4 Preoperative Evaluation Flashcards
(89 cards)
1
Q
Current known medical problems, past medical problems, previous surgeries, anesthesia types, and anesthesia- related complications must be noted. A simple notation of diseases or symptoms such as hypertension, diabetes mellitus, ischemic heart disease, shortness of breath, or chest pain is not sufficient. Rather: (6)
A
- Gravidade
- Estabilidade
- Limitacoes de atividade
- Exacerbacoes (current or recent)
- Tratamentos previos
- Intervencoes planejadas
2
Q
Melhores escores para CF do paciente
A
- DASI
- MET-REPAIR Questionnaire
Optimal thresholds for identifying patients capable of ≥4 METs include self-reported ability to climb ≥3 flights of stairs, DASI score ≥32, and ≥6 METs on the MET-REPAIR questionnaire. Conversely, perioperative cardiac risk is increased in patients who self-report being unable to climb two flights of stairs, or have a DASI score <32 (with a score <25 representing a clinically meaningful increase in risk)
3
Q
Como calcular o peso ideal?
A
- Equacao de Devine
4
Q
Quais os componentes do exame de via aerea? (7)
A
- Mallampati
- Status dentario e anormalidades
- Grau de mobilidade cervical
- Circunferencia cervical
- DTM
- Tipo fisico (obesidade, magreza…)
- Deformidades pertinentes
5
Q
Preditores de ventilacao dificil (frances)
A
- Idade > 55a
- IMC > 26
- Ausencia de dentes
- Barba
- Ronco
6
Q
Preditores de ventilacao Impossivel (americano)
A
- Hx de radiaçao no pescoco
- Homens
- Apneia do sono
- Mallampati III-IV
- Barba
7
Q
Outros fatores de risco possiveis para dificuldade de ventilacao alem daqueles citados como “dificil” ou “impossível”
A
- Circunferencia cervical
- Deformidades em face ou pescoço (cirurgia previa, trauma, anormalidades congênitas)
- Esclerodermia
- Trissomia 21 (Down)
- Doenca de coluna cervical
- Cirurgia previa em coluna cervical
8
Q
Em que pacientes a ausculta de carótidas é especialmente importante? (3)
A
- AVE previo
- AIT previo
- Irradiacao em cabeça e pescoço
The presence of a carotid bruit significantly increases the likelihood of an important lesion (i.e., 70%–99% stenosis) in both symptomatic or asymptomatic patients, but the absence of a bruit does not rule out carotid stenosis.
9
Q
O que deve incluir o exame basico neurológico? (6)
A
- Satus mental
- Fala
- Marcha
- Funcao de pares cranianos
- Funcao de nervos motores
- Funcao de nervos sensitivos
10
Q
Performance- based physical tests can also provide more objective assessment of function, with a commonly recommended test being the Timed Up- and- Go test. The Timed Up- and- Go test involves timing patients while they perform the following tasks in sequence: (4)
A
- Stand up from a chair (without using arm rests if possible)
- Walk 10 feet
- Turn around and walk back to chair
- Sit down in chair
11
Q
Qual a importancia do Timed Up- and Go- test?
A
- Associado a complicacoes pos-op
- Mortalidade em 1 ano
12
Q
O Declinicio Cognitivo esta associado a que riscos pos-operatorios? (4)
A
- Delirium
- Declinio funcional
- Complicacoes
- Mortalidade
13
Q
Como fazer screening de Declinio Cognitivo em Idosos? (2)
A
- Mini-Mental State Exam (MMSE)
- Montreal Cognitive Assessment (MoCA)
Ambos os testes necessitam de 10 minutos para completar
14
Q
The most common adverse events related to poor nutritional status are: (3)
A
- infectious complications
- wound complications
- Increased length of stay
15
Q
The ACS/AGS practice guidelines recommend the following steps to screen for poor nutritional status (older adults with limited material resources are at particular risk for food insecurity) (3)
A
- Peso, altura e IMC
- Albumina e prealbumina
- Perda de peso nao-intencional
+ Mini-Nutri Assessment
16
Q
Criterios de fragilidade de Fried (5)
A
- Perda de peso
- Exaustao
- Lentificacao de marcha
- Baixa atividade fisica
- Perda de forca de preensao
17
Q
The frailty phenotype described by Fried and colleagues is based on the identification of traits associated with the occurrence of (5)
A
- Disease
- Hospitalization
- Falls
- Disability
- Death
18
Q
More recent evidence has pointed to the ___1___ as being the most feasible clinical approach to accurately assess frailty during preoperative evaluation.
A
- Nine-level Clinical Frailty Scale (CFS)
Indirect comparison of the CFS against the modified Fried Index, clinicians found the CFS to be easier to use, more feasibly applied in the clinical environment and quicker to complete (<1 minute versus 5 minutes).
19
Q
The Patient Health Questionnaire- 2 (PHQ-2) is an efficient instrument to screen for depression that includes only two questions:
A
- “In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least two weeks?”
- “In the past 12 months, have you ever had a time, lasting at least two weeks, when you didn’t care about the things that you usually care about or when you didn’t enjoy the things that you usually enjoy?
20
Q
Among individuals aged ≥65 years, 13% of males and 8% of females consume at least two alcoholic drinks per day. Alcohol and substance use disorders are associated with increased rates of: (3)
A
- post-op mortality
- post-op complications (pneumonia, sepsis, wound infection and disruption)
- prolonged stay
21
Q
Como fazer o screening de uso de alcool e substancias em pacientes?
A
CAGE questionnaire modificado
22
Q
Quais os 4 dominios a serem otimizados pre-op no paciente idoso?
A
- Cognição
- Depressão
- Função
- Nutrição
23
Q
Por que é importante o screening de Depressao no pre-op de pacientes idosos? (7)
A
- Complicações pos-op
- Mortalidade
- Tempo de internação
- Percepção de dor
- Risco de delirium
- Segurança
- Encaminhamento multidisciplinar
24
Q
Como é a classificacao de Angina pela Canadian Cardiovascular Society (CCS)?
A
25
**Algorithm for noncardiac surgery proposed by the 2022 European Society of Cardiology guidelines.**
* Qual o primeiro passo?
A Cirurgia é de Emergencia / Urgencia?
* Sim: cirurgia
* Nao: passo 2.
26
**Algorithm for noncardiac surgery proposed by the 2022 European Society of Cardiology guidelines.**
* Qual o segundo passo?
A cirurgia é tempo-sensível?
* Sim: avaliacao e decisao multidisciplinar para determinar a abordagem individualizada para teste cardiaco
27
**Algorithm for noncardiac surgery proposed by the 2022 European Society of Cardiology guidelines.**
* Qual o terceiro passo?
Estimar risco por procedimento:
* Baixo risco: cirurgia
* Intermediario: Se FR-CV ou DCV ou _>_ 65a → Ver CF, ECG, Biomarcadores (trop, BNP ou NT-pro-BNP)
* Alto risco: ECG, Biomarcadores, CF, ±Cardiologia, ±Eco-TE
28
The CCS guidelines recommend routine troponin surveillance for **___1___** after surgery for patients who are not classified as low cardiac risk based on their preoperative BNP or NT pro- BNP testing.
48 to 72 hours
*These individuals have significantly elevated
risks of progression to death, IHD, or heart failure.*
29
Principais diferenças do Guideline Americano x Europeu
Pergunta 2: Doenca cardiovascular para compensar (IAM, ICC descompensada, Arritmias descompensadas, Doenca valvular grave)
30
Quais arritmias devem ser compensadas antes de cirurgias eletivas?
* FA sintomatica ou FC > 100
* Arritmias ventirculares
* Bradicardia sintomatica
* Bloqueio 3° Grau
31
Diferenca entre DASI _<_ 34 (equivalente a 14.6 MET) e CF _<_ 4 MET, na pratica.
* DASI é importante para estratificacao de risco e valores _<_ 34 were associated with higher odds of 30-day death or MI after surgery.
* CF > 4MET Indicates basic fitness for low/moderate-risk surgeries.
32
While both natriuretic peptides and high- sensitivity troponins have been shown to improve the accuracy of preoperative risk stratification, prognostically important conditions other than myocardial ischemia can cause elevations in either cardiac biomarker. For example, **___1___**, **___2___**, and **___3___** can result in elevations in these biomarkers.
1. RV dysfunction
2. Cardiac valvular disease
3. Atrial Fibrillation
33
Nonoperative data suggest that natriuretic peptides have limitations as prognostic biomarkers in certain disease states, including: (2)
* Obesity
* Chronic Renal Disease
34
Limitacoes do uso do RCRI para estratificada de risco (3)
1. performance discriminativa modesta
2. Aplicavel apenas em cirurgia eletiva
3. Nao considera variacoes no risco cardiaco em diferentes procedimentos
35
At present, both American and European guidelines only recommend consideration for revascularization in patients who meet usual nonoperative indications (eg. **___1___**, **___2___**), while the CCS guidelines recommend against preoperative revascularization in any patient with stable IHD.
1. left main coronary artery stenosis,
2. triple-vessel coronary artery disease
36
Principais achados do POISE-1 trial (2008) (2)
* Metoprolol reduz risco de infarto
* Metoprolol aumenta AVE, hipotensao e óbitos.
37
Principais achados do POISE-2 trial (3)
* Iniciar Clonidina ou Aspirina no pre-op nao reduz mortalidade e elevou sangramentos.
*The lack of clear benefit may be explained, in part, by acute thrombosis being a relatively infrequent contributor to perioperative myocardial infarction*
* a reasonable strategy is to only continue aspirin selectively in patients where the risk of cardiac events is felt to exceed the risk of major bleeding.*
38
A large retrospective cohort study of about 26,600 patients found that the risk of noncardiac surgery early after stent implantation was particularly elevated when PCI had been performed for acute MI, as opposed to non-acute coronary syndrome indications.
Thus, the ESC guidelines recommend an ideal PCI- to- surgery interval of **___1___** after elective PCI and **___2___** after PCI for an acute coronary syndrome, where the patient would remain on DAPT during this interval.
In the case of time- sensitive noncardiac surgery following implantation of a newer-generation DES, this interval can be reduced to **___3___** after elective PCI and **___4___** after PCI for an acute coronary syndrome.
1. six months
2. 12 months
3. one month
three months
39
During preoperative evaluation, the anesthesiologist should determine the presence, **___1___**, **___2___**, and **___3___** of any coronary stent.
1. Tipo (medicamentoso x metálico)
2. Localizacao
3. Indicacao original
40
Como é a classificacao da NYHA para Insuficiencia Cardiaca?
41
While postoperative mortality is increased in patients with both HFrEF and HFpEF the magnitude of elevated risk increases progressively with **___1___**.
1. worsening systolic dysfunction.
42
The anesthesiologist should enquire about recent weight gain, fatigue, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, peripheral edema, hospitalizations, and recent changes in medical management.
* Qual a enfermidade base?
Insuficiencia Cardiaca
43
On physical examination, the findings of HF may be subtle. Furthermore, they can vary between HFrEF versus HFpEF, and between compensated versus decompensated states. More useful signs for ruling in HF include: (4)
1. 3ª bulha
2. Distensao jugular
3. Estertores pulmonares
4. Edema de MMII
44
Furthermore, the American and European guidelines are supportive of selective preoperative echocardiography in clinically stable patients with known ventricular dysfunction who (2)
1. have not undergone testing in the prior year, or
2. are scheduled for high-risk noncardiac surgery.
45
46
Em que situacao interromper diuréticos de alça (furosemida?
* Procedimentos de alto risco com grande perda sanguinea ou necessidade de grande quantidade de fluidos.
* Interromper na manha da cirurgia
47
When preoperative assessment identifies a cardiac murmur, the subsequent goals are to identify: (3)
1. sintomas cardiovasculares associados (dispneia, desconforto toracico, ortopedia, fadiga, sincope)
2. determinar a causa
3. distinguir sopros importantes de nao-importantes
48
Benign functional murmurs occur with turbulent flow across the aortic or pulmonic outflow tracts during high- flow states such as (3)
1. gravidez
2. hipertireoidismo
3. anemia
49
A Valsalva maneuver decreases right and left heart filling, thereby reducing the intensity of most murmurs except those of (2)
1. mitral valve prolapse
2. hypertrophic cardiomyopathy.
50
Qual manobra aumenta os sopros de prolapso de valva mitral e CMH?
* Levantar-se
*Standing also decreases preload, and thereby increases the intensity of murmurs of mitral valve prolapse and hypertrophic cardiomyopathy.*
51
Agachamento aumenta o RV e Pos-Carga, aumentando os sopros, com excecao de (2)
1. mitral valve prolapse
2. hypertrophic cardiomyopathy.
52
Pedir ao paciente repetidamente fazer hand-grip aumenta FC e PA, intensificando os sopros de **___1___** e **___2___**
Esta manobra diminui os sopros de: **___3___** e **___4___**.
1. regurgitacao mitral
2. insuficiencia aortica
3. estenose aortica
4. CMH
53
Como graduar a intensidade de sopros cardiacos?
54
Perioperative guidelines recommend preoperative echocardiography for any patient with clinically suspected moderate or severe valvular stenosis or regurgitation (i.e., associated murmur, signs, and symptoms), especially in the absence of an echocardiogram within the prior year.
For patients with known valvular heart disease, repeat echocardiography is recommended if there has been a significant change in clinical status or physical examination since the last test.
* V ou F?
Verdadeiro
55
Qual a valvopatia conforme a localizacao do sopro?
1. 2-3° Espaco paraesternal
2. 3-4° Espaco paraesternal
3. Apice
1. Estenose Ao
2. Insufic Ao
3. Estenose Mi, Reg Mi, Prolapso de Valva Mi
56
Aortic stenosis severity is classified based on the aortic valve area, mean transvalvular pressure gradient, transvalvular jet velocity, other hemodynamic sequelae (e.g., left ventricular ejection fraction), and presence of symptoms. Severe aortic stenosis is typically, but not always, associated with a **___1___** and **___2___**.
1. valve area < 1.0 cm²
2. mean transvalvular pressure gradient >40 mm Hg
*A limitation of pressure gradient for assessing severity is that the gradient may decrease if the left ventricle systolic function begins to decrease.*
57
The cardinal symptoms of severe aortic stenosis are **___1___**, **___2___**, **___3___**, but patients may be more likely to report **___4___** and **___5___**.
1. angina,
2. heart failure,
3. syncope
4. exertional dyspnea
5. decreased exercise tolerance.
58
Caracteristicas do sopro de Estenose Aortica
* Borda external D superior, irradiando para o pescoco
* Elevação do pulso carotídeo retardada
* desdobramento paradoxal da segunda bulha cardíaca
* ECG com hipertrofia VE (padrazo strain), desvio eixo para E, BRE
59
Como diferenciar o sopro de estenose Ao e esclerose Ao? (2)
* Estenose Aortica irradia para o pescoco
* EAo apresenta elevação do pulso carotídeo retardada e desdobramento paradoxal da segunda bulha cardíaca
60
Cuidados periop de pacientes com Estenose Aortica Grave assintomática e sintomática com indicacao de cirurgia não-cardíaca eletiva.
* Assintomatica: monitorizacao hemodinâmica intra- e pos-op adequada em cirurgias de grande porte
* Sintomatica: considerar troca valvar (cirurgica ou transcateter) antes de cirurgia de qualquer porte.
61
Sopro mesossistólico, ejetivo, em diamante. Pulso parvus et tardus.
Crescendo–decrescendo, radiates to the carotids; +/− S3, S4; Valsalva and
sustained hand grip exercise decrease intensity.
* **Qual a valvopatia:**
Estenose Aortica
62
Patients with moderate to severe aortic stenosis also have an increased risk of bleeding from an acquired:
* Von Willebrand syndrome.
63
Holodiastolico, regurgitative, Pulso em martelo d’água ou de Corrigan. Pressão de pulso aumentada, ictus desviado.
* de Musset sign (head bob with each heart beat),
* Duroziez sign (systolic and diastolic bruit heard over the femoral artery when it is partially compressed), and
* Quincke pulses (capillary pulsations in the fingertips or lips).
Decrescendo, blowing, high pitched, radiates to the carotids; Austin–Flint
rumble at the apex; squatting, hand grip exercise and leaning forward
increase intensity
Insuficiencia Aortica
64
Expert consensus from current guidelines is supportive of patients with mild to moderate aortic insufficiency proceeding to major noncardiac surgery with:
* careful perioperative management, including hemodynamic monitoring, afterload control, and fluid balance.
65
If a patient being considered for intermediate- or high-risk noncardiac surgery has severe aortic insufficiency that meets usual indications for valve replacement (e.g., symptoms, left ventricular dysfunction, significant ventricular dilatation):
* possible valve replacement should be considered before the noncardiac surgery.
66
Mitral stenosis involves progressive reduction of cross-sectional area of the mitral valve, with shortness of breath with exertion occurring when the area falls **___1___**, and symptoms at rest occurring once the area falls **___2___**
1. below 2.5 cm²
2. below 1.5cm²
67
Severe stenosis is typically associated with a **___1___**, and a **___2___**
1. pulmonary artery systolic pressure >50 mm Hg
2. resting mean transvalvular gradient ≥10 mm Hg.
68
For patients with mitral stenosis who meet guideline- based indications (e.g., symptomatic severe stenosis, systolic pulmonary arterial pressure >50mm Hg for valvular intervention such as a percutaneous mitral balloon commissurotomy), consideration should be given to perform this intervention before:
* before major elective non cardiac surgery
69
If an asymptomatic patient with severe mitral stenosis has valve morphology that is not favorable for a percutaneous intervention, it is still reasonable to proceed with major elective noncardiac surgery provided that:
* appropriate intraoperative and postoperative hemodynamic monitoring is used.
70
Opening snap; low- pitched rumble radiates to the axilla; squatting and hand grip exercise increase intensity
Sopro diastólico com reforço pré-sistólico em ruflar, B1 e B2 hiperfonéticas, estalido de abertura.
* **Qual a valvopatia?**
Estenose Mitral
71
Current guidelines suggest that most patients with asymptomatic severe mitral regurgitation can proceed to major elective noncardiac surgery with appropriate hemodynamic monitoring, especially in the absence of:
* concomitant pulmonary hypertension (i.e., pulmonary systolic artery pressure <50 mm Hg)
72
High pitched, blowing, radiates to the axilla; loud S3; standing decreases intensity; squatting and hand grip exercise increase intensity
Sopro holossistólico, regurgitativo, B1 hipofonético.
* **Qual a valvopatia?**
Regurgitacao Mitral
73
Principal preocupação em pacientes com Prolapso de Valva Mitral no perioperatorio:
Diferenciar pacientes com regurgitação mitral clinicamente importante daquele com achado incidental do prolapso e que nao necessita de mais avaliacao.
74
Crescendo, mid- systolic click; Valsalva and standing increase intensity; squatting decreases intensity
Sopro mesotelessistólico, clique mesossistólico.
* Qual a valvopatia?
Prolapso de Valva Mitral
75
**___1___** is a common valvular abnormality, with 70% of normal adults exhibiting a small degree of regurgitation on echocardiography. Since it is usually asymptomatic and not easily audible on physical examination, it is often noted as an incidental echocardiographic finding.
* Tricuspid regurgitation
76
Holosystolic murmur that is heard best at the midsternal border or subxiphoid area. Nonetheless, the murmur is often absent or very soft, even with severe regurgitation. The intensity of the murmur can be increased using maneuvers that increase venous return (e.g., inspiration, abdominal pressure).
Sopro holossistólico, regurgitativo, B1 hipofonético.
Aumenta com inspiração profunda. Onda V gigante no pulso venoso jugular.
* Qual a valvopatia?
* Insuficiencia Tricuspide
77
The preoperative management of patients with severe tricuspid regurgitation should be guided by the presence of: (3)
* Any underlying conditions,
* Right- sided heart failure,
* Known or suspected pulmonary hypertension.
78
Em pacientes com valva prostética, o que deve ser investigado na avaliacao pre-op?
* Indicacao da troca valvar
* Tipo
* Idade
* status atual da valva
* Anticoagulacao de longo prazo
* Manejo periop da anticoagulacao
* Ecocardiograma
* Hemograma - *anemia hemolitica relacionada a valva*
79
Em que situacoes é recomendada a profilaxia para Endocardite? (4pp)
* Valvas cardicas proteicas
* Material prosthetic usado para reparo de valva cardiaca
* Doenca cardiaca congenita cianotica complexa
* Endocardite previa
*Prophylaxis is required when eligible patients undergo dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa.*
*Prophylaxis is not required when these same individuals undergo nondental procedures (e.g., transesophageal echocardiography, gastroscopy, colonoscopy, cystoscopy, dermatologic procedures), unless there is active infection at the procedure site.*
80
The presence of a bundle branch block is not itself an indicator of increased perioperative cardiovascular risk, especially after accounting for known clinical risk factors.
* Em quais pacientes é necessaria maior investigação?
81
Como classificar a Fib At?
* Paroxistica
* Persistente
* Permanente
*The arrhythmia is classified as paroxysmal (i.e., terminates spontaneously or with intervention within seven days of onset), persistent (i.e., fails to self- terminate within seven days), long- standing persistent (i.e., lasts more than 12 months), or permanent (i.e., persistent atrial fibrillation where a joint decision has been made by the patient and clinician to no longer pursue a rhythm control strategy).*
82
Como é o escore que ajuda a estimar o risco de embolização a longo-prazo de pacientes com Fib Atrial?
CHA₂DS₂-VASc score
*Patients can be classified as low risk (0 points: 0.2% annualized stroke rate), intermediate risk (1 point: 0.6% annualized stroke rate), or high risk (≥2 points: >2.2% annualized stroke rate).*
83
Em que pacientes com Fib Atrial não-valvar iniciar (ou nao) a anticoagulacao? (3)
* escore _>_ 2 em homens e _>_ 3 em mulheres
* escore 1 em homens e 2 em mulheres: pode ser considerada anticoagulacao
* Escore 0 em homens e 1 em mulheres: nao fazer
*CHA₂DS₂-VASc score. Podem ser usados tanto antagonistas da vit-K ou DOACs.*
84
Perguntas para considerar no manejo perioperatorio de anticoagulantes em pacientes com Fib Atrial: (3)
1. A interrupcao é necessaria?
2. Quando deve ser interrompido?
3. É necessaria ponte com HBPM?
85
Em que situacao é possivel continuar com o anticoagulante oral em paciente com Fib Atrial? (2)
* Sem FR para sangramento relacionados ao paciente (doenca hepatica, funcao renal anormal, complicacoes previas de sangramento)
* Cirurgia de baixo risco de sangramento
*In all other cases, patients should temporarily discontinue anticoagulant medications before surgery, including all patients who are receiving DOACs or who might need neuraxial anesthesia.*
86
Qundo interromper antagonistas da vitamina K?
* 5 dias antes da cirurgia
* Checar INR 1 dia antes
87
Quais fatores devem ser considerados para a interrupção de DOACs? (2)
* Droga especifica
* Risco de sangramento esperado
* Funcao renal
* Anestesia neuroaxial planejada
88
Em que situacoes deve ser feita a ponte com HBPM conforme ACCP-2022 no periop sem valva mecanica?
* DOACs: nao fazer
* ant-Vit-K e situacoes de alto risco: valva mecanica, Fib At, TEV
89
A avaliacao pre-op de indivíduos com Doenca Arterial Periferica deve abordar: (5)
* Sintomas (claudicara intermitente, dor em repouso, etc)
* Fatores de risco (HAS, DM, tabagismo CKD)
* Comorbidades (doenca isquemica cardiaca, doenca cerebrovascular)
* PA nos dois membros
* Ausculta de sopros abdominais e arteria femoral
