344 Obstetrics and Gynecology Board Review •••
❍ What are risk factors for postoperative mortality in diabetics?
Serum creatinine >2.0 mg/dL, vascular disease, and onset of diabetes prior to age 40.
❍ What would be optimal preoperative insulin management for a diabetic patient in poor control?
Admission 1 to 2 days prior to surgery for glucose control, likely by insulin drip. There is a threefold increase in
morbidity and a doubling in mortality if an operation is performed in a diabetic patient with poor control.
❍ What is the most common etiology for hyperthyroidism?
Graves disease.
❍ What anesthetic concerns arise in the hyperthyroid patient?
Tracheal compression or deviation caused by the enlarged thyroid, tachycardia exacerbated by medications, and
thyroid storm.
❍ Chronic glucocorticoid use prior to surgery may lead to what perioperative complications?
(1) Hypothalamic-pituitary-adrenal (HPA) axis insufficiency resulting in intraoperative adrenal crisis.
(2) Impaired wound healing.
(3) Increased risks of bone fracture, infection, gastrointestinal hemorrhage, or ulcers.
(4) Increased friability of skin and superficial blood vessels resulting in an increased risk of subcutaneous
hematomas and skin ulcerations.
❍ For which patients, should stress dose steroids be administered?
Perioperative supplemental steroids should be given to patients with known adrenal insufficiency (Addison disease)
or with recent significant steroid use. The HPA axis is suppressed in any patient who clinically has Cushing
syndrome or uses the equivalent of 20 mg/day of prednisone for >3 weeks. The HPA axis is not suppressed in
patients who use any dose of steroids for <3 weeks or who use the equivalent of 5 mg of prednisone each morning
or less for any duration of time.
❍ How can one test for preoperative pituitary-adrenal axis insufficiency?
An adrenocorticotropic hormone (ACTH) stimulation test can be performed. A cortisol level > 18 μg/dL
(497 nmol/L) 30 minutes after 250 μg ACTH stimulation predicts an adequate adrenal reserve during surgery
with no need for glucocorticoid coverage perioperatively.
❍ How would one handle a patient with Addison disease or significant chronic steroid use?
Hydrocortisone 100 mg intramuscularly (IM) on call to the OR, then 50 mg IV/IM in the recovery room, then
give every 6 hours for 3 doses, then taper to a maintenance dose over the next 3 days.
❍ What potential complications may be caused by administration of stress dose steroids?
Hypertension, hyperglycemia, fluid retention, and increased risk of infection
❍ What is the relationship between chronic hypertension and perioperative morbidity/mortality?
No increased adverse results unless accompanied by cardiac disease.