Peri-Operative Management

Alcoholics

• Add Thiamine 100mg IV/PO QD (prevents Wernicke's encphalopathy) and Folate 1mg IV QD
• Consider DT prophylaxis with benzodiazepines: Lorazepam(Ativan) 1.5-2mg IV/IM/PO Q6hours; diazepam(Valium) 2-10mgPO TID; Oxazepam(Serax) 15mg PO TID.

Chest Pain (post-operative)

• Angina and MI are most common cause
• Consider: PE, aortic dissection, pericarditis, endocarditis, pneumonia, pneumothorax, esophageal rupture, cholecystitis, pancreatitis, dyspepsia, GERD, vertebral fracture, rib fractrue, constochondritis, herpes zoster
• IF Cardiac:
  2liters Oxygen via nasal cannula
  Stat EKG
  SL nitroglycerin after EKG
  Nitropaste 1-2"
  Aspirin
  Cardiac enzymes
  Medicine consult

Coumadin (Perioperative managment of patients on coumadin / oral anticoagulants)

• 10mg given the night of surgery.
  None the following night.
  Then coumadin dose = 20-PT.
  Also coumadin dose = 10(2.1 - INR)
• Patients on coumadin at high risk of thromboembolic event who undergo invasive procedures need the coumadin withheld and perioperative intravenous heparin, LMWH, or carry out the invasive procedure on sub-therapeutic anticoagulation at INR range of 1.5 to 2.0
• Discontinue warfarin 4-7 days prior to surgery. Start LMWH 36hours after warfarin discontinued. Surgery perform 12-24hours after last LMWH dose. Check INR 24hours prior to surgery; If INR >1.5 but less than 2, give a 1 or 2 mg oral dose of vitamin K. If INR > 2, postpone the procedure.
• INR must be <1.5 before surgery.
• If INR is between 2.0 and 3.0, usually 4 doses of warfarin must be withheld for INR to fall below 1.5; 5 days for < 1.3.
• Postoperatively restart heparin and warfarin as soon as is possible, ideally post-op day 0 or 1, depending on risks for bleeding.
• (Dunn A, Arch Intern Med 2003;163:901).

IV Fluids

• 100cc/Kg for the first 10Kg
• 50cc/Kg for the second 10Kg
• 20cc/Kg > 20Kg
• Average person: D5 1/2 NS + 20meQ KCL/L @ 100cc/hr

Pre-Operative Evaluation

• Order: EKG, U/A, Chest xray,
• see list from pre-op nurses.

Post-Operative Ileus

• Work-up: check lytes, Mg, C. Dif toxin x 3, flat and upright abdominal xrays