What is the perioperative plan for a 65-year-old male with a positive stress test undergoing colectomy?

Perioperative Management for 65-Year-Old Male with Positive Stress Test Undergoing Colectomy

A 65-year-old male with a positive stress test undergoing colectomy requires cardiology consultation for stress test interpretation and potential coronary angiography before proceeding with elective surgery. 1

Preoperative Cardiac Evaluation

• Perform comprehensive cardiac risk assessment using the Revised Cardiac Risk Index (RCRI) to estimate perioperative cardiac risk 1
• Evaluate the need for coronary angiography based on the extent of abnormality on stress test and clinical risk factors 1
• Consider revascularization only if indicated independently of the planned surgery, as routine coronary revascularization does not reduce perioperative risk 2
• Optimize medical therapy for any identified cardiovascular conditions, including continuation of beta-blockers, statins, and antihypertensives 1

Preoperative Preparation

• Avoid routine preoperative sedative medications as they delay postoperative recovery 1
• Implement preoperative carbohydrate loading (400ml with 50g CHO) 2 hours before surgery unless contraindicated 1
• Allow clear fluids up to 2 hours and light meal up to 6 hours before anesthesia induction 1
• Avoid routine mechanical bowel preparation for colonic surgery 1
• Consider statin therapy preoperatively as it's associated with fewer postoperative cardiovascular complications and lower mortality 2

Intraoperative Management

• Use standard anesthetic protocol with short-acting agents for rapid awakening 1
• Consider thoracic epidural analgesia (T7-10) with local anesthetics and low-dose opioids for open colectomy 1
• Maintain normothermia (>36°C) using warming devices and warmed intravenous fluids 1
• Implement goal-directed fluid therapy using cardiac output monitoring to optimize hemodynamics 1
• Consider laparoscopic approach if feasible to reduce inflammatory response and improve outcomes 1, 3
• Avoid high-dose β-blockers (e.g., 100 mg metoprolol succinate) 2-4 hours before surgery as they increase risk of stroke and mortality 2

Postoperative Care

• Continue thoracic epidural analgesia for 48-72 hours for open surgery 1
• Implement multimodal analgesia with acetaminophen and NSAIDs to reduce opioid requirements 1
• Use a multimodal approach to PONV prophylaxis, especially in patients with ≥2 risk factors 4, 1
• Encourage early mobilization (within 24 hours) and early oral feeding 1
• Remove nasogastric tubes before reversal of anesthesia 1
• Continue thromboprophylaxis with compression stockings and LMWH 1
• Monitor for epidural-related hypotension and treat appropriately with vasopressors after confirming euvolemia 1

Special Considerations

• Be aware of increased risk of perioperative myocardial infarction in patients aged 65 years or older 2
• Avoid fluid overload as it can contribute to postoperative ileus 1
• Preoperative beta-blockade (if patient is already on therapy) should be continued as it's associated with reduced short-term and long-term mortality following elective colon cancer surgery 5
• Routine drainage of the peritoneal cavity after colonic anastomosis is discouraged 1
• Consider transurethral bladder drainage for 1-2 days 1