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Flashcards in 4: Peri-operative - Smith Deck (20)

ASA classification of physical status

I - normal healthy
II - mild systemic disease
III - severe systemic disease that limits activity but is not incapacitating
IV - incapacitating systemic disease that is a constant threat to life
V - moribund pt not expected to survive 24 hr with or without surgery
E - emergency surgical procedure


how does surgery affect DM?

- surgical stress creates endocrine metabolic rxn that results in glucagon, Ne, Epi and cortisol secretion
- blood glucose levels rise
- resultant insulin production in response to hyperglycemia inhibited by feedback loop
- albumin status inhibits healing


elective surgery should be avoided when blood sugar greater than ______

200 mg/dl
- schedule surgery in am
- get ECG if considering general anesthesia (increased insulin demand increases risk of silent MI)


dosing of insulin for surgery ***

give one half insulin dose preoperatively and second half of insulin after surgery and give 5% dextrose during surgery


who needs to be worked up for atlantoaxial subluxation

surgical candidate with RA
- present in 40% rheumatoid pts
- marked flexion of neck can cause fracture or neurological interruption


when do you stop ASA and NSAIDs before surgery?

stop ASA 2 wks prior to surgery
stop NSAIDs 3-5 d prior to surgery


corticosteroid use and the steroid suppressed pt: if oral cortisone used w/i last year ...

do not need to supplement if less than 5 mg/d or intra-articular injection


corticosteroid (hydrocortisone) supplementation for pt on long term steroid therapy

minor surgery - 25 mg/d 1 d
moderate surgery - 50-75 mg/d - 1-2 d
major surgery - 100-150 mg/d - 2-3 d

ex: hydrocortisone 100mg IV/IM evening prior to surgery, another dose directly before surgery, continue every 8 hr for next day postop


should a pt continue to take immunosuppressive drugs?

yes - benefits (decrease arthritic flare ups) outweigh risks


what uses prophylactic antibiotics?

joint replacement and immunosuppression

ancef 1-2 mg IV 30 min before surgery
vancomycin 1 mg IV 1 hr before surgery


what should you do if your surgical candidate is taking coumadin?

- stop coumadin 3-5 d prior to surgery
- may start on heparin or levonox
- post surg continue coumadin until PT is therapeutic with heparin


reversal of coumadin

vitamin K and/or FFP


reversal of heparin

protamine sulfate


risk of postop gout attacks due to trauma, dehydration and interruption of uricosuric meds during surgery. what should you do?

oral colchicine 0.6 mg BID for two days before surg and one day postop

colchicine 2 mg VI preop to avoid GI side effects


what should be evaluated preop for a pt with HTN

potassium (greater than 3.5 mEq)
- HTN is controlled by anestheis if the pt has not taken oral meds


avoid elective surg if pt has had an MI w/i _________

last 6 months
- cardiac consult for ANY surgery with pre-existing ischemic heart disease


why would you ask someone during your pre-op workup if they get prophylaxis at the dentist?

- rhematic heart disease and mitral valve prolapse prone to bacterial endocarditis
- need to be prophylaxed with antibiotics
- in office: amoxicillin


what sedatives should be avoid due to hepatotoxicity ?

halothane and amides


why do patients with renal/hepatic dz have increased bleeding tendency?

due to decreased platelets and extrinsic pathway


clarks rule for dosing general anesthesia to ped pt

weight/150 = fraction of adult dose

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