4 Pre-op: Endocrine, Kidney, Liver

Question 1

During the preoperative evaluation of a patient with diabetes mellitus, the anesthesiologist should document the disease type (i.e., type 1 versus type 2) and (4)

Answer 1

• current usual glycemic control,
• history of hypoglycemic episodes,
• current therapy,
  *the severity of any end-organ complications.

Question 2

Perguntas para verificar neuropatia autonómica em diabéticos (3)

Answer 2

• vertigem postural
• saciedade precoce
• vomitos pos-prandiais

Question 3

Por que é importante o exame de articulações (especialmente cervicais) no pré-operatório de pacientes com diabetes? Qual a relacao da doenca com isso?

Answer 3

• Pacientes diabéticos frequentemente desenvolvem rigidez articular devido à glicação de proteínas (ligação de glicose às proteínas)
• Afeta especialmente a coluna cervical, limitando a mobilidade e dificultando o posicionamento durante a intubação

Question 4

In the nonoperative setting, the American Diabetes Association recommends a target HbA1c concentration ___1___ for most nonpregnant diabetic patients.

While preoperative HbA1c is correlated with postoperative glycemic control, evidence remains inconsistent with respect to its role as a predictor of postoperative complications, both in patients with diabetes and those without diabetes.

Despite the limitations in the underlying evidence base, the Australian Diabetes Association has recommended delaying elective surgery for a HbA1c **___2___* while the Association of Anaesthetists of Great Britain and Ireland recommended delaying elective surgery for a value ___3___.

Answer 4

1. <7%
2. ≥9%
3. ≥8.5%

Question 5

There is growing interest in novel
markers that characterize shorter-­ term glucose control such as ___1___, which assesses average glucose control in the prior two weeks and may also predict post-operative complications.

Answer 5

1. fructosamine

Question 6

Qual o melhor momento para fazer a cirurgia em paciente diabético?

Answer 6

• Manhã

Ideally, all diabetic patients should have their surgery as an early morning case to minimize disruptive impact of preoperative fasting of their diabetic management

Question 7

Tight perioperative glucose control in the immediate perioperative period is controversial. Intensive perioperative glucose control may theoretically help decrease risks of postoperative complications, but randomized controlled trials have not consistently shown these benefits, but have consistently shown elevated rates of hypoglycemia.

• V ou F

Answer 7

Verdadeiro

Question 8

Em que momento as medicacoes para DM devem ser suspensas (exceto insulina)

Answer 8

• SGLT-2: suspender 24h antes de cirurgia eletiva e 72h antes de cirurgia de grande porte (risco de cetoacidose euglicemica no periodo pos-operatorio)
• Suspender as outras na manha da cirurgia

Question 9

Em que momento suspender as insulinas rápidas?

Answer 9

• Suspender enquanto jejum

Exceto: bomba de infusao de insulina subcutânea continua

Question 10

Em que momento suspender as insulinas longas/intermediarias?

Answer 10

Controverso

• DM1: 1/3 a 1/2 da dose da manha.
• DM2: suspender ou tomar 1/2 da dose na manha da cirurgia

Question 11

If surgery is urgent, hyperthyroid patients can be treated with (3)

Answer 11

• β-adrenergic blockers,
• Antithyroid medications (e.g.,
  methimazole, propylthiouracil, potassium iodide)
• corticosteroids.

Question 12

All thyroid replacement therapy and antithyroid drugs should be continued on the day of surgery.

• V ou F

Answer 12

Verdadeiro

Question 13

Calculating an eGFR is especially important in patients who are (3)

Answer 13

• older,
• have elevated creatinine concentrations, or
• have other risk factors for CKD

Given the inaccuracy of these equations at lower creatinine concentrations, values of eGFR that are greater than 60 mL/kg/min/1.73 m2 should simply be reported as “>60 mL/kg/min/1.73 m2.

Question 14

Classifying AKI into pre-renal, renal, and post-renal causes allows for a systematic approach. Prerenal causes can often be differentiated by calculating the fractional excretion of sodium (FENa) using the following formula:

Answer 14

• P: plasma
• U: urina

Question 15

CKD is also associated with chronic anemia due to reduced erythropoietin production by the kidneys. While treatable with erythropoiesis stimulating agents, complete “normalization” of hemoglobin concentration (i.e., 13.5 g/L vs. 11.3 g/L) may actually increase morbidity and vascular events.

Hence, current KDIGO guidelines recommend using erythropoiesis stimulating agents to treat hemoglobin concentrations:

Answer 15

• <9.0 g/L,
• but avoid increasing the concentration to above 13.0 g/L.

Question 16

Anormalidades hematológicas de pacientes com Doenca Renal Cronica: (3)

Answer 16

• Anemia
• disfuncao plaquetaria
• ↑sangramento - mesmo com contagem normal de plaquetas, TAP e TTPa
• ↑Coagulabilidade apos dialise

Question 17

Problemas neurologicos com pacientes CKD:

Answer 17

• neuropatia autonomica
• Neuropatia periferica (sensorial e motora)

Question 18

Principais disturbios hidoreletroliticos em pacientes CKD

Answer 18

• Acidose metabolica cronica
• Hipercalemia
• HIpocalcemia
• ↑troponinas

Question 19

Paciente com CKD e Diabetes com melhora do controle glicêmico ou hipoglicemia inesperada - o que suspeitar?

Answer 19

• Piora da funcao renal

Since insulin is metabolized by the kidneys, worsening renal function should be suspected in diabetic patients with ESRD who develop improved glycemic control or unexpected hypoglycemia.

Question 20

Many drugs are also metabolized or cleared by the kidneys. Drugs with perioperative implications are the:

Answer 20

• HBPM
• DOACs

LMWHs are cleared by the kidneys and are not removed during dialysis; thus, they have a prolonged duration of action in patients with CKD.

Question 21

Patients with CKD need an ECG and blood sampling to measure (5)

Answer 21

• electrolyte,
• calcium,
• glucose,
• albumin,
• creatinine concentrations.

Further evaluation is needed if the ECG shows LVH (hypertension), peaked T waves (hyperkalemia), flattened T waves, a prolonged PR interval, or a prolonged QT interval (hypokalemia). A chest radiograph (infection, volume overload), echocardiogram (murmurs, HF), and cardiology evaluation may be necessary in some cases.

Question 22

Preoperative renal replacement therapy (dialysis) schedules should be coordinated with the timing of the planned surgery. Dialysis is important for correct volume overload, hyperkalemia, and acidosis before planned surgery.

Ideally, elective surgery should be performed about ___1___
after dialysis.

Answer 22

1. 24 hours

Performance of surgery shortly after dialysis should be avoided, because of the risks of acute volume depletion and electrolyte alterations. Specifically, dialysis leads to fluid shifts and electrolyte (i.e., sodium, potassium, magnesium, phosphate) imbalance, especially related to shifting of electrolytes between intracellular and extracellular compartments.

Question 23

Paciente com doenca hepatica que desenvolve ou piora a encefalopatia, o que pesquisar? (4)

Answer 23

• infeccao
• Efeitos de drogas
• Sangramentos
• DHEL

Question 24

Em pacientes com doenca hepatica, quais situacoes devem postergar a cirurgia eletiva?

Answer 24

• Episodio agudo de hepatite (ou exacerbacao de doenca cronica)
• Nova disfuncao hepatica (ate estabelecer o diagnostico)