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Surgery > Dr. Smith preop lecture > Flashcards

Dr. Smith preop lecture Flashcards

1
Q

What does a preop eval allow you to do?

A 
Assess the medical condition
Evaluate the pt's overall health status
Determine RFs
Educate the pt
Explain the procedure in detail
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2
Q

Advantages of pt education

A

Pt can:
Understand the procedure and ask questions
Consider alternatives
Realize which complications may occur

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3
Q

Emergency

A

Life-threatening situation requiring immediate intervention (trauma, ruptured aneurysm)

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4
Q

Urgent- examples

A

Intestinal obstruction
Appendicitis
Wounds

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5
Q

Elective surgery

A 
Can be done when convenient and sometimes not at all
Hernia
Varicose veins
Breast CA
Breast implants
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6
Q

What are the goals of the preop eval?

A

Anticipate difficulties
Made advance preparations and organize facilities, equipment and expertise
Enhance pt safety and minimize opportunity for error
Relieve fear and anxiety for the pt

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7
Q

What is part of preop?

A 
Hx and PE
Special investigation
Informed consent
Specific orders
DVT prophylaxis
Abx prophylaxis
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8
Q

What specific questions and components should be asked?

A

Presenting complaint dictates urgency
PMHx: look into a dz that will affect outcome
Surgical hx: may affect incision, length of operation, ability to access
Bleeding problems
Bad reaction to anesthesia, such as malignant hyperthermia, prolonged emergence, hyperemesis?
Drugs and allergy hx: esp look for anticoags, abx sensitivity, steroids (adrenal crisis)

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9
Q

What should you look for in FHx?

A

Hypercoagulable disorders more prevalent than bleeding disorders
Malignant hyperthermia
Pseudocholinesterase deficiency

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10
Q

What to ask about in social hx?

A

Smoking: increases O2 demand and decreases delivery
Alcohol: May affect dosing in OR and after, some pts may require DT prophylaxis
Illegal drugs: affects pain control post-operatively
Some pts may experience withdrawal sx

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11
Q

How to do a PE

A

Do not rely on examinations of others
Pay attention to vitals
Cardiac, resp, abdomen, neuro, peripheral vasculature
Orifice- look in or put a finger in all of them

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12
Q

What does an emergency PE consist of?

A 
Airway
Breathing
Circulation
Pupils
GCS
Exposure of body for something glaringly obvious
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13
Q

What preoperative investigations should be performed?

A 
Confirmation of dx
Exclusion of alternate dx
To know the extent of the dz
Assessment of fitness for surgery
Risk to others
Medico-legal considerations
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14
Q

When should you get a CBC?

A

All emergencies
All pts age >60
Menstruating females
Surgery where large blood loss is expected
Anytime you suspect anemia, clotting or bleeding d/o, sepsis, kidney dz

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15
Q

When to get electrolytes and BUN/creatinine

A 
Age >60
On meds, such as diuretics or steroids
Cardiac, pulmonary, liver, or renal dz
Malnourished or has had nausea, vomiting or diarrhea
Anyone receiving IVF
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16
Q

When to get amylase/lipase

A

Anyone with suspected abdominal pathology

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17
Q

When to get glucose

A

Acute abdomen or sepsis
Age >60
Anyone with obesity, DM, malnourished

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18
Q

When to get liver enzymes

A

Excessive alcohol use
RUQ pain or known gallbladder or liver dz
Suspected hepatitis
Jaundice

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19
Q

When to get coagulation studies?

A 
Cardiothoracic procedure
Vascular procedure
Neuro procedure
Known anticoagulant use
Hx of coagulation problems
Alcohol abuse
Liver dz or jaundice
Cannot get a hx
20
Q

When to get a type and crossmatch

A

Emergency surgery
Anyone with anemia
Cases with known opportunity for large blood loss
Pregnancy

21
Q

When to get pregnancy test

A

Any female with a uterus over the age of 9 unless hysterectomy or menopausal

22
Q

When to get CXR

A 
Trauma to neck, chest, abdomen, or pelvis
Unconscious pt
All elective cases over age 60
Thoracic surgery
Septic pts
Perforated viscous
Hx of lung dz
23
Q

When to get EKG

A

Age >50
Morbid obesity
Known cardiac dz

24
Q

Major predictors of increased risk?

A 
Acute or recent MI
Unstable or severe angina
Strongly positive stress test
Decompensated heart failure: edema, rales, venous distention, SOB
Severe valvular dz
Significant arrhythmias
25
Q

Intermediate predictors of increased risk

A 
Mild angina
Previous MI by hx or by Q waves
Compensated heart failure
DM
Renal insufficiency (Cr >2.0)
26
Q

Minor predictors of increased risk

A 
Advanced age
Abnl EKG (LVH, LBBB, ST changes)
Low functional capacity
Hx of stroke
Uncontrolled systemic HTN
27
Q

ASA grade I

A

Nl healthy individual

28
Q

ASA grade II

A

Mild systemic dz that doesn’t limit activity

29
Q

ASA grade III

A

Severe systemic dz that limits activity

30
Q

ASA grade IV

A

Severe systemic dz that is constant threat to life

31
Q

ASA grade V

A

Moribund, not expected to survive 24 hrs with or without surgery

32
Q

What are some assessment tools for cardiac?

A

Goldman cardiac risk index
Detsky modified multifactorial index
Eagle’s criteria for cardiac assessment
Revised cardiac risk index

33
Q

What surgeries are considered high risk?

A

Emergent major surgery
Aortic and other major vascular
Peripheral vascular
Anticipated prolonged or associated with large fluid shift and/or blood loss

34
Q

What surgeries are considered intermediate risk?

A 
Carotid endarterectomy
Endovascular AAA repair
Head and neck
Intraperitoneal and intrathoracic
Orthopedic 
Prostate
35
Q

What surgeries are considered low risk?

A

Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery

36
Q

How is DVT prophylaxis performed?

A

Done preoperatively and intraoperatively
Compression hose
Mechanical prophylaxis
Chemical prophylaxis

37
Q

Class I surgical wound

A

Operative wound clean
Non-traumatic, with no inflammation encountered
No break in technique
Respiratory, GI and GU tracts not entered
C-section, elective, no PROM or trial of labor

38
Q

Abx prophylaxis and class I

A

May not require prophylaxis unless a foreign body is inserted

39
Q

Abx prophylaxis and class II

A

Single perioperative antibiotic given within 30 mins of incision

40
Q

Abx prophylaxis and classes III and IV

A

Depends, but should at least have a dose prior to incision

41
Q

Common abx for cardiac

A

Cefazolin

Vancomycin

42
Q

Common abx for esophageal, gastroduodenal

A

High risk only: cefazolin

43
Q

Common abx for biliary tract

A

High risk only: cefazolin

44
Q

Common abx for colorectal

A

Oral: neomycin-erythromycin or metronidazole
Parenteral: cefazolin + metronidazole or ampicilin-sulbactam

45
Q

Common abx for GU

A

High risk only: ciprofloxacin

46
Q

Common abx for neurosurgery

A

Cefazolin

Vancomycin

47
Q

Common abx for thoracic (non-cardiac)

A

Cefazolin OR
Cefuroxime OR
Vancomycin

Surgery (30 decks)

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