Perioperative

Issues in Medical Conditions

Fluid Management
• Maintenance
o Follow 4/2/1 for the maintenance fluid management
§ 4cc/kg for the first 10kg
§ 2cc/kg for second 10 kg
§ 1cc/kg for each kg therafter
o Additional fluid infusion for instance such as
§ Fever
§ Drains
§ Gastrointestinal losses
§ Burns
o Decreased fluid infusion for instances such as
§ Edematous states
§ Hypothyroidism
§ Renal failure
• Hypovolemia
o Colloid versus crystalloid therapy
§ Crystalloid therapy is gold standard except in cases of
severe blood loss; begin therapy with 2 liters of isotonic
crystalloid fluid
o Blood transfusion
§ Used in cases of severe hemorrhagic hypovolemia or
hemorrhagic shock
• Postoperative fluid overload
o Signs of pitting edema, hypertension, lung crackles, SOB, increased
JVD
o Treatments:
§ Fluid restriction
§ Sodium restriction
§ Diuretic therapy
§ Monitor urine output
 § Reposition patient to decrease dependent collection of
fluids
Cardiovascular Management
Beta blockers
• High risk patient may benefit from preoperative beta blockade,
careful monitoring for appropriate heart rate and blood
pressure is critical
• Choice of beta blockers should be discussed with cardiologist
Hypertension
• Ensure patient taking preoperative medication
• Look for other causes (pain, bladder distension, hypoxia,
hypervolemia)
Atrial fibrillation
• Rule out the thyroid disease, systemic illness, pulmonary
embolus, and acute MI
• Symptoms include palpitation, dizziness, irregularly irregular
pulse
• ECG will show a wavy baseline with loss of P waves

• Acute-onset AF in an unstable patient require immediate
electrical cardioversion
• Acute onset atrial fibrillation in a stable patient require rate
control with beta blockers and calcium channel blockers
 o Once rate is achieved, cardioversion is requiresd to
convert patient back to normal sinus rhythym
o If arrhythmia has been present for more than 48 hours,
anticoagulation is required for 3 weeks before and 4
weeks after cardioversion
o Earlier cardioversion is done if no thrombus is present
on transesophageal echocardiogram
Chest pain
• ECG ( ST elevations, T wave changes, Q waves for acute MI)

• Chest radiograph
• Test for troponins and creatine kinase MB (will elevate 6-8
hours post chest pain onset) so the test should be performed 2
times (during symptoms and 6 hours after symptoms)
• Supplemental oxygen
• Speak to cardiologist regarding therapy for IHD
o Beta blockers
o Aspirin
o Nitroglycerin
o Heparin therapy
Pulmonary Management
Acute respiratory distress syndrome (ARDS)
• Hypoxemic respiratory failure with bilateral lung infiltrates
• No evidence of heart failure
o Symptoms include tachypnea and diffuse lung crackles
 o Chest x rays show bilateral alveolar infiltrates (yellow
arrow)

o Pulmonary wedge pressure is less than 18 mmHg
o PaO2/FiO2 is less than 200mmHg (if 200-300 mmHg
can be diagnosed as lung injury)
• Treatments
o Treat underlying cause
o Low tidal volume (6cc/kg)
o Low PEEP
o Conservative fluid management
o Plateau pressure less than 30cm H2O
Postoperative respiratory failure
• Asthma
o Supplemental oxygen
o Short-acting beta agonist
o Systemic steroids
o IV magnesium sulfate
• Pulmonary embolus
 o Supplemental oxygen
o Heparin therapy
• Pneumonia
o Culture sputum
o Empiric therapy with unasyn (ampicillin sodium-
sulbactam sodium) or zosyn (pipeacillin-tazobactam)
Diabetes management
Patient on insulin
• Preop: Give 50% long acting insulin dose on the morning of
surgery; start IV glucose drip
• Postop: Start IV glucose drip
Patient not on insulin
• Preop: Discontinue oral hypoglycemic and metformin 24 hours
preop
• Postop: Insulin drip with short-acting sliding scale
Steroid management
Patient taking steroid chronically
• Daily dose 20mg or more prednisone or equivalent
• More than 3 weeks of steroid treatment
• An acute cortisol deficiency secondary to surgical stress; in a
patient with adrenal insufficiency, will lead to adrenal crisis
(headaches, nausea, vomiting, shock, and confusion) without
steroid dosing this can be fatal
Treatments: Steroid dosing
• Minor surgery: Normal dose pre and post op
• Moderate surgery (I&D, Extraction with flap, OD): pre op with
Normal AM dose plus 50 IV hydrocortisone; postop with Normal
AM
• Major surgery ( resection): Preop with normal dose plus 100mg
hydrocortisone; postop with normal dose plus 25mg
hydrocortisone every 8 hr for 24 hours
Antibiotic prophylaxis
Condition that require prophylaxis for oral procedures


Anticoagulation Therapy
Antiplatelet therapy (aspirin, clopidogrel)
• We need to consider the risk of thrombosis and MI after
withdrawal of antipletel drugs
• The current guidelines for the aspirin therapy patients:
o For the simple extraction with the dose of the aspirin
<100mg/day, the aspirin can’t be continued to be
consumed
o Unless for the procedure that require a flap or the the dose
>100mg, aspirin can be discontinued for 3 days before the
procedure with the consultation of physician
Warfarin/Coumarin therapy
• INR level can be used to measure the warfarin therapy
• Dental:
• If infection is present, treat prior to providing elective
dental care
• INR 2-3 – dosage doesn’t have to be altered
• INR 3-3.5 – dosage may be altered, usually will be altered
for the major oral surgery
 • INR greater 3.5 – delay invasive procedure until dosage in
decreased
• Effect of reduced dosage takes 3-5 days