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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2804_Библиотеки_им_академика_М_И_Перельмана

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☆
Cosyntropinstimulationtestmayalsobeperformedtodetermineadrenalresponsiveness,measuringa singlecortisollevelat60minutesafter250μgofcosyntropin.Thiscanbedoneanytimeofdayand baselinecortisolisnotneeded.Levels>18μg/dLat60minutesgenerallysuggestanintacthypothalamic– pituitaryaxis.
TREATMENT
If there is concern for secondary adrenal insufficiency, it is reasonable to simply continue prior steroiddosingperioperatively.
106
ItmaybeprudenttoswitchtoanIV formulationtoensureitis not withheldwhilethepatientisNPO. For patients with primary adrenal insufficiency, a stress stratification scheme has been developed, basedonexpertopinion.
ChronicRenalInsufficiencyandESRD
GENERALPRINCIPLES
Chronic renal insufficiency (CRI) is an independent risk factor for perioperative cardiac complications,soallpatientswithrenaldiseaseneedappropriatecardiacriskstratification.
11
PatientswithESRDhaveasubstantialmortalityriskwhenundergoingsurgery.
107
Mostgeneralanestheticagentshavenoappreciablenephrotoxicityoreffectonrenalfunctionotherthan thatmediatedthroughhemodynamicchanges.
108
TREATMENT
Volumestatus
Every effort should be made to achieve euvolemia preoperatively to reduce the incidence of volume-relatedcomplicationsintraoperativelyandpostoperatively.
109
PatientswithCRInotreceivinghemodialysismayrequiretreatmentwithloopdiuretics. Patientsbeingtreatedwithhemodialysisshouldundergodialysispreoperatively,whichiscommonly performedonthedaypriortosurgery.Hemodialysiscanbeperformedonthedayofsurgeryaswell, butthe possibilityshould be considered that transient electrolyteabnormalities andhemodynamic changespostdialysiscanoccur.
Electrolyteabnormalities
Hyperkalemiainthepreoperativesettingshouldbetreated,particularlybecausetissuebreakdown
associatedwithsurgerymayelevatethepotassiumlevelfurtherpostoperatively.
Forpatientsondialysis,preoperativedialysisshouldbeundertaken. ForpatientswithCRInotundergoingdialysis,alternativemethodsofpotassiumexcretionwillbe necessary.
□ Loopdiureticscanbeused,particularlyifthepatientisalsohypervolemic. □ Sodiumzirconiumcyclosilicateisanoptionifvolumestatusisnotanissue.
Althoughchronicmetabolicacidosishasnotbeenassociatedwithelevatedperioperativerisk,some localanestheticshavereducedefficacyinacidoticpatients.Preoperativemetabolicacidosisshould becorrectedwithsodiumbicarbonateinfusionsordialysis.
Bleedingdiathesis
Plateletdysfunctionhaslongbeenassociatedwithuremia.
The value of a preoperative bleeding time in predicting postoperative bleeding has been
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questioned.
110
Apreoperativebleedingtimeis,therefore,notrecommended.
Patientswithevidenceofperioperativebleedingshould,however,betreated.
□ DialysisforpatientswithESRDwillimproveplateletfunction. □ Desmopressin(0.3μg/kgIVorintranasally)canbeutilized. □ Cryoprecipitate,10unitsover30minutesIV,isanadditionaloption. □ Inpatientswithcoexistinganemia,RBCtransfusionscanimproveuremicbleeding. □ For patients with a history of prior uremic bleeding, preoperative desmopressin or
conjugatedestrogens(0.5mg/kg/dIVfor5days)shouldbeconsidered.
Heparingivenwithdialysiscanincreasebleedingrisk.Heparin-free dialysisshould be discussed
withthepatient’snephrologistwhensurgeryisplanned.
AcuteRenalFailure
GENERALPRINCIPLES
Surgeryhasbeenassociatedwithanincreasedriskofacuterenalfailure(ARF).
109
PatientswithCRIareatincreasedriskofARF. ARFamongpatientswithnormalpreoperativerenalfunctionisarelativelyrareeventbutisassociated withincreasedmortalitywhenitoccurs.
111
DIAGNOSIS
The approach to ARF in the perioperative setting is not substantially different from that in the nonoperativesetting(seeChapter13,RenalDiseases). However, certain additional factors have to be considered when evaluating the cause in the perioperativesetting:
Intraoperative hemodynamic changes, particularly hypotension, should be investigated. Intraoperative vasopressor and diuretic administration have been associated with postoperative ARF.
TREATMENT
ForadetaileddiscussionregardingthemanagementofARF,pleaserefertoChapter13,RenalDiseases.
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2
NutritionSupport
KaiJones,DominicReeds,KatrinaHan
NutrientRequirements
GeneralPrinciples
Energy
Totaldailyenergyexpenditure(TEE)iscomposedofrestingenergyexpenditure(normally 70%of TEE),thethermiceffectoffood(normally 10%ofTEE),andenergyexpenditureofphysicalactivity (normally 20%ofTEE). Use of predictive equations can provide a reasonable estimate of daily energy requirements that shouldbemodifiedbasedonthefactorsthataffectthepatient’smetabolicrate. Malnutrition andhypocaloricfeedingmaydecrease resting energyexpenditureto15%–20%below expectedforactualbodysize,whereasmetabolicstressors,suchasinflammatorydiseasesortrauma, oftenincreaseenergyrequirementsby 30%–50%. The Harris–Benedict equation provides a reasonable estimate of resting energy expenditure (in kilocalories [kcal] per day) inhealthy adults. Ittakesinto accountthe effects of bodysize andlean tissue mass (which are influenced by gender and age) on energy requirements and can be used to estimatetotaldailyenergyneeds inhospitalizedpatients(whereWis theweightinkilograms, H the heightincentimeters,andAistheageinyears).
1
Men=66+(13.7×W )+(5×H )−(6.8×A)
Women=665+(9.6×W )+(1.8×H )−(4.7×A) Energy requirements per kilogram of body weight are inversely related to body mass index (BMI) (Table2-1).Thelowerrangewithineachcategoryshouldbeconsideredininsulin-resistant,critically illpatientsunlesstheyaredepletedinbodyfat.
TABLE2-1
ESTIMATEDENERGYREQUIREMENTSFORHOSPITALIZEDPATIENTSBASEDON BODYMASSINDEX
BodyMassIndex(kg/m2) EnergyRequirements(kcal/kg/d)
15 35–40
15–19 30–35
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