Pocket ObGyn – Perioperative Patient Management

Pocket ObGyn – Perioperative Patient Management
See Abbreviations

Preoperative Evaluation

Preop eval is needed for all pts before all procedures, w/ complete medical/surgical Hx & periop risk

American Society of Anesthesiologists’ (ASA) physical status classification system
ASA-I	Normal, healthy
ASA-II	Mild systemic dz
ASA-III	Systemic dz that is not incapacitating
ASA-IV	Incapacitating systemic dz that is constant threat to life
ASA-V	Moribund pt not expected to survive
From ASA. http://www.asahq.org/Home/For-Members/Clinical-Information/ASA-Physical-Status- Classification-System.

Review of current meds & allergies: Discuss holding NSAIDs, antiplatelet agents, anticoagulant supplements (eg, fish oil); consider bridging long-acting anticoagulants to shorter acting meds (eg, warfarin to heparin)
Review relevant prior operative
Most healthy women w/ no identifiable RFs require no further testing or
Consider ECG in women >50 Depending on invasiveness & urgency of procedure, periop eval by PCP ± anesthesia or other specialist is recommended. Additional testing based on identified risk.
Informed consent, w/ balanced discussion of:

Risks, benefits, alternatives (including nontreatment & poss additional procedures), & complications.

Healthcare team & their roles including trainee & supportive teams Permission to take photos or videos for documentation or teaching Possibility of bld or bld product use

Identify existing advance directive & healthcare proxy/power of attorney. Consider creating an advance directive if one does not already
Discuss expected postop course (hospital stay, recovery, change in fxn, )
Identify special needs for OR (eg, interpreter services)

Perioperative Optimization

New or uncontrolled medical conditions ® consultation/optimization w/ appropriate specialist + primary care

• Pulm dz:

RFs = older age, current smoking, obesity, obstructive sleep apnea, low serum albumin (<3 g/dL) & BUN >30 mg/dL, higher ASA scores are a/w higher risk for postop pulm complications (Ann Surg 2000;232:242; Ann Intern Med 2006;144(8):581).

Well-controlled asthma not a/w pulm postop complications

Advise smoking cessation >8 w before elective Surg (if <8 w, no dec in pulm complications)

Preop PFTs/CXR if unexplained dyspnea or respiratory sx; consider if COPD of unclear severity.

Postoperatively: Deep breathing exercise, incentive spirometry, early ambulation, upright position, & adequate pain control after Surg are effective in preventing postop pulm complications.

• Cardiovascular dz:

Most abdominal/pelvic Surg is considered as an intermediate risk regarding cardiac morbidity

Selected procedures may be of low risk (eg, D&C) or high risk (major debulking Surg)

Nonemergent Surg should be delayed or cancelled if pt has (1) unstable coronary syns, (2) decompensated heart failure, (3) signif arrhythmia, or (4) sev valvular dz.

Revised cardiac risk index (RCRI)

Presence of any of the following puts pt at higher risk for major periop cardiac morbidity:

1. Ischemic heart dz (h/o MI, angina, use of sublingual nitroglycerin, positive stress test, Q wave on ECG)

2. Heart failure

3. Cerebrovascular dz

4. Insulin-requiring diabetes

5. Renal insufficiency w/ Cr >2 mg/dL

From Circulation 1999;100(10):1043.

Testing by RCRI factors
Low risk	No RCRI factors	No testing Consider ECG for >50 yo
Intermediate risk (1–2 RCRI factors)	Good functional status, no h/o angina or PVD	No testing
Intermediate risk (1–2 RCRI factors)	Poor/indeterminate functional status, h/o angina or PVD	Consider noninvasive stress test: If negative: No further intervention indicated If positive: Discuss cardiac catheterization & revascularization w/ cardiology Evid does not support periop beta blockade in pts w/ RCRI scores £2. Dec risk of MI, but inc risk of nonfatal stroke. (Lancet 2008;372:1962)
High risk (3+ RCRI factors)	Primary sx are related to failure, arrhythmia, or valve	Medical optimization
High risk (3+ RCRI factors)	Pts w/ >2 cardiac RFs who ALSO have extensive stress- induced ischemia on noninvasive testing	Revascularization (Eur Heart J 2009;30:2769)
Beta blockers & statins should be initiated only if indication for long-term use. Start rx weeks prior to surgery. Target HR 60–80 bpm. From 2009 ACCF/AHA; J Am Coll Cardiol 2009;54:2102. doi:10.1016/j.jacc.2009.07.004.

• Hematology:

Anemia: Investigate if unexplained; correct anemia w/ iron suppl if there is time before Surg or transfuse if Hgb <7 g/dL, symptomatic, or for high anticipated bld loss. Consider menstrual suppression if menorrhagia is a contributing factor.

Consider erythropoiesis-stimulating agents if xfusion is refused.

Thrombocytopenia: Goal is Plts >50000

Pt on anticoagulation:

Determine risk of stopping anticoagulation perioperatively. Stop warfarin 5 d prior to procedure, goal INR <1.5. Consider heparin bridge if at high risk of thrombosis.

Avoid elective Surg w/i 1 mo of acute venous or arterial thrombosis Consider IVC filter if recent thrombosis & high risk of bleeding w/ anticoag

• Endocrine:

DM:

Periop gluc problems: (1) surgical stress, (2) preop NPO, (3) decreased PO postop, (4) type of anesthesia (general > neuraxial). Critical considerations: (1) type 1, type 2, or gestational diabetes; (2) timing, length, & invasiveness of pro- cedure; (3) current med regimen.

Poor periop gluc control a/w (1) increased risk of infxn, (2) poor wound healing,

(3) neuro/cardiac sequelae of hypoglycemia. Postop goals: Maintain euglycemia (<150–180 mg/dL) & prevent ketoacidosis & nonketotic hyperosmolar state.

Metformin contraindicated w/ renal insufficiency or poor tissue perfusion; thia- zolidinediones may exacerb edema or precipitate CHF.

Perioperative DM management
PREOP	Type 2 DM, diet controlled	Fingerstick gluc pre- & postop
	Type 2 DM, PO med controlled	Hold meds morning of Surg
	Insulin-controlled DM (type 1 or type 2)	Continue basal/long-acting insulin. Reduce preop intermediate acting PM dose 50% (eg, NPH). D5 in IVF. IV insulin only for very long, complex cases.

POSTOP

Noninsulin-requiring DM

SS inferior to basal/bolus regimen, use only if needed & NPO (Diabetes Care 2011;34:256)

Resume home meds if no contraindication, as soon as taking PO well.

Insulin-requiring DM

Continue basal insulin to prevent ketogenesis.

NPO: Home basal insulin + regular SS q6 h, D5 in IVF.

W/ PO diet: Home basal/bolus regimen OR 0.5 U/kg divided btw basal & preprandial short acting (AC) insulin at meals.

• Thyroid dz:

Hyperthyroid: If new dx or uncontrolled, postpone Surg, consult endocrinology, continue chronic meds.

Hypothyroid: Consider endocrinology consult if new dx. Otherwise, continue meds. No need for IV/IM thyroid replacement if NPO for <7 d.

For hypo- & hyperparathyroidism: Follow for calcium imbalance

• Adrenal insufficiency:

Higher risk for periop adrenal crisis (HoTN, HoNa)

Minimal suppression of the HPA axis in pts w/ <5 mg prednisone (or equiv) daily;

<10 mg prednisone every other day; or ANY dose of glucocorticoid for <3 w. These pts do not require supplemental steroids (N Engl J Med 2003;348:727).

Replacement based on type of Surg (JAMA 2002;287:236):

Minor Surg (outpt Surg or minimally invasive): ® consider 25 mg hydrocorti- sone on day of procedure ® pt returns to regular dose.

Obstetric cases & all gynecologic Surg: ® 50 mg hydrocortisone just before procedure ® followed by 25 mg IV every 8 h for 24 h ® back to maint dose

For sev surgical stress (consider in extensive debulking surgeries): 100–150 mg hydrocortisone on day of procedure ® rapid taper to usual dose over 1–2 d

Critically ill pts (septic shock): ® 50–100 mg hydrocortisone IV q6–8 h or

0.18 mg/kg/h as a continuous infusion & 50 mg/d fludrocortisone until shock is resolved ® taper slowly (monit sodium).

• Elderly pts:

Polypharmacy: Carefully review meds & potential interactions

Avoid bowel prep due to higher risk of dehyd/electrolyte derangement Higher risk for the following postoperatively (Am J Obstet Gynecol 2003;189:1584)

Delirium & mental status changes; ensure sleep hygiene, orientation to environ- ment & careful dosing of psychoactive meds. W/u medical causes of delirium.

Pulm edema w/ heart failure due to fluid overload; monit fluid balance MI & stroke

Slow return of bowel fxn Longer hospital stay

• Obese pts:

Higher risk for the following postoperatively (Am J Obstet Gynecol 2010;202:306): SSI; plan incision & dose Abx appropriately

Pulm complications; encourage early ambulation & pulm toilet Thromboembolic complication; consider weight-based anticoagulant dosing per

pharmacy guidelines

Preoperative Measures

Preg test: For ALL women of reproductive age
Bld type & Ab screen: Consider cross-match for high-risk surgeries

• Antibiotic ppx for prevention of SSI: See below

Antibiotic ppx for prevention of SBE:

Not routinely recommended for GU procedures. Used in women w/ highest potential risk (prosthetic valve, prev infective endocarditis, pt w/ unrepaired cya- notic heart dz, repaired heart dz w/i 6 mo of procedure, or repaired dz w/ residual defects near prosthetic material, cardiac xplant w/ signif valvular dysfxn)

(Circulation 2008;118(8):887).

Venous thromboembolism ppx: See below
Bowel prep: Mechanical bowel preparation (eg, magnesium citrate, polyethylene glycol) not recommended for most gynecologic or colorectal Surg (Am J Obstet Gynecol 2011;205:309).
Fasting: Preop NPO reduces aspiration Milk or fried/fatty food: 8 h; light meal not including milk: 6 h; clear fluids: 2 h (Anesthesiology 2011;114:495).

Skin prep: SSI, see below
Positioning & incision selection: Neurologically neutral positioning & padding of all Avoid prolonged lithotomy (>4 h) or steep Trendelenburg. Select incision for appropriate exposure & to avoid excessive retraction.

Common nerve injury in gynecologic surgery
	Mech/RFs	Measures to avoid injury
1. Femoral nerve (L2–4):	Femoral nerve pierces the psoas muscle to pass under the inguinal ligament. Common neuropathy after gynecologic Surg, esp abd hysterectomy. (~11%). RFs include: Use of self-retaining retractors Wide Pfannenstiel or Maylard incision BMI <20 kg/m² Operation >4 h Poorly developed rectus muscle Narrow pelvis Hip hyperflexion or external rotation in lithotomy	Avoid compression of the psoas muscle by the self-retaining retractors Avoid extending Pfannenstiel incision beyond the lateral border of rectus abdominis Avoid hyperflexion & external rotation of the hip
2. Ilioinguinal (T12–L1) & iliohypogastric (T12–L1) nerves	Ilioinguinal nerve & iliohypogastric nerve course ~3 cm inferomedially to ASIS. Risk of entrapment at the lateral edge of Pfannenstiel incision. Prone to neuroma formation after injury.	If need to extend incision lateral to rectus muscle body, curve the fascial incision cephalad Avoid lateral placement of sutures when closing the fascia (no more than 1.5 cm lateral to the edge)
3. Genitofemoral (L1–2) & lateral-femoral (L2–3) nerves	These nerves lie on the belly of the psoas muscle lateral to the external iliac artery – Excessive lateral retraction – Transection during pelvic LN.	Avoid lateral excessive lateral traction on the psoas muscle Isolate the nerves during pelvic LN
4. Obturator nerve (L2–4)	Obturator nerve lies post to the psoas muscle & passes through the obturator canal Direct injury during pelvic LN Passing of the TOT sling	Careful dissection in the obturator fossa Careful passing of the trocar during TOT sling
5. Pudendal nerve (S2–4)	Exits pelvis through the greater sciatic foramen & enters again through the lesser foramen around the ischial spine (lateral 1/3 of the sacrospinous ligament) Injury during sacrospinous fixation Entrapment w/ vaginal mesh kits	Avoid the lateral 1/3 of sacrospinous ligament during fixation
6. Peroneal nerve (L4–5, S1–2)	Wraps around the lateral fibular head Excessive compression on the lateral aspect of the knee	Good padding of the lateral aspect of the knee during Surg Early ambulation after Surg
7. Brachial plexus (C5–8, T1)	Wraps around the lateral aspect of the neck & upper shoulder Hyperabduction of the shoulder Compression w/ shoulder braces	Avoid use of shoulder braces (preferred antislip devices include egg-crate foam or vacuum-beanbag mattresses) Avoid abduction of the shoulder >90°
From Obstet Gynecol 2004;103:374.