Peri-op & Anaesthesia : Surgical pts on (1) ANTI COAGULATION (2) STEROIDS (3) DIABETIC TREATMENT

Question 1

What happens to the steroid demand in the body when acute stress is experienced?

Answer 1

When the body experiences acute stress (e.g. illness, trauma, surgery), the steroid demand increases.

Question 2

Why cant pts on regualr steroids respond to acute stressors e.g. illness in the same way as others?

Answer 2

Patients on long term steroids cannot respond to this demand because their adrenal function is suppressed.

Therefore, patients who are on long term steroids usually need more steroids than usual during periods of physiological stress e.g. surgery or acute illness

Question 3

What crisis is a pt at risk of if you dont alter their steroids?

Answer 3

Risk of Addisonion crisis if steroids stopped

Question 4

What is ther peri-op management of steroids

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Answer 4

• Switch oral steroids to 50-100mg IV hydrocortisone.
• If there is associated hypotension then fludrocortisone can be added.
• Teach me Surgery: (a simple conversion rate is 5mg PO prednisolone = 20mg IV hydrocortisone)

Question 5

When can oral steroids be restarted?

Answer 5

minor operations:
* oral prednisolone can be restarted immediately post-operatively.

Major surgery:
* may require IV hydrocortisone for up to 72 hours post-op.

Question 6

Potential complications of poorly managed diabetes during surgery?

Answer 6

• undetected hypoglycaemia whilst a patient is under a GA.
  Diabetic patients have:
• increased risk of wound & respiratory infections
• increased risk of post-operative acute kidney injury
• increased length of hospital stay

Question 7

Principals of management of diabetic pts having surgery

Answer 7

• Put DM patients first on the list
• Regularly check blood glucose
• if surgery needs prolonged fasting or more than one missed meal a VRIII will be needed
• insulin dependant with good glycaemic control ((HbA1c < 69 mmol/mol) may be able to adjust their ususal insulin regime.
• Most pts on only oral meds with be able to manipulate medication on the day of the surgery (some exceptions) where you would use VRIII

Question 8

Management of DM in post-op period depends on factors such as:

i.e. the things u are asking yourself about pt, what will happen etc.

Answer 8

• required duration of fasting
• timing of surgery (morning or afternoon)
• usual treatment regimen (insulin, antidiabetic drugs or diet)
• prior glycaemic control
• other co-morbidities

Question 9

When to stop oral anitdiabetic drugs

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Answer 9

Question 10

Key management principals for insulin dependant diabetics.

Answer 10

Question 11

Pathophysiology of why alterations in diabetic medication is needed post -op

Answer 11

The need for specific peri-operative management in diabetics arises due to physiological changes in response to stress (such as surgery), combined with the patient’s underlying metabolic disorder.

• Surgical stress can induce hyperglycemia
• alterations in medication timing or dosage may be necessary due to fasting or changes in renal function.

Question 12

What are risks of a diabetic pt having anaesthesia and surgery?

Answer 12

• During surgery: Stress of surgery/trauma/infection can make hyperglycaemia harder to control as there is insensitivity to insulin
• Before and after surgery:GA/NBM before surgery/ post surgery vomiting means keeping glucose in normal range is challenging
• Increased risk of hospital infections
• Renal impairment
• MI and cardiac ischamia can be painless in a DM pt.
• Ketoacidosis can be mistaken

Question 13

What is the target blood glucose in peri-operative /anaesthesia management?

Answer 13

Target capillary blood glucose 6-10mmol/L (for DM pt).

Question 14

What three groups are DM pt divided into peri-operatively?

Answer 14

Insulin dependent, oral hyperglycaemic managed, diet controlled.

Question 15

How do you (peri-operatively) manage insulin dependent DM pt?

Answer 15

• Establish good diabetic control before the operation.
• Give insulin as a continuous iv infusion during operative period
• Give infusion of dextrose through op (to balance the insulin or to make up dietary intake)
• Add potassium to dextrose
• Monitor blood glucose and electrolytes in op and after.

Question 16

If patient has diet controlled DM, how would you manage them peri-operatively?

Answer 16

Do blood glucose. May not need intervention.

Question 17

How do you manage poorly controlled DM on emergency admission?

Answer 17

Risk of DKA. Aim is to control glucose with rehydration and infusion of insulin, glucose and potassium.

Question 19

What should be given alongside VRIII?

Answer 19

IV glucose, K, NaCl substrate solution

Question 20

What is the aim of a pre-assessment before an operation?

Answer 20

• Assess good glycaemic control <8.5% Hba1c.
• Determie safest anaesthetic
• Timing of operation on the list (i.e. do they need to be first to limit starvation)
• VTE assessment risk
• Need for home support after surgery
• Assess other co-morbidities and complications
• Bloods

Question 22

Regarding blood sugar, what are your aims whilst in the operating theatre?

Answer 22

• Regular blood glucose measurements.
• Feet visible, limit pressure sores, ensuring fluids are given

Question 23

What is the half life of IV insulin?

Answer 23

6mins. Some are 15 mins.

Question 24

Describe what happens in addisonian crisis?

Answer 24

Reduced glucocorticoid and mineralcorticods. 
Hyponatraemia 
Hyperkalaemia 
Hypoglycaemia 
Reduced consciousness
Low BP/blood vol

Question 25

Why is addisonian crisis hard to detect post surgery/in surgery?

Answer 25

• Manifestations = hypotension, tachycardia, hypoxia and fever. These mimic common post op complications
• Can present as nausea, vomiting, diarrhoea = similar to effects of anaesthetic drugs