🩺 內科專科考前版
📌 一頁重點（22E focus）
- 22E 重要更新：
- POISE-2：clonidine + ASA peri-op 不 routine recommend
- ASA 2023 GLP-1 RA guideline：weekly hold ≥ 1 wk 是新 standard of care
- SGLT2i euglycemic DKA：FDA black box；hold 3-4 d pre-op
- CARP trial：prophylactic revasc no benefit
- 2024 ACC/AHA noncardiac surgery guideline：simplified algorithm；stress test only if changes management
- AS contemporary cohort：severe asymptomatic preserved EF + low/mod surgery → 多 OK；不像 old guideline 一律避免
- ACEi/ARB hold morning：confirmed standard
- Taiwan：健保大部分 peri-op drug；GLP-1 RA 自費為主（dulaglutide、semaglutide）；SGLT2i 健保條件（DM + 心 / 腎 indication）；DOAC 健保條件（Afib + CHADS-VASc / VTE）；stress dose hydrocortisone 健保；α-blocker for pheo 自費為多
🌟 Pearls (20)
Cardiac
- 2024 ACC/AHA：emergency / ACS / low-risk / 良好 METs → 不需 stress；只在 elevated risk + 不明 / 差 METs + 結果會 change mgmt 才 stress
- PMI（perioperative MI）多 silent（opioid 掩蓋）；發生在 POD 1-3；多 due to plaque rupture or demand mismatch
- High-sensitivity troponin peri-op surveillance for high-risk patients = MINS（myocardial injury after noncardiac surgery）；MINS associated 30-d mortality
- CARP trial：vascular surgery + stable CAD revasc vs no revasc → no difference outcome；除非 left main / 3-vessel + LV dysfunction
- POISE-1：β-blocker MI ↓ 但 stroke + death ↑ → 不 day-of 新開；continue chronic only
- POISE-2：clonidine no MI benefit + hypotension/cardiac arrest ↑；ASA peri-op for primary prevention 無 benefit
Endocrine（盧醫師核心）
- SGLT2i euglycemic DKA：urine ketone + serum βOHB；治療 IV fluid + insulin drip + glucose (避 hypo)；可發生雖 glucose 正常
- GLP-1 RA aspiration：multiple case reports；ASA 2023 statement weekly ≥ 1 wk hold；endoscopy 高 risk
- Insulin pump peri-op：endocrine team co-manage；continue basal during NPO；bolus hold；急 disconnect 風險 → DKA within hours
- Stress dose 不是固定 protocol：個體化 surgery severity、 expected duration、baseline steroid；taper rate flexible
- Pheo crisis intra-op：BP > 200/120 + arrhythmia + LV failure；治療 phentolamine IV、nitroprusside、esmolol；avoid catecholamine drug
- Subclinical hypothyroid（TSH 4-10、free T4 normal）多可 proceed；treat if TSH > 10 + symptomatic
Anticoag
- BRIDGE trial：AF + CHADS2 1-4 → bridging with LMWH 增 bleeding 無 thromboembolic benefit；不 bridge 多
- POAF（postoperative AF）：常見 post-cardiac + thoracic surgery；多 self-limited；anticoag 30-d benefit unclear
Pulmonary
- ARISCAT 預測 post-op pulmonary complications；高 score 高 incidence
- ERAS（Enhanced Recovery After Surgery） protocol：incentive spirometry、early ambulation、multimodal analgesia、avoid opioid、minimize NG tube → outcome 大幅 improve
Valvular / Other
- TAVI before noncardiac surgery 為 severe symptomatic AS 不能耐受 SAVR 的 option；recovery 快
- Aortic regurgitation severe 多 stable peri-op（unlike MR）；avoid bradycardia + HTN
- HCM peri-op：avoid hypovolemia、avoid tachycardia、avoid afterload reduction；β-blocker continue；careful regional anesthesia
Cancer / Special
- Immunotherapy on（ICI）+ surgery：multidisciplinary；mostly continue; 注意 immune-related adverse events thyroiditis / colitis / pneumonitis influence post-op
📍 Taiwan + 健保
Drugs
- 健保 β-blocker (atenolol, metoprolol, bisoprolol, carvedilol, propranolol, esmolol IV)
- 健保 ACEi / ARB
- 健保 CCB
- 健保 statin (atorvastatin, rosuvastatin, simvastatin, pitavastatin)
- 健保 ASA、clopidogrel (條件)、prasugrel (條件)、ticagrelor (條件)、cangrelor 自費
- 健保 LMWH (enoxaparin) 條件 (high VTE risk)
- 健保 UFH
- 健保 warfarin
- 健保 DOAC (apixaban, rivaroxaban, edoxaban, dabigatran) 條件 (Afib + CHA2DS2-VASc; VTE)
- 健保 metformin
- 健保 insulin (NPH, regular, glargine, detemir, degludec, aspart, lispro, glulisine)
- 健保 SGLT2i 條件 (DM + 心/腎 indication)
- 健保 DPP4i (sitagliptin, vildagliptin, saxagliptin, linagliptin) 條件
- 自費 GLP-1 RA 多 (semaglutide, dulaglutide, liraglutide); 部分條件健保
- 健保 sulfonylurea
- 健保 hydrocortisone IV (Solu-Cortef)
- 健保 prednisolone PO
- 健保 LT4
- 健保 PTU、methimazole
- 健保 calcitonin (rare)
- 健保 bisphosphonate IV (zoledronic acid)
- 健保 vasoactive (norepinephrine, phenylephrine, dopamine, dobutamine)
- 健保 antiemetic (ondansetron, metoclopramide)
- 自費 phenoxybenzamine、doxazosin for pheo
- 健保 desmopressin (DDAVP) for DI 條件
Imaging / Test
- 健保 ECG 12-lead, stress echo, stress nuclear scan (dobutamine, dipyridamole, regadenoson)
- 健保 cardiac MRI 條件
- 健保 CT coronary angiography (CCTA) 條件
- 健保 echocardiography
- 健保 PFT spirometry
- 健保 ABG
- 健保 troponin
- 健保 BNP / NT-proBNP 條件
- 健保 HbA1c
- 健保 24-h urine metanephrines
- 健保 plasma metanephrines (自費部分)
- 健保 ACTH stim test (cosyntropin)
學會 / 指引
- ACC/AHA 2024 noncardiac surgery guideline (新)
- ESC 2022 noncardiac surgery
- Endocrine Society peri-op guidelines
- ADA Standards of Care peri-op section
- ASA 2023 GLP-1 RA statement
- KDIGO peri-op CKD
- Taiwan Society of Anesthesiologists peri-op recommendations
🎓 內專必懂 (15)
- RCRI + NSQIP MICA + ACC/AHA 2024 algorithm
- Stress test 適應症：only if change management; for elevated risk + poor/unknown METs
- Post-PCI surgery delay：BMS / DES / ACS
- β-blocker、statin、ACEi/ARB、ASA、DAPT 個別 management
- SGLT2i euglycemic DKA + 3-4 d hold
- GLP-1 RA ASA 2023 + 1 wk hold
- Insulin pump peri-op
- Chronic steroid HPA suppression + stress dose
- Pheochromocytoma α→β block
- Hyperthyroid uncontrolled → thyroid storm risk
- Anticoag bridging decisions（BRIDGE trial）
- Pulmonary ARISCAT、OSA STOP-BANG
- VTE prophylaxis Caprini + LMWH / DOAC
- AS contemporary management（severe asymptomatic OK low/mod）
- IE prophylaxis 2021 update（限制適應症）
⚙️ Pre-op Cardiac Risk Workflow（2024 ACC/AHA）
Step 1 — Urgency:
- Emergency → proceed; risk-mitigated post-op care
- Time-sensitive → similar
- Elective → continue
Step 2 — ACS?
- Yes → treat ACS first (goal-directed); delay surgery
Step 3 — Surgical risk:
- Low (<1% MACE) → proceed without further testing
- Elevated → continue
Step 4 — Clinical risk (RCRI / NSQIP MICA):
- Low → proceed
- Elevated → continue
Step 5 — Functional capacity (METs):
- ≥ 4 → proceed
- < 4 or unknown → continue
Step 6 — Pharmacologic stress test (only if 結果 would change mgmt):
- DSE (dobutamine stress echo)
- Nuclear (dipyridamole/regadenoson Tc-99m)
- Negative → proceed
- Positive + indication for revasc independent of surgery → revasc first
- Positive but no indication → continue medical mgmt + proceed (most cases)
- 注意：revasc 不為了 noncardiac surgery 而做（CARP trial）
Step 7 — Optimization:
- β-blocker chronic continue; not day-of new
- Statin continue + 新開 (vascular)
- ASA / DAPT individualized
- Glycemic, BP, anemia, electrolytes optimization
- Smoking cessation
- VTE prophylaxis
- IE prophylaxis if indicated
⚙️ Endocrine Peri-op Detail（盧醫師核心）
DM Peri-op:
- HbA1c review; > 8-9% consider delay elective + optimize
- Glycemic target peri-op 100-180 mg/dL
- 監測 q1-2 h glucose intra-op for major; q4-6 h post-op
- Long-acting insulin: 50-100% basal continue (NPO 防 DKA)
- Short-acting: hold while NPO
- Pump: continue basal; bolus hold; endocrine consult
- IV insulin drip for long surgery / DKA risk
Oral DM agent hold:
- SGLT2i: 3-4 d (euglycemic DKA)
- GLP-1 RA daily: day of; weekly: ≥ 1 wk (some 2 wk; ASA 2023)
- Metformin: day of (traditional); continue if normal renal + no contrast (new)
- Sulfonylurea: day of
- DPP4i: day of
- TZD: day of (CHF concern)
Adrenal Peri-op:
- Chronic steroid > 5 mg/d × ≥ 3 wk → assume HPA suppressed
- Minor surgery: 25 mg HC × 1 IV
- Moderate: 50-75 mg HC/d × 1-2 d
- Major: 100-150 mg HC/d × 2-3 d → taper
- Sepsis/ICU: 加 fludrocortisone if primary AI
- Resume usual steroid when stable
Thyroid Peri-op:
- Hyperthyroid uncontrolled → delay elective
- Storm risk: severe untreated; emergency:
- β-blocker (propranolol/labetalol)
- PTU 600-1000 mg load → 200 q4-6h
- SSKI 5 drops q6h (1 h after PTU)
- Hydrocortisone 100 mg IV (T4→T3 block)
- Hypothyroid mild → proceed; severe → treat
- LT4 7-d half-life; can skip 1-2 wk PO; long NPO → IV LT4 (PO × 0.7)
Pheochromocytoma:
- α-block ≥ 14 d (phenoxybenzamine 10 mg PO BID titrate to BP < 130/80 supine; doxazosin 2 mg PO qd titrate)
- β-block 加 in AFTER α-block (atenolol, metoprolol)
- Saline 1-2 L/d × 24-48 h
- Avoid: ketamine, ephedrine, cocaine, morphine, β-block alone
- Intra-op crisis: phentolamine 5 mg IV q5 min, nitroprusside, esmolol
Pituitary:
- DI: DDAVP continue; I/O + Na q4-6 h
- Panhypopituitarism: LT4 (acute hypoT vs chronic), HC stress dose, sex hormones maintenance
- Acromegaly: airway evaluation; difficult intubation; sleep apnea
Calcium / PHPT:
- Severe (Ca > 12) defer non-urgent
- Hydration NS + bisphos + denosumab + calcitonin
- Cinacalcet rare for peri-op
⚙️ Anticoagulation Peri-op Detail
Warfarin:
- 5 d hold pre-op
- Check INR day before (< 1.5 OK; 1.5-2 give Vit K 1-2 mg PO; 2-3 give Vit K 2.5 mg PO)
- High thromboembolic risk → bridge LMWH:
- Therapeutic enoxaparin 1 mg/kg BID
- Start when INR < 2
- Hold last dose 24 h pre-op
- Resume warfarin POD 1 (no loading)
- Resume LMWH POD 1-2 (hemostasis OK) until INR therapeutic 2 d
Bridge YES:
- Mechanical mitral valve
- Mechanical aortic with risk factors
- Recent VTE < 3 mo
- AF + CHADS2 ≥ 5
- Recent CVA < 3 mo
Bridge NO (BRIDGE trial):
- AF + CHADS2 1-4
- Remote VTE
- Mechanical aortic without risk factors (controversial)
DOAC (短 half-life, no bridging usually):
Apixaban / Edoxaban / Rivaroxaban:
- Low BR: 24 h hold (CrCl > 50)
- High BR: 48 h hold
- CrCl 30-50: 36-48 h
Dabigatran:
- CrCl > 50: 24-48 h
- CrCl 30-50: 48-96 h
- CrCl 15-30: 96-120 h
Resume DOAC:
- Low BR: 24 h post-op
- High BR: 48-72 h post-op
Reversal:
- Warfarin: Vit K + 4-factor PCC or FFP
- Dabigatran: idarucizumab
- Apixaban / Rivaroxaban: andexanet alfa or 4-PCC
- Heparin: protamine
⚙️ Pulmonary Peri-op Detail
Screening:
- ARISCAT score
- Functional status
- OSA STOP-BANG
Modifiable:
- Smoking cessation (≥ 8 wk preferred)
- COPD optimize bronchodilator + steroid
- Asthma peak flow + bronchodilator + steroid burst
- OSA CPAP continue
- Treat respiratory infection before elective
Intra-op:
- Lung-protective ventilation (low tidal volume 6-8 mL/kg)
- Avoid prolonged neuromuscular blockade
- Adequate PEEP
Post-op:
- Incentive spirometry
- Deep breathing exercises
- Coughing
- Early ambulation
- Optimal pain control (avoid excessive opioid)
- CPAP / BiPAP if OSA or hypoventilation
- Selective NG tube use
🔬 Special Topics
MINS（Myocardial Injury after Noncardiac Surgery）
- 高 troponin post-op without ischemic symptoms
- 30-d mortality 高
- Surveillance for very high-risk patients
- Treatment：optimize medical therapy (β-blocker、statin、ASA)；不一定 cath
TAVI Before Noncardiac Surgery
- Severe symptomatic AS + 不能耐受 SAVR
- Recovery 快（< 7 d）
- 後續 noncardiac surgery 1-3 mo later
POAF（Postoperative Atrial Fibrillation）
- Cardiac surgery 30-50%、thoracic 10-20%
- Risk factors：age、HTN、LA enlargement、HF
- Multifactorial：inflammation、catecholamine、volume shift
- 多 self-limited within 6 wk
- Anticoag decision controversial：CHADS-VASc + 持續性
ERAS（Enhanced Recovery After Surgery）
- Pre-op carbohydrate loading
- Avoid prolonged NPO
- Multimodal analgesia（avoid opioid）
- Early ambulation
- Early enteral nutrition
- Minimize NG tube + drain
- Outcomes：LOS ↓、complications ↓、satisfaction ↑
Frailty + Surgery
- Frailty score（Fried、CGA）
- 高 frailty → 高 morbidity、mortality、ICU LOS
- Pre-habilitation：exercise、nutrition、smoking cessation
- Geriatric consult
Sleep Apnea + Surgery
- STOP-BANG ≥ 3 高 risk
- Pre-op：home CPAP usage、severity
- Intra-op：avoid long-acting opioid、neuromuscular blocker reversal complete
- Post-op：continuous SpO2 + capnography、CPAP continue、prolonged monitoring
⚠️ AI 草稿。