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PERIOPERATIVE POCKET MANUAL 2005  (Contents)  - 3rd Edition

Maracus Magallanes, MD 2005



*The risk of perioperative stroke in patients with prior history of stroke or TIA is likely to be increased, although clinical data has not confirmed this consistently.  Patients with recent TIA’s, however, clearly represent the group at the highest risk of perioperative stroke and mortality.  Furthermore, as a group, patients with known cerebrovascular disease are at increased cardiac risk for surgery due to coexisting coronary artery disease.  (The reciprocal is true as well: patients with known CAD are more likely to have coexisting cerebrovascular disease.)


Understanding the cause of a prior stroke helps in determining the subsequent risk of recurrence and the modalities for prevention, if any.  Thrombotic strokes are most commonly due to atherosclerosis and hypertension.  Embolic strokes may be due to atrial fibrillation, cardiac valvular disease, LV thrombus, or vascular plaque.  Lacunar strokes are related to hypertension.  (Hemorrhagic strokes are a completely different category.)

The timing of surgery following a completed stroke is not clearly defined.  The best data available (carotid endarterectomy procedures following acute stroke) shows the highest mortality among patients who had surgery within 24 hours following a stroke (44%).  Between 1 day and 2 weeks the mortality was 14%, and after 2 weeks the mortality was 6%.  The decision to perform surgery after an acute stroke clearly depends on the urgency of the procedure itself.  If at all possible, urgent procedures should be delayed at least one or two days after an acute stroke; non-urgent procedures should be delayed 2 weeks or more.  Elective surgery should wait 6 weeks.


Data regarding the timing of surgery in patients with TIA’s is even less clearly defined.  The presence of TIA’s, however, does represent a more unstable pattern of symptomatic cerebrovascular disease.  Perioperative stroke risk is certainly higher in patients with recent TIA’s than in those with a history of completed stroke.  Perioperative management of these patients to prevent stroke should be aggressive.


Patients with asymptomatic carotid bruits are NOT at any increased risk of perioperative stroke.  Preoperative carotid doppler studies are certainly not warranted for these inpatients.  (Statistically, the presence of a carotid bruit is actually a better predictor of perioperative cardiac mortality than of stroke.)

The data for carotid stenosis is similar, although there have been contrasting studies.  In general, the likelihood of perioperative stroke is low in patients with asymptomatic, greater-than-50% stenosis.  Non-elective surgery should not be delayed simply because of a known asymptomatic carotid stenosis.  (Elective surgery is more controversial in this regard, since the intervention for asymptomatic high-grade stenosis is itself an elective surgical procedure.)


1)      Antiplatelet therapy—aspirin, plavix, persantine, and ticlid are usually held before surgery to minimize bleeding risk; however, in patients with a history of TIA’s or multiple strokes, the benefit of continuing the antiplatelet therapy up until the time of surgery may outweigh the risk of increased surgical bleeding. *Always inform the surgeon if you are continuing the antiplatelet therapy up until surgery.  Postoperatively these medications can safely be resumed if surgical hemostasis is satisfactory and there is no evidence of bleeding.  (For NPO patients, aspirin can be given rectally at the same dose.)

2)      Anticoagulation therapy—patients who are chronically anticoagulated on coumadin for stroke or TIA should have their anticoagulation reversed by the time of surgery.  The need to place these patients on heparin drip or therapeutic-dose enoxaparin postop depends on the perceived risk of perioperative stroke.  If low, then simply resume coumadin alone when patient can take pills postop.  If moderate to high, then I would recommend interim anticoagulation with heparin drip or enoxaparin once surgical bleeding risk has subsided and continue until the protime is therapeutic on coumadin.

3)      Beta-blockers—any patient with a history of non-hemorrhagic stroke should be at least considered for prophylactic beta-blocker therapy, given the very high incidence of coexisting coronary artery disease and the proven increased perioperative cardiac risk among patients with prior stroke.

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The most important factor in assessing risk for postoperative seizure in a patient with a chronic seizure disorder is the patient’s preoperative control.  Patients with good control of seizures by history do not need to have any medication adjustments performed, even if the anticonvulsant drug level is subtherapeutic.  Patients who do not have good control of seizures should have their anticonvulsant drug level brought into the therapeutic range preoperatively; an additional anticonvulsant drug should be considered if a patient does not have good control of seizures despite a therapeutic drug level already.  

Anticonvulsant medications should be continued perioperatively.  Phenobarbital, Dilantin, and Valproic Acid can be given IV if the patient is NPO, usually at the equivalent dose of the PO medication.  (Checking levels while on the IV drug is a good idea to avoid overdosing and toxicity.)  Tegretol is not available parenterally, but there is a liquid form which is sometimes easier for patients to take postop.

Knowing the type of seizure disorder is also important.  In general, simple partial (focal) seizures and absence seizures do not pose a serious problem perioperatively even if they are recurrent.  Alcohol-related seizures do not require chronic anticonvulsant medication and typically do not respond well anyway.  Management is acute therapy for alcohol withdrawal (benzodiazepines, beta-blockers, IVF).

Postoperative seizure in a patient with previously controlled seizure disorder or without a prior history of seizures should prompt a diagnostic workup to rule out an underlying etiology (infection, electrolyte abnormality, hypoxia, hypoglycemia, etc.).  Postop seizures are generally NOT due to anesthesia effects.

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