistence of angina after infarction
Angina
Silent ischaemia
Coronary artery bypass grafts

21. Chest Pain Work Up History of event Physical exam 12-Lead ECG CXR ABG
Cardiac Panel
BMP, M/P, CBC, PT, PTT, INR
Chart Review

22. Tachycardia Delivery O2=1.34 hgb X O2 sat X SV X HR
Hypovolemia (Think Bleeding)
Anemia
Hypoxemia MI
Arrhythmia PE
Pain
anxiety

23. Cardiac disease in peri-op periodMI
arrhythmias
CHF
CAD can cause any of these
Risks for CAD:
age, sex, HTN, XOL, DM, tobacco
Modify those risk factors you can... X
medical therapy
will cover later. . .

24. Coronary Artery Disease
Definition of CAD....
Physiology of surgery:
 myocardial oxygen demand
 catecholamines:  HR,  contractility, PVR
 HR also causes decreased diastolic filling
Coronary arteries fill in diastole
Less blood flowing in coronaries: less myocardial O2 supply

25. Myocardial Infarction
Pt without risks has 0.5% chance of MI
Pt with risks has 5% chance of perioperative MI
Perioperative MI has 17-41% mortality
CAD causes MI....look at PMH
Risk stratifications:
MI w/in 3 months of OR
27% reinfarction rate
MI 3-6 months before OR
10% reinfarction rate
MI >6 months of OR
5-8% reinfarction rate*

26. Myocardial infarction
O2 supply / demand imbalance: ANGINA
Surgical stress increases demand
Treatment – “MONAB”
Morphine
Oxygen
Nitroglycerin
Aspirin
Beta-blockers
Cardiac panel (troponin, CK-MB), ?Heparin

27. Prevention of perioperative cardiac events
Wait 6 months if possible
Beta-blockade*
200 pts with CAD or risk factors for CAD
atenolol pre-op and peri-op in ½
MI reduced 50% in first 48h
2 year mortality 10% vs 21%
Maintain peri-operative normothermia
 cardiac events, esp. arrhythmias
Treat peri-operative hypertension
* Mangano NEJM 335:1713, 1996.

28. Prevention of perioperative cardiac events
Invasive monitoring (Swan Ganz) – no help
Pre-op CABG (CARP trial) – no difference
American College of Cardiology / AHA now recommends CABG in preop pts who ordinarily meet CABG criteria:
L main dz
3V dz with LV dysfxn
severe prox LAD stenosis
MI despite maximal medical Rx

29. Prevention of perioperative cardiac events
Watch for and treat arrhythmias
Causes?
Treatment?
Drugs, electrolytes, ischemia, fluid shifts, body T
underlying cause, rate control, conversion

30. Arterial hypertension
Heart failure
Valvular disease
Cardiomyopathies
Cerebrovascular disease
Peripheral vascular disease
Dysrhythmias and heart blocks

32. Action:
Evaluation:
Clinical, Specialist opinion, ECG, Stress ECG, CXR, Echo
..others(Holter monitoring, Exercise electrocardiography, Nuclear imaging, Cardiac catheterization)
IF Major:
Cancel unless life threatening
Consider CABG prior to elective surgery.
If intermediate:
Objective performance.
Hypertension:
Indicates CAD
More likely to develop hypotension during surgery.
Control prior to surgery.

33. Perioperative medical care:
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

34. Patients with special preoperative needs
37 yo WM with longstanding type I DM and with ESRD for 20 years, HD dependent, severe retinopathy, and s/p multiple LE amputations for non-healing diabetic ulcers.
Admitted for Abx for wound infection
Evening RN calls you for “nausea and sweating”

35. Patients with diabetes
Possible occult CAD (diabetic neuropathy)
Look for “anginal equivalents”
SOB
Nausea
“All patients with longstanding DM have CAD”
EKG, cardiac enzymes

36. Patients with diabetes
Hyperglycemia facilitates infection
Warm medium with food for bacteria
Treat suspected infection aggressively
Tight glucose control is one of 2 therapies that has been shown to improve outcome of septic patients in the ICU
What is the other?

37. Diabetes
Patients are more sensitive to protein depletion, U&E& glucose imbalance.
Surgical stress can precipitate DKA.
DKA is a cause of acute abdomen
Decreased phagocytosis, neutrophil activation and antibody production
Small vessel disease
Peripheral vascular disease
Peripheral neuropathy
Autonomic neuropathy
Recognition of hypo/Hyperglycaemic attacks

38. Management Specialist Opinion required NSC Minor LA
4 hourly close observations
Omit dose in mane.
Either low dose infusion or fixed dose insulin
Type II GA
GIK
G: 500 ml 10% dextrose
I : Insulin sliding scale
K : Potassium 10 mmol
Continue till first light meal
Type I GA

39. Renal: Identify the cause: Pre-renal, eg: cardiac, hypovolaemia
Renal, eg: acute tubular necrosis( drug induces)
Post renal, eg: obstructive uropathy.
Identify pt for renal dialysis.
Check K levels
Accurate fluid balance
Look for signs of fluid overload.
Do not misinterpret poly ureamic phase

40. Perioperative medical care:
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Dialysis dependent
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

41. Renal dysfunction Not all renal failure is oliguric H&P Check BUN/Cr
Assume DM have CRI
Volume status
Electrolytes.....sequelae?
Which ones?
Drug metabolism

42. Renal dysfunction Dialyze preop to improve electrolytes, volume status
No K+ in MIVF
Very judicious MIVF while NPO
Altered drug metabolism
Altered platelet fxn

43. Post op care In renal failure
Fluid and electrolyte balance
Anaemia and bleeding
Drug prescription

44. ACUTE RENAL FAILURE

45. MANAGEMENT Diagnosis Exclusion of obstruction
Recognition and correction of prerenal failure
Recognition of pre-existing chronic renal failure
Immediate management and indications for urgent dialysis
Prophylaxis and attempts at reversal

46. haematological Disorders

47. Liver disease
Chronic renal failure
Vitamin K deficiency
Anticoagulants
Massive blood transfusion
Cardiopulmonary bypass
CONGENITAL DISORDERS OF COAGULATION e.g Haemophilia

49. haematological Disorders
Anaemia
Correction 1 week pre-op
Correction day preop is undesirable
Haemodilution
Thrombocytopaenia
In splenomealy, Platelets must be transfused immediately preop and on ligating the arterial supply.
Sickle cell disease
Crisis caused by : dehydration, infection, hypoxia, hypothermia.
Jaundice & anaemia
Splenic infarctions: sepsis
Prevention: Warm, well hydrated, well analogised
Consider exchange transfusion in SS
Correction of coagulopaties

50. MYELOPROLIFERATIVE DISORDERS LYMPHOPROLIFERATIVE DISORDERS
THROMBOPHILIA
HAEMOGLOBINOPATHIES
Sickle-cell disease
Sickle-cell trait
Thalassaemia
MYELOPROLIFERATIVE DISORDERS
LYMPHOPROLIFERATIVE DISORDERS
AUTOIMMUNE DISORDERS e.g Idiopathic thrombocytopenic purpura

51. Hepatic problems

52. Hepatic dysfunction
Postoperative hepatic dysfunction in surgical patients can be due to
(1) overproduction of bilirubin
(2) hepatocellular dysfunction
(3) extrahepatic biliary obstruction

54. THE SURGICAL PATIENT WITH PRE-EXISTING LIVER DISEASE
Improvement of the preoperative status of patients with liver disease can significantly decrease their operative morbidity and mortality. Specific attention should be given to:
(1)correction of coagulopathy to normal by administering vitamin K and fresh frozen plasma;
(2)improving the nutritional status;
(3)treatment of renal impairment;
(4)treatment of infection;
(5)control of ascites.

55. Jaundice poses a risk for:
Patients with obstructive jaundice are at risk of postoperative renal failure, haemorrhage, and deterioration in liver function.
Jaundice poses a risk for:
Sepsis
Clotting disorders
Renal failure
Liver failure
Fluid and electrolyte abnormalities
Drug metabolism
Management:
Vit k & FFP
Adequate hydration and diuretics & oral Lactulose
Antibiotics
Nutrition.

56. Perioperative medical care:
(SUMMARY)
AMPLE history
Wait 6 months, Beta block, MONAB
Risk stratify (patient, family, surgery team)
Monitor e’lytes, volume closely
Correct coagulopathy; risk stratify
Glucose control, anginal equivalents
Reverse anticoagulation if tolerated
Anticipate and plan
Feed enterally
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Anticoagulated
Malnourished

57. Question?

58. Thank You