MANAGEMENT OF MEDICAL CONDITIONS IN SURGICAL PATIENT

Principle

The medical condition must be stabilised as much as possible before surgery.
Pre-operative management

  • Establish whether condition is stable or unstable
  • If unstable, control or correct the condition

Operative and post-operative management

  • Anaesthesia technique based on condition and nature of surgery
  • Maintain the stable condition

TREATMENT

Hypertension

  • Diastolic of 90 mmHg and systolic of 140 mmHg are acceptable
  • If hypertension not adequately controlled, there is risk of vasoconstriction, hypovolaemia,
    exaggerated vasoactive response to stress leading to hypo or hypertension, hypertensive
    complications during anaesthesia

    • Control hypertension pre-operatively
    • Patient should take antihypertensive medicines on schedule even on the day of operation
    • General anaesthesia technique is preferred
    • Ensure adequate depth of anaesthesia and analgesia

Anaemia

Condition of reduced oxygen carrying capacity; patient prone to hypoxia

  • Heart failure may occur
  • Hypotension or hypoxia can cause cardiac arrest
  • Correct anaemia to acceptable level depending on urgency of surgery
  • Regional anaesthesia is the preferred method
  • If general anaesthesia is used, avoid myocardial depressant, e.g. thiopental
  • Use small doses of anaesthetics
  • Use high oxygen concentration
    • Intubate and ventilate except for very short procedures
    • Replace blood very carefully
    • Extubate patient when fully awake
    • Give oxygen in the post-operative period

For sickle cell anaemia, the above also applies, as well as avoiding use of tourniquet

Asthma

  • Avoid drugs and other factors likely to trigger bronchospasms, e.g. thiopental
  • Regional anaesthesia is the preferred method

Diabetes

  • Achieve blood glucose control using standard treatment pre-operatively
  • If diabetic ketoacidosis:
    • Delay surgery even in emergency for 8-12 hours
    • Correct and control all associated disturbances
  • Hyperglycaemia under general anaesthesia is safer than hypoglycaemia
  • Patient should be operated early in the morning and MUST be first on theatre list
  • Regional anaesthesia is the method of choice where applicable

Minor surgery

  • Stop usual antidiabetic dose on the morning of surgery
  • Start infusion of 5% glucose infusion rate of 2 ml/ minute in theatre
  • Monitor blood sugar
  • Usual medication is resumed as soon as the patient is able to take orally

Major surgery

  • Control on sliding scale of insulin
  • Infusion of 5% glucose started on the morning of surgery, or glucose insulin potassium infusion
  • Monitor blood sugar ≤200 mg/dl