High risk surgery - % reported risk - surgeries

5% - emergent major surgery (esp old age) - aortic/major vascular surgery - large fluid shifts/blood loss

Intermediate risk surgery - % reported risk - surgeries

5% - CEA (Carotid endarterectomy) - Head/Neck - intraperitoneal/intrathoracic sx - orthopedic/prostate sx

- Optimize patients comorbidities - consults - specialized testing - further work up

- correlated with latex hypersensitivity Banana, avocado, kiwi, chestnut, plum, peach, cherry, papaya, tomato, potato, fig, apricot

Exam 1 L1 Flashcards by Rachel Unknown

Most stressful part of anesthesia

Induction

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2 main factors for surgical specific risk

Type of surgery

2. Degree of hemodynamic stress

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Other surgical specific risk factors

Duration of surgery
Age of patient
Comorbidities

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Risk of complications related to time of surgery

60% risk of 16+ hours in surgery

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High risk surgery

% reported risk
surgeries

emergent major surgery (esp old age)
aortic/major vascular surgery
large fluid shifts/blood loss

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Intermediate risk surgery

% reported risk
surgeries

<5%

CEA (Carotid endarterectomy)
Head/Neck
intraperitoneal/intrathoracic sx
orthopedic/prostate sx

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Low risk surgery

% reported risk
surgeries

<1%
- endoscopic/superficial
Cataract/breast surgery

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Non-operative or less invasive tx

Defer surgery

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Delay surgery

Optimize patients comorbidities
consults
specialized testing
further work up

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Individual hx of anesthesia problems

PONV
PDPH
difficult intubation

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Food allergies

correlated with latex hypersensitivity

Banana, avocado, kiwi, chestnut, plum, peach, cherry, papaya, tomato, potato, fig, apricot

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Pt under influence - plan for surgery?

Delay or cancel elective surgery

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Pt - EToh Hx

D/c within 4weeks

Decreases risk of arrhythmia, infxn, w/d

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Pt hx smoking

Minimum d/c 12-48h prior to surgery D/c 8weeks prior: decreases risk of PNA, atelectasis

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AEs of smoking

CVS & O2 carrying to tissues impaired

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Labs needed - day of surgery

Renal fxn tests, lytes, starting HCT, platelets
Beta HCG - all women of childbearing age
Coags (hx bleeding/bruising (Rx))

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Which patients require X-RAY on day of surgery?

Trauma, CHF, COPD

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Clinical Predictors of increased periop CVS - Major risk

Unstable coronary syndrome
Decompensated HF
Significant arrhythmias
Severe Valvular dx

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Unstable coronary syndromes associated with increased periop CVS risk

Acute (>7d) or recent MI (<3 months) with evidence of ischemic risk
Unstable severe angina

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Significant arrhythmias associated with increased periop CVS risk

High grade AV block: Mobitz II, 3rd degree block
Symptomatic ventricular arrhythmia
SVT uncontrolled rate
afib RVR

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Clinical Predictors of increased periop CVS - intermediate risk

Mild angina pectoris 
Previous MI (>3 months) by hx pathological Q waves
Compensated or prior heart failure
DM (esp insulin dependent)
Rena insuff. (creatinine > 2)

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Clinical Predictors of increased periop CVS - Minor risk

Advanced Age
Abnormal EKG (other than sinus)
Low functional capacity (can’t climb flight of stairs)
Hx stroke 
Uncontrolled systemic HTN

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Definition of one MET

The amount of oxygen consumed while sitting at rest and is equal to 3.5 mL per kg body weight per min

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METs above 4

Able to climb a flight of stairs, dancing, bicycling

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Accounts for 1/2 all periop deaths

Cardiovascular disease

Associated with postop MI + mortality

Degree of preop HTN

HTN defined as

BP > 140/90

Prevalence HTN

25% adults | 70% adults > 70

METs above 9

Able to swim quickly, run, or jog briskly

Delay surgery for severe HTN

Delay elective surgery: SBP > 200; DBP >115

Proceed with elective surgery for severe HTN

SBP <180; DBP < 110

Conditions under which surgery should be postponed

``` *if possible Active cardiac conditions -unstable coronary syndromes (severe/unstable angina, MI) -decompensated HF/new onset -significant arrhythmias -severe valvular dx (severe AS/MS) ```

Risk factors that increase periop ischemic events

- ischemic heart disease - HF - TIA/stroke - DM - renal insufficiency

Stent placement - bare metal

Postpone (elective) < 30 days | Urgent - continue dual antiplatelet therapy

Stent placement - Drug eluding

Postpone (elective) < 1 year *if proceeding —> consult cardiology Urgent - continue dual antiplatelet therapy

Decompensated heart failure

“Suffocating” or “air hungry”

NYHA Class III & IV - proceed/delay/cancel elective procedures?

Postponing

Aortic Stenosis - proceed/delay/cancel elective procedures?

Severe/critical: Preclude (do not let it happen) non-cardiac surgery *unless life saving emergency Echo recommended

Risks associated with aortic stenosis

40% increased MI risk | 50% increased CV death

Symptoms associated with aortic stenosis

``` Angina Heart failure Syncope Decreased ET Exertional dyspnea ```

Risks associated with aortic insufficiency

Well tolerated in periop | ECG needed

S/S aortic insufficiency

Widened pulse pressure

S/S associated with mitral stenosis

H/o rheumatic disease | Dyspnea, fatigue, orthopnea, pulm edema, he opts is, afib, pHTN

Risks associated with mitral stenosis

N/A | Echo + ECG necessary

Risks associated with mitral regurgitation

Acute: ischemia + infarction Chronic: mitral stenosis, MVP, cardiomyopathy chronic - well tolerated periop ECG/echo may be necessary

Risks assoc. with mitral valve prolapse

N/A Also known as late systolic click murmur Common in women

Present in 70% of adults

Tricuspid regurgitation *often occurs with mitral regurgitation Asymptomatic/not audible on exam

Pts with syncope on exertion/family h/o sudden death - surgical prep?

ECG

Associated with higher risk of periop adverse events

SVT, ventricular arrhythmias

High risk clinical indicators to postpone elective surgery

Uncontrolled afib/vtach

Management of cardiovascular implantable electronic devices

Disable/set to asynchronous mode if any chance of interference with surgical procedure

Interference likely with cardiac implantable device

Electrocautery Radio frequency ablation MRI Radiation therapy

Intraoperative management of ICDs

All procedures above umbilicus that use electrocautery or radiofrequency ablation Apply magnet over device remove magnet after procedure, assess device postop

Risk of pulmonary problems

Smokers, COPD, obesity, > 70 y/o, thoracic or upper abd surgery, anesthesia > 2h

BMI

(Weight kg / height cm^2) x 10^4 | Example: (52/152^2) x 10,000 = 22

High risk OSA

3 or more: Stop (snoring, tired, observed(stop breathing), bP BANG (BMI >35, age > 50, neck circum > 40, gender:m)

Low risk OSA

<3 Stop (snoring, tired, observed(stop breathing), bP BANG (BMI >35, age > 50, neck circum > 40, gender:m)

ASA physical status classification

1. Healthy 2. Mild systemic dx, no fxn limitations 3. Severe systemic dx + fxn limitations 4. Severe systemic dx + constant threat to life 5. Moribound pt not expected to survive w/o operation 6. Brain dead, organs to be harvested

NPO - clear liquids

Up to 2 hours before surgery

NPO - breast milk

Up to 4 hours before surgery

NPO - light meal or non-human milk

Up to 6h before surgery

NPO - heavy meal

8 hours or more before surgery

Lethal triad

Hypothermia, Acidosis, + coagulopathy | *refers to coagulopathy assoc. with massive hemorrhage/injury

Sepsis requirement

SIRS + identifiable source of infxn

Endothelium is permeable to _____ solutions

Isotonic + hypotonic

Major issue in pts with CARS

susceptible to nosocomial infxns | Compensatory anti-inflammatory response syndrome

Tx - hemorrhage

1. Limit crystalloid use 2. Optimal transfusion: MTP 1:1:1 (FFP: PLT: RBC) 3. TXA 1g over 10 mins, then 1g over 8 hours

Hyperdynamic shock

Sepsis | Traumatic

Common denominator in both sepsis + trauma

Systemic inflammation

Most heat loss occurs

During first 40 minutes of case | *decrease FGF

Steroid supplementation should be considered for

Anyone receiving steroid supplementation (even topical) over past year

Universal donor blood

O negative

Naturally occurring colloids

Albumin + FFP

Pt population that should not receive albumin

TBI

SSI - infection to spaces near operation within

30 days of surgery

Blood cannot be given with

LR (d/t calcium = clotting)

Prophylactic antbx should be given

Within the 60 minutes prior to surgical incision

First rule of transport

Patient must be stabilized prior to transport