4 - Peri-operative Evaluation of Surgical Patient

Question 1

Patient work up

Answer 1

• History and Physical
• Preoperative laboratory studies
• Vascular workup
• Radiographs
• Special studies
• Medical problems

Question 2

History and physical

Answer 2

• Concentrate on major organ systems and rule out medical contraindications to surgery
• Identify true allergies and potential drug interactions
• Anesthesia risks

Social history
o Convalescence and rehabilitation
o Tobacco (“before I will do the surgery, you have to stop smoking” – ↓ bone healing)
o Recreational drugs (certain anesthetics can interact with cocaine –> heart attack)

Question 3

American society of anesthesiologists - classificaiton system of patienst

Answer 3

ASA Class I
ASA Class II
ASA Class III
ASA Class IV
ASA Class V
E

Question 4

ASA Class I

Answer 4

A normal healthy patient

Question 5

ASA Class II

Answer 5

A patient with mild systemic disease

Question 6

ASA Class III

Answer 6

A patient w/ severe systemic disease that limits activity, but is not incapacitating

Question 7

ASA Class IV

Answer 7

A patient with incapacitating systemic disease that is a constant threat to life

Question 8

ASA Class V

Answer 8

A moribund patient not expected to survive 24 hours with or without surgery

Question 9

E

Answer 9

Designates an emergency surgical procedure

Question 10

Laboratory studies

Answer 10

• Follow hospital protocol
• CBC
• ESR (sed rate)
• Electrolytes
• PT/PTT
• Chemistry Panel (LFT, BUN, creatinine, cardiac enzymes)
• UA pregnancy test

Question 11

Vascular workup

Answer 11

When there is doubt about adequacy of arterial or venous circulation, order the appropriate vascular studies
o	Doppler with segmental pressures
o	Ankle/arm indices
o	Transcutaneous oximetry
o	Angiography (MRI)

Question 12

Radiographs

Answer 12

• Foot and ankle radiographs for soft tissue and osseous evaluation
• Templates
• Chest x-ray (especially if patient is a smoker)
• Cervical spine films

Question 13

Special studies

Answer 13

Nuclear scans

CT scans
o Osseous affinity
o Fracture and tumor evaluation

MRI
o Soft tissue affinity
o Evaluation of tumors, infection and tendon pathology

Question 14

Medical problems

Answer 14

• Assess circulatory status of lower extremity
• Treat underlying medical conditions
• Adjust medical therapy
• Inform members of healthcare team about potential problems

Question 15

Diabetes mellitus

Answer 15

• DM is a complex systemic disease that affects multiple organ sites that include vascular, neurologic and dermatologic

Question 16

Surgical stress in diabetes mellitus

Answer 16

Surgical stress creates endocrine metabolic reaction that results in glucagon, norepinephrine, epinephrine and cortisol secretion
o Blood glucose levels rise
o Resultant insulin production in response to hyperglycemia inhibited by feedback loop

Question 17

Other surgical considerations for diabetes mellitus

Answer 17

• Albumin status inhibits healing
• Elective surgery should be avoided when blood sugar greater than 200 mg/dl
• Schedule surgery early in am
• ECG, especially when considering general anesthesia (Increased insulin demand increases risk of silent MI)
• Give one half insulin dose preoperatively and second half of insulin after surgery and give D5W

Question 18

Arthritis

Answer 18

• Includes all forms of arthritis

- Avoid joint surgery during flare-ups

Question 19

Surgery in rheumatoid patient

Answer 19

Surgery in the rheumatoid patient should be goal oriented
o PAIN RELIEF
o IMPROVEMENT OF OVERALL FUNCTION
o CORRECTION OF THE DEFORMITY

Note: one of the goals is NOT cosmetic

Question 20

Patient management in rheumatoid arthritis

Answer 20

• ASA or NSAID discontinuation
• Pre-operative corticosteroid supplementation
• Adjustment of antirheumatic drugs
• Prophylactic antibiotics (joint replacement)
• Prophylaxis for DVT
• Workup for atlantoaxial subluxation (C1, C2)

Question 21

ASA and NSAIDs

Answer 21

• Preoperative Labs = PT, PTT, bleeding time, serum transaminase, BUN, creatinine, uric acid
• Stop ASA 2 weeks prior to surgery
• Stop NSAIDs 3-5 days prior to surgery

Question 22

Corticosteroid use and steroid suppressed patient

Answer 22

• HPA-Axis suppression

- Oral cortisone has been used within last year ***Do not need to supplement if

Question 23

Corticosteroid supplementation

Answer 23

Recommended perioperative hydrocortisone dosage for patients on long-term steroid therapy

General
o Hydrocortisone 100mg IV/IM evening prior to surgery
o Another dose directly before surgery
o Continue every 8 hours for the next day postoperatively

Question 24

Surgery type and stress dose for corticosteroid supplementation

Answer 24

• Minor (hernia) = 25 mg/day for 1 day
• Moderate (total joint) = 50-75 mg/day for 1-2 days
• Major (cardio bypass) = 100-150 mg/day for 2-3 days

Question 25

Immunosuppressive drugs

Answer 25

Antimalarials, gold salts, penicillamine and methotrexate should be CONTINUED to decrease arthritic flare-ups Do NOT stop immunosuppressive drugs when taking someone to surgery

Question 26

Prophylactic antibiotics

Answer 26

Used for joint replacement and immunosuppressed patients - Ancef 1-2 mg IV 30 minutes before surgery - Vancomycin 1 gm IV 1 hour before surgery

Question 27

DVT and atrial fib

Answer 27

- Stop Coumadin 3-5 days prior to surgery - May start on Heparin or Lovenox - Start Coumadin for 3-5 days until PT is therapeutic, continue heparin during this time - Reversal of Coumadin with vitamin K and/or FFP

Question 28

Atlantoaxial subluxation

Answer 28

- Present in 40% of rheumatoid patients | - Marked flexion of neck can cause fracture or neurological interruption

Question 29

Evidence based medicien

Answer 29

- Large analysis of literature that reviews various aspects of RA medications and surgery - Level 3 systematic review of literature - Found that methotrexate is safe and does not need to be discontinued

Question 30

Gout

Answer 30

- Risk for post-operative gout attack due to surgical trauma, dehydration and interruption of uricosuric medication - Oral colchicine 0.6 mg BID for two days before surgery and one day postoperatively - Colchicine 2 mg IV preoperatively to avoid GI side effects

Question 31

Cardiovascular disease

Answer 31

- Hypertension - Ischemic heart disease - Rheumatic heart disease - Mitral valve prolapse

Question 32

Hypertension

Answer 32

- Increased medical and surgical risk - Controlled by anesthesia if patient has not taken oral medication - Mild hypertension will often resolve with induction medication and pain medication - Evaluate preoperative potassium (>3.5 mEq)

Question 33

Ischemic heart disease

Answer 33

- Avoid elective surgery if patient has had an MI within the last 6 months - Cardiac consult for any surgery with pre-existing ischemic heart disease

Question 34

Rheumatic heart disease and mitral valve prolapse

Answer 34

- Prone to bacterial endocarditis - Prophylaxis with antibiotics (ask “do you get prophylaxis when you go to the dentist?” If yes, need to look into it and figure out why) - In office prophylaxis with amoxicillin

Question 35

Renal and hepatic disease

Answer 35

- Previously discussed in renal course - LFTs, alkaline phosphatase, albumin, bilirubin, PT, CBC - Increased bleeding tendency due to decreased platelets and extrinsic pathway - Avoid halothane and amides because of hepatotoxicity

Question 36

Pediatric pateints

Answer 36

- Parental presence during anesthesia induction and in recovery room is beneficial - General anesthesia favored - Prevent hypothermia due to poor thermoregulation created by large surface area/weight ratio - Clark’s rule: Weight/150 = fraction of adult dose (or you can always contact pharmacy)

Question 37

Geriatric pateints

Answer 37

- Multiple medications and possible drug interactions - Decreased renal function with age - Inability to clear medications - Respiratory depression with medications - Rehabilitation concerns --> Recovery time often doubled - Avoid preventable ulcerations