9. Perioperative care

Question 1

Postoperative risks

Answer 1

1) Bleeding (1-5%)
2) Arrhythmia (1-4%)
3) Wound infection (0,2-11%)
4) Pneumonia (0,1-7%)
5) Thromboembolism (0,1-5%)
6) MI (0,1-4%)
7) Stroke (0,1-4%)

Question 2

Perioperative timeline

Answer 2

1) Assessment, prepping
2) OR
3) Postoperative care

Question 3

Perioperative risks (complication)

Answer 3

1) Death (0-0,4%)
2) Brain damage (0,01-0,1%)
3) Nerve damage (0,01-1%)
4) Permanent dysfunction (0-10%)
5) Awareness (0,1-0,4%)

Question 4

Influencing factors in perioperative risk

Answer 4

1) Age
2) Comorbidities
3) Surgery type
4) Anesthesia method

Question 5

Preoperative risk assessment: person specific risks

Answer 5

• Medical history, physical assessment, lab
• ASA grade (likelihood for mortality)
• Intubation difficulty
• Risk of bleeding/thromboembolism
• Chronic illness

Question 6

Mallampati classification

Answer 6

Evaluation of the palate and throat prior to intubation

Question 7

Difficult airway algorhythm

Answer 7

1) Direct laryngoscopy -> tracheal intubation
2) If failed intubation: ILMA or LMA
3) Failed oxygenation: Revert to facemask -> oxygenation and ventilate
4) Failed oxygenation: LMA
5) Increasing hypoxemia: do cannula cricothyroidotomy or surgical cricothyroidotomy

Question 8

Assessment of PO risk: Obesity

Answer 8

• Perioperative risk increased (ASAII)
• Intubation difficulty, CVS, resp comp inc., infection
• BUT! Mortality doesnt increase (obesity paradox)

Question 9

Assessment of PO risk: Malnutrition

Answer 9

• Infections
• Dec. wound healing
• Pressure sores

Question 10

Assessment of PO risk: Smoking

Answer 10

• CVS, resp comp inc.,
• Impaired wound healing, infections more common
• Mortality inc
• Cessation right before surgery might worsen outcome (stop >2months prior)

Question 11

Preop prep.: Premedication

Answer 11

1) Chronic therapy adjustment
2) Anxiolysis - CVS risk reduc.
3) Preventive pain management - CVS risk reduc., postop compl. reduc.
4) Antacids - aspiration risk reduction
5) Thromboprophylaxis
6) Fasting

Question 12

Included in chronic therapy adjustment

Answer 12

1) Anti-HTN
2) Antidiabetics - change to contollable drug (insulin)
3) Antiepileptics - withdrawal seizure
4) Hormone supp. - Preset therapy
5) Psychogenic drugs - withdrawal vs. sedative effect

Question 13

Mortality rate in intraop. transfusion

Answer 13

80% in 10 year

Question 14

Antiplatelet therapy adjustments

Answer 14

1) Low bleeding risk -> double APT
2) Med. bleeding risk, low/medium cardiac risk -> continue ASA, stop clopidogrel (5 days)
3) Med. bleeding risk, high CVS risk, high stent thrombosis risk -> double APT is possible
4) High bleeding risk, low CVS risk -> continue ASA if possible
5) High bleeding risk, medium/high CVS risk, high stent thrombosis risk -> iv glycoprotein, IIb/IIIa inhibitor?

Question 15

Thromboprophylaxis in orthopedic surgery

Answer 15

Mechanical (IPC) and long term pharmacological LMWH (10-14), 35 days

Question 16

Thromboprophylaxis based on DVT probability

Answer 16

• Very low risk: early mobilisation
• Low risk: mechanical prophylaxis
• Med. or high risk: pharmacological or mechanical prophylaxis

Question 17

Fasting before surgery

Answer 17

• Clear liquid 2h
• Breast milk 4h
• Formula 6h
• Milk 6h
• Food 6h

Question 18

Risk reduction in CVS patients

Answer 18

• 6-8 w. prior to surgery
• Pharmacological: statins, betablockers
• Anesthetic: avoid hypothermia, avoid anemia, avoid hypotension

Question 19

Heart + lung transplant: CI recipient selection

Answer 19

• Tumor
• Other organ failures
• Infections
• Addictions
• Psychological/social issues
• Relative: >65 y, BMI >30, insuf. functional state