Perioperative Considerations for Foot & Ankle Surgery PDF

Perioperative Considerations for Foot & Ankle Surgery Clinical Podiatric Biomechanics & Surgery 3/19/24 Kevin Smith, DPM, PhD FACFAS CPMS Mission Statement To educate a diverse group of highly competent and compassionate podiatric health professionals to improve lives in a global community. Lecture...

Perioperative Considerations for Foot & Ankle Surgery Clinical Podiatric Biomechanics & Surgery 3/19/24 Kevin Smith, DPM, PhD FACFAS CPMS Mission Statement To educate a diverse group of highly competent and compassionate podiatric health professionals to improve lives in a global community. Lecture Objectives Identify the elements of a pre-operative history and physical with and without comorbidities. Demonstrate knowledge of patient risk assessment, fluid and electrolyte replacement and pre-operative laboratory studies. Patient Workup History and Physical Preoperative laboratory studies Vascular workup Radiographs Special studies Medical problems History and Physical Concentrate on major organ systems and rule out medical contraindications to surgery Identify true allergies and potential drug interactions Anesthesia risks Social history ▫ Convalescence and rehabilitation ▫ Tobacco ▫ Recreational drugs The American Society of Anesthesiologists Classification of Physical Status ¨ ASA Class I A normal healthy patient ¨ ASA Class II A patient with mild systemic disease ¨ ASA Class III A patient with severe systemic disease that limits activity, but is not incapacitating ¨ ASA Class IV A patient with incapacitating systemic disease that is a constant threat to life ¨ ASA Class V A moribund patient not expected to survive 24 hours with or without surgery ¨ E Designates an emergency surgical procedure Laboratory Studies Follow hospital protocol CBC ESR Electrolytes PT/PTT Chemistry Panel (LFT, BUN, creatinine, cardiac enzymes) UA pregnancy test Vascular Workup When there is doubt about adequacy of arterial or venous circulation order appropriate vascular studies ▫ ▫ ▫ ▫ Doppler with segmental pressures Ankle/arm indices Transcutaneous oximetry Angiography (MRI) Radiographs Foot and ankle radiographs for soft tissue and osseous evaluation ▫ Templates CXR Cervical spine films Special Studies Nuclear scans CT scans ▫ Osseous affinity ▫ Fracture and tumor evaluation MRI ▫ Soft tissue affinity ▫ Evaluation of tumors, infection and tendon pathology Nuclear Scans CT Scans MRI Fluid Replacement Normal adults are considered to have a minimal obligatory water intake or generation of approximately 1600 mL per day, composed of the following: Ingested water – 500 mL Water in food – 800 mL Water from oxidation – 300 mL Fluid Replacement The sources of obligatory water output in normal adults are composed of the following: Urine – 500 mL Skin – 500 mL Respiratory tract – 400 mL Stool – 200 mL Distribution of Total Body Water Total Body Water (TBW): ▫ Wt (Kg) X.6 (m).5 (f) = TBW in liters ▫ 70 x.6 = 42L Next consider the different fluid compartments within the body ▫ “2/3, 1/3” rule Fluid Compartments TBW Intracellular Fluid 2/3 of TBW Extracellular Fluid 1/3 of TBW Interstitial Fluid 2/3 of ECF Intravascular Fluid 1/3 of ECF Fluid Compartments 70 kg male: ▫ TBW = 42 L ▫ Intracellular Volume =.66 X 42 = 28 L ▫ Extracellular Volume =.34 X 42 = 14 L – Interstitial Volume =.66 x 14 = 9 L – Intravascular Volume =.34 x 14 = 5 L Intravenous Fluids 0.9 % Saline ▫ Na: 154 Cl: 154 0.45 % Saline ▫ Na: 77 Cl: 77 Lactated Ringers ▫ Na: 130 Cl: 109 Lactate 28 K: 4 Ca: 3 D5 ▫ Adds 50 gm glucose per liter Intravenous Fluids https://www.pharmaceuticaljournal.com/learning/learningarticle/intravenous-fluid-therapy-backgroundand-principles/10032372.article Medical Problems Assess circulatory status of lower extremity Treat underlying medical conditions Adjust medical therapy Inform members of healthcare team about potential problems Diabetes Mellitus DM is a complex systemic disease that affects multiple organ sites that include vascular, neurologic and dermatologic. Diabetes Mellitus Surgical stress creates endocrine metabolic reaction that results in glucagon, norepinephrine, epinephrine and cortisol secretion. Blood glucose levels rise Resultant insulin production in response to hyperglycemia inhibited by feedback loop Albumin status inhibits healing Diabetes Mellitus Elective surgery should be avoided when blood sugar greater than 200 mg/dl Schedule surgery early in am ECG , especially when considering general anesthesia ▫ Increased insulin demand increases risk of silent MI Give one half insulin dose preoperatively and second half of insulin after surgery and give D5W Arthritis Includes all forms of arthritis Avoid joint surgery during flare-ups Surgery in the rheumatoid patient should be goal oriented ▫ PAIN RELIEF ▫ IMPROVEMENT OF OVERALL FUNCTION ▫ CORRECTION OF THE DEFORMITY Patient Management Decisions in Rheumatoid Arthritis ASA or NSAID discontinuation Pre-operative corticosteroid supplementation Adjustment of antirheumatic drugs Prophylactic antibiotics (joint replacement) Prophylaxis for DVT Workup for atlantoaxial subluxation ASA and NSAID’s Preoperative Labs ▫ PT, PTT, bleeding time, serum transaminase, BUN, creatinine, uric acid Stop ASA 2 weeks prior to surgery Stop NSAID’s 3-5 days prior to surgery Corticosteroid Use and the SteroidSuppressed Patient HPA-Axis suppression Oral cortisone has been used within last year ▫ Do not need to supplement if < 5.0 mg/day or intraarticular injection Physical and emotional stress of surgery require up to ten times the normal level of endogenous corticosteroid Patient does not have enough endogenous steroid to cover stress Result in hypotensive crisis and cardiovascular collapse Corticosteroid Supplementation Recommended perioperative hydrocortisone dosage for patients on long-term Steroid therapy Surgery Type Stress Dose Duration Minor (hernia) 25 mg/day 1 day Moderate (total joint replacement) 50-75 mg/day 1-2 days Major (Cardiopulmonary bypass) 100-150 mg/day 2-3 days Salem M, Tainish RE JR, Bromberg J, Loriauz DL, Chernow B. Perioperative Glucocorticoid coverage: A reassessment 42 years after emergence of a problem. Ann Surg 1994; 219: 416 – 425. Corticosteroid Supplementation Hydrocortisone 100mg IV/IM evening prior to surgery Another dose directly before surgery Continue every 8 hours for the next day postoperatively Immunosuppressive Drugs Antimalarials, gold salts, penicillamine and methotrexate should be continued to decrease arthritic flare-ups Prophylactic Antibiotics Used for joint replacement and immunosuppression Ancef 1-2 gm IV 30 minutes before surgery Vancomycin 1 gm IV 1 hour before surgery DVT and Atrial Fibrillation Coumadin – Vitamin K antagonist ▫ Stop Coumadin 3-5 days prior to surgery ▫ May start on Heparin or Lovenox as bridge ▫ Start Coumadin for 3-5 days until PT is therapeutic, continue Heparin during this time ▫ Reversal of Coumadin with Vitamin K and/or FFP ▫ Reversal of Heparin with Protamine Sulfate DVT and Atrial Fibrillation Direct-Acting Oral Anticoagulants (DOACs) ▫ Thrombin inhibitor – Dabigatran (Pradaxa) – Reversed with Idarucizumab (Praxbind) ▫ Direct Factor Xa inhibitor – – – – Apixaban (Eliquis) Rivaroxaban (Xarelto) Edoxaban (Savaysa) Reversed with Andexxa (Coagulation Factor Xa) DVT and Atrial Fibrillation DOACs ▫ Stop 1 day before low/moderate bleeding risk procedures ▫ Stop 2 days before high bleeding risk procedures ▫ Resume 1 day after low/moderate bleeding risk procedures ▫ Resume 2 days after high bleeding risk procedures High bleeding risk – Coronary artery bypass, kidney biopsy and any procedure > 45 minutes Atlantoaxial Subluxation Present in 40% of rheumatoid patients Marked flexion of neck can cause fracture or neurological interruption Atlantoaxial Subluxation EBM Reference http://www.sciencedirect.com/science/article/pii/S0049017206001612 Large analysis of literature that reviews various aspects of RA medications and surgery Level 3 systematic review of literature Found that methotrexate is safe and does not need to be discontinued Gout Risk of postoperative gout attack due to surgical trauma, dehydration and interruption of uricosuric medication Oral colchicine 0.6mg Bid for two days before surgery and one day postoperatively Colchicine 2 mg IV preoperatively to avoid GI side effects Cardiovascular Disease Hypertension Ischemic Heart Disease Rheumatic Heart Disease Mitral Valve Prolapse Hypertension Increased medical and surgical risk Controlled by anesthesia if patient has not taken oral medication Mild hypertension will often resolve with induction medication and pain medication Evaluate preoperative potassium (> 3.5 mEq) Ischemic Heart Disease Avoid elective surgery if patient has had an MI within last 6 months Cardiac consult for any surgery with pre-existing ischemic heart disease Rheumatic Heart Disease and Mitral Valve Prolapse Prone to bacterial endocarditis Prophylaxis with antibiotics In office prophylaxis with Amoxicillin Renal and Hepatic Disease Previously discussed in Renal course LFT’s, alkaline phosphatase, albumin, bilirubin, PT, CBC Increased bleeding tendency due to decreased platelets and extrinsic pathway Avoid halothane and amides because of hepatotoxicity Pediatric Patients Parental presence during anesthesia induction and in recovery room is beneficial General anesthesia favored Prevent hypothermia due to poor thermoregulation created by large surface area/weight ratio Clark’s rule ▫ Weight/150 = fraction of adult dose Geriatric Patients Multiple medications and possible drug interactions Decreased renal function with age Inability to clear medications Respiratory depression with medications Rehabilitation concerns ▫ Recovery time often doubled Avoid preventable ulcerations Thank You