Chapter 32 - Preoperative evaluation

Question 1

American society of anesthesiologist classifications

Answer 1

ASA 1 = healthy good exercise tolerance ASA 2 = controlled medication without significant systemic effects ASA 3 = medical condition with systemic effects; functional compromise ASA 4 = medical condition with significant dysfunction; potential threat to life ASA 5 = critical condition, little chance of survival with or without surgery ASA 6 = brain death, organ donation

Question 2

AHA/ACC categorization of vascular surgery by type

Answer 2

Intermediate risk = CEA, EVAR High risk = every other major vascular surgery

Question 3

Cardiac testing not necessary before vascular surgery in these cases

Answer 3

1) Adequate functional capacity > 4 METs 2) coronary revasc within 5 years 3) normal coronary angio or stress test within 2 year

Question 4

Stepwise approach to perioperative cardiac assessment

Answer 4

FIGURE 32.1

Question 5

Cardiac implantable electronic devices and surgery

Answer 5

Monopolar electrocautery can cause problems need magnet

Question 6

POISE trial key point

Answer 6

beta blocker helps with reducing primary cardiac events high dose beta blocker in naive patients can be harmful

Question 7

DECREASE-IV trial

Answer 7

beta blockers started well before surgery titrating HR 50-70 is cardioprotective

Question 8

CARP trial

Answer 8

1) stable CAD 2) CABG or PCI does not improve long term outcomes 3) pre-op cardiac surgery cause increase procedure-related complication EXCEPT LM > 50% disease both LCX and LAD occlusion

Question 9

HTN before surgery

Answer 9

Delay if > 200 mmHg systolic > 120 mmHg diastolic delay elective Hydrate patient to prevent sudden hemodynamic shift

Question 10

Factors related with pulmonary complication

Answer 10

1) COPD 2) age > 60 3) ASA >2 4) functionally dependent 5) smoking 6) FEV < 1L 7) CHF 8) obesity

Question 11

Treatment for COPD and bronchospasm before surgery

Answer 11

1) inhaled bronchodilator 2) beta 2 agonist 3) anticholinergic start 5 days before surgery 4) steroids if FEV1 < 80%

Question 12

Lung expansion techniques

Answer 12

1) incentive spirometry 2) chest physical therapy 3) cough 4) postural drainage 5) ambulation 6) continuous positive airway pressure

Question 13

Treatment of hyperkalemia

Answer 13

1) Polystyrene binding resins 2) insulin with dextrose 3) calcium carbonate 4) IV bicarb 5) dialysis

Question 14

Problem with uremia

Answer 14

1) platelet dysfunction 2) increase incidence of perioperative bleeding

Question 15

Option to improve uremia-induced platelet dysfunction

Answer 15

1) dialysis 2) desmopressin 3) cryoprecipitate 4) conjugated estrogen 5) tsf RBC or platelet

Question 16

Methods to limit contrast-induced nephropathy

Answer 16

1) avoid contrast 2) use only non-ionic low osmolar agents 3) hydration with isotonic saline

Question 17

HbA1c and surgical complicadtions

Answer 17

< 7% decreases infection by 2.13x lower 30 day mortality

Question 18

Perioperative glycemic management with insulin key points

Answer 18

1) avoid alteration of long acting basal insulin day before surgery 2) reduce evening NPH to 75% day before surgery; only 50-75% morning of surgery 3) no prandial insulin when fasting 4) maintain glucose 100-180 mg/dl 5) for patients not insulin naive, use 60-80% of calculated daily insulin requirement based on last 6hr of iv insulin 6) if naive, use 50%

Question 19

Stress dosing of steroids key points

Answer 19

< 5 mg/day prednisone (4 mg methylpred, 0.5 mg dexamethasone, 20 mg hydrocortisone) for < 3 weeks = no intraop steroid coverage but keep taking doses > 20 mg/day prednisone = need supplement: 50 mg hydrocortisone intraop and then q8hr for 48-72 hours range 25 - 100 mg based on severity of surgery and taper back to home dose in 1-3 days

Question 20

Corticotropin stimulation test

Answer 20

250 mcg cosyntropin given IV or IM –> measure cortisol baseline then at 60 min plasma cortisol > 20 mcg/dl (552 nmol/l) at either time is adequate function

Question 21

Low dose stimulation test corticotropin

Answer 21

1 mcg cosyntropin IV and measure at baseline and 30 min plasma cortisol > 18 mcg/dl (497 nmol/l) = adequate funcdtion

Question 22

Recommendations for thromboprophylaxis in various risk groups

Answer 22

TABLE 32.2

Question 23

Patient with history of HIT anticoagulation method

Answer 23

if still have heparin antibodies then use alternative if no antibodies then heparin can be used again

Question 24

High risk patients needing bridging anticoagulation

Answer 24

1) mitral valve 2) caged/tilting disk aortic prosthesis 3) recent stroke/TIA (6 months) 4) CHADS 5-6 5) afib with rheumatic valve disease 6) VTE (3 months)

Question 25

LMWH and spinal or epidural

Answer 25

Prophylactic LMWH stopped 10 hours prior, resume 6 hours after therapeutic stopped 24 hr prior and restart 24 hr after

Question 26

Dabigatran before surgery

Answer 26

stopped 5 days before as per american society of regional anesthesia

Question 27

Level of albumin signifying malnutrition and risk of mortality

Answer 27

< 3.5 g/dl

Question 28

Weight loss before surgery in relation to increased mortality

Answer 28

5% in 1 month 10% in 6 month

Question 29

Albumin half life

Answer 29

18-21 days

Question 30

Condition for a legal action against physician to be successful

Answer 30

1) provider had duty to care for patient 2) duty of care was breached in deviation from standard 3) breach caused loss or damage to patient

Question 31

Key components of consent

Answer 31

1) date and time 2) diagnosis explained 3) risk/benefit of procedure explained 4) alternative explained 5) consent read by patient 6) opportunity to ask question 7) express understanding and wish to proceed