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

44 yo WF who presented to ER today with RUQ three days ago.  RUQ U/S showed gallstones.  CT scan of the abdomen/pelvis showed gallstones.
Pre-op this patient”
History and physical
Informed consent for operation and blood
Type and screen or type and cross
CXR (age greater than 20)
12-lead ECG (age greater than 40)
BMP, M/P, CBC, PT, PTT, INR
Nill per Oral after MN (IV Fluids)
Pre-op Note
Pre-op Orders (hep 5000 units SQ, Abx, beta blocker)
?Bowel Prep

Chest Pain Work Up
Coronary Artery Disease
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

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

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


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