clinical

1. Chairperson: Prof. M.I.M. Nasim Sobhani
khondker
Professor and head of the
department
Department of
surgery,MMCH
Speaker: Dr. S.M.Sufi Shafi-Ul-Bashar
Assistant Registrar
Co-existing diseases in
surgical practice

2. Introduction:
Every Surgical procedure involves some
risk of significant post operative
complications or death.
In most cases, the risk is below 1% but
it increases 10%-15% in high risk
population.
This high risk surgical population
accounts for over 80% of surgical death.

3. Characteristics of the high
risk population:
 Elderly
Comorbid conditions
Needing emergency surgery(no time for
optimisation)

4. Some common comorbid
conditions in surgery ward:
Diabetes mellitus
Thyroid diseases
IHD
COPD

5. Surgery in a patient with
DM:
Preoperative assessment:
Pre-operative assessment must be done in close contact
with the physician, surgeon &anaesthetist.Aim should be to
have optimal control of diabetes in all diabetics undergoing
surgery( exception- emergency surgery).
Assess glycaemic control
 Consider delaying surgery and referral to the diabetes
team if HbA1c > 75 mmol/mol (9%). Acceptable HbA1c should be
b/w 8%-9%.
Assess cardiovascular status
 Optimise blood pressure
 ECG for evidence of (possibly silent) ischaemic heart disease .
Assess Renal function
Serum creatinine & Blood Urea.

6. Preoperative assessment (DM)
contd:
 Assess foot risk
Patients with high-risk feet should have suitable
pressure relief provided during post-operative nursing.
 Others:
Serum electrolytes-( hypokalaemia or hyperkalaemia)
Urine for- Proteinuria
UTI
CXR- to identifying any hidden pneumonia or pulmonary
oedema.

7. Perioperative management(DM)
Day prior to surgery:
Patient on long acting secretogogues(such as
glibenclamide, glimepiride)should be stopped 36-48 hrs
before operation .
Metformin should be stopped at least 24 hours before
operation.
For major surgery,the patient should keep nil per oral(NPO)
overnight prior to surgery,in patients with gastroparesis
duration of NPO should be around 10- 12 hours.
For all type1 & poorly controlled type2 DM:
Insulin is used to control the diabetes in all types of
operation.
Hospitalize the patient at least 3 days before

8. Perioperative management(DM)
contd:
Day of surgery:
 Anti diabetic medications are omitted(continue long acting
analogues-glargine, detemir) on the morning of the operation.
 Schedule surgery as early as possible.
 In all major surgeries start glucose-insulin infusion. 10units
of regular insulin is added to 1L of 5% dextrose in half normal
saline& give I/V @ 100-180mL/hour. This gives the patient 1-
1.8 units of insulin per hour& keeps the blood glucose within the
range of (5.5-13.9)mmol/L.
 Blood glucose should be monitored 1to 2 hourly. It should be in
the range of 6.0-11.0 mmol/L.
 If blood glucose >12 mmol/L, start glucose-insulin-
potassium(GKI) sliding scale regimen according to the situations.

9. Perioperative management(DM)
contd.

10. Postoperative
management(DM)
 The glucose-insulin administration is continued( where
required) till the patient able to take oral food.
 During this time fluid balance & electrolytes level
should be
monitor carefully.Insulin- glucose infusion causes
hypokalaemia and also hyponatraemia.thus I/V fluid
during prolong infusion should include saline &
potassium supplementation.
 At this time , if blood glucose is not under fair control or
patient controlled on tablets previously may require
temporary short acting insulin s/c until increased stress
of surgery, wound healing or infection has resolved.
 Once patient is back on his routine diet & stable ,he
can be managed with the regimen prior to surgery and

11. Emergency surgery in diabetic
patient:
Insulin infusion started & frequent monitoring
of blood glucose is done.
 Electrolytes, acid base status & urinary
ketone levels are checked.
If feasible surgery is delayed till blood glucose
comes below 20 mmol/L& ketonuria
disappears.
If delaying is not possible, operation with
intensive management of diabetic state is to
be done.
Other managements according to general
principles of emergency surgery should be

12. Surgery in a patient with thyroid
diseases:
 Preoperative preparation of patients
with hypothyroidism is essential
because these patients are subjected to
acute hypotension,shock & hypothermia
during surgery.
 Delayed recovery from anaesthesia is
an important manifestation of a
hypothyroid patient.

13. Surgery with thyroid diseases
contd.
Complications :
• Preoperative-
Hypoventilation
Severe CO2 retention
Myxoedema coma- suspected if patient fail
to awaken promptly from anaesthesia,manifested
by co2 retention,co2 necrosis & hypothermia.
• Postoperative-
Myxoedema coma: present with altered
mental status, hypothermia, cardiac failure.
Infection
Poor wound healing, wound dehiscence
etc.

14. Surgery with thyroid diseases
contd.
Preoperative preparation of a hypothyroid
patient:
For routine operation:
To achieve euthyroid state- Replacement dose of
levothyroxine in adults range from 0.05 to 0.2
mg/day or 1.6-1.7 micro gram/kg/day. After 4-6wks
dose is adjusted based on the serum TSH level.
• In older patient and patient with cardiac disease
start with a low dose of levothyroxine , that is
0.025-0.05 mg/day or(25micro gram/d) which
increased by 25 microgram/day every 2 to 3
months until TSH is normal.
• For TSH suppression in patient post thyroidectomy
for thyroid cancer ,dose of LT4 is 2.2

15. Surgery with thyroid diseases
contd.
For Emergency operation:
Levothyroxine sodium 500microgram(0.5mg) by
I/V or NG tube/ Orally.
 It is always advisable to obtain a baseline
cortisone level before the treatment of
Myxoedema to ruleout coexisting Addison’s
disease, since levothyroxine therapy can precipitate
Addisonian crisis.

16. Surgery with thyroid diseases
contd.
Prepare a hyperthyroid (thyrotoxic) patient
for surgery:
Preoperative preparation of a patient with
hyperthyroidism in order to make the patient
euthyroid or near euthyroid at operation; before
giving or starting antithyroid drug- thyroid profile
should be done with-Free T3, Free T4 and
TSH.
Preparation of the patient:
A. Routine elective surgery:
1. Carbimazole (antithyroid drug) is the drug
of choice.
a. Carbimazole 30-40 mg once daily

17. Surgery with thyroid diseases
contd.
b. When patient becomes euthyroid
after 8/-12
weeks the dose may be reduced to 5
mg every 8
hourly- last dose of Carbimazole
may be given
on the evening before surgery.2. Lugol's iodine - 5 drops thrice daily in milk.
Lugol's iodine should be started 10-14 days
before surgery or Potassium iodide (KI) tablet
60 mg TDS.

18. Surgery with thyroid diseases
contd.
B. For rapid control (rapid symptomatic relief):
1. Tab. Propranolol 40 mg thrice daily-
should be
continued 7 days postoperatively
or
2. Long acting nadolol 80 mg twice daily or
160 mg once
daily.

19. Surgery in a patient with IHD:
Risks/complications:
1. Chance of peroperative MI is about
3.5-7.5% in a patient who has history of
MI.
2. Chance of re-infarction is more if
patient has recent MI within 6 months of
period.

20. Surgery in a patient with IHD:
A. Preoperative preparation:
1. Postpone the surgery of patient who has
recent MI within 6 months.
2. Patients of angina& MI: Preoperative β-
blocker, GTN, statins should be given which
reduce further episodes of ischaemic event.

21. Surgery in a patient with IHD:
B. Peroperative: In peroperative care
by anaesthetist is very important.
1. Anaesthetist must avoid:
a. Tachycardia.
b. Hypotension.
c. Hypertension.
d. Any condition that increase myocardial O2
demand.
2. Avoid atropine as preanaesthetic medication
as this drug causes tachycardia.
3. Use of halothane during anaesthesia.

22. Surgery in a patient with IHD:
C. Postoperative:
1. Adequate postoperative analgesia (by
adequate dose of opioid), because it reduce
TPR→ Hypotension.
2. Regular monitoring the blood gas analysis;
because normal PO2 and PCO2 are
mandatory.
3. Regular serial ECG and cardiac monitoring.
Postoperative care of the ischaemic
heart disease patient should be

23. Surgery with COPD:
Preparation for surgery is required in a
patient with COPD because there is a
chance of postoperative morbidity due to
postoperative pulmonary complications.

24. Surgery with COPD:
Preoperative preparation:
1. Timing of elective surgery- Preferable to
summer, when period of remission of
symptoms.
2. Smoking should be stopped 6 weeks
before operation.
3. Bronchodilator should be continued until
time of surgery.
4. Steroid should be continued
5. Preoperative chest physiotherapy and
exercise tolerance test.
6. Premedication with diazepam,

25. Surgery with COPD:
Peroperative preparation:
1. Additional dose of steroid.
2. Regular monitoring- R/R and pattern;
temperature, O2 saturation.
3. In severe case- Tracheostomy.
Postoperative:
1. Immediate postoperative clearance of
secretion by oropharyngeal suction.
2. O2 inhalation by O2 mask.

26. Surgery with COPD:
Postoperative care contd.
3. Nebulization by bronchodilator/ Intravenous
bronchodilator.
4. Steroid should be continued.
5. Antibiotics (appropriate antibiotics).
6. Adequate analgesia.
7. Chest physiotherapy & encourage for deep
breathing.
8. Periodic hyperventilation by incentive spirometer.
9. Early ambulation.
10. Regular monitoring-
a. O2 saturation.
b. Arterial Blood Gas analysis (ABG).

27. Conclusion:
By proper management of
coexisting diseases in surgical
practice we can reduce
mortality & morbidity rate and
ensure better outcome of the
patient.

28. `
Thank you
all.