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Referral and warning signs
When to refer
Refer to Physician/Specialist (Cardiologist, Endocrinologist, Pulmonologist etc.) for optimization of poorly controlled conditions before elective surgery. Consult Anaesthetist early regarding management plan.
Red flags
- Unstable angina / Recent MI.
- Severe, uncontrolled hypertension.
- Decompensated heart failure.
- Severe symptomatic anaemia.
- Poorly controlled asthma with recent exacerbation.
- Diabetic ketoacidosis or severe hyperglycaemia.
- Significant renal or liver failure.
Signs and symptoms
- Focus is on identifying and stabilizing pre-existing conditions before elective surgery, or managing them concurrently during emergency surgery.
- Symptoms related to the specific medical condition (e.g., high BP readings, low Hb, wheezing, high/low blood sugar).
Risk factors
- Having pre-existing hypertension, anaemia, asthma, diabetes, cardiac disease, renal disease, etc.
Diagnosis
Clinical assessment
Thorough pre-operative history and physical examination to identify comorbidities. Review medications. Assess stability of the condition.
Investigations
- Targeted based on condition: BP measurement, Hb/CBC, ECG, Blood glucose/HbA1c, Renal function tests, Chest X-ray, Spirometry (if severe respiratory disease).
Diagnostic criteria
Identifying unstable or poorly controlled medical conditions requiring optimization before elective surgery, or specific management considerations for emergency surgery.
Management
Non-pharmacological management
- General Principle: Stabilize medical condition as much as possible before elective surgery. For emergencies, stabilize concurrently with surgical preparation.
- Optimize nutrition.
- Smoking cessation advised well before elective surgery.
Pharmacological treatment
- Hypertension:
- - Aim for BP <160/100 (ideally <140/90) pre-operatively for elective cases.
- - Continue usual antihypertensive medications, including on the morning of surgery (except possibly ACEi/ARBs - consult anaesthetist).
- - Avoid cancelling elective surgery for mild-moderate stable hypertension.
- - Manage intra/post-op BP fluctuations carefully.
- Anaemia:
- - Investigate cause pre-operatively.
- - Correct significant anaemia (Hb <7-8 g/dL or symptomatic) before major elective surgery (oral/IV iron, rarely transfusion).
- - For emergency surgery, transfuse based on clinical need/ongoing loss, not just Hb number.
- - Consider regional anaesthesia if possible.
- - Maintain high oxygenation during GA.
- Asthma:
- - Ensure asthma is well-controlled pre-operatively (minimal symptoms, optimal medication).
- - Patient should take usual inhalers (including steroid inhaler) on morning of surgery.
- - Consider short course oral steroids pre-op if recently unstable.
- - Avoid triggers (e.g., certain anaesthetic agents like thiopental).
- - Regional anaesthesia preferred if suitable.
- Diabetes:
- - Aim for reasonable glycaemic control pre-op (e.g., HbA1c <8-9%, avoid severe hyper/hypoglycaemia).
- - Schedule diabetic patients first on the list.
- - Medication Management (Day of Surgery):
- - Oral agents: Usually omit morning dose (esp. Metformin, Sulfonylureas).
- - Insulin: Adjust dose based on type/regimen (e.g., reduce long-acting, omit short-acting). Requires specific plan.
- - Intra-operative: Monitor blood glucose frequently. Use sliding scale insulin infusion or Glucose-Insulin-Potassium (GIK) infusion for major surgery or poor control.
- - Post-operative: Resume usual regimen once eating/drinking, monitor glucose closely.
- - Regional anaesthesia preferred if suitable.
Monitoring
Perioperative monitoring tailored to condition (BP, ECG, SpO2, Blood Glucose, Hb).
Complications
- Increased risk of perioperative cardiovascular events (MI, stroke, arrhythmia).
- Increased risk of respiratory complications (bronchospasm, hypoxia).
- Poor wound healing, increased infection risk (diabetes, anaemia, malnutrition).
- Hypo/Hyperglycaemic emergencies.
- Delayed recovery.
Prevention
- Thorough pre-operative assessment.
- Optimization of chronic medical conditions.
- Appropriate choice of anaesthetic technique.
- Careful perioperative monitoring and management.
Patient education
- Importance of disclosing all medical conditions and medications.
- Need for optimizing condition before elective surgery.
- Instructions regarding medications on the day of surgery.
- Post-operative expectations related to their condition.
Uganda-specific notes
Pre-operative assessment often relies heavily on clinical evaluation due to limited investigations. Common comorbidities include hypertension, diabetes, anaemia (often severe), HIV. Balancing surgical urgency with medical stability is key. Regional anaesthesia often preferred when possible.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 24, Section 24.1.3