Approach to the Surgical Patient: Preoperative Care Flashcards
(87 cards)
1
Q
Phases of Surgical Management
A
- Preoperative Care
- Preoperative Evaluation – complete H&P
- Diagnostic Work-Up -pertinent labs/imaging
- Preoperative Preparation – education/medication/optimization
- Operative Care and Anesthesia
- Postoperative Care
2
Q
3 purposes of a general health assessment
A
- identify risk
- dictate what other diagnostic procedures, consultations, etc. need to be addressed before surgery
- Diagnostic tests and labs needed vary depending on pt health assessment findings AND surgical procedure - identify other conditions that need to be treated before surgery
3
Q
Most common presenting symptoms for general surgery
6
A
- Pain / Claudication
- N/V/hematemesis
- Change in bowel habits / blood in stool
- Lump or mass
- Injury / Trauma
- Numbness / Weakness
4
Q
difference between elective/urgent PE vs emergent PE?
A
Elective/Urgent - Complete Physical Exam
- At minimum: general survey, CV, Resp, Abd, Ext.
- More as needed depending on CC.
Emergent - Focused Physical Exam
- ALWAYS perform Airway Assessment, Heart, Lungs, Abdomen
5
Q
components of abdominal PE
A
- Inspection
- Auscultation
- Palpation - light and deep
- Special Tests and Signs
- McBurneys point
- Rovsing Sign
- Murphy’s Sign
- Obturator Sign
- Psoas Sign
6
Q
how/what to assess for abdominal masses?
A
- Soft, hard, fluctuant
- Tender vs non tender
- Reducible vs non reducible
- Pulsatile
- Organomegaly
7
Q
No abdominal exam is complete without ?
A
rectal exam
8
Q
components of a rectal exam
A
- Palpate for rectal masses, prostate masses in men
- Patient should be on their side, knees flexed, 360 degree palpation of rectum - Hemoccult test
- Assesses for the presence of occult blood
9
Q
components of a breast exam
A
- Inspection - asymmetry, discoloration, dimpling of skin
- Palpation - masses, areas of tenderness, nipple discharge
- Masses
- Location
- Size
- One or multiple
- Mobile or Fixed
- Firm or Hard
- Nodular or Smooth
- Tender or Nontender
10
Q
what are the 3 positions for a breast exam?
A
- sitting or standing with both arms down and relaxed on each side
- sitting or standing with both arms held up overhead
- laying flat on back with arm of breast being examined placed overhead
11
Q
Where is most common site for breast malignancy?
A
Left breast, upper right quadrant
12
Q
how to exam the extremities?
components
A
- Inspection - color, hair, dryness (scaly), muscle tone, lesions/ulceration
- Skin temperature
- Sensory testing
- Peripheral pulses - palpation/handheld doppler US
- Ankle-Brachial Index (ABI)
13
Q
what are some s/s of RF for PAD?
A
- Smoking.
- High blood pressure.
- Atherosclerosis.
- Diabetes.
- High cholesterol.
- Age above 60 years.
14
Q
what assesses if the pt needs a stent or bypass?
A
ABI
ABI = < 0.9 or > 1.4
15
Q
Laboratory examinations in surgical patients have the following objectives:
Preoperative Testing
A
- Screening for asx disease that may affect the surgical result (eg, unsuspected anemia or DM)
- Appraisal of diseases that may CI elective surgery or require tx before surgery (eg, DM or HF)
- Diagnosis of disorders that require surgery (eg, hyperparathyroidism or pheochromocytoma)
- Evaluation of nature and extent of metabolic or septic complications
16
Q
Diagnostic Tests to Consider for preop testing
A
- Labs - CBC, CMP, PT/INR/PTT, BHCG
- Imaging - Plain films, U/S, CT, MRI/MRA
- ECG
- ECHO
17
Q
INR needs to be
?
for elective surgery
A
< 1.5
18
Q
what conditions would prompt you to order an EKG
A
pt with known CAD, arrhythmia, PVD, cerebrovascular disease, structural heart disease or pt undergoing intermediate/high risk surgery.
any known heart problem
19
Q
what conditions would prompt you to order a CXR
A
pt with cardiopulmonary disease or pt ≥50 undergoing AAA sx or upper abdominal/thoracic sx.
any abdominal or thoracic
20
Q
what would prompt you to order labs (CBC, CMP, PT/PTT) for preoperative testing?
A
- ASA recommends against routine screening in healthy pts.
- Acceptable to use labs in the last 4 mo.
21
Q
all pre-menopausal women should get what lab?
A
BHCG
22
Q
Components of the General Health Assessment
Special Considerations for Surgical Pts
A
- Physiologic Age Assessment
- Nutritional Assessment
- Assessment
- assessment of immune competence
- wound healing assessment
- hemostasis assessment
- thromboembolism assessment
- pulmonary function assessment
- CV risk assessment
23
Q
what are functional METs?
A
assessed based on Physiologic Age
- 1 MET: basic ADLs, eat, dress, go to bathroom
- 4 METs: can walk up small incline, single flight of stairs, walks at 3-4mph on level ground
- 5-10 METs: heavy house work, scrubbing floors, climbing stairs
- > 10 METs: participates in sports, swimming, skiing
24
Q
What METs activities w/o sx is thought to be a good prognostic indicator?
A
4 METs
25
how can malnutrition affect surgery during a nutritional assessment?
1. Increases operative death rates
1. Increases infection rates
1. Prolongs recovery time
1. May require pre and/or postoperative hyperalimentation
- Some may require tube feeds
- Protein shakes
26
how to assess nutrition?
| 3
1. Question about wt loss
1. Question about diet and eating habits
1. Labwork: CBC with diff, serum albumin/prealbumin, vitamin B12
27
Greatest risk associated with weight loss what percent of baseline?
> 10%
28
This condition/finding is common in cancer patients and those with intestinal disorders
malnutrition
29
risks of obesity affect surgery?
Increase risk for:
* Post-op infections and wound complications
* Cardiopulmonary complications
* DVT
* Concomitant chronic diseases
30
risks of being underweight affect surgery?
Increase risk for:
* Malnutrition/vitamin deficiencies
* Delayed wound healing
* Concomitant chronic diseases
31
If surgery is non emergent strong efforts for what are encouraged before procedure?
| hint: nutrition
weight loss (or weight gain)
32
Factors that can impair immune function and increase risk of infection:
* Malnutrition
* Elderly patients
* Severe trauma and burns
* Cancer
* Certain medications (corticosteroids, prolonged abx use, immunomodulators)
* Uncontrolled DM
* CKD
33
Risk Factors Leading to Delayed Wound Healing
1. Malnutrition
1. Anemia
1. Marked dehydration
1. Marked edema
1. Poorly controlled DM
1. Smoking
1. Radiation
1. Meds - Corticosteroids, Chemotherapy
1. CV disease - CHF, Arrhythmias, PAD
there has to be adequate blood supply to the tissue.
34
Hx of hemostasis assessment
1. Any h/o bleeding tendencies
- Epistaxis
- Gingival Bleeding
- Easy Bruising
- Menorrhagia
- Excessive bleeding with other surgeries/injury
2. FHX bleeding disorders
- Hemophilia
- Von Willebrand Disease
3. Drug hx
- ASA, NSAIDS, Clopidogrel, Warfarin, Pradaxa, Xarelto
35
what PE finding are you searching for during a hemostasis assessment?
Ecchymosis
36
Hemostasis Screening Work up Includes ?
PT/INR, PTT and CBC
37
RFs to be aware of in Thromboembolism Assessment
1. Prior history of DVT or PE
1. Cardiac conditions (A. fib)
1. Cancer patients
1. Smokers
1. Drug History - OCP’s
1. Obesity
1. Advanced Age
1. Sedentary condition
1. h/o clotting disorders
- Lupus anticoagulant
- Protein C/S deficiency
- Factor V Leiden
38
Factors that impair pulm function increase risk of postop pulm complications
RF/Hx:
* Heavy Smoking
* SOB/DOE
* Chronic cough
* Pulmonary Diseases
* COPD
* Asthma
* Restrictive Lung Diseases
* Obstructive Sleep Apnea
PE:
* Heavy Smoking
* SOB/DOE
* Chronic cough
* Pulmonary Diseases
* COPD
* Asthma
* Restrictive Lung Diseases
* Obstructive Sleep Apnea
39
work-up in pulmonary function assessment
* CXR, ECG
* ABG- poorly controlled COPD
* PFTs-undiagnosed DOE, COPD/Asthma not at baseline
40
how to screen for OSA?
STOP-Bang questionnaire
at increased risk for post op complications: atelectasis, aspiration, resp failure, cardiac event, post op delirium, reintubation, prolonged hospital stay and even death.
41
Used to determine risk of postoperative pulmonary complications
ARISCAT Calculator
42
Preoperative Preparation for compromised pulmonary function:
1. Abstinence from/quit smoking (ideally **8 wks before procedure**)
1. Optimize chronic issues
- Bronchodilators (Inhalers, Nebulizers)
- Chest physiotherapy (percussion, vibration, postural drainage)
1. Pre-op/post-op supplemental O2
43
Preoperative treatment with ____ can significantly decrease incidence of surgical site infections
high flow oxygen therapy
44
Postoperative Pulmonary Complications Include:
* Atelectasis
* Hypoxia
* Pneumonia
* Respiratory Failure
* PE
45
Increased Risk of Perioperative Cardiac Complications Associated with:
1. Patients with known cardiovascular disease
1. Symptomatic pts who have not been diagnosed w/ cardiac disease - Chest pain, palpitations, DOE, syncope
1. Advanced age
1. Smokers
1. Obesity
1. Concomitant Chronic Medical Conditions
46
during a CV risk assessment, what is associated with a very low surgical cardiac risk
Absence of sx and good functional assessment
47
components of the Assessment of Cardiac Function
1. Hx: sx, METs
2. PE: BP, heart auscultation, carotid auscultation
3. diagnostic work-up: ECG, echo, stress test, carotid doppler
48
Major Predictors of cardiac complications
| AHA/ACC Guidelines
* Recent MI (within 6 months)
* Unstable angina
* Recent PCI
* Active CHF
* V. Tach, AV Blocks
49
Intermediate Predictors for cardiac complications
* CAD
* Stable angina
* Remote MI
* Compensated CHF
* Renal Insufficiency
* DM
* CVD
* Obesity
50
minor predictors for cardiac complications
A. fib
Age > 70
Abnormal EKG findings
LVH, LBBB
Poorly controlled HTN
51
2 ways to calculate surgical risk depends on the type of procedure
* ACS NSQIP Calculator
* Revised Cardiac Risk Index (RCRI)
52
what is the NSQIP
Risk stratification; Takes into consideration 20 pt factors as well as the surgical procedure being performed
53
AHA/ACC Guidelines - CV Management
* No cardiac sx, OR mild cardiac symptoms with good functional capacity undergoing low risk surgery - NO WORK UP NEEDED
* Low risk (+1 minor predictors) - ECG
* Intermediate risk (1-2 intermediate predictors) and/or intermediate risk surgery – ECG, pertinent labs
* High risk (+3 intermediate predictors) or those undergoing high risk surgery - ECG, labs, ECHO, cardiac consult
* Very High risk (+1 Major predictors) - cardiac consult - surgery postponed until condition can be stabilized (unless emergency)
54
4 components of the preop preparations
1. Pre-anesthesia assessment
1. Medical Clearance/Consultations
1. Patient Education/Preoperative Orders
1. Informed Consent/Operative Permit
55
All Anesthetics cause:
* CNS depression/loss of consciousness
* Respiratory Depression
* Cardiac Depression
56
what is PreAnesthesia Testing (PAT) or PreAnesthesia Care (PAC)?
1. Pt seen the week before surgery - Low Risk Surgery or Low Risk Patient, can be performed day of surgery
2. Preop labs and diagnostic tests ordered by surgeon performed
3. Evaluated by healthcare provider (PA/NP) *AND* anesthesia provider (CRNA/anesthesiologist)
- PA/NP performs H&P
- Anesthesia provider reviews and performs airway examination/classification and counsels on anesthetic approach
3. Operative and anesthesia consents are signed
57
What is the ASA classification?
PreAnesthesia Assessment:
ASA I - healthy
ASA II - mild systemic disease
ASA III - severe systemic disease
ASA IV - severe systemic disease that is a constant threat to life
ASA V - moribund pt whois not ecpected to survive w/o the operation
ASA VI - brain-dead
58
Airway Assessment Components
1. Neck ROM
1. Neck circumference
1. Mouth opening/jaw protrusion
1. Dentition
1. Mallampati Classification - oropharyngeal assessment used to predict ease of intubation
59
name each class of the Mallampati score
* Class I - complete visualization of soft palate
* Class II - complete visuzalization of uvula
* Class III - visualization of only base of uvula
* Class IV - soft palate not visible at all
60
MC medical clearances
* Cardiac clearance
* Pulmonary clearance
* Medical clearance (DM, CKD, etc)
* Social Worker if patient will require special help or arrangements postoperatively
Either the surgeon or anesthesiologist may require pt to obtain medical clearance prior to surgery
61
components of informed consent
* Is this surgery necessary?
* Are there other options?
* What are the risks and benefits with each option?
* What are the side effects?
62
parts of the operative consent
* Must include brief description of the surgery/operative process
* Must include reason surgery is indicated
* Must include alternatives to surgery
* Must include risks of surgery
* Must include benefits of surgery
* Must be signed by patient or legal medical POA
* Must be signed by provider reviewing consent
* Must be signed by witness
63
parts of the anesthesia consent
* Must include brief description of the anesthesia process
* Must include different types of anesthesia and type of anesthesia that is being used for this surgery
* Must include risks associated with anesthesia
* Must be signed by patient, anesthesiologist, and witness
64
PreOperative Instructions
1. NPO after midnight before surgery
2. Medications
- Provide list of what medications (OTC & herbals) to stop and how long, and what medications they can take morning of surgery
- New “premedications” ordered before surgery with instructions
3. Patient prep
- Some procedures may require specific prep
65
Medications to Continue on Day of Surgery
1. CV - BB, ACE, CCB, Nitrates, Clonidine, antiarrhythmics, digoxin
1. Anticonvulsants - Phenytoin, Tegretol
1. Anti-Parkinsons - Sinemet
1. Lithium
1. Asthma/COPD - singulair, theophylline, inhalers
1. Thyroid - Synthroid
1. OCP’s
1. BPH - Terazosin
1. GERD - Prilosec, Prevacid, Zantac
66
Medications to Take up until the Day Before Surgery
1. Cholesterol - Statins
1. Diuretics - Lasix, HCTZ
1. Antidepressants - SSRI’s, TCA’s
1. Antianxiety - BZD
1. Insulins - adjustments made to PM doses
- Check AM glucose - if OK - skip AM dose
- If elevated, take 1/2 usual dose of intermediate/LA
- **Do not take SA insulin morning of surgery**
1. Oral Hypoglycemics - Metformin, Glucotrol
1. Opioids - Hydrocodone, Oxycodone
*Depending on situation, may allow to take anxiety meds/opioids day of surgery
67
Medications to Stop Before Surgery (typically 5-7 days before surgery)
1. Oral anticoagulants –Coumadin, Plavix, Pradaxa, Eliquis, Xarelto, ASA
- Off 2 days w/ Pradaxa
1. NSAIDS
1. OTC vitamins containing Vitamin E
1. Most herbal preparations
68
What if they need emergent surgery and they are on anticoagulants?
Reversal agents
69
Increased surgical risks with DM
Infections, delayed wound healing, cardiopulmonary events, electrolyte disturbances, renal insufficiency
70
Preoperative Work-Up for DM
1. Complete H&P/General Assessment
1. Diagnostic Work-Up if indicated - ECG, CXR, UA, CMP, CBC, blood glucose monitoring
1. Medical Clearance/Consultation
1. Patient Education – be sure they understand how to take their medication
71
Goal for DM before surgery?
tight glucose control
* Hyperglycemia - Trauma, illness, physical & emotional stress can elevate blood glucose
* Hypoglycemia - Preoperative fasting and preps
**Must check blood glucose (fingerstick) AM of surgery**
72
Perioperative Management for DM
1. Sliding scale insulin
1. Often require longer postop observation period
1. Resume regular medications once normal diet is tolerated and glucose levels stable - Often in consultation with Medical Service
73
risks associated with operating on a patient with thyroid disease?
Hyperthyroidism
* Thyrotoxicosis and Thyroid Storm
* Hypertension
* Cardiac Arrhythmias
* Congestive Heart Failure
* Hyperthermia
* Airway difficulty with goiters
Hypothyroidism
* Myxedema coma
* Acute hypotension
* Hypothermia
* Shock
* Hypoventilation/CO2 retention
* Poor wound healing
74
Preop management for hyperthyroidism disease
1. **Propylthiouracil (PTU)** x 1-6 wks
2. For Emergency surgery:
- **BB (Propranolol)**
- Potassium iodide
3. Monitor TSH levels!
75
preop management for Hypothyroidism
* **Levothyroxine** (Synthroid)
* Monitor TSH levels!
76
risks of Adrenal Insufficiency
with surgery?
1. **Addisonian Crisis** - triggered by illness and/or stress of surgery
- Hypovolemia, Hypotension, Shock, Death
1. Increase Risk of infection
1. Delayed Wound Healing
1. Electrolyte abnormalities
1. Blood glucose abnormalities
Risk remains present during entire perioperative period!
77
Preoperative management for Adrenal Insufficiency
1. Should be admitted 1-2 days preoperatively for IV fluids, sodium replacement and cortisol therapy
- **IV or IM cortisol injections** continued throughout the surgery and postoperative period.
2. Diagnostic Work-Up
- BMP (monitor electrolytes throughout perioperative period), cortisol levels, glucose levels
- **Electrolyte abnormalities should be corrected prior to surgery**
3. Medical/Endocrinology Consultation
4. Corticosteroids may be required for acute flare
- Associated with greater risks for:
--- More severe electrolyte abnormalities/Hyperglycemia
--- Hypertension
--- Postoperative Infections
--- Renal problems
78
risks with surgery in Pulmonary Disease
| Asthma, COPD, Restrictive Lung Disease, OSA
1. Hypoxia
1. Hypercapnia (esp. with COPD)
1. Pneumonia
1. Bronchospasm/Laryngospasm (esp. with Asthma)
1. Prolonged extubation/Difficulty waking up
1. Increased risk for continued post-operative ventilation
1. Respiratory Failure
79
FEV1 of what percent is associated with high rate of pulmonary complications
< 50%
80
mangement for pulmonary disease after surgery
* **Any acute pulmonary disease should be treated prior to surgery**
* Obtain good control of disease/treat any exacerbations before surgery
* Smoking Cessation - quit/abstain for 8 weeks prior to procedure
* Peak flow / Preoperative Incentive Spirometry
81
what is the most common cause of perioperative death
MI
82
warrants more thorough workup when assess cardiac risk factors?
**One or more Cardiac RF** in a pt undergoing an _intermediate/major surgery_ with **elevated NSQIP score** and **low METs** warrants more thorough workup
83
management for patients with cardiovascular disease after surgery
1. HTN treated and within normal limits
1. pt to continue CV meds throughout perioperative processes
- BB typically continued during surgery
1. Any new cardiac factors found on testing should be treated BEFORE surgery
1. If PCI - specified amount of time must elapse before safe to do elective surgery
- Angioplasty alone: 2-4 wks
- Angioplasty with metal stents: 4-6 wks
- Angioplasty with drug-eluting stent: 1 year
1. MVP / Prosthetic heart valves - endocarditis prophylaxis: Amoxicillin 2 gm single dose 30 - 60 min preop (Strep. viridans)
1. Acute exacerbations of CHF - should be tx *PRIOR* to surgery
1. Pacemakers/Defib - must have been checked within 3 - 6 mo prior to surgery
84
Antibiotic endocarditis prophylaxis is reserved for ?
Pts at high risk for IE and only for those procedures that have higher likelihood of bacteremia
85
Patients at risk for endocarditis prophylaxis
* Prosthetic heart valves
* Prior endocarditis
* Cyanotic congenital heart disease (unrepaired, repaired, or partially repaired)
* Cardiac transplantation recipients who developed cardiac valvulopathy
86
Dental Hygiene is important for what type of sugery procedures?
CV
87
what is the most common source of spontaneous bacteremias
gingivitis
