Pre-op Risk Assessment

Question 1

Endoscopy, cataract, plastics, breast.

What is the risk of these procedures? - low/mod/high

Answer 1

Low

Question 2

Head and neck, abdominal, orthopedic, prostate

What is the risk of these procedures? - low/mod/high

Answer 2

Moderate

Question 3

Aortic and vascular, peripheral vascular, cardiothoracic, emergent

What is the risk of these procedures? - low/mod/high

Answer 3

High

Question 4

How long should you wait to do non-cardiac surgery on someone who recently had an MI

Answer 4

> 60 days should elapse before non-cardiac surgery

Question 5

In heart failure, what has the strongest association with MACE (major advserse cardiac events)?

Answer 5

3rd heart sound and JVD

Risk is greatest with diastolic dysfunction

Question 6

A patient for preop eval has mod-severe valvular stenosis or regurgitation. What evaluation should you ensure they have complete?

Answer 6

Echo if:

• no echo within last year
• clinical changes
• unknown cause of dyspnea

Question 7

What is the definition of 1 MET (metabolic equivalent)

Answer 7

1 MET = resting or basal O2 consumption of 40-year-old, 70 kg man

Question 8

Definition of < 4 METs

Answer 8

poor function capacity (slow ballroom dancing, golfing with cart, playing musical instrument)

Question 9

Definition of 4-6 METs

Answer 9

moderate functional capacity (climbing flight of stairs, walking up hill, heavy housework)

Question 10

Definition of 7-10 METs

Answer 10

good functional capacity (mod-vigorous exercise)

Question 11

Definition of > 10 METs

Answer 11

excellent functional capacity (vigorous exercise)

Question 12

What does the ACC/AHA perioperative guidline recommend in the following case:

Known CAD and emergency situation

Answer 12

Proceed to surgery with appropriate monitoring

Question 13

What does the ACC/AHA perioperative guidline recommend in the following case:

Urgent or elective surgery

Answer 13

Refer to cardiology

Question 14

What does the ACC/AHA perioperative guidline recommend in the following case:

stable CAD
low risk surgery

Answer 14

no further testing required

Question 15

What does the ACC/AHA perioperative guidline recommend in the following case:

stable CAD
Moderate-risk surgery
METs > 4

Answer 15

no further testing required

Question 16

What does the ACC/AHA perioperative guidline recommend in the following case:

stable CAD
moderate risk surgery
METs < 4

Answer 16

increased risk of MACE and further testing indicated

Question 17

What does the ACC/AHA perioperative guidline recommend in the following case:

stable CAD
high risk surgery

Answer 17

proceed to further testing

Question 18

In which situations should stress testing be considered in pre-op eval?

Answer 18

• high risk procedures

- pts with elevated risk and poor or unknown functional capacity

Question 19

What are risk factors for pulm complications that might indicate need for pre-op CXR?

Answer 19

• COPD
• CHF
• functional dependence
• hypoalbuminemia
• emergency or prolonged procedure
• surgical sites close to diaphragm: involving thorax, upper abd, AAA

Question 20

How long should pts quit smoking prior to surgery?

Answer 20

2 months

8 weeks

Question 21

When should you get pre-op UA?

Answer 21

only for implantation fo foreign material (hip replacement, heart valve) or urologic procedures

Question 22

What preop eval should is a specific consideration for pts with rheumatoid arthritis?

Answer 22

C spine XR for atlanto-axial sublucation prior to intubations

• prevent spinal cord injury during intubation

Question 23

Goal blood sugar level for perioperative time period

Answer 23

140-180 mg/dL

Question 24

Should statins be continued in peri-op period?

Answer 24

ABSOLUTELY YES

may be reasonable to start them 4 weeks prior in pts who will have vascular surgery

Question 25

Should Beta blockers be continued in peri-op period?

Answer 25

Yes continue them

careful with initiation 1 week prior to surgery

Question 26

How long should you hold aspirin prior to surgery?

Answer 26

POISE-2 trial

• stop 5-7 days prior to surgery
• safety fo stoping in pts with prior MI still questionable so may continue in these pts

Question 27

Should DAPT be held prior to surgery?

Answer 27

DAPT should be continued if possible when

• <4-6 wks after bare metal stent
• < 1 year after DES

If must be stopped continue aspirin

Question 28

How should you manage pre-op warfarin in pt with lower thromboembolic risk?

Answer 28

• Stop warfarin 5 days pre-op
• If INR 1.5-1.9 can stop 3-4 days prior
• restart postop when taking PO

Lower risk =

• A fib with no CVA or embolism in last 12 months
• biologic heart valve > 3 months out
• vascular gract
• DVT > 3 months out and not hypercoagulable
• no current systemic arterial embolism

Question 29

How should you manage pre-op warfarin in pt with higher thromboembolic risk?

Answer 29

• stop warfarin 4 days preop and start LMWH
• stop LMWH 12-18 hrs preop
• restart LMWH 6 hours postop
• restart warfarin when able to take PO
• stop LMWH when INR = 2.0