Administration of high-dose steroids should be stopped as soon as possible postoperatively because they can inhibit wound healing and promote infection. Hypertension and glucose intolerance can develop. When a prolonged or involved procedure is performed and longer steroid use is necessary, careful tapering may be required. The previously recommended approach was to halve the dose of hydrocortisone on a daily basis until a dose of 25 mg is reached. Eliminating one daily dose each day until the drug is stopped was considered the safest method of withdrawal; no consensus on the timing or duration of steroid tapering exists. Addison’s disease is uncommon but should be considered in the differential diagnosis if the patient develops perioperative hypotension after steroids are withdrawn. In addition to blood and isotonic ﬂuid replacement, a “stress” dose of steroids should be given if adrenal insufficiency is suspected and sepsis and hypovolemia are excluded.
Cardiovascular Diseases The incidence of perioperative cardiovascular complications decreased markedly as a result of improvements in preoperative detection of high-risk patients, preoperative preparation, and surgical and anesthetic techniques (174).
Preoperative Evaluation The goal of a preoperative cardiac evaluation is to determine the presence of heart disease, its severity, and the potential risk to the patient during the perioperative period. Every patient should be questioned about symptoms of cardiac disease including chest pain, dyspnea on exertion, peripheral edema, wheezing, syncope, claudication, or palpitations. Patients with a history of cardiac disease should be evaluated for worsening of symptoms, which indicates progressive or poorly controlled disease. Records of previous treatment should be obtained. Prescriptions for antihypertensive, anticoagulant, antiarrhythmic, antilipid, or antianginal medications may be the only indication of cardiac problems. In patients without known heart disease, the presence of DM, hyperlipidemia, hypertension, tobacco use, or a family history of heart disease identifies patients at higher risk for heart disease who should be more carefully screened.
On physical examination, the presence of findings such as hypertension, jugular venous distention, laterally displaced point of maximum impulse, irregular pulse, third heart sound, pulmonary rales, heart murmurs, peripheral edema, or vascular bruits should prompt a more complete evaluation. Laboratory evaluation of patients with known or suspected heart disease should include a blood count and serum chemistry analysis. Patients with heart disease tolerate anemia poorly. Serum sodium and potassium levels are particularly important in patients taking diuretics and digitalis. Blood urea nitrogen and creatinine values provide information on renal function and hydration status. Assessment of blood glucose levels may detect undiagnosed DM. Chest radiography and electrocardiography are mandatory as part of the preoperative evaluation, and the results may be particularly helpful when compared with those of previous studies.
Coronary Artery Disease Coronary artery disease is a major risk factor for patients undergoing abdominal surgery. In an adult population without a prior history of myocardial infarction, the incidence of myocardial infarction following surgery is 0.1% to 0.7% (175). In patients who had a prior myocardial infarction, the reinfarction rate is 2.8% to 7% (176). The risk of reinfarction is inversely proportional to the length of time between infarction and surgery. At 3 months or less, the risk of reinfarction is 5.7%, and from 3 to 6 months, the rate falls to 2.3%. Six months after myocardial infarction, the reinfarction rate is 1.5% (175). Careful perioperative management can lower the reinfarction rate in patients who had recent infarctions. Perioperative myocardial infarction is associated with a mortality rate of 26% to 70% (177).