What are the key considerations for preoperative, intraoperative, and postoperative management?

Comprehensive Perioperative Management Guidelines

The most effective perioperative management strategy requires a systematic approach addressing preoperative risk assessment, intraoperative monitoring, and postoperative care to minimize morbidity and mortality while optimizing quality of life. 1, 2

Preoperative Management

Risk Assessment

• Evaluate cardiac risk using the revised Lee cardiac risk index based on: high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, renal dysfunction, and age >75 1
• Measure hemoglobin A1c preoperatively for risk stratification, aiming for levels <7% to reduce complications including deep sternal wound infections and ischemic events 1
• Assess serum albumin levels preoperatively as hypoalbuminemia correlates with increased ventilator time, acute kidney injury, infection, longer hospital stays, and mortality 1
• For vascular surgery patients, consider starting beta-blockers (bisoprolol 2.5-5 mg/day) one month before surgery for patients with ≥1 risk factor, titrated to heart rate <70 bpm 3

Medication Management

• Consider withholding ACE inhibitors and angiotensin receptor antagonists on the morning of surgery to reduce risk of intraoperative hypotension 1
• For patients with coronary stents, maintain antiplatelet therapy according to stent type: continue aspirin for bare metal stents after 6 weeks, and maintain dual antiplatelet therapy for 12 months with drug-eluting stents 1
• Initiate statin therapy preoperatively (ideally 30 days before surgery) using long-acting formulations to decrease MI, stroke, and mortality risk 3

Special Considerations

• For patients with heart failure, quantify severity of systolic and diastolic dysfunction preoperatively to guide fluid management during surgery 1
• For patients with hypertrophic obstructive cardiomyopathy, avoid beta-adrenergic agonists as they may increase dynamic obstruction and decrease diastolic filling 1
• Patients with unstable cardiac conditions (unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease) should be considered for delay of surgery for cardiac stabilization 2

Intraoperative Management

Anesthetic Considerations

• For adult patients under 55 years classified as ASA-PS I or II, propofol induction typically requires 2-2.5 mg/kg when unpremedicated or premedicated with oral benzodiazepines or intramuscular opioids 4
• For elderly, debilitated, or ASA-PS III/IV patients, reduce propofol induction dose to 1-1.5 mg/kg (approximately 20 mg every 10 seconds) and avoid rapid bolus administration to prevent cardiorespiratory depression 4
• Maintain propofol infusion rates at 50-100 mcg/kg/min in adults during maintenance to optimize recovery times 4

Hemodynamic Management

• Monitor for surgical stress response which induces tachycardia and hypertension, increasing myocardial oxygen demand 1
• Be vigilant for intraoperative hypotension, which has been associated with greater perioperative cardiac and renal complications than intraoperative hypertension 1
• Manage fluid shifts carefully, especially in patients with heart failure or cardiomyopathy, as these can exacerbate cardiac stress 1

Monitoring

• Implement appropriate cardiac monitoring based on patient risk factors and surgical complexity 1
• For high-risk procedures or patients with significant cardiac disease, consider more invasive hemodynamic monitoring 2

Postoperative Management

Medication Resumption

• Restart ACE inhibitors only after confirming the patient is euvolemic to decrease risk of perioperative renal dysfunction 1
• Continue beta-blocker therapy throughout the perioperative period to reduce cardiac complications 2, 3
• Maintain statin therapy postoperatively for long-term cardiovascular benefit 3

Pain Management

• Implement multimodal analgesia to reduce opioid requirements and associated complications 2
• Titrate pain management to facilitate early mobilization and reduce pulmonary complications 2

Monitoring and Complications

• Monitor for cardiac complications including myocardial ischemia, heart failure, and arrhythmias, particularly in high-risk patients 1
• Be vigilant for postoperative hypercoagulability which may lead to coronary thrombosis due to elevated fibrinogen, increased platelet activation, and reduced fibrinolysis 1

Patient Education and Communication

• Provide clear preoperative education about surgical and anesthetic procedures to reduce patient anxiety and improve outcomes 2, 5
• Ensure effective communication among all perioperative team members (surgeon, anesthesiologist, primary care provider, consultants) to optimize patient care 1, 2
• Address patient concerns about uncertainty surrounding surgery through individualized communication and involvement of social support 5

Common Pitfalls to Avoid

• Viewing preoperative evaluation as simply "medical clearance" rather than comprehensive risk assessment 2
• Performing unnecessary tests that will not influence perioperative management 2
• Abrupt discontinuation of propofol infusions which may result in rapid awakening with anxiety, agitation, and resistance to mechanical ventilation 4
• Failing to recognize that preoperative cardiac management is only one aspect of overall perioperative care 6