perioperative medicine

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Information about perioperative medicine
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Published on September 30, 2008

Author: ashrafalabasiry

Source: authorstream.com

Slide 1: بسم الله الرحمن الرحيم . : . Perioperative Medicine CME presentation on Sunday, April 23, 2006 SSH Slide 3: DR. Hatem Younes Specialist Internal Medicine Saad Specialist Hospital :  **The perioperative Medicine in patients with :- Cardiac, Pulmonary, Kidney, Liver and/or Thyroid Diseases. **The perioperative Medicine in patients on Corticosteroid Therapy **Hemostasis and transfusion in surgery. **Common Medications Adjustment in the perioperative period. The pre-operative cardiac evaluation : : The pre-operative cardiac evaluation : The most widely used algorithm for the preoperative assessment of cardiac risk for non-cardiac surgery was published in 1996 and updated in 2002 by the American Heart Association (AHA), and it classifies patients into 3 groups of risk factors :- : The most widely used algorithm for the preoperative assessment of cardiac risk for non-cardiac surgery was published in 1996 and updated in 2002 by the American Heart Association (AHA), and it classifies patients into 3 groups of risk factors :- Slide 8: 1.Major risk factors : Unstable coronary syndromes. De-compensated CHF. Significant arrythmias. Sever valvular disease.2.Intermediate risk factors: Mild angina pectoris. Previous MI. Compensated or previous CHF. DM. Renal insufficiency.3.Minor risk factors: Advanced age. Abnormal ECG/Rhythm other than sinus. Low functional capacity. H/O Stroke. Uncontrolled systemic HTN. Slide 9: The Cardiac Risk Index :- **In which the following criteria are included: age.>70 {5} , prev. MI in last 6/12 {10} , S3 gallop or JV dist. {11} , significant valvular AS {3} Rhythm other than sinus or APC’s {7} , PVC’s>5/min. {7} , PO2<60 or PCO2>50 or K.<3.0 or HCO3 <20 or BUN>50 or Crea.>3.0 mg/dl or abnormal SGOT or signs of liver damage {3} & nature of surgery: Intraperitoneal, intrathoracic or aortic op. {3} or Emergency op. {4} . **The total possible points are 53 . :  There are 4 classes of risk : - class 1 0-5 points…….fewer complications. - class 2 6-12 points…..few complications. - Class 3 13-25 points…..more complications. -Class 4 26 0r more……life threatening complications. In case of class 4 :- surgery should be delayed if possible to lower the risk of complications. Slide 11: Surgery specific Cardiac Risk .Emergent major operations > 5% .Major vascular surgery. .Anticipated prolonged procedures with large fluid shifts or blood loss. .Intermediate risk operations< 5% .Carotid endarterectomy. .Head & neck surgery. .Orthopedic surgery. .prostatic surgery. .intraperitoneal surgery. .Low risk operations< 1% .Endoscopic or superficial procedures .Cataract surgery. .Breast surgery. Pre-operative management of specific cardiovascular conditions: : Pre-operative management of specific cardiovascular conditions: Slide 14: Hypertension *Controlled HTN Usually does not increase the risk of general anesthesia or major surgery. Slide 15: *In the peri-operative period, poorly controlled HTN is associated with increased incidence of :-.Ischemia .Left Vent. Dysfunction .Arrhythmia .Stroke Slide 16: *Patients with HTN are at higher risk for:- Labile HTN & for hypertensive emergencies during surgery & immediately following extubation Slide 17: *Patients should continue taking pre-operative antihypertensive medications throughout the peri-operative period. Slide 18: *Patients maintained on anti-hypertensive agents up to the time of surgery, with good control of BP, suffer the fewer episodes of hypotension & HTN during anesthesia. Slide 19: The goal should be SBP<140 & DBP<90 before proceeding with elective surgery. *In any patient with stage 3 HTN(>180/110) BP should be well controlled before surgery. Slide 20: *IV Esmolol, Labetalol, Nitroprusside or NTG may be used for acute episodes of HTN, where as Calcium channel blockers, or ACE inhibitors may be used in less acute situations. Slide 21: Continuation of the preoperative antihypertensive treatment throughout the peri-operative period is critical, especially when the patient is receiving :- Slide 22: *Beta-blockers or Clonidine :- Withdrawal of these agents may result in tachycardia and rebound HTN. Slide 23: *Cardio-selective beta-blockers Have a dramatic effect in reducing peri-operative cardio-vascular events. Slide 24: * ACE & ARB’s : Holding these medications on the day of surgery may reduce peri-operative hypotension as this class of medication is blunting the compensatory activation of the renin-angiotensin system peri-operatively. Slide 25: Coronary artery disease: *Patients with chronic stable angina :- Usually tolerate well anesthesia & surgery. Slide 26: *Patients with unstable angina : Tolerate surgery poorly and should be considered for myocardial revascula-risation e.g., (bypass surgery or angioplasty) before elective surgery. Slide 27: Myocardial Infarction : *An acute MI is defined as occurring within 7 days. *A recent MI is defined as occurring within 7 days to one month. *Old MI refers to an MI occurring more than one month. Slide 28: *Life threatening procedures should be performed regardless of cardiac risk, but * Elective surgery should be postponed until at least six months after the infraction Medications in CAD : Medications in CAD - NTG ointment or patches can be applied before surgery to an area away from the surgical site, where it will not be wiped off or removed. - IV NTG should be available in the operating room. Slide 30: Propranolol or any other beta-blockers Should be kept in the patient’s therapy till morning of operation & resumed post-op. Slide 31: Surgical stress Can lead to:- release of catecholamines that mediate arrhythmias & may predispose to coronary plaque rupture. Slide 32: Pre-operative betablockers: *Has been shown to reduce cardiac events in patients who are undergoing non-cardiac surgery. *They are indicated in high-risk patients, defined as having 2 or more of the following risk factors: Age: > 70 years HTN Current smoking Cholesterol level >240 mg/dl. DM. Slide 33: *Atenolol 5-10 mg. IV 1-h. before surgery and immediately after surgery followed by 50-100 mg PO qd for 7 d. post-op. produced 15% absolute reduction compared to placebo in the combined end point of MI, Unstable angina, CHF, or Death at 6 months. Slide 34: *Bisoprolol Has produced dramatic results as well. When started 7 d. pre-op., titrated to a resting HR of 50-60 bpm, and continued for 30 d. post-op., leads to 90% reduction in MI or death from cardiac event Slide 35: *Verapamil Should be used with special caution in the presence of Left Ventricular Dysfunction, because most anesthetic agents also reduce myocardial contractility. Valvular heart disease: : Valvular heart disease: Symptomatic Stenotic lesions Such as mitral & aortic stenosis are associated with CHF & Shock and pre-operative valvotomy or replacement is often needed. Slide 37: Symptomatic regurgitate lesions are generally better tolerated peri-operatively and can be managed medically. Exception to this are those with regurgitant lesions with LV dysfunction, who may need surgical management pre-op. as these patients have reduced hemodynamic reserve Myocardial heart disease : : Myocardial heart disease : Dilated cardiomyopathy and obstructive cardiomyopathy are both associated with a higher incidence of peri-op. CHF. These patients should be managed to optimizing preoperative hemodynamic status & providing intensive post-op. medical treatment. Slide 39: CHF : *Medications proven to show both morbidity & mortality benefit include: -ACE inhibitors, B-Blockers, Spironolactone & ARBs. -On the other hand Digoxin & Diuretics have shown to improve morbidity rates without reducing mortality rates Slide 40: *In patients with decompensated CHF:- Non-emergency surgical procedures should be delayed until compensation is stabilized for at least 1 week before undergoing elective surgery. Arrhythmias and conduction anomalies : Arrhythmias and conduction anomalies When an arrhythmia is detected pre-op., assessment for an underlying cause should be sought. The indications for pre-op. arrhythmia management & pacemaker insertion are the same as in the non-op. setting. Tachyarrhythmias : Tachyarrhythmias *PAC or Junctional beats - If occurring rarely do not require therapy. - If they are frequent, pre-op. digitalization should be considered. Slide 43: *PVC : -When they are > 5/min.,multifocal, in runs, or R on T phenomenon, Lidocaine should begin pre-op. & continued during the operation. *SVT : -The patient with SVT should be digitalized & in some cases cardioverted. - Beta-blockers & verapamil have also been used. Brady arrhythmias : Brady arrhythmias *SA pause or 2nd or 3rd degree AV block or clear H/O Stokes Adams Attack. Should have temporary or permanent pacemakers. *Bifasicular block : The need for temporary pacemaker has been controversial. Pacemakers *Avoid electro-surgery in patients who are unstable & who are strongly dependant on pacemakers.*Avoid surgery near the heart or pacemaker : Pacemakers *Avoid electro-surgery in patients who are unstable & who are strongly dependant on pacemakers.*Avoid surgery near the heart or pacemaker Congenital Heart Disease : : Congenital Heart Disease : Non-cyanotic cong. Heart disease lesions who don’t have evidence of HF tolerate surgery with very few complications. Cyanotic patients are at greater risk. Slide 47: *Patients with congenital Heart disease:- Should receive antibiotic prophylaxis as for valvular heart disease. Pre-operative Pulmonary Evaluation : Pre-operative Pulmonary Evaluation Slide 50: The most common complications include: pneumonia, respiratory failure, bronchospasm, atelectasis and exacerbation of underlying chronic lung disease. Slide 51: The patient should be evaluated by pulmonary function studies. Smoking cessation is mandatory. Slide 52: In COPD patients: Symptoms should be aggressively treated preoperatively by giving Bronchodilators , physical therapy & corticosteroids to reduce risk of postop. pulmonary complications. Slide 53: Although not all patients with COPD respond to corticosteroid therapy a 2-weeks preop. Course is reasonable for symptomatic patients already receiving maximal bronchodilator therapy who are at their best personal baseline level as determined by :- exam., CXR & spirometry. Slide 54: Patients with recent sputum changes: May benefit from preoperative course of antibiotic. Slide 55: Patients with sever COPD ( FEV in 1 second {FEV1}< 40% of the predicted) are 6 times more likely to complications, in such case elective surgery should be postponed. Slide 56: Before surgery, patients with asthma :- should be free of wheezing with PEFR greater than 80% of predicted or personal best level. Slide 57: Sleep Apnea:- *The intra-op. & post-op. use of sedatives and narcotics should be minimized whenever possible. *The patients should be treated with nasal continuous positive pressure (CPAP). *These patients often benefit from regional anesthesia rather than general anesthesia. Surgery in the Patient with Liver Disease :- : Surgery in the Patient with Liver Disease :- Slide 60: The serum albumin level, leukocytosis, and increased PT are the most sensitive indicators of perioperative mortality Slide 61: The risk of peri-operative morbidity or mortality is related to the extent of hepatic dysfunction. Patients with acute symptomatic liver disease should have elective surgery postponed, if possible, until they have recovered. Slide 62: However if surgery is emergent :- The following steps should be taken to optimize preoperative status:- Slide 63: 1.Coagulation status The following may be needed: *Vit. K deficiency should be corrected by a single dose of 10 mg. PO. *Further coagulation anomalies may require FFP, given as needed. *If prothrombin time remains prolonged Cryoprecipitate can be used. *For refractory coagulopathy Plasma exchange can be used . *For thrombocytopenia ( platelet count < 20,000 ) prophylactic platelet transfusions can be considered. Slide 64: 2.Encephalopathy *Give Lactulose,30 ml PO q 6-hours to 2-3 soft bowel movements per day. *Restrict Protein . *Avoid sedatives. Slide 65: 3.Renal and electrolyte abnormalities: * Careful attention should be paid to Volume status & electrolytes imbalance. **Nephrotoxic substances such as: NSAIDs and Aminoglycosides should be avoided. Slide 66: 4.Patients with cirrhosis :- Often have Hypokalemia and Alkalosis : These should be corrected preoperatively to minimize the risks of cardiac arrhythmias and to limit encephalopathy. Slide 67: 5.Ascitis: *large volume paracentesis is indicated preoperatively. *Excessive use of saline solutions and medications containing sodium should be avoided. Slide 68: *The use of albumin, blood products, or FFP may be useful for intravascular volume expansion and to slow re-accumulation of ascitis. (( In patients with normal renal function & absence of hyponatremia, up to 20 liters of ascetic fluid can be removed over 3-hrs. followed by 40 gm. Salt poor albumin over 1/2 hour & 3 hours after the paracentesis. )). *If hyponatremia occurs, free water restriction may be required. Slide 69: 6.Jaundiced patients : Patients with obstructive jaundice :- Are particularly prone to develop RF after surgery ( Hepato-renal syndrome ), this may be because of the toxic effect of bilirubin on The kidneys. Slide 70: In practice, this means that :- Good urine output must be maintained in jaundiced patients around the time of surgery. Slide 71: To maintain good urine output in jaundiced patients going for surgery Pre-operative :- .Avoid Morphine in the pre-medication. . Insert IV line and run 1 lit. of 0.9% saline over 30-60 min. following the pre-medication, unless the patient has heart failure. . Insert a urinary catheter. .Give Mannitol 500 ml. of 10% IV over 20 min. 1-h. before operation. Slide 72: - Peri-operative . Measure urinary output hourly. . Give Mannitol 100 ml. of 10% IV if urine output is < 60 ml/h. . Give 0.9% saline IV to match urine output. Slide 73: - Post-operative :- .Measure urine output q 2-h. . Give Mannitol 10% 100 ml. IV over 15-min. if the urine output is < 100 ml. in 2-h. . Give 0.9% Saline at rate to match urine output and fluids lost through NGT & give 2 lit. of D5%NSS q 24 h. . Measure urea & electrolytes daily. . Give KCL 20 mmol / litre of fluid if urine output is good. Perioperative Diabetes Management : Perioperative Diabetes Management Slide 76: The stress of surgery itself results in impairment of glucose regulation. Patients with diabetes mellitus undergo surgical procedures are at a higher risk than do non-diabetic persons. The persistent hyperglycemia is a risk factor for post-op. sepsis. Slide 77: Elective surgery in Diabetic patients :- Slide 78: *Patients should be booked after acceptable glycemic control has been achieved. *If possible the surgery should be in the early morning to minimize prolonged fasting. Slide 79: Pateints managed with diet alone: Slide 80: May require no special intervention if diabetes is well controlled i.e.,<11 mmol/l. Fasting and intra-operative blood glucose should be monitored hourly. Slide 81: *If FBG is 11 mmol/l or greater :- Small doses of SC actrapid or IV infusion of insulin and 5% Dext. In water should be considered, depending on the nature & duration of surgery. Slide 82: Patients treated with oral antidiabetic agents Slide 83: Short-acting sulfonylureas and other oral agents should be withheld on the operative day. Slide 84: Metformin and long acting sulfonylureas :-Should be withheld 1 day before planned surgical procedures. Slide 85: .Blood glucose Should be monitored before , during & after surgery. If it is 11 mmol/l or greater :- Slide 86: small doses of actrapid SC or IV insulin infusion and 5% dextrose in water should be considered, depending on the nature and duration of surgery. Slide 87: .For minor surgery:- Diabetic medications can be started once the patient starts eating. Slide 88: Metformin therapy Should be withheld for 48 hours postoperatively and restarted after documentation of normal serum creatinine and absence of contrast-induced nephropathy Slide 89: Insulin-treated patients Slide 90: Patients undergoing minor surgery of short duration :- Require no special intervention if the FBG is 11 mmol/l or less. BG should be monitored q 1 h. intraoperatively and immediately after operation. Slide 91: Perioperative. Hyperglycemia *can be managed with :- small SC doses of Actrapid insulin. *The usual insulin treatment can be resumed once oral intake is established. Slide 92: 2. Patients undergoing major surgery :- *Should have check of blood glucose & serum electrolytes . *Any metabolic or electrolytes abnormalities should be corrected before surgery. Slide 93: **The most appropriate approach is :- “IV insulin infusion” **Another alternative is to give 1/3 to 1/2 of the total daily dose of insulin administered SC before surgery. Slide 94: The Glucose-Insulin-Potassium solution, *Which infusing 5-10 gram dextrose, 1-2 u. Actrapid & 100-125 ml. of fluid / hour. *This has one major draw back, which is : In order to respond to each abnormal glucose measurement, a different Dextrose to Insulin ratio is required, which in turn requires a new bag to be mixed in each instance. Slide 95: IV insulin infusion : 1.initial insulin infusion rate : Can be estimated as ½ of the patient’s total daily insulin dose divided by 24 h. expressed as units / h 0.5-1.0 U/hour is an appropriate dose for most patients with type I DM. Slide 96: Dextrose 5% in water at 100 ml/h. should also be started. An initial insulin infusion rate of 1-2 U/hour can be used in patients treated with oral anti-diabetic agents who require peri-operative insulin infusion. Slide 97: Maintenance infusion rates : Check BG hourly, the goal is to maintain the intra-op. blood glucose in the 7-11 mmol/l range. Slide 98: In patients with persistent hyperglycemia, the insulin infusion rate should be increased by 25-50%. Conversely, if the blood glucose is less than 7 mmo/l the insulin infusion should be stopped for 1 hour, then to be restarted at 25-50%of the initial rate Slide 99: 3. Potassium chloride: 10 mEq. is added to each 500 ml dextrose 5% to maintain normo-kalemia in patients with normal renal function. Slide 100: The duration of insulin and dextrose infusions *Should be continued until oral intake starts, after which the usual diabetes treatment can be resumed. (( Use ½ normal drug dose until normal diet is established )). *1st dose of SC insulin should be given 30 min. before DC the IV insulin. Diabetic Patients who are undergoing urgent surgery : Diabetic Patients who are undergoing urgent surgery . . : . D/C the prevailing mode of therapy. Give Dextrose 5% in water at rate of 100-125 ml/h. Start continuous intravenous infusion of Actrapid through an infusion pump. Check the BG hourly by glucocheck and adjust the rate of IV glucose infusion as per giving sliding scale: Sliding Scale ( example ): BG level Actrapid dosage <7 mmol/l nothing 7.1-10 mmol/l 0.5 units 10.1-13 1.0 13.1-16 2.0 16.1-19 3.0 19.1-22 4.0 22.1 or more 5.0 *Monitor S. potassium & add KCL to the running fluids as needed to keep it in the normal range( 3.5 - 5 mmol/l ). *Continue IV insulin until the patient is eating normally, then switch back to the previous mode of therapy provided this was controlling the diabetes. Peri-operative corticosteroid management : : Peri-operative corticosteroid management : . Slide 105: The following patients should be considered to have functional suppression of their Hypothalamic Pituitary Axis : 1. Any patient who has received more than 20 mg/d of prednisone or equivalent for more than 3 weeks during the year preceding surgery. 2. Any patient who has clinical Cushing’s syndrome. Slide 106: Guidelines for adrenal supplementary therapy 1. Patients who receive 5 mg/d. of prednisone or less should be given their normal daily replacement dose pre-operatively. Slide 107: 2. Patients who are taking more than 5 mg/d. :- Should receive their normal daily dose in addition to supplementary therapy according to the surgical stress they are about to undergo:- Slide 108: A: Minor surgical stress e.g colonoscopy, cataract surgery :- Administer 25 mg hydrocortisone or 5 mg methyl-prednisolone IV on the day of the procedure only. Slide 109: B: Moderate surgical stress (e.g.cholecystectomy, hemi-colectomy): Administer 50-75 mg hydrocortisone or 10-15 mg methyl-prednisolone IV on the day of surgery and taper quickly over 1-2 days to the usual dose. Slide 110: C: Major surgical stress (e.g., cardiothoracic) :- Administer 100-150 mg Hydrocortisone or 20-30 mg Methyl-prednisolone IV on the day of the procedure & taper to the usual dose over the next 1-2 days. Slide 111: D:Critically ill patients undergoing emergent surgery :- Administer 50-100 mg hydrocortisone IV every 6-8 h.(0.18 mg/kg/h), plus 50 mg/day of flurocortisone until the shock has resolved, then gradually taper the dose. Monitor the vital signs and s.Na closely. Peri-operative care of patients with kidney disease : : Peri-operative care of patients with kidney disease : Slide 114: Patients with ESRD:- Hyperkalemia is the most frequent complication, followed by infection, hemodynamic instability, bleeding and arrhythmias Slide 115: Preoperatively: Potassium level of less than 5.5 mmol/l is recommended. 2. Metabolic acidosis should be corrected. Slide 116: 3.Uremia-induced platelet dysfunction Prolongs the bleeding time. **All ESRD patients should undergo hemodialysis on the day before surgery (the goal is to reduce BT under 10-15 min.) **Other options for correcting bleeding time include: Desmopressin, 0.3 mg/kg. IV 1 hour before surgery. Cryoprecipitate, 10 U over 30 minutes iv. Conjugated estrogens, 0.6 mg/kg./day IV or PO for 5 days; some effects by 6 hours, peak effect at 7 days. Slide 117: 4. Anemia : Patients with ESRD should have hematocrit levels greater than 26% before surgery. Slide 118: 5. Antibiotic prophylaxis:- Even for minor surgical procedures, prophylactic antibiotics using the standard endocarditis protocols are recommended for the six months after the placement of synthetic vascular access grafts to prevent bacterial seeding before endothelialization. Slide 119: The management of Postoperative renal insufficiency involves :- Slide 120: *Early detection of worsening renal function. *Withdrawal of nephrotoxins *Reversal of hypo- perfusion. *Correction of metabolic and electrolyte abnormalities. Hemostasis & Transfusion in surgery : Hemostasis & Transfusion in surgery Slide 123: The patient’s own blood is still the safest, but this can usually only be used when the patient is not anemic and undergoing elective surgery with adequate time { 3 weeks } available for blood donation. Slide 124: Transfusion triggers {e.g. ,Hgb < 10 g/dl }, are not supported by data and should not be used. Estimates of operative blood should be based on :- “hematocrit measurements” Slide 125: Erythropoietin: 600 U/kg SC weekly before surgery has been approved for use peri-operatively in mildly anemic patients (Hgb. Between 10 – 13) under elective non-cardiac surgery. Slide 126: The combination of erythropoietin with iron is indicated in patients with IDA. Oral iron supplementation is sufficient in patients whose serum iron is > 100 ng/ ml. For individuals whose ferritin level is less than 100 ng/ml, parenteral iron is indicated. Patients with sickle cell anemia may require transfusion before surgery to reduce the % of Hgb. S. Patients with Thyroid Disease who are for thyroid Surgery : : Patients with Thyroid Disease who are for thyroid Surgery : Slide 129: Thyroid surgery for Hyperthyroidism - If sever hyperthyroidism: Give carbimazole untill euthyroid(15 mg/8 h.POx4 wks ), then gradually reduce the dose according to the TFT q 1-2 months. Maintain on about 5 mg/8 h. for 12-18 months , then withdraw. Slide 130: - There is about 50% relapse. - Immediate symptomatic relieve should be achieved by propranolol 40 mg/ 6 hours PO. - Arrange operation date and stop Carbimazole 2 weeks before the surgery, and strat K-iodide 60 mg/ 8 h. PO , continue up until surgery. Slide 131: - In mild hyperthyroidism .Give Propranolol 80 mg/ 8 h. PO at the first consultation. .10 days before surgery give K-iodide 60 mg./ 8 h. PO. .Stop K-iodide on the day of surgery , but continue Propranolol for 5 days post-operatively. Patients with Thyroid Disease who are for surgery other than thyroid surgery :- : Patients with Thyroid Disease who are for surgery other than thyroid surgery :- Slide 134: Patients with hyperthyroidism : Hyperthyroid patients should continue taking their oral agents( i.e.,propylthiouracil ) up to & including the day of surgery because control of the overactive gland is essential for safe surgery & recovery. Beta-blockers also can be used to control the effects of hyperthyroidism Slide 135: Patients with Hypothyroidism : - Levothyroxine should be continued until the time of surgery. The drug has a half life of 6-7 days and can be replaced IV at half the oral dose if the patient remains NPO beyond this time. Common Medication Adjustments in the peri-operative period : Common Medication Adjustments in the peri-operative period Slide 138: Aspirin : Should be stopped at least 7 days before surgery, Then it should be restarted as soon as possible, when the risk of bleeding from surgery is diminished. Slide 139: NSAIDs :- *Short acting agents:- Should be stopped 1-day before surgery. *Long acting agents:- Should be stopped 2-3 days in advance of any procedure to prevent antiplatelet effects. Slide 140: Lipid-lowering agents -All can cause :- myopathy or rhabdomyolysis -These agents should be DC the day before surgery & resumed when the patient is eating a full diet. Slide 141: Anticoagulants:- *Coumadin therapy: Should be DC 4-5 days before elective surgery. *Patients with high risk for TE events include those with prosthetic valves in the mitral position, AF associated with mitral valve disease & H/O TE, should receive IV/SC UF heparin or SC LMW heparin before & after surgery. .Prevetion of PE 1.Early ambulation.2.Intermittent pneumatic compression applied intra-op. & post-op.3.Heparin : * UF heparin: 5000 SC 2- h. pre-op. , then 5000 u SC q 8-12 h. or * LMW heparin: 40 u. SC 10- 12 h. before surgery ,then od : .Prevetion of PE 1.Early ambulation.2.Intermittent pneumatic compression applied intra-op. & post-op.3.Heparin : * UF heparin: 5000 SC 2- h. pre-op. , then 5000 u SC q 8-12 h. or * LMW heparin: 40 u. SC 10- 12 h. before surgery ,then od Slide 143: Inhaled medications : e.g., Inhaled beta agonists & corticosteroids should all be continued through the peri-operative period. Slide 144: Anti-epileptics These agents should be continued in the peri-operative period. If the patient is taking an agent that does not have an IV form and the surgery requires prolonged fasting, the patient can be converted to an antiepileptic with an IV form pre-operatively. Slide 145: Anti-parkinsonian medication : e.g Carbidopa-Levodopa= Sinemet *Should be continued in the peri-operative period because worsening muscle rigidity complicates post-operative care. *Sinemet interacts with many drugs used in anesthesia, which results in arrhythmias. Slide 146: Benzodiazepines and opioid analgesics : *These medications when used chronically, can lead to physiologic and psychological dependence. *They should be continued in the peri-operative period. IV & transdermal formulations exist for patients who are NPO References : : References : The web site : www.emedicine.com “ Articles & CME updates 2006 “. Current Medical Diagnosis & treatment 2006. Kumar & Clark Clinical medicine 5th. Edition 2003. Critical care secrets 3rd. Edition 2003. Current Clinical Strategies Medical Book 1st. Edition 2003. Cecil Textbook of Medicine 20th. Edition.2002. Oxford text book of Clinical Medicine 2nd. Edition 1991. Thank you….. : Thank you…..

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