NMS. Casos Clínicos

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Part I ♦ Foundations

◆ ◆ Sequential compression stockings and/or prophylactic subcutaneous heparin are also important in the prevention of DVT.

Case 1.3 Common Problems in a Patient Waiting to Enter the Operating Room You plan to repair an inguinal hernia in a male patient. He arrives at the hospital, and you reassess him just before he is moved into the operating room. Q: How would your proposed management change in each of the following situations? Case Variation 1.3.1. The patient is known to be diabetic, and this morning the blood glucose is 320 mg/dL. ◆ ◆ Perioperative blood glucose levels should be 100–250 mg/dL. ◆ ◆ Surgery should be delayed until the glucose level is brought under control. ◆ ◆ The man may need subcutaneous insulin or an insulin drip to lower his glucose level, and he may also require IV drip of a dextrose solution to prevent the blood glucose level from becoming too low. Infection may also be a problem. Patients with poorly controlled diabetes mellitus have a higher incidence of postoperative wound infections. Case Variation 1.3.2. The patient has cellulitis from an infected hair follicle in the axilla. ◆ ◆ Surgery performed in the presence of an active infection elsewhere in the body is associated with a significant increase in wound infection at the operative site. ◆ ◆ Elective surgery should be postponed until the acute infection is resolved, regardless of its location. Unrecognized toe and foot infections are not uncommon in diabetics, who should be examined carefully. Case Variation 1.3.3. The patient experiences burning on urination. ◆ ◆ A urinalysis and a urine culture should be performed. If the urinalysis is positive for infection, surgery should be postponed until the urinary tract infection (UTI) has been successfully treated with antibiotics. ◆ ◆ A repeat urinalysis and culture indicates resolution of the infection. Urologic consultation may be needed to determine the cause of the UTI. Case Variation 1.3.4. The patient’s BP, which was 140/88 mm Hg in your office, has risen to 180/110 mm Hg. ◆ ◆ Diastolic BP greater than or equal to 110 mm Hg is a risk factor for devel- opment of cardiovascular complications such as malignant hypertension, acute MI, and congestive heart failure (CHF). ◆ ◆ Patients with hypertension have a 25% incidence of perioperative hypotension or hyperten- sion. Significant data suggest that beta-blockers may help reduce the risk of cardiac com- plications following surgery. SAMPLE