Duke Internal Medicine Residency Curriculum
Pre-operative Assessment
Rami Baddredine, MD (Anticoagulation)
Miriam Jacob, MD (Anticoagulation and diabetes)
Karen Joynt, MD (Pulmonary)
James Yau, MD (Cardiovascular)
Edited by Amy Shaheen, MD
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Learning Objectives
• At the completion of this presentation, the learner should
be able to:
–
–
–
–
–
Describe appropriate pre-operative cardiovascular evaluation
Describe appropriate pre-operative pulmonary evaluation
Manage anticoagulation in the peri-operative period
Manage diabetes in the peri-operative period
Locate resources related to the above topics on the internet
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Presentation Outline
•
•
•
•
•
•
•
Cardiovascular evaluation
Pulmonary evaluation
Management of anticoagulation
Management of diabetes
Online resources
Quiz
References
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Cardiovascular Pre-op evaluation
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Cardiac Preoperative Evaluation
• Epidemiology
– The prevalence of cardiovascular disease increases
with age.
– Estimated that the number of people >65 in the US
will increase by 25-35% over next 30 years.
– This is the same population in which the most
surgical procedures are performed.
– Number of noncardiac surgeries may increase from
6 million per year to 12 million per year; some of
which have been associated with significant periop
cardiac morbidity and mortality.
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Cardiac Preoperative Evaluation
• ACC/AHA Guideline on Perioperative
Cardiovascular Evaluation for Noncardiac
Surgery
♥ http://www.acc.org/clinical/guidelines/perio/update/pdf/perio_update.pdf
– First developed by ACC/AHA Task Force on
Practice Guidelines in 1996.
– Updated in 2002.
– Provides framework for considering cardiac risk in
noncardiac surgeries.
– Provides tables and algorithms for quick reference
and decision making.
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Cardiac Preoperative Evaluation
• Purpose
– Not to give “medical clearance”.
– Perform an evaluation of the patient’s current
medical status.
– Make recommendations concerning the evaluation,
management, and risk of cardiac problems over the
entire perioperative period
– No test should be performed unless it will influence
patient treatment.
– Must be carefully tailored to the patient and the
circumstance.
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Cardiac Preoperative Evaluation
Need for noncardiac surgery
Urgent or elective
Coronary revascularization
Within 5 years?
YES
Operate
(OK for surgery)
Recurrence of symptoms
NO
NO
Recent coronary evaluation
Within 2 years?
NO
emergency
YES
CLINCAL PREDICTORS
(see next set of algorithms)
YES
Recent stress test or
Coronary angiogram
favorable results
Unfavorable results
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Cardiac Preoperative Evaluation
• Next step is to evaluate the patient’s risk and the inherent
riskiness of the surgery
• Patient’s risk is determined by clinical predictors and
functional capacity
• Surgery riskiness is determined by the type and site of
surgery
• Once patient’s risk and surgery’s risk are known,
additional algorithms can be used to determine the
appropriate course of action
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Cardiac Preoperative Evaluation: Clinical predictors
Clinical Predictors of Increased Perioperative Cardiovascular Risk
Major
Intermediate
Low
Unstable coronary synd‫٭‬
Mild angina
Advanced age
Decompensated CHF
Prior MI (hx or ECG)
Abnormal ECG †
Significant arrhythmias#
Compensated or prior CHF
Rhythm other than sinus
Significant valvular dz
Diabetes mellitus
Low functional capacity
Renal insufficiency
History of stroke
Uncontrolled HTN
‫٭‬acute (within 7 days) or recent (7-30 days) MI or class III or IV symptoms
#high grade AV block, symptomatic ventricular arrhythmia with underlying heart disease, or
SVT with uncontrolled ventricular rate
†LVH, LBBB, ST-T abnormalities
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Cardiac Preoperative Evaluation: Functional capacity
• Functional capacity is also an important part of the algorithm
and relies on “METs”, or metabolic equivalents, to rate a
patient’s functionality
• 1 MET is equivalent to a metabolic rate consuming 3.5 milliliters
of oxygen per kg of body weight per minute or 1 kilocalorie per
kg of body weight per hour
• In a treadmill test, actually measuring METs requires that the
person being tested wear a mask in order to measure his or her
oxygen consumption (and the carbon dioxide exhaled)
• However, METs can be estimated as follows:
– 1-4 METs: daily activities, walking 1-2 blocks on level ground at 2-3
mph, light housework
– 4-10 METs: climbing stairs or hill, jogging short distance, heavy
housework, bowling, dancing, golf, swimming
– 10-14 METs: running (at least an 8-minute mile), downhill skiing,
rock climbing, etc.
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Cardiac Preoperative Evaluation: surgical riskiness
Cardiac Risk* Stratification for Non-cardiac Surgical Procedures
High (>5%)
Intermediate (<5%)
Low (<1%)
Emergent major operations,
especially in the elderly
Carotid endarterectomy
Endoscopic procedures
Major vascular or peripheral
vascular surgery
Head and neck operations
Superficial procedures
Prolonged surgery with large Intraperitoneal and
fluid shifts or blood loss
intrathoracic operations
Orthopedic procedures
Cataract surgery
Breast surgery
Prostate surgery
‫٭‬combined risk of cardiac death and nonfatal myocardial infarction
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Cardiac Preoperative Evaluation
Patient with
MAJOR CLINICAL
PREDICTORS
Consider delaying or canceling
non-cardiac surgery
Consider coronary angiography
Medical management and
risk factor modification
Subsequent care* dictated by
findings and treatment results
*subsequent care may include delay or canceling surgery, coronary
revascularization followed by non-cardiac surgery, or intensified care.
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Cardiac Preoperative Evaluation
Patient with INTERMEDIATE
CLINICAL PREDICTORS
Poor functional capacity
(<4 METS)
Mod or excellent
(>4 METS)
high
surgical risk
Noninvasive testing
Low risk
Intermediate
surgical risk
low
surgical risk
Operate
High risk
Consider coronary
angiography
Subsequent care dictated by
findings and treatment results
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Cardiac Preoperative Evaluation
Patient with NO OR MINOR
CLINICAL PREDICTORS
Poor functional capacity
(<4 METS)
high
surgical risk
Noninvasive testing
Mod or excellent
(>4 METS)
Intermediate or
low surgical risk
Low risk
Operate
High risk
Consider coronary
angiography
Subsequent care dictated by
findings and treatment results
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Pulmonary Pre-op evaluation
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Pulmonary evaluation
• Currently no published guidelines are available for the
general surgical patient
• Existing literature focuses on:
– Evaluation of the lung cancer patient prior to lung resection
– Evaluation of risk for post-operative pneumonia
• General guidelines are reportedly forthcoming this year
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Evaluation of the lung cancer patient prior to lung resection
• 30,000 lung resections are performed annually
• Mortality rate from lung resection surgery is 7-11%
• Accurate pulmonary evaluation can predict risk of
operative mortality and help stratify patients in terms of
treatment options (Beckles 2003, Datta 2003)
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Preoperative evaluation
• Staged, stepwise assessment to evaluate risk of complications
(Beckles 2003, Datta 2003), starting with careful history and
physical examination and then proceeding to objective testing
• Stage I assessment
– Spirometry / DLCO measurement, +/- ABG
– If FEV1>80% predicted or >2L, MVV is >55% predicted, and
DLCO is >60% predicted, pt is suitable for resection including
pneumonectomy without further evaluation
– If pt does not meet these criteria, proceed to stage II testing
• Stage II assessment
– Quantitative V/Q scan or differential lung scan
– If predicted postoperative (ppo) FEV1 is >40% predicted and ppo
DLCO is >40% predicted, pt is suitable for resection including
pneumonectomy
– If pt does not meet these criteria, proceed to stage III testing
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Preoperative evaluation continued
• Stage III assessment
– Exercise testing
– If VO2 max is greater than 20 mL/kg/min, pt is suitable for
surgery
– If VO2 max is less than 10 mL/kg/min (roughly the ability to
walk up one flight of stairs), pt is at greatly increased risk of
complications and death from surgery and non-surgical
management should be pursued
• Alternative algorithm (Wyser 1999)
– If FEV1 or DLCO <80% predicted, proceed directly to
exercise testing
• If VO2 max >20, proceed to surgery
• If VO2 max 10-20, undergo quantitative V/Q and
calculate ppo values as before
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Evaluation of risk for post-operative pneumonia
• Why is post-op PNA important?
– Pneumonia is the 3rd most common postop complication
(after UTI, wound infection) (Garibaldi 1981)
– Pneumonia occurs in 10-40% of patients in the post-op
period and carries a mortality of 30-46% (Brooks-Brunn
1997)
– 25% of deaths occurring within 6 days of surgery are
pulmonary in etiology (Brooks-Brunn 1995)
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Risk Assessment for Post-op PNA
• Risk index developed in a sample of 10 VA hospitals using data
from the Department of Veterans Affairs National Surgical
Quality Improvement Program (NSQIP)
• 160,805 patients in derivation cohort, 1997-1999
• 155,266 patients in validation cohort, 1995-1997
• 2,466 patients developed pneumonia (1.5%), compared with
myocardial infarction in only 0.4%
– Patients with post-op PNA had a 30-day mortality of 21%,
compared with only 2% of the remaining patients
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PNA Predictors
• Most important predictors (Odds Ratios, OR, listed for
those predictors with OR for development of PNA of
greater than 1.5):
• Type of surgery
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–
–
–
–
AAA, OR=4.29
Thoracic surgery, OR=3.92
Upper abdominal surgery, OR=2.68
Neck surgery, OR=2.30
Neurosurgery, OR=2.14
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PNA Predictors, continued
• Age
– >80, OR=5.63
– 70-79, OR=3.58
– 60-69, OR=2.38
• Functional status prior to surgery
– Totally dependent, OR=2.83
– Partially depentent, OR=1.83
• Weight loss > 10% in last 6 months, OR=1.92
• History of COPD, OR=1.72
• General anesthesia, OR=1.56
• “Impaired sensorium,” OR=1.51
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Development of Risk Index
• Predictors were then turned into a scoring system, based on
strength of association, to allow prospective grading of postoperative risk
• Scoring system (“risk index”) was then validated on an
independent cohort
• Notable study limitations: veteran population, very few women,
many comorbidities, no data about PFTs was included, no
correction for prophylactic antibiotics was possible
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Postoperative PNA Risk Index
Preoperative Risk Factor
Point value
Type of surgery
Preoperative Risk Factor
Point value
Weight loss >10% in past 6 months
7
AAA repair
15
History of COPD
5
Thoracic surgery
14
Receipt of general anesthesia
4
Upper abdominal surgery
10
Impaired sensorium
4
Neck surgery
8
History of CVA
4
Neurosurgery
8
Blood urea nitrogen level
Vascular surgery
3
Age
<8 mg/dL
4
22-30 mg/dL
2
≥30 mg/dL
3
≥80 years
17
70-79 years
13
Transfusion of > 4 units of blood
3
60-69 years
9
Emergency surgery
3
50-59 years
4
Steroid use for chronic condition
3
Current smoker within one year
3
Alcohol intake > 2 drinks/d in past 2 wks
2
Functional status
Totally dependent
10
Partially dependent
6
From Arozullah et al 2001
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Risk Index and Outcomes
Risk Class
1
(0-15 pts)
2
(16-25 pts)
3
(26-40 pts)
4
(41-55 pts)
5
(>55 pts)
Rate of
postop PNA in
development
cohort, %
0.24
1.19
4.0
9.4
15.8
Rate of
postop PNA in
validation
cohort, %
0.24
1.18
4.6
10.8
15.9
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Pre-op evaluation of coagulation
and
Peri-op management of anticoagulation
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Management of bleeding risk
• Management of bleeding risk in the peri-op period
requires consideration of risk of bleeding
• Defining the level of hemostatic risk for the proposed
surgery is essential
• Low Risk surgery:
-nonvital organs are involved
-surgical site is exposed
-limited degree of surgical dissection
-local hemostatic measures are likely to be effective
-the site does not have local fibrinolysis
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Risk assessment, continued
• Moderate / High risk surgeries
– Vital organs are involved, with deep or extensive
dissection
– The site is associated with local fibrinolysis (eg,
prostatic surgery, tonsillectomy, oral or nasal surgery)
– Local hemostatic measures are ineffective (eg, closed
liver or kidney biopsy)
– The surgical procedure or the underlying condition is
expected to induce a hemostatic defect (eg,
cardiopulmonary bypass, brain injury, extensive
malignancy)
– Bleeding complications are frequent and/or are likely
to compromise the surgical result
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Pre-op workup
• For low risk surgeries : if the history and physical exam
do not suggest bleeding then no more tests are needed
• For high risk surgeries : Hx , Physical , platelet count, PT
and PTT must be done
• If Hx/ PE or Coags suggest high risk bleeding then more
sophisticated tests should be obtained ( heme consult
would not hurt)
• A “ Bleeding Time “ is NOT warranted pre-op because it
does not predict severity of bleeding
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Patients already on anticoagulation
• Patients might be on prophylactic or treatment
anticoagulation preoperatively
• Factors to consider when evaluating risk of bleeding with
surgery: Age, comorbidities, type of surgery,
anticoagulant regimen/ duration and degree of monitoring
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Venous Thromboembolism ( VTE)
• Temporal relation of VTE to surgery is key
• Within the first month after DVT patients must receive
both pre and post-op anticoagulation
• Between 2-3 months, pre-op anticoagulation is only
needed for high risk patients but post-op anticoagulation
is recommended to all patients
• After 3 months, the risk of bleeding is more than the
benefit of anticoagulation so only prophylactic pre and
post-op anticoag. is recommended
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Arterial Thromboembolism (ATE)
• The risk of bleeding is similar pre and post-op in patients
with ATE
• Continue anticoagulation preop for all patients
• Continue post-op anticoagulation only if the surgery is
minor
• High risk ATE patients (Like anticoagulation for prosthetic
valves): a heparin bridge is recommended and restart
anticoagulation ASAP post-op
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General Recommendations
• Always weigh the risk of thrombosis against risk of
bleeding
• Patients on oral AC , allow INR to reach 2 pre-op unless
high risk bleeding ( INR< 1.5)
• Bridge with Heparin if high risk re-thrombosis
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Peri-op management of diabetes
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Diabetes- Preoperative Management
• Why do we care?
• Increased risk of pre-operative infection
• Increased post-operative cardiovascular morbidity and
mortality
• Focus is on cardiopulmonary risk assessment and management
• History
• Laboratory Studies
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Diabetes- Preoperative Management
• History
• Long term complications of DM (i.e. retinopathy,
nephropathy, neuropathy, CHD, PVD)
• Baseline glycemic control (freq of monitoring, average
BS)
• Hypoglycemia (frequency, severity, awareness, timing)
• Therapy (pharmacologic and non-pharmacologic)
• Surgery
• Major vs. Minor surgery
• When to stop eating
• Duration of procedure
• Type of Anesthetic – epidural vs. general
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Diabetes- Preoperative Management
• Laboratory Studies
• Baseline EKG, renal function
• Baseline glucose levels
– Use this to assess risk for postoperative wound
infections
• In case-control study of post-CABG patients,
multivariable analysis found patient with
preoperative glucose >200 mg/dL had OR of 10.2
for deep sternal wound infections (independent
risk factor)2.
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Diabetes- Preoperative Management
Baseline HbA1c – Not recommended
Study of cardiothoracic surgeries – pt with sternal
wound infection had mean HbA1c of 8.44 vs. 7.80
in those without infection but was not statistically
significant (p=0.09)3
Non-invasive cardiac testing dependent on risk
stratification
Preoperative Glycemic Control – Goals
• Avoid hyperglycemia and hypoglycemia
• No consensus about how “tight” the control must be (there is
data in ICU and post-MI patients not in surgery patients- unsure
if this translates)
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Diabetes- Preoperative Management
• Type 2 – Diet modification only
– Check BG preoperatively and after
• Type 2 – Oral agents
– Discontinue agent on morning of surgery
– Supplemental sliding scale insulin
• Type 1 or 2 – Insulin Therapy
– For short procedures, continue SQ regimen
– 1-2 day before, may switch from long-acting to
intermediate acting insulin
– May reduce night time intermediate insulin if pt has
borderline hypoglycemia
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Diabetes- Preoperative Management
•
•
•
•
If in AM and lunch will be eaten- convert as follows
• Once daily intermediate in AM  2/3 dose
• Twice daily  ½ total dose as intermediate
If pt misses lunch as well – less AM insulin
• Once daily  ½ total dose as intermediate
• Twice daily  1/3 total dose as intermediate
• Multiple short and intermediate  1/3 total dose as intermediate
• Multiple short acting  1/3 pre-meal short-acting
• Continuous insulin  continue basal infusion, use SSI prn
Later in the day – less AM insulin and start dextrose containing IVF
Long, complex surgeries – use IV Insulin (less variability in BG than with
SQ regimen), start early in AM, closely monitor electrolytes.
No optimal regimen has been found, based on experience and expert
opinion.
No particular regimen has been found to affect morbidity, mortality, or
length of stay.
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Online resources for further info
• Cardiovascular evaluation
– http://www.acc.org/clinical/guidelines/perio/clean/I_definitio
n.htm
• Pulmonary evaluation
– http://www.thoracic.org/
• Management of diabetes
– http://www.diabetes.org
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Quiz
•
Question One:
–
Question: A 76 year-old man with history of CAD s/p CABG (3 years ago),
HTN, DM2, CVA, CRI, and newly diagnosed lung mass was sent to the
cardiology clinic by the surgeon for “cardiac clearance” for resection of the
mass. Patient reports that he had been doing well and in his USOH, and the
mass was discovered on a recent CXR. What is the most appropriate
recommendation for this pt?
•
•
•
•
–
A) Pt will need at least a noninvasive test prior to the surgery
B) Pt may proceed with the surgery without further cardiac evaluation
C) Pt will need a coronary angiogram prior to the surgery
D) The surgery should be delayed until he is on optimal medical regimen
Answer: B. Pt may proceed with the surgery without further cardiac
evaluation. Pt had recent revascularization procedure (within 5 years –
CABG 3 years ago), and has not had recurrence of symptoms. Therefore, he
can proceed to noncardiac surgery without any further cardiac evaluation. Pt
still need to continue medical therapy and postoperative risk stratification and
risk factor modification.
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Quiz continued
• Question Two:
– Question: As the cardiology consult resident, you are seeing a 72 year-old
woman with history of DM2, COPD, and on-going tobacco abuse who was
admitted with a fractured pelvis after a fall at home. The patient is a resident at
an ALF and fell when she tripped over some furniture. She reports that she
has had some difficulty with worsening fatigue and DOE, and she can barely
walk across the room because of her symptoms. What is the most
appropriate recommendation for this pt awaiting an orthopedic procedure?
•
•
•
•
A) Pt will need at least a noninvasive test prior to the surgery
B) Pt may proceed with the surgery without further cardiac evaluation
C) Pt will need a coronary angiogram prior to the surgery
D) The surgery should be delayed until she is on optimal medical regimen and has
stopped smoking
– Answer: A. Pt should have at least a noninvasive cardiac evaluation given that
she has at least one intermediate clinical predictor (DM) and poor functional
capacity (METS<4). If low risk on the noninvasive test, then she may proceed
to the OR; but if high risk, she may need more invasive testing such as
coronary angiography.
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Quiz continued
•
Question Three:
– You are asked to evaluate Mr. L, a 65 year old male with known COPD, in preop clinic preceding planned resection for a 2 cm right upper lobe nodule.
Which of the following statements is FALSE:
• A) If Mr. L’s FEV1 is 40% predicted, he should undergo quantitative V/Q scanning and
possibly exercise testing prior to surgery
• B) If Mr. L’s FEV1 is 50% predicted, he can proceed to surgery without further testing
so long as lobectomy is not planned
• C) If Mr. L’s FEV1 is 90% predicted with a normal DLCO and MVV, he can proceed to
surgery including lobectomy without further testing
• D) If Mr. L’s FEV1 is 2.2L, but his DLCO is only 40% predicted, he should undergo
further testing prior to surgery
– Answer: B – If Mr. L has an FEV1 of 50% predicted, he shouldn’t go directly to
surgery – instead, he should undergo quantitative V/Q testing and possibly
exercise testing prior to surgery for further risk stratification
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Quiz continued
• Question Four:
– Question: Which of the following is NOT a significant risk factor for
the development of postoperative pneumonia, based on the VA
study outlined above?
•
•
•
•
A) Thoracic surgery
B) Age greater than 70
C) History of inhaler use
D) Receipt of general anesthesia
– Answer: C – there is no evidence that a history of inhaler use is
directly related to risk for post-op PNA, although COPD has been
shown to be a risk factor in various smaller studies.
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Quiz continued
• Question Five:
– Question: Mr Green is a 69 yo healthy male scheduled to
have CABG in 2 weeks. You are asked to asses his bleeding
risk. How would you asses him?
•
•
•
•
A) History alone
B) History and physical exam
C) PT/PTT/platelets
D) All of the above
– Answer: D. CABG is a high-risk surgery, so he will need a
thorough evaluation prior to the procedure.
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Quiz continued
• Question Six:
– Question: Mr. Smith is a 68 year old male on Coumadin for a
prosthetic mitral valve. He is scheduled to have an inguinal
hernia repair. How would you manage his coumadin
pre/post-op?
• A) Stop Coumadin 3 days pre-op, no need for bridge. Restart
Coumadin 3 days post-op
• B) Stop Coumadin 3 days preop, bridge with heparin when
INR<2.5, restart heparin ASAP post-op, and then restart
Coumadin
• C) Continue Coumadin through surgery
• D) Stop Coumadin one day prior to surgery and do not resume
until 1-2 weeks post-op
– Answer: B. This patient is at high risk for ATE despite the
low-risk nature of the surgery and needs a heparin bridge for
his procedure.
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• Question Seven:
– Question: Ms. Apple is a 28 year old female undergoing
thyroidectomy in one week. Pre-op labs show a PTT of 68,
INR of 1.1, and a normal CBC. She give no history of
abnormal bruising or bleeding. Your next step is:
•
•
•
•
A) Proceed with surgery
B) Consult hematology for further workup
C) Proceed with surgery after 4 units FFP
D) Proceed with surgery after 5 mg of Vitamin K SQ x1
– Answer: B. This patient has a high-risk surgery (head and
neck) and therefore needs further workup (i.e. mixing study,
etc.).
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• Question Eight:
– Question: What aspect of history, physical or laboratory
studies is associated with increased risk of post-operative
wound infections?
•
•
•
•
A) Baseline hemoglobin A1c
B) History of retinopathy
C) Preoperative glucose level
D) Use of insulin
– Answer: Preoperative blood glucose > 200 has been
associated with increased risk of deep sternal wound
infections in post-CABG patients (found to have OR of 10.2).
Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education
Services
Duke Internal Medicine Residency Curriculum
References
•
Cardiovascular evaluation:
•
Pulmonary evaluation:
– ACC/AHA Guideline on Perioperative Cardiovascular Evaluation for Noncardiac
Surgery,
http://www.acc.org/clinical/guidelines/perio/update/pdf/perio_update.pdf
– Arozullah AM, Khuri SF, Henderson WG et al. Development and validation of a
multifactorial risk index for predicting postoperative pneumonia after major
noncardiac surgery. Ann Intern Med 2001;135:847-857
– Beckles MA, Spiro SG, Colice GL et al. The physiologic evaluation of patients
with lung cancer being considered for lung resectional surgery. Chest
2003;123:105S-114S
– Brooks-Brunn JA. Predictors of postoperative pulmonary complications
following abdominal surgery. Chest 1997;111:564-71
– Brooks-Brunn JA. Postoperative atelectasis and pneumonia. Heart Lung
1995;24:94-115
– Datta D, Lahiri B. Preoperative evaluation of patients undergoing lung
resection surgery. Chest 2003;123:2096-2103
– Garibaldi RA, Britt MR, Coleman ML et al. Risk factors for postoperative
pneumonia. Am J Med 1981;70:677-80
– Wyser C, Stulz P, Soler M et al. Prospective evaluation of an algorithm for the
functional assessment of lung resection candidates. Am J Respir Crit Care Med
1999;159:1450-6
Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education
Services
Duke Internal Medicine Residency Curriculum
References
•
Anticoagulation:
•
Diabetes:
– The clinical impact of increased sensitivity PT and APTT coagulation assays.
Am J Clin Pathol 1999; 112:225.
– Williams' Hematology. Beutler, E, Lichtman, MA, Coller, BS, et al (eds).
McGraw-Hill, New York, 6th edition, 2001; p. 1471
– Outcomes of patients with no laboratory assessment before anesthesia and a
surgical procedure. Mayo Clin Proc 1997; 72:505
– Usefulness of preoperative laboratory assessment of patients undergoing
elective herniorrhaphy. Arch Surg 1992; 127:801
– Management of anticoagulation before and after elective surgery. N Engl J Med
1997; 336:1506
– 1. Khan NA, Ghali WA. Perioperative management of diabetes mellitus. In:
UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2005.
– 2. Trick WE, et al. Modifiable risk factors associated with deep sternal site
infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000
Jan;119(1):108-14.
– 3. Latham R, et al. The association of diabetes and glucose control with
surgical-site infections among cardiothoracic surgery patients. Infect Control
Hosp Epidemiol 2001 Oct;22(10):607-12.
Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education
Services