Dr. Smith preop lecture Flashcards Preview

Surgery > Dr. Smith preop lecture > Flashcards

Flashcards in Dr. Smith preop lecture Deck (47):
1

What does a preop eval allow you to do?

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

2

Advantages of pt education

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

3

Emergency

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

4

Urgent- examples

Intestinal obstruction
Appendicitis
Wounds

5

Elective surgery

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

6

What are the goals of the preop eval?

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

7

What is part of preop?

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

8

What specific questions and components should be asked?

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)

9

What should you look for in FHx?

Hypercoagulable disorders more prevalent than bleeding disorders
Malignant hyperthermia
Pseudocholinesterase deficiency

10

What to ask about in social hx?

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

11

How to do a PE

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

12

What does an emergency PE consist of?

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

13

What preoperative investigations should be performed?

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

14

When should you get a CBC?

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

15

When to get electrolytes and BUN/creatinine

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

16

When to get amylase/lipase

Anyone with suspected abdominal pathology

17

When to get glucose

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

18

When to get liver enzymes

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

19

When to get coagulation studies?

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

20

When to get a type and crossmatch

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

21

When to get pregnancy test

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

22

When to get CXR

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

When to get EKG

Age >50
Morbid obesity
Known cardiac dz

24

Major predictors of increased risk?

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

Intermediate predictors of increased risk

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

26

Minor predictors of increased risk

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

27

ASA grade I

Nl healthy individual

28

ASA grade II

Mild systemic dz that doesn't limit activity

29

ASA grade III

Severe systemic dz that limits activity

30

ASA grade IV

Severe systemic dz that is constant threat to life

31

ASA grade V

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

32

What are some assessment tools for cardiac?

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

33

What surgeries are considered high risk?

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

34

What surgeries are considered intermediate risk?

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

35

What surgeries are considered low risk?

Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery

36

How is DVT prophylaxis performed?

Done preoperatively and intraoperatively
Compression hose
Mechanical prophylaxis
Chemical prophylaxis

37

Class I surgical wound

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

Abx prophylaxis and class I

May not require prophylaxis unless a foreign body is inserted

39

Abx prophylaxis and class II

Single perioperative antibiotic given within 30 mins of incision

40

Abx prophylaxis and classes III and IV

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

41

Common abx for cardiac

Cefazolin
Vancomycin

42

Common abx for esophageal, gastroduodenal

High risk only: cefazolin

43

Common abx for biliary tract

High risk only: cefazolin

44

Common abx for colorectal

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

45

Common abx for GU

High risk only: ciprofloxacin

46

Common abx for neurosurgery

Cefazolin
Vancomycin

47

Common abx for thoracic (non-cardiac)

Cefazolin OR
Cefuroxime OR
Vancomycin