Nagelhout Chapter 20 Flashcards
1
Q
What are the main goals of preoperative assessment?
A
Identify anesthesia-related risks, optimize patient condition before surgery, and predict and reduce surgical complications.
2
Q
What is the Preanesthesia Assessment Clinic (PAC)?
A
The most effective way to provide comprehensive preoperative evaluation in a single visit.
3
Q
What are the benefits of the PAC?
A
Reduces patient anxiety & direct costs, lowers last-minute surgery cancellations, shortens hospitalization, decreases unnecessary testing, and improves patient education.
4
Q
What key services are provided at the PAC?
A
Patient registration & medical history collection, physical examination & patient education, scheduling consultations & preoperative testing, and ensuring compliance with surgical and anesthesia guidelines.
5
Q
What is a goal related to perioperative risks?
A
Minimize perioperative risks by assessing and mitigating anesthesia-related factors.
6
Q
What should be determined to prevent surgical delays?
A
The appropriate setting for surgery (ambulatory, inpatient, ICU).
7
Q
What should be assessed regarding medical conditions?
A
The need for further investigations & specialty consultations and optimizing preexisting medical conditions (e.g., smoking cessation, weight management).
8
Q
What preoperative preparation instructions should be provided?
A
Instructions on fasting, glucose management, and medication guidelines.
9
Q
How can patient anxiety be reduced?
A
Educate patients on anesthesia, surgery, and postoperative expectations.
10
Q
What general medical conditions benefit from early preoperative evaluation?
A
Medical conditions inhibiting ability to engage in normal daily activity; conditions necessitating continual assistance or monitoring at home within the past 6 months; admission within the past 2 months for acute episodes or exacerbation of chronic condition; use of medications (e.g., anticoagulants or monoamine oxidase inhibitors) for which modification of schedule or dosage might be required.
11
Q
What cardiocirculatory conditions should be evaluated preoperatively?
A
History of angina, coronary artery disease, myocardial infarction, symptomatic arrhythmias; history of cardiac rhythm device requiring interrogation or reprogramming; poorly controlled hypertension (diastolic >110 mm Hg, systolic >160 mm Hg); history of congestive heart failure.
12
Q
What respiratory conditions warrant early preoperative evaluation?
A
Asthma or chronic obstructive pulmonary disease requiring chronic medication; acute exacerbation and progression of these diseases within the past 6 months; history of major airway surgery, unusual airway anatomy, or upper or lower airway tumor or obstruction; history of chronic respiratory distress requiring home ventilatory assistance or monitoring.
13
Q
What endocrinologic conditions should be considered for preoperative evaluation?
A
Diabetes treated with insulin or oral hypoglycemic agents (unable to control with diet alone); adrenal disorders; active thyroid disease.
14
Q
What hepatic condition is relevant for early preoperative evaluation?
A
Active hepatobiliary disease or compromise.
15
Q
What musculoskeletal conditions should be evaluated preoperatively?
A
Kyphosis or scoliosis causing functional compromise; temporomandibular joint disorder with restricted mobility; cervical or thoracic spine injury.
16
Q
What oncologic conditions warrant early preoperative evaluation?
A
Patients receiving chemotherapy; other oncological processes with significant physiologic compromise.
17
Q
What gastrointestinal conditions benefit from early preoperative evaluation?
A
Obesity (BMI of 35 or greater); hiatal hernia; symptomatic gastroesophageal reflux.
18
Q
What is the first step in the process of preoperative assessment?
A
The process begins with reviewing medical records followed by patient interview & physical exam.
19
Q
What guides additional tests or specialist referrals during preoperative assessment?
A
Findings from the initial assessment guide additional tests or specialist referrals if needed.
20
Q
What factors determine the extent of the preoperative assessment?
A
The extent of the assessment depends on the patient’s medical condition & surgical complexity.
21
Q
Does the timing of the preoperative assessment impact surgical outcomes?
A
No, the timing of the assessment does not significantly impact surgical outcomes.
22
Q
Who must conduct the preoperative assessment?
A
The assessment must be conducted by a qualified anesthesia provider.
23
Q
Why is reviewing past medical records essential for preoperative assessment?
A
It is essential for patients with prior anesthesia exposure to retrieve previous anesthesia records, especially if complications occurred.
24
Q
What should be done if past anesthesia records are unavailable?
A
If records are unavailable, patient history should provide details of prior anesthetic experiences.
25
What precautions should be taken for rare conditions before surgery?
For rare conditions, records should be reviewed before surgery or appropriate precautions taken (e.g., avoiding succinylcholine).
26
What should be verified in current medical records during preoperative assessment?
Verify surgical & anesthesia consents for accuracy, ensuring patient name, surgeon, date, and procedure match OR schedule.
27
What baseline data should be obtained from the admission record?
Baseline data such as age, height, weight, vitals, and fluid balance should be obtained.
28
What do progress notes & consultation reports provide?
They provide a comprehensive health history and help guide anesthesia planning.
29
What additional insights can nursing notes provide?
Nursing notes may provide insights such as cultural background, coping mechanisms, or physical limitations (e.g., hearing impairment).
30
What is the objective of promoting interactive communication between patient and care provider?
To encourage patient participation in making decisions about perioperative care.
31
How can patient self-care skills be maximized during the postoperative phase?
By enhancing patient participation in continuing care.
32
What is one goal related to the patient's ability to cope?
To increase the patient's ability to cope with their own health status.
33
What should individualized preoperative instructions include?
Details on laboratory tests, consultations, and diagnostic procedures.
34
What is an important instruction regarding food and drink before surgery?
The appropriate time at which the patient should cease ingestion of food and drink.
35
What personal considerations should be communicated to the patient?
Comfortable clothes to wear, no jewelry or makeup, personal items to bring, and leaving valuables at home.
36
What postoperative considerations should be included in preoperative instructions?
Anticipated recovery course, discharge instructions, and how to deal with complications.
37
Who should the patient contact if their physical condition changes?
A designated person for issues like upper respiratory tract infection or cancellation.
38
What should be detailed regarding arrival at the surgical facility?
The process of arrival and registration, including time and location.
39
What legal information should be reviewed with the patient?
Advance directive information as required by law in some states.
40
What should be explained to the patient and family regarding the surgical facility?
The surgical facility policies.
41
What are the objectives of the patient interview?
Confirm patient’s medical history and identify risk factors. Determine the most appropriate anesthesia plan.
42
How can patient education enhance compliance and reduce anxiety?
Education should be verbal & written for better patient understanding. Preoperative fasting & medication instructions, expected intraoperative & postoperative care, and what to expect in the recovery process should be included.
43
What are the benefits of a well-executed interview and education process?
Reduces patient anxiety & increases satisfaction, improves compliance with perioperative instructions, decreases surgical delays & cancellations, reduces hospital length of stay & overall costs, and enhances clinical outcomes.
44
Why is a thorough medical history important?
Structured, systematic questioning helps ensure no critical information is omitted. Open-ended and direct questions allow detailed responses.
45
What should be assessed in a patient's surgical history?
Key details to assess include complications (e.g., uncontrolled bleeding, peripheral nerve injury) and unusual surgical events that may require further investigation.
46
What is important about anesthetic history?
Key anesthetic reactions to assess include prolonged vomiting, difficult airway, malignant hyperthermia, postoperative delirium, and anaphylaxis.
47
What familial conditions should be assessed regarding anesthetic history?
Malignant hyperthermia, atypical plasma cholinesterase deficiency, porphyria, and glycogen storage diseases (e.g., G6PD deficiency).
48
What should be reviewed in a patient's drug history?
All prescribed and over-the-counter drugs, including dosages, schedules, duration of use, purpose, effectiveness, side effects, and potential interactions with anesthesia.
49
What considerations are there for discontinuing medications before surgery?
Not all medications should be stopped; weigh benefits vs. risks of discontinuation and allow 3–5 half-lives for clearance if discontinuing.
50
How should drug allergies be differentiated?
Differentiate between allergies and adverse reactions. A true allergy is an absolute contraindication to drug use.
51
What is the significance of latex sensitivity in surgery?
Up to 20% of intraoperative anaphylaxis cases are linked to latex, especially in high-risk patients.
52
What precautions should be taken for latex-allergic patients?
Schedule as the first case of the day, ensure a no-latex environment in the OR, and perform preoperative skin-prick or in-vitro testing if necessary.
53
What are the effects of smoking on perioperative complications?
Smoking increases perioperative complications such as wound healing and pulmonary risks.
54
How does chronic alcohol use affect anesthetic requirements?
Chronic alcohol use increases anesthetic requirements due to tolerance and enzyme induction.
55
What is the average lifespan reduction associated with alcohol abuse?
Alcohol abuse shortens lifespan by an average of 29 years.
56
What is the increased risk of postoperative complications for heavy alcohol users?
Heavy alcohol users have a 2-5x increased risk of postoperative complications such as arrhythmias, infections, and withdrawal syndromes.
57
What is a life-threatening complication of alcohol withdrawal?
Alcohol withdrawal (delirium tremens) is a life-threatening complication.
58
How does acute alcohol intoxication affect anesthetic requirements?
Acute intoxication reduces anesthetic requirements due to CNS depression.
59
What are some increased risks of postoperative complications due to alcohol use?
Increased risks include poor wound healing, infections, pneumonia, bleeding due to liver dysfunction, and further hepatic deterioration in patients with liver disease.
60
What tools can be used to assess alcohol use risk?
Use AUDIT (Alcohol Use Disorders Identification Test) or CAGE questionnaire to assess risk.
61
What are the CAGE criteria for assessing alcohol dependence?
CAGE Criteria: Cut down, Annoyed, Guilty, Eye-opener. ≥2 positive responses indicate high risk for alcohol dependence and withdrawal.
62
What symptoms are associated with alcohol withdrawal?
Symptoms include tremors, tachycardia, hypertension, insomnia, anxiety, nausea, restlessness, hallucinations, agitation, and seizures.
63
What preoperative medication may be needed to prevent alcohol withdrawal?
Preoperative benzodiazepines may be needed to prevent withdrawal.
64
What should be optimized in perioperative nutrition for alcohol users?
Optimize perioperative nutrition to address deficiencies such as thiamine, magnesium, and folate.
65
What are the health risks associated with smoking?
Smoking causes 90% of lung cancer deaths, 80% of COPD-related deaths, and increases the risk of coronary heart disease and stroke by 2-4x.
66
How does carbon monoxide affect oxygenation in smokers?
Carbon monoxide (CO) binds to hemoglobin 250-300x more than oxygen, reducing tissue oxygenation.
67
What is the impact of smoking on postoperative pulmonary complications?
Smoking increases postoperative pulmonary complications (pneumonia, atelectasis) nearly 6-fold.
68
What is the risk of perioperative complications for heavy smokers?
>20 pack-years of smoking increases the risk of perioperative complications.
69
What are the benefits of short-term smoking cessation before surgery?
Short-term cessation (12-48 hours pre-op) improves CO levels, BP, and HR but does not reduce pulmonary risks.
70
What are the benefits of long-term smoking cessation before surgery?
Cessation >8 weeks pre-op results in improved pulmonary function, ciliary function, and immune response.
71
What advice should be given to patients regarding smoking cessation?
Patients should be advised to quit smoking at any time preoperatively without fear of worsening pulmonary outcomes.
72
What are the risks of secondhand smoke exposure in children during surgery?
Children exposed to secondhand smoke have increased risks of laryngospasm, coughing during induction/emergence, postoperative desaturation, hypersecretion, and reactive airway disease.
73
What complications does illicit drug use cause in anesthesia?
Illicit drug use complicates anesthesia due to drug interactions, tolerance, and withdrawal risks.
74
When may urine drug screening be necessary?
Urine drug screening may be necessary for suspected recent use.
75
What are the high-risk substances related to cocaine and methamphetamines?
Cocaine and methamphetamines are high-risk due to cardiovascular effects.
76
What cardiovascular issues can cocaine and methamphetamines cause?
They can cause severe hypertension, arrhythmias, and myocardial ischemia.
77
What is the risk associated with cocaine and methamphetamines regarding catecholamines?
They sensitize the heart to catecholamines, increasing the risk of hypertensive crisis.
78
Which medications should be avoided in patients using cocaine and methamphetamines?
Avoid ephedrine and ketamine, which exacerbate cardiovascular instability.
79
When should elective surgery be delayed for patients with recent cocaine or methamphetamine use?
Elective surgery should be delayed if recent use was within 24-72 hours.
80
What effects does marijuana (Cannabis, THC, CBD) have on anesthesia?
Marijuana increases anesthetic and sedative requirements.
81
What cardiovascular effects can marijuana cause?
It may cause tachycardia, anxiety, and hypotension.
82
What are the potential long-term effects of chronic marijuana use?
Chronic use may lead to airway hyperreactivity and bronchospasm.
83
What is the impact of chronic opioid use on pain management?
Chronic opioid users have higher pain thresholds and require increased postoperative analgesia.
84
What risk is associated with chronic opioid use?
There is a high risk of opioid-induced hyperalgesia.
85
What is recommended for pain management in chronic opioid users?
Multimodal analgesia (NSAIDs, ketamine, regional anesthesia) is recommended.
86
What should be discussed if opioid substitution therapy is used?
Discuss withdrawal risk and pain management strategies.
87
What risks are associated with hallucinogens?
Hallucinogens can cause unpredictable cardiovascular and psychological effects.
88
What complications can arise from hallucinogen use?
There is a risk of hypertensive crisis, serotonin syndrome, and postoperative delirium.
89
What risks are associated with inhalants?
Inhalants pose a risk of sudden cardiac arrest due to myocardial sensitization.
90
What long-term effects can result from inhalant use?
Long-term use can cause neuropathy and cognitive impairment.
91
What physical exam findings suggest substance abuse?
Track marks, skin abscesses, and venous thrombosis indicate IV drug use.
92
What does constricted pupils indicate?
Constricted pupils suggest opioid use.
93
What does dilated pupils indicate?
Dilated pupils suggest cocaine or amphetamine use.
94
What does nystagmus indicate?
Nystagmus is indicative of PCP use.
95
What does nasal perforation suggest?
Nasal perforation indicates cocaine abuse.
96
What does poor dental health indicate?
Poor dental health is associated with methamphetamine use.
97
What does malnutrition suggest in the context of drug use?
Malnutrition may indicate chronic amphetamine use.
98
What are common medications for opioid abstinence?
Common medications include Methadone, Buprenorphine, and Naltrexone.
99
What is Methadone?
Methadone is a full opioid agonist. for opioid abstinence
100
What is Buprenorphine?
Buprenorphine is a partial agonist (e.g., Suboxone). for opioid abstinence
101
What is Naltrexone used for?
Naltrexone is an opioid antagonist used for both opioid and alcohol dependence.
102
Signs and symptoms of cannabis (marijuana or hashish) abuse?
Tachycardia, labile blood pressure, headache, euphoria, dysphoria, depression, occasional anxiety and panic reactions, psychosis (rare). Poor memory and decreased motivation with chronic use.
103
Signs and symptoms of cocaine and amphetamines abuse?
Tachycardia, labile blood pressure, hypertension, myocardial ischemia, arrhythmias, pulmonary edema, excitement, delirium, hallucinations to psychosis. Euphoria: feeling of excitation, well-being, and enhanced physical strength and mental capacity. Hyperreflexia, tremors, convulsions, mydriasis, sweating, hyperpyrexia, exhaustion, coma with overdose.
104
Signs and symptoms of hallucinogens (LSD, PCP) abuse?
Sympathomimetic and weak analgesic effects, altered perception and judgment; high doses may progress to toxic psychosis. PCP produces dissociative anesthesia with increasing doses.
105
Signs and symptoms of opioid abuse?
Respiratory depression, hypotension, bradycardia, constipation, euphoria (most marked with heroin). Pinpoint pupils with overdose; decreased level of consciousness to coma.
106
What is required for opioid-tolerant patients for pain control?
Higher doses of opioids are required for pain control.
107
What should be considered for multimodal pain management?
Regional anesthesia, NSAIDs, ketamine, IV lidocaine, clonidine, COX-2 inhibitors, and management of methadone & buprenorphine in collaboration with addiction specialists.
108
Why is a thorough social history important in MAT patients?
It allows for early intervention and risk reduction.
109
How should patients be approached about substance use?
Patients may not disclose substance use unless specifically asked in a professional, nonjudgmental manner.
110
What is the purpose of assessment in MAT patients?
Assessment helps in tailoring anesthesia plans and educating patients on the risks of substance use in the surgical setting.
111
What approach should be used to encourage honest disclosure from patients?
Use open-ended, nonjudgmental questions.
112
What are anabolic steroids self-administered for?
To increase muscle mass, strength, and athletic performance.
113
What are the hepatic risks associated with long-term anabolic steroid use?
Impaired liver function, cholestatic jaundice, hepatic adenocarcinoma, and peliosis hepatis.
114
What cardiovascular risks are associated with anabolic steroid use?
Increased risk of myocardial infarction, atherosclerosis, stroke, hypertension, dyslipidemia, and hypercoagulopathy.
115
What endocrine and psychiatric risks are associated with anabolic steroid use?
Testicular atrophy, gynecomastia in males, menstrual irregularities in females, aggressive behavior, mood swings, psychosis, and depression.
116
What preoperative tests should be obtained for chronic steroid users?
Preoperative liver function tests (LFTs) should be obtained due to hepatic impairment.
117
What cardiovascular status should be monitored in chronic steroid users?
Monitor for risk of myocardial infarction, hypertension, and stroke.
118
What should be assessed regarding coagulation status in chronic steroid users?
Assess for hypercoagulability which increases the risk of thrombosis.
119
What potential issue should be considered for chronic steroid users?
Potential adrenal insufficiency due to long-term steroid suppression of the hypothalamic-pituitary-adrenal (HPA) axis.
120
What may be required perioperatively for chronic steroid users?
Stress-dose steroids may be required for adrenal suppression.
121
What risks do certain herbal dietary supplements pose perioperatively?
They can affect blood clotting, glucose control, CNS function, and interact with anesthesia.
122
What should patients do with their herbal products before surgery?
Patients should bring their herbal products to preoperative assessment if unsure.
123
Which herbs increase bleeding risk?
Garlic, ginkgo, ginger, ginseng, vitamin E, feverfew.
124
What effect does St. John’s Wort have on warfarin?
It reduces warfarin effect and increases clotting risk.
125
Which herbs can cause hypoglycemia?
Aloe vera, ginseng, fenugreek, cinnamon.
126
What CNS effects do kava and valerian root have?
They increase sedation and potentiate anesthetic agents.
127
What risks are associated with ephedra (Ma Huang)?
Increases blood pressure, heart rate, arrhythmia risk, and may cause hypertensive crisis.
128
What effect does St. John’s Wort have on medications?
Induces CYP enzymes, reducing efficacy of anesthesia and other medications.
129
How long before surgery should patients discontinue herbal supplements?
2–3 weeks before surgery to avoid interactions.
130
What should be monitored if anticoagulant herbal use is suspected?
Monitor for excessive bleeding.
131
What risk should be assessed in diabetic patients using herbal glucose modulators?
Assess for hypoglycemia risk.
132
What caution should be taken with herbal supplements that enhance sedation?
Be cautious with supplements like kava and valerian.
133
Why is airway assessment important?
Every patient must undergo a preoperative airway evaluation to identify risks for difficult mask ventilation or endotracheal intubation.
134
What does the airway assessment include?
The assessment includes inspection of teeth, mouth, mandibular space, and neck to determine airway management challenges.
135
What is the Mallampati Classification?
Assesses tongue size relative to oral cavity.
136
How is the Mallampati Classification performed?
Patient sits upright, mouth wide open, tongue fully extended, and no phonation to prevent palate elevation.
137
What does Class I of the Mallampati Classification indicate?
Full visibility of soft palate, fauces, uvula, tonsillar pillars → Easy intubation.
138
What does Class II of the Mallampati Classification indicate?
Uvula partly visible → Moderate ease of intubation.
139
What does Class III of the Mallampati Classification indicate?
Only base of uvula visible → Potential difficulty.
140
What does Class IV of the Mallampati Classification indicate?
No uvula or soft palate visible → High risk of difficult intubation.
141
What is a limitation of the Mallampati classification?
It has a high false-positive and false-negative rate and should not be used alone.
142
What is Thyromental Distance (TMD)?
Measures the distance from thyroid cartilage to mandibular border with neck fully extended, mouth closed.
143
What TMD measurement is associated with difficult intubation?
<6-7 cm (~3 fingerbreadths) is associated with difficult intubation due to misalignment of pharyngeal and laryngeal axes.
144
What does Interincisor Distance measure?
Measures mouth opening capability, which depends on temporomandibular joint (TMJ) mobility.
145
What is considered a normal Interincisor Distance?
≥4 cm (2-3 fingers width) = normal.
146
What Interincisor Distance indicates a risk for difficult intubation?
<2 fingers width = risk for difficult intubation.
147
What can affect mouth opening after anesthesia?
Some patients may have adequate mouth opening while awake but reduced TMJ mobility after anesthesia.
148
How can jaw protrusion help with intubation?
Forward protrusion of the mandible may help compensate for restricted mouth opening.
149
What does Head & Neck Mobility assess?
Moderate flexion of the neck + full extension of the atlantooccipital joint ('sniffing position') optimizes alignment of the oral, pharyngeal, and laryngeal axes.
150
What conditions can limit neck extension?
Limited extension (e.g., cervical arthritis, prior neck surgery, small C1 gap) pushes the larynx anteriorly, making intubation difficult.
151
What is the Jaw Protrusion Test?
Patients should attempt to protrude the lower jaw forward and bite the upper lip.
152
What does inability to move the jaw forward indicate?
Inability to move the jaw forward may indicate difficult laryngoscopy due to reduced maneuverability.
153
What is the formula for Ideal Body Weight (IBW) for males?
IBW (male) = 105 lb + 6 lb for each inch >5 ft
154
What is the formula for Ideal Body Weight (IBW) for females?
IBW (female) = 100 lb + 5 lb for each inch >5 ft
155
How do you calculate Body Mass Index (BMI)?
BMI = Weight in kg/(height in meters)
156
What are the most common anesthesia-related medicolegal claims?
Dental injuries are the most common anesthesia-related medicolegal claims, accounting for one-third of all claims in the U.S.
157
What are the risk factors for perioperative dental injury?
Risk factors include preexisting poor dentition, limited neck motion, history of craniofacial abnormalities or previous difficult intubation, and prior head and neck surgery.
158
What should be done during preoperative dental assessment?
Inspect and document the condition of teeth before airway management to prevent false attribution of preexisting damage to anesthesia.
159
What is the risk associated with loose or protuberant maxillary incisors?
Loose or protuberant maxillary incisors pose a high risk of tooth injury or loss during laryngoscopy.
160
What should patients with fragile dentition be informed about?
Patients with fragile dentition must be informed of the risk of tooth damage, and this discussion should be documented in the anesthesia consent.
161
What should be noted regarding crowns, braces, dentures, and prosthetic devices?
Crowns, braces, dentures, and prosthetic devices should be noted and removed unless necessary for mask fit.
162
What may need to be done with extremely loose teeth before laryngoscopy?
Extremely loose teeth may need extraction before laryngoscopy to prevent aspiration.
163
What is a comorbid condition associated with obesity related to sleep?
Known sleep apnea in which the patient is noncompliant with continuous positive airway pressure (CPAP)
164
What HbA1c level indicates a comorbid condition associated with obesity?
HbA1c (glycosylated hemoglobin) >8% (average blood sugar >200 mg/dL)
165
What diabetic complications are comorbid conditions associated with obesity?
Diabetic nephropathy, retinopathy, or neuropathy
166
What liver condition is a comorbidity associated with obesity?
Cirrhosis
167
What cardiovascular condition is associated with obesity?
Pulmonary hypertension
168
What neurological condition can be a comorbidity of obesity?
Pseudotumor cerebri (with severe headaches or impending vision loss)
169
What bleeding condition is associated with obesity?
Significant coagulopathy (including history of pulmonary embolus, bleeding diathesis, hypercoagulable syndrome, excessive bleeding, more than one deep venous thrombosis, taking Coumadin or clopidogrel medication)
170
What therapy is considered a comorbidity associated with obesity?
Chronic steroid therapy
171
What oxygen requirement is a comorbidity associated with obesity?
Oxygen dependent (does not necessarily have to be constant)
172
What mobility condition is associated with obesity?
Wheelchair-bound most of the time
173
What systemic diseases indicate poor functional capacity associated with obesity?
Systemic disease and poor functional capacity (including multiple sclerosis, inflammatory bowel disease, scleroderma, lupus, cancer)
174
What skin condition is a comorbidity associated with obesity?
Severe venous stasis ulcers
175
What recent symptom may indicate a comorbidity associated with obesity?
Recent complaint of chest pain (undiagnosed)
176
What is the classification of obesity based on body weight?
Body weight >20% over ideal body weight = obesity.
Body weight >100% over ideal weight = morbid obesity.
177
What are the BMI classifications for obesity?
Overweight: 25–29.9 kg/m²
Class 1 Obesity: 30–34.9 kg/m²
Class 2 Obesity: 35–39.9 kg/m²
Class 3 Obesity (Severe): ≥40 kg/m²
178
What percentage of U.S. adults are overweight or obese?
Two-thirds of U.S. adults are overweight or obese.
179
What are the health risks associated with obesity?
Increased risk for:
- Cardiovascular disease
- Sleep-disordered breathing
- Difficult airway management
- Metabolic disorders (diabetes, dyslipidemia)
- Increased perioperative complications
180
What preoperative considerations should be made for the obese patient?
Assess cardiovascular health per American Heart Association guidelines.
Screen for coronary disease if:
- Abnormal ECG
- History of coronary/valvular disease
- Age >50 years with two or more risk factors (diabetes, hypertension, smoking, dyslipidemia, family history).
181
Do obese patients with no comorbidities require extensive preoperative testing?
Obese patients with no comorbidities may not require extensive preoperative testing.
182
What percentage of bariatric surgery patients have OSA?
More than 70% of bariatric surgery patients have OSA.
183
What symptoms should be screened for OSA?
Screen for OSA symptoms:
- Snoring
- Apneic episodes
- Frequent arousals during sleep
- Morning headaches
- Daytime somnolence
184
What does the physical exam for OSA focus on?
Physical exam focuses on:
- Airway evaluation
- Neck circumference
- Tonsil size
- Tongue volume
185
What is the STOP-Bang Questionnaire used for?
STOP-Bang Questionnaire for OSA Screening: High sensitivity for identifying OSA risk.
186
What is the gold standard for diagnosing OSA?
Polysomnography (sleep study) is the gold standard for diagnosis.
187
What should be done if OSA is diagnosed?
If OSA is diagnosed, optimize CPAP settings preoperatively.
188
What is the incidence of difficult intubation in obese patients with OSA?
Obese patients with short, thick necks or OSA have a higher incidence (8%) of difficult intubation compared to the general population (0.045%).
189
What should be prepared for if difficulty in intubation is anticipated?
Prepare for possible awake tracheal intubation if difficulty is anticipated.
190
What does the 'S' in STOP stand for?
Snoring: Do you snore loudly (loud enough to be heard through closed doors)?
191
What does the 'T' in STOP stand for?
Tired: Do you often feel tired, fatigued, or sleepy during daytime?
192
What does the 'O' in STOP stand for?
Observed: Has anyone observed you stop breathing during your sleep?
193
What does the 'P' in STOP stand for?
Blood Pressure: Do you have or are you being treated for high blood pressure?
194
What does 'Bang' refer to in the STOP-Bang Questionnaire?
BMI: BMI >35 kg/m²?
195
What is the age criterion in the Bang section?
Age: Age >50 years?
196
What is the neck circumference criterion in the Bang section?
Neck circumference: Neck circumference >40 cm?
197
What is the gender criterion in the Bang section?
Gender: Male?
198
What indicates a high risk of OSA?
High risk of OSA: Yes to ≥3 questions.
199
What indicates a low risk of OSA?
Low risk of OSA: Yes to <3 questions.
200
What are some preoperative medication considerations?
Antiobesity drugs (amphetamines, Schedule IV appetite suppressants) and antidepressants (fluoxetine, sertraline), which may interact with anesthesia.
201
What are common musculoskeletal disorders relevant to anesthesia?
Osteoarthritis (degenerative disk disease), ankylosing spondylitis (AS), and rheumatoid arthritis (RA).
202
What should be considered preoperatively for AS & RA patients?
Chronic pain and inflammation can limit mobility and surgical positioning. Patients may require perioperative corticosteroid supplementation if on chronic steroid therapy.
203
Who is at risk for adrenal insufficiency?
Patients receiving >20 mg hydrocortisone daily for >3 weeks in the past year and those on chronic corticosteroid replacement therapy.
204
What is a strategy for perioperative steroid management?
Minimize steroid dosage to reduce risk of surgical site infection and wound healing.
205
What increases the risk of difficult intubation in patients with AS and RA?
Limited TMJ and cervical spine mobility increases risk of difficult intubation.
206
What complications may RA patients experience related to airway management?
RA patients may have cricoarytenoid arthritis, causing stridor, hoarseness, painful speech, and dysphagia.
207
What airway evaluation may be required for RA patients?
RA patients may have tracheal stenosis, requiring airway evaluation before intubation.
208
What physical limitations do AS patients face that affect intubation?
AS patients may have a rigid spine and kyphosis, limiting head extension.
209
What respiratory issues are associated with AS patients?
AS patients may have restrictive lung disease and pleural effusions.
210
What is papilledema?
Swelling of the optic disc due to increased intracranial pressure.
211
What are the signs of mydriasis?
Unilateral or bilateral dilation of the pupils.
212
What types of headaches are associated with increased intracranial pressure?
Headaches that are postural, worse in the morning, and made worse by coughing.
213
What gastrointestinal symptoms may occur with increased intracranial pressure?
Nausea and vomiting.
214
What speech changes may indicate increased intracranial pressure?
Slurred speech.
215
What cognitive changes may occur with increased intracranial pressure?
Disorientation and altered levels of consciousness.
216
What motor symptoms can result from increased intracranial pressure?
Flaccid hemiplegia or hemiparesis.
217
What cranial nerve palsies may be present?
Abducens or oculomotor palsy.
218
What physical sign indicates neck stiffness?
Neck rigidity.
219
What respiratory symptoms may occur?
Respiratory disturbances.
220
What cardiovascular changes may occur with increased intracranial pressure?
Arterial hypertension with corresponding decreases in heart rate.
221
What ECG changes may indicate hypothalamic ischemia?
The appearance of Q waves, deep and inverted T waves, prolonged QT intervals, and ST segment elevations.
222
What systemic effects may AS and RA present with?
Restrictive lung disease, pleural and pericardial effusions, cardiac conduction abnormalities, and increased risk of difficult venous access.
223
What are pharmacologic considerations in RA patients?
DMARDs and biologic agents cause immunosuppression, increasing the risk of delayed wound healing, wound dehiscence, and surgical site infections.
224
What should be monitored in RA patients during anesthesia?
Monitor progression of neurologic dysfunction, including coma, obtundation, and decerebrate rigidity.
225
What Glasgow Coma Scale (GCS) score indicates coma?
A GCS score of <8 indicates coma and need for intubation.
226
What diagnostic tests are used for neurologic disorders?
Electromyography (EMG), electroencephalography (EEG), CT or MRI scans, and cerebral arteriography.
227
What are indicators of intracranial hypertension?
CT or MRI showing ≥0.5 cm midline shift of the brain, hydrocephalus, cerebral edema, or obliteration of CSF cisterns.
228
What considerations are there for cerebrovascular disease?
Carotid endarterectomy patients require a full cardiac workup, and patients with vertebral artery disease should avoid extreme head flexion, extension, or rotation.
229
What is the anesthetic management for patients with intracranial hypertension?
Avoid CNS depressants (opioids, benzodiazepines) in patients with ICP and altered consciousness.
230
What should be assessed in a preoperative neurologic assessment?
Observe gait, ability to toe-and-heel walk, arm extension, grip strength, sensory perception, muscle reflexes, cranial nerve abnormalities, and mental status.
231
Why is it important to recognize neurologic disease?
To identify signs of increased intracranial pressure (ICP) or cerebral ischemia and monitor progression of neurologic dysfunction.
232
What should be done with anticonvulsants perioperatively?
Continue anticonvulsants (phenytoin, phenobarbital) perioperatively.
233
When is routine serum drug level monitoring necessary for anticonvulsants?
Routine serum drug level monitoring is unnecessary unless withdrawal or major dose change is expected.
234
What should be monitored in long-term phenytoin users?
Monitor CBC in long-term phenytoin users due to the risk of agranulocytosis.
235
What corticosteroids should be continued perioperatively in CNS tumors?
Dexamethasone or methylprednisolone therapy should be continued perioperatively.
236
How do steroids affect cerebral edema?
Steroids reduce cerebral edema via capillary membrane stabilization.
237
What should be monitored closely due to steroid therapy?
Monitor blood glucose closely due to steroid-induced hyperglycemia.
238
What are the risks associated with long-term steroid use?
Increased risk of pulmonary infection and gastrointestinal irritation in long-term steroid users.
239
What conditions are included in preexisting cardiac disease?
Hypertension, ischemic heart disease, valvular dysfunction, cardiac arrhythmias, cardiac conduction abnormalities, and ventricular failure.
240
What factors should be assessed in disease severity and stability?
Assess current management and medication use, and determine stability of condition and history of decompensation.
241
What are the high-risk surgeries according to the Revised Cardiac Risk Index?
Aortic, major vascular, and peripheral vascular surgeries.
242
What constitutes ischemic heart disease in the Revised Cardiac Risk Index?
Previous myocardial infarction, positive stress test, use of nitroglycerin, typical angina, ECG Q waves, previous PCI or CABG.
243
What indicates a history of compensated previous congestive heart failure?
History of heart failure, previous pulmonary edema, third heart sound, bilateral rales, evidence of heart failure on chest radiograph.
244
What defines a history of cerebrovascular disease in the Revised Cardiac Risk Index?
Previous TIA or previous stroke.
245
What is considered diabetes mellitus in the context of the Revised Cardiac Risk Index?
Diabetes mellitus with or without preoperative insulin.
246
What level of creatinine indicates renal insufficiency in the Revised Cardiac Risk Index?
Creatinine >2.0 mg/dL.
247
What is the estimated rate for postoperative major cardiac complications with 0 risk factors?
0.4%.
248
What is the estimated rate for postoperative major cardiac complications with 1 risk factor?
0.9%.
249
What is the estimated rate for postoperative major cardiac complications with 2 risk factors?
7%.
250
What is the estimated rate for postoperative major cardiac complications with more than 3 risk factors?
11%.
251
What are unstable coronary syndromes that require evaluation before noncardiac surgery?
Unstable or severe angina and recent myocardial infarction (MI) within 30 days.
252
What condition is classified as decompensated heart failure?
Decompensated heart failure requires evaluation before noncardiac surgery.
253
What are significant arrhythmias that necessitate evaluation before noncardiac surgery?
High-grade atrioventricular block, symptomatic ventricular arrhythmias, supraventricular arrhythmias (>100 beats/min at rest), symptomatic bradycardia, and newly recognized uncontrolled ventricular tachycardia.
254
What constitutes severe valvular disease requiring evaluation before noncardiac surgery?
Severe aortic stenosis (mean pressure gradient >40 mm Hg, area <1 cm² or symptomatic) and symptomatic mitral stenosis.
255
What are the clinical risk factors for evaluation before noncardiac surgery?
History of ischemic myocardial disease, currently stable but history of heart disease, history of cerebrovascular disease, diabetes (insulin dependent), and renal failure (serum creatinine (SCr) >2 mg/dL).
256
What are the cardiac high-risk surgical procedures?
Aortic surgery, major vascular surgery, peripheral vascular surgery.
## Footnote
Cardiac risk >5%.
257
What are the cardiac intermediate-risk surgical procedures?
Intraperitoneal, transplant (e.g., renal, liver, pulmonary), carotid, peripheral arterial angioplasty, endovascular aneurysm repair, head and neck surgery, major neurologic/orthopedic (e.g., spine, hip), intrathoracic, major urologic.
## Footnote
Cardiac risk 1%-5%.
258
What are the cardiac low-risk surgical procedures?
Breast, dental, endoscopic, superficial, endocrine, cataract, gynecologic, reconstructive, minor orthopedic (e.g., knee surgery), minor urologic.
## Footnote
Cardiac risk <1%.
259
What is 1 MET?
1 MET represents poor functional capacity, including activities like self-care, eating, dressing, or using the toilet, and walking indoors or around the house.
## Footnote
Example activities include walking 1-2 blocks on level ground at 2-3 mph.
260
What is 4 METs?
4 METs indicate good functional capacity, involving light housework, climbing stairs without stopping, or walking on level ground at 4 mph.
## Footnote
Example activities include running a short distance, heavy housework, and moderate recreational activities like golf or dancing.
261
What are activities greater than 10 METs?
Activities greater than 10 METs signify excellent functional capacity, including strenuous sports and high-intensity exercises.
## Footnote
Example activities include basketball, cross-country skiing (>8 km/hr), rope skipping, running, soccer, swimming (>3.5 km/hr), and weight training.
262
What is perioperative cardiac risk stratification?
It involves assessing major cardiac conditions associated with increased perioperative risk, warranting referral to a cardiologist for further assessment.
263
What tool is used for predicting major postoperative cardiac complications?
The Revised Cardiac Risk Index (RCRI) is used for predicting major postoperative cardiac complications.
264
What is the significance of Metabolic Equivalent (MET) assessment?
Functional capacity is a key predictor of perioperative cardiac complications.
265
What MET level indicates good functional capacity?
Patients with good functional capacity are those with >4 METs.
266
What questions can assess functional capacity?
1. Can you walk four blocks without stopping, regardless of symptoms? 2. Can you climb two flights of stairs without stopping, regardless of symptoms?
## Footnote
Inability to do so indicates poor functional capacity (<4 METs) and higher perioperative cardiac risk.
267
What should patients with <4 METs undergo?
They should undergo further cardiac risk stratification.
268
What is the New York Heart Association (NYHA) Classification used for?
It is used to categorize the severity of heart failure and functional impairment based on symptoms.
269
What are the classifications of hypertension according to updated guidelines?
1. Normal BP: <120/80 mmHg 2. Elevated BP: 120–129/<80 mmHg 3. Stage 1 Hypertension: 130–139/80–89 mmHg 4. Stage 2 Hypertension: ≥140/≥90 mmHg 5. Stage 3 (Severe) Hypertension: ≥180/≥110 mmHg.
270
What is hypertension's significance in health?
Hypertension is the most common circulatory disorder affecting humans and is a major risk factor for coronary artery disease and increased perioperative mortality.
271
What comorbid conditions increase cardiac risk?
1. Diabetes mellitus 2. Peripheral vascular disease 3. Chronic pulmonary disease 4. Obesity.
272
How does the type of surgery influence cardiac risk?
The type of surgery influences perioperative cardiac risk, with major cardiac events (MI, cardiac death) being more likely in high-risk procedures.
273
What is Class I in the New York Heart Association Functional Classification?
Patients with cardiac disease have no functional limitations to physical activity. Ordinary physical activity is not associated with undue fatigue, palpitations, dyspnea, or anginal pain.
274
What is Class II in the New York Heart Association Functional Classification?
Patients with cardiac disease are comfortable at rest but have slight functional limitations to physical activity. Activities such as walking or climbing stairs rapidly, or during emotional stress, may cause fatigue, palpitations, dyspnea, or anginal pain.
275
What is Class III in the New York Heart Association Functional Classification?
Patients with cardiac disease have marked limitations to physical activity. They are comfortable at rest, but less than ordinary physical activity causes fatigue, palpitations, dyspnea, or anginal pain.
276
What is Class IV in the New York Heart Association Functional Classification?
Patients with cardiac disease are unable to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or anginal syndrome may be present even at rest, and any physical activity increases discomfort.
277
What is the effect of hypertension on perioperative risk?
Hypertension increases the risk of myocardial ischemia and perioperative hemodynamic instability.
278
What blood pressure level indicates significantly higher risk of complications?
Uncontrolled hypertension is defined as BP >180/110 mmHg.
279
What conditions increase perioperative risk in hypertensive patients?
Target-organ damage such as ischemic heart disease, heart failure, renal disease, and cerebrovascular disease increases perioperative risk.
280
When should elective surgery be postponed in hypertensive patients?
Elective surgery should be postponed if BP >180/110 mmHg or there is evidence of uncontrolled target-organ damage.
281
Is delaying surgery beneficial for mild to moderate hypertension?
Delaying surgery for mild to moderate hypertension (systolic <180 mmHg, diastolic <110 mmHg) is generally not beneficial.
282
What should be included in the preoperative hypertension evaluation?
History and medication review to identify coexisting diseases and review all antihypertensive medications.
283
What symptoms should be evaluated in hypertensive patients?
Evaluate for symptoms of cerebrovascular insufficiency (syncope, dizziness) and orthostatic hypotension (drop in BP upon standing).
284
What physical examination findings suggest Cushing’s disease?
Truncal obesity, purpura, and striae.
285
What vital sign measurement is important in hypertensive patients?
Measure BP in both arms to check for discrepancies.
286
What should be assessed in the neck during a physical examination?
Check for carotid bruits, distended veins, and thyroid enlargement.
287
What cardiac assessments are important in hypertensive patients?
Assess for abnormal rhythm, murmur, and cardiomegaly.
288
What lung conditions should be checked in hypertensive patients?
Look for rales or bronchospasm.
289
What abdominal findings should be assessed in hypertensive patients?
Check for bruits, masses, enlarged kidneys, or abnormal aortic pulsations.
290
What extremity findings may indicate aortic coarctation?
Delayed or absent femoral pulses.
291
What is a key anesthesia consideration for hypertensive patients?
Combination of antihypertensive drugs and anesthetics can cause excessive hypotension.
292
What is the risk for patients with uncontrolled hypertension during surgery?
They are more prone to intraoperative BP fluctuations.
293
What is ischemic heart disease (IHD)?
IHD occurs due to an imbalance between myocardial oxygen demand and supply.
294
What are common risk factors for ischemic heart disease?
Advanced age, smoking, diabetes mellitus, hypertension, pulmonary disease, history of myocardial infarction, left ventricular dysfunction, and peripheral vascular disease.
295
What percentage of surgical patients in the U.S. are at high risk for cardiovascular disease?
One-third of surgical patients are at high risk.
296
What symptoms should be investigated in the preoperative assessment for ischemic heart disease?
Undue fatigue, angina pectoris, palpitations, syncope, and dyspnea.
297
When is a 12-lead ECG recommended in preoperative assessment?
For known coronary artery disease, significant structural heart disease, or symptoms suggestive of ischemia or arrhythmia.
298
Is routine ECG recommended for low-risk surgeries?
No, routine ECG is NOT recommended for low-risk surgeries.
299
What characterizes stable angina?
Substernal discomfort with exertion, relieved by rest or nitroglycerin within 15 minutes.
300
What are the surgical considerations for stable angina?
Stable angina does not significantly increase MI risk perioperatively.
301
What defines unstable angina?
New-onset angina within the past 2 months, progressively worsening angina, angina occurring at rest, or lasting >30 minutes.
302
What are the surgical considerations for unstable angina?
Elective surgery must be postponed until cardiac status is optimized, and advanced cardiac evaluation is required.
303
What is the risk of perioperative reinfarction post-myocardial infarction?
Post-MI reinfarction rates are 33% <30 days, 19% 1–2 months, 6% 3–6 months, and lowest >6 months.
304
What is the mortality risk if reinfarction occurs post-MI?
Post-MI mortality if reinfarction occurs is 50%.
305
What is the recommended delay for elective surgery after a myocardial infarction (MI)?
Elective surgery should be delayed at least 60 days post-MI.
306
What is the risk for patients with prior coronary revascularization and no symptoms?
Patients with prior coronary revascularization and no symptoms have lower risk.
307
What is the restenosis rate for Bare Metal Stents (BMS)?
BMS reduce restenosis but still have a 20% restenosis rate.
308
What is the restenosis rate for Drug-Eluting Stents (DES) after 2 years?
DES reduce restenosis further to 5% after 2 years.
309
What does Dual Antiplatelet Therapy (DAPT) include?
DAPT includes aspirin (continued indefinitely) and a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) for at least 6 months.
310
What percentage of patients with stents will require non-cardiac surgery within a year?
5% of patients with stents will require non-cardiac surgery within a year.
311
What risks are associated with early surgery post-stent placement?
Early surgery post-stent placement increases the risk of stent thrombosis, perioperative MI, hemorrhagic complications, and death.
312
What should be considered for preoperative management of stent patients?
Timing of elective surgery should be coordinated with a cardiologist, and bridging strategies and continuation of antiplatelet therapy must be evaluated.
313
What is a significant cardiovascular risk factor for patients undergoing noncardiac surgery?
Active left ventricular failure is a significant cardiovascular risk factor.
314
What are the two categories of heart failure?
Heart failure can be classified into Preserved Ejection Fraction (EF ≥ 50%) (HFpEF) and Reduced Ejection Fraction (EF < 49%) (HFrEF).
315
How does heart failure affect perioperative mortality risk?
A diagnosis of heart failure increases perioperative mortality risk significantly.
316
What is the perioperative sudden death risk associated with severe aortic stenosis?
Severe aortic stenosis (valve area <1 cm²) is linked to a 14 times higher perioperative sudden death risk.
317
What is required for patients with moderate/severe valvular disease before noncardiac surgery?
Echocardiography is required for patients with moderate/severe valvular disease.
318
What should be done for symptomatic aortic stenosis before elective surgery?
Symptomatic aortic stenosis requires cardiology consultation before elective surgery.
319
What are prominent signs of heart failure?
Prominent signs include moist rales, tachypnea, jugular vein distention, peripheral edema, and resting tachycardia.
320
What diagnostic tests are used for heart failure?
Diagnostic tests include cardiac MRI, radionuclide angiography, echocardiography, and ventriculography.
321
What is the risk for patients with left ventricular ejection fraction (EF) < 35%?
Patients with EF < 35% have higher rates of postoperative heart failure and mortality.
322
What should be done for patients with confirmed congestive heart failure before elective surgery?
Elective surgery should be postponed until optimal ventricular performance is achieved.
323
What are the most common lesions in Valvular Heart Disease?
The most common lesions involve the aortic and mitral valves.
**Footnote rheumatic heart disease remains a major cause
324
What is the risk associated with severe aortic stenosis?
Severe aortic stenosis (valve area <1 cm²) is linked to a 14 times higher perioperative sudden death risk.
325
What is required for patients with moderate/severe valvular disease before noncardiac surgery?
Echocardiography is required.
326
What is necessary for symptomatic aortic stenosis before elective surgery?
Cardiology consultation is required.
327
What does valvular stenosis lead to?
Valvular stenosis leads to hypertrophy due to increased workload.
328
What should preoperative evaluation assess regarding cardiac arrhythmias?
Preoperative evaluation should assess arrhythmia type, severity, and associated heart disease.
329
What symptoms may indicate worsening cardiac conditions?
Symptoms like palpitations, dizziness, dyspnea, and angina may indicate worsening cardiac conditions.
330
What diagnostic tests are included for arrhythmias?
Diagnostic tests include ECG, electrolyte levels (potassium/magnesium), and drug level monitoring.
331
How are arrhythmias classified?
Arrhythmias are classified into benign, potentially malignant, and malignant.
332
What increases perioperative risk in patients?
Increased perioperative risk is seen in patients with severe coronary artery disease, recent MI, or peripheral vascular disease.
333
What minimizes risk to patients with Cardiovascular Implantable Electronic Devices?
Proper preprocedural assessment minimizes risk.
334
What are essential considerations for CIEDs?
Essential considerations include device type, indication for use, and functional status.
335
What is required to assess a CIED?
Direct interrogation by a qualified CIED team is required to assess battery status, lead performance, and adequacy of current settings.
336
What can pacemakers mask?
Pacemakers can mask toxicity from antiarrhythmic drugs, electrolyte disorders, and myocardial ischemia.
337
What are ECG findings of pacemaker malfunction?
ECG findings include unexpected pauses or pacing spikes without myocardial contraction.
338
What should be done if symptoms of pacemaker failure return?
Cardiology consultation is needed.
339
What can chest radiography confirm regarding pacemakers?
Chest radiography can confirm electrode placement, lead integrity, and battery depletion.
340
What can the Valsalva maneuver do in relation to pacemakers?
The Valsalva maneuver can slow the heart rate, making pacing impulses more visible on an ECG.
341
What are indications for temporary preoperative pacing?
Indications include persistent bradycardia unresponsive to atropine, history of syncope with bifascicular block, and exercise-induced dizziness near the device site.
342
What anesthetic considerations should be taken for pacemakers?
Avoid muscle fasciculations and shivering, which can inhibit pacemaker function.
343
What is the purpose of preoperative cardiac testing?
Preoperative cardiac testing should only be done if the results will influence patient management.
344
Who are noninvasive tests primarily used for?
Noninvasive tests are primarily used for high-risk patients with three or more risk factors and poor functional capacity.
345
What is the role of a 12-lead ECG in preoperative testing?
The 12-lead ECG is not a strong predictor of perioperative cardiac events and is often used as an adjunct to other testing methods.
346
What does the Exercise Stress ECG help detect?
The Exercise Stress ECG helps detect myocardial ischemia by increasing heart workload and documents cardiovascular function and tolerance.
347
What findings indicate ischemia during an Exercise Stress ECG?
Findings that indicate ischemia include ST-segment depression > 0.2 mV, early ST-segment depression, and a hypotensive response during the test.
348
What is pharmacologic stress testing used for?
Pharmacologic stress testing is used for patients unable to perform exercise testing.
349
What agents are used in pharmacologic stress testing?
Dipyridamole or adenosine causes coronary blood flow redistribution, while dobutamine increases heart rate and contraction strength.
350
What are advanced imaging techniques used for?
Advanced imaging techniques help identify ischemic heart disease and cardiac risk, but there is insufficient evidence to support routine testing before all surgeries.
351
When is cardiac catheterization recommended?
Cardiac catheterization is recommended for high-risk surgical patients or those with NYHA Class III or IV heart failure.
352
What does cardiac catheterization identify?
It identifies significant arterial narrowing, such as 70% blockage in major coronary arteries and 50% blockage in the left main coronary artery.
353
What are key imaging findings that indicate poor ventricular function?
Key findings include cardiac index < 2.2 L/m², left ventricular end-diastolic pressure > 18 mmHg, ejection fraction < 40%, and akinesis or hypokinesis.
354
Who should receive prophylactic pharmacotherapy before surgery?
High-risk patients (history of angina, prior MI, heart failure, stroke, diabetes, or moderate-to-poor functional capacity) should receive prophylactic pharmacotherapy before surgery.
355
What are the benefits of Statins?
Statins improve endothelial function, reduce oxidative stress and inflammation, and increase plaque stability, lowering the risk of rupture.
356
What are common Statins used?
Common Statins include Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Rosuvastatin, and Simvastatin.
357
When should Statin therapy be started before surgery?
Statin therapy should be started at least 30 days before surgery for maximal effect and continued perioperatively.
358
What are the benefits of β-Blockers?
β-Blockers reduce oxygen demand mismatch, lower myocardial oxygen consumption, stabilize heart rate, and reduce perioperative myocardial infarction (MI) and death in high-risk surgical patients.
359
Who should receive β-Blockers?
Patients already on β-blockers for ischemic heart disease, arrhythmias, or hypertension, and high-risk cardiovascular patients (those with stress-induced myocardial ischemia) should receive β-Blockers.
360
What caution should be taken with β-Blockers?
DO NOT start β-blockers perioperatively in low-risk patients as it may increase the risk of mortality, stroke, bradycardia, and hypotension if initiated too close to surgery.
361
What are the benefits of ACE Inhibitors?
ACE Inhibitors are used to reduce heart failure symptoms and improve long-term outcomes.
362
In which patients are ACE Inhibitors beneficial?
ACE Inhibitors are beneficial in patients with heart failure with reduced ejection fraction (HFrEF), a history of MI, and moderate-to-severe cardiovascular disease.
363
What should be managed when using ACE Inhibitors perioperatively?
Perioperative use of ACE Inhibitors should be carefully managed to avoid hypotension.
364
What are commonly used ACE Inhibitors?
Commonly used ACE Inhibitors include Captopril, Enalapril, Lisinopril, Benazepril, and Ramipril.
365
When are ACE Inhibitors recommended?
ACE Inhibitors are recommended for intermediate- to high-risk surgeries and considered for low-risk surgery if appropriate.
366
What is Dual Antiplatelet Therapy (DAPT)?
Includes Aspirin and P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor, Cangrelor).
## Footnote
Used to prevent stent thrombosis after percutaneous coronary intervention (PCI) with stent placement.
367
When should elective non-cardiac surgery be delayed after Bare Metal Stent (BMS) placement?
30 days after BMS placement.
## Footnote
Elective surgery should also be delayed 6 months after Drug-Eluting Stent (DES) placement.
368
When should elective surgery not be performed after BMS implantation?
Within 30 days of BMS implantation.
## Footnote
Also, within 3 months of DES implantation if DAPT discontinuation is necessary.
369
What should be done for patients undergoing surgery that requires stopping P2Y12 inhibitors?
Continue aspirin if possible. Restart P2Y12 inhibitor as soon as feasible after surgery.
370
What are Novel Oral Anticoagulants (NOACs) used for?
Used for Atrial fibrillation (AF), deep venous thrombosis (DVT), pulmonary embolism (PE), and sometimes prosthetic heart valves.
371
What are the types of NOACs?
Factor Xa Inhibitors: Rivaroxaban, Apixaban. Thrombin Inhibitors: Dabigatran.
372
What is the reversal agent available for Thrombin Inhibitors?
Idarucizumab (Praxbind) for emergency reversal.
373
What are preoperative therapeutic maneuvers to decrease the risk of pulmonary complications?
Instruction in and application of respiratory maneuvers, smoking cessation, antibiotic treatment of pulmonary infection, antibiotic treatment of chronic bronchitis, expectorants, psychologic preparation, bronchodilator therapy for asthmatics, maintenance of good nutrition, chest physiotherapy, weight reduction.
374
What are postoperative therapeutic maneuvers to decrease the risk of pulmonary complications?
Adequate pain control with minimization of postoperative opioid analgesia, avoiding nasogastric intubation when possible, maximal inspiration maneuvers, incentive spirometry, chest physiotherapy, mobilization of secretions, early mobilization of elderly patients, cough encouragement, heparin prophylaxis in selected cases.
375
What is the role of adequate pain control in postoperative care?
Minimization of postoperative opioid analgesia with epidural analgesia when appropriate, and PCA administration of opioids rather than intravenous boluses as needed, using opioid sparing techniques with ERAS pathways.
376
What are some techniques for maximizing respiratory function postoperatively?
Maximal inspiration maneuvers, incentive spirometry, chest physiotherapy.
377
What is the importance of early mobilization in postoperative patients?
Early mobilization of elderly patients is crucial to decrease the risk of pulmonary complications.
378
What is the frequency of asthmatic attacks?
Frequency of asthmatic attacks, wheezing at exercise, or wheezing >3 times in last 12 months?
379
What is the time interval since the last asthma attack?
Time interval since the last attack?
380
Has there been a recent asthma exacerbation?
Recent asthma exacerbation? How long since the patient was last hospitalized or treated in the emergency department for an asthmatic attack?
381
What is the increased use of inhaled short-acting ß-agonists?
Increased use of inhaled short-acting ß-agonists? Use per week?
382
What is the current or past use of inhaled corticosteroids?
Current or past use of inhaled corticosteroids?
383
What was the most recent course of oral corticosteroids?
Most recent course of oral corticosteroids?
384
What works best for treating an acute asthmatic event?
What works best for treating an acute asthmatic event?
385
Has there been a recent upper respiratory tract infection?
Recent upper respiratory tract infection (<2 weeks) or sinus infection?
386
Has there been a recent pneumonia?
Recent pneumonia? Was this documented on chest radiograph?
387
What was the severity of the asthma attacks?
The severity of attacks: Was endotracheal intubation or intensive care unit admission required?
388
Is there a history of pulmonary complications with prior surgical procedures?
History of pulmonary complications with prior surgical procedures?
389
Is there a history of long-term corticosteroid use?
History of long-term corticosteroid use or corticosteroid-dependent asthma?
390
Is there a nocturnal dry cough?
Nocturnal dry cough
391
Is there a history of hay fever?
Hay fever
392
Has there been exposure to passive smoke?
Exposure to passive smoke
393
Is there a concern about obesity?
Obesity
394
Is there a history of obstructive sleep apnea?
Obstructive sleep apnea
395
What is the CHADS₂ scoring system used for?
It is used to assess the risk of stroke in patients with atrial fibrillation.
396
What are the components of the CHADS₂ score?
1 point for congestive heart failure, hypertension, age >75, diabetes; 2 points for stroke/TIA.
397
What does a CHADS₂ score >4 indicate?
High risk.
398
What does a CHADS₂ score of 3-4 indicate?
Intermediate risk.
399
What does a CHADS₂ score <3 indicate?
Low risk.
400
When should NOACs be stopped before surgery?
3 elimination half-lives before surgery.
401
When can NOACs be restarted after surgery?
24-48 hours post-surgery if bleeding is controlled.
402
What is bridging therapy?
It may be needed for high-risk patients during the perioperative period.
403
What percentage of adults have respiratory diseases?
Approximately 25%.
404
What is a major risk factor for post-operative pulmonary complications?
COPD (chronic bronchitis, emphysema).
405
What are risk factors for increased postoperative pulmonary complications?
Preoperative sepsis, emergency surgeries, age >50, smoking, cardiovascular disease, diabetes, kidney disease, obesity, upper abdominal/thoracic surgery, prolonged anesthesia, pulmonary hypertension, ASA status III or higher.
406
Which surgical sites pose the highest risk for pulmonary complications?
Thoracic and upper abdominal surgeries.
407
When should elective surgery be postponed for COPD patients?
If there is severe dyspnea, wheezing, pulmonary congestion, or hypercarbia (PaCO₂ > 50 mmHg).
408
What is the role of antibiotics in preoperative management?
Indicated for thick, purulent sputum with pulmonary infiltrates; routine prophylactic antibiotics are NOT recommended.
409
What is the benefit of incentive spirometry?
It reduces post-operative pulmonary complications after upper abdominal surgery.
410
How long should smoking cessation occur before surgery to reduce risks?
8 weeks.
411
When are routine preoperative chest X-rays (CXR) indicated?
If undergoing major thoracic, esophageal, or upper abdominal surgery.
412
When are pulmonary function tests (PFTs) necessary?
Only if severe COPD or myasthenia gravis is suspected.
413
What does FEV₁/FVC < 80% suggest?
An obstructive disease.
414
What is associated with increased post-operative pulmonary risk?
PaO₂ < 60 mmHg or PaCO₂ > 45 mmHg.
415
What are key characteristics of asthma?
Reversible airflow obstruction, airway inflammation, hyperreactivity to stimuli.
416
What are common triggers for asthma?
Allergens, exercise, infections, stress, unidentified factors.
417
What indicates a severe asthma history?
Frequent nocturnal awakenings, prior hospitalizations, high corticosteroid use, coexisting cardiovascular disease.
418
What should be done if active asthma symptoms are present on surgery day?
Postpone surgery.
419
What preoperative evaluations are recommended for asthma patients?
ECG if right ventricular hypertrophy is suspected, CXR if pneumonia or worsening condition is suspected, ABG for chronic respiratory insufficiency.
420
What are key preoperative interventions for respiratory management?
Respiratory exercises, smoking cessation, antibiotics (if indicated), bronchodilators for asthma/COPD patients, nutritional support, chest physiotherapy (select cases only).
421
What are key postoperative strategies to reduce pulmonary complications?
Adequate pain control, avoid nasogastric tubes, encourage deep breathing & incentive spirometry, mobilization of secretions, early ambulation, encourage coughing, use heparin prophylaxis in selected cases.
422
What is the normal Peak Expiratory Flow Rate (PEFR)?
80-100% of baseline.
423
What indicates a moderate exacerbation in PEFR?
50-80% of baseline.
424
What should be done in case of severe exacerbation (PEFR <50%)?
Delay surgery and intensify treatment.
425
What medications should be continued for perioperative asthma management?
All medications, including corticosteroids and bronchodilators.
426
What should be used on the morning of surgery for asthma management?
β-agonist inhalers.
427
What should be confirmed if the patient is on theophylline?
Therapeutic theophylline levels.
428
Why is it important to minimize fasting time before surgery?
Ensures hydration and prevents airway desiccation.
429
What is a key aspect of preoperative anxiety management?
Avoids psychologic triggers.
430
What is the risk of airway complications for children <1 year old with a URI?
2 to 7 times higher risk.
431
How long does the risk of complications from a URI persist?
Up to 6 weeks due to heightened airway reactivity.
432
What are some complications of URI in surgery?
Bronchospasm, laryngospasm, atelectasis, mucous plugging, impaired oxygenation.
433
What are common symptoms of URI?
Sore throat, nasal congestion, rhinorrhea, malaise, fever (37.5°C-38.5°C), wheezing, stridor.
434
What should be considered for elective surgery in children with URI?
If the child always has a runny nose but is otherwise well, surgery may proceed.
435
What should be done if a child has a productive cough and lower respiratory tract involvement?
Delay surgery for at least 2 weeks.
436
What is the recommendation if a child has a fever (>38°C) and lower respiratory tract signs?
Delay surgery for 4-6 weeks.
437
What should be discussed with parents and the surgical team regarding a child with a URI?
Increased perioperative risks.
438
What is recommended to avoid during intubation for a child with a URI?
Avoid intubation if possible; use LMA or mask anesthesia instead.
439
What should be used preoperatively for bronchospasm prophylaxis?
Albuterol.
440
What should be used to prevent airway dryness during surgery?
Humidified gases.
441
What should be done for febrile children or those with abnormal lung sounds?
Reschedule their surgery.
442
What gastrointestinal symptoms should be looked for in preoperative evaluation?
Nausea, vomiting, diarrhea, bleeding, pain, distension, dysphagia, reflux.
443
What should be checked for fluid and electrolyte imbalances?
Associated with weight loss or malabsorption.
444
What should be checked in case of active gastrointestinal bleeding?
Hemoglobin & hematocrit.
445
What imaging should be considered to check for obstruction or masses?
CT scan/X-ray.
446
What should be considered for patients with GERD or Peptic Ulcer Disease?
Use prophylactic measures to reduce aspiration risk.
447
What types of liver disease should be considered preoperatively?
Acute & chronic liver disease (e.g., hepatitis, cirrhosis).
448
What is a common issue in cholestatic liver disease?
Biliary obstruction.
449
What is a limitation of laboratory tests in liver disease detection?
They often fail to detect early liver disease.
450
What are symptoms of mild hepatic dysfunction?
Malaise, weight loss, mild jaundice.
451
What may indicate early cirrhosis or hepatitis?
Mildly elevated bilirubin & transaminases.
452
What should be done for unexplained jaundice or liver enzyme elevation?
Further testing is required.
453
What are symptoms of severe hepatic dysfunction and failure?
Coagulopathy, extreme jaundice, ascites, encephalopathy, hepatorenal failure.
454
What should be done for patients with severe hepatic dysfunction?
Emergency or palliative procedures only; elective surgery postponed.
455
What is the risk for patients with liver failure undergoing surgery?
High morbidity & mortality risk.
456
What should be done for high-risk patients with liver disease?
Consultation with a gastroenterologist.
457
What should be corrected in patients with coagulopathy?
Vitamin K, fresh frozen plasma, cryoprecipitate.
458
What should be monitored due to the risk of hypoglycemia?
Blood glucose.
459
What should be avoided in hepatic encephalopathy?
Sedatives.
460
What should be assessed for fluid/electrolyte balance?
ABG, liver function tests.
461
What are the limitations of liver function tests (LFTs)?
AST/ALT are not liver-specific.
462
What does alkaline phosphatase elevation suggest?
Cholestasis (bile duct obstruction).
463
What does direct bilirubin elevation indicate?
Hepatobiliary obstruction.
464
What is the most reliable indicator of acute liver dysfunction?
Prolonged prothrombin time (PT).
465
What does the Child-Pugh Score predict?
Surgical mortality in cirrhosis.
466
What are the scoring criteria for the Child-Pugh Score?
Bilirubin, albumin, INR, ascites, encephalopathy.
467
What is the surgical mortality risk for Class A in Child-Pugh Score?
10% surgical mortality (low risk).
468
What is the surgical mortality risk for Class B in Child-Pugh Score?
30% surgical mortality (moderate risk, requires pre-op optimization).
469
What is the surgical mortality risk for Class C in Child-Pugh Score?
80% surgical mortality (surgery should be delayed if possible).
470
What are some considerations for renal system preoperative evaluation?
Acute kidney injury (AKI), chronic kidney disease (CKD) or renal failure.
471
What are signs of dehydration to assess fluid status?
Dry mucosa, postural hypotension, tachycardia.
472
What can polyuria indicate?
Diabetes insipidus or uncontrolled diabetes.
473
What is urinary retention commonly associated with?
Chronic prostate enlargement or neurogenic bladder.
474
What should be ruled out for recurrent infections?
Cystitis, pyelonephritis, or glomerulonephritis.
475
What are the diagnostic criteria for acute kidney injury (AKI)?
Serum creatinine >26.4 µmol/L within 48 hours.
476
What is another criterion for diagnosing AKI?
Serum creatinine >1.5 times baseline in 7 days.
477
What urine output indicates AKI?
Urine output <0.5 mL/kg for 6 hours.
478
Why is Blood Urea Nitrogen (BUN) not a reliable indicator of kidney function?
Due to dietary & metabolic influences.
479
What is more accurate than BUN for assessing kidney function?
Serum creatinine.
480
What may serum creatinine appear in elderly patients despite declining renal function?
Normal.
481
What is a more reliable estimation of kidney function than serum creatinine?
Creatinine Clearance (GFR estimation).
482
What GFR indicates mild renal dysfunction?
GFR 50-80 mL/min.
483
What GFR indicates end-stage renal failure?
GFR <10 mL/min.
484
What is the formula for GFR calculation?
GFR = (U x V)/ P
485
What is the preoperative consideration for renal disease patients regarding urinalysis?
Preoperative urinalysis & culture → Treat infections before surgery.
486
What should be monitored in renal disease patients before surgery?
Monitor electrolyte imbalances (K+, Na+, Ca2+).
487
What medications should be avoided in renal disease patients preoperatively?
Avoid nephrotoxic medications (NSAIDs, contrast dyes).
488
What is the goal for chronic renal failure patients preoperatively?
Optimize hydration & correct metabolic abnormalities.
489
What are key concerns for dialysis patients preoperatively?
Maintain homeostasis despite abnormal BUN & creatinine levels.
490
What is crucial to monitor in dialysis patients regarding fluid balance?
Check for weight gain, jugular vein distension, edema, and pulmonary congestion.
491
When should potassium levels be checked before surgery in renal patients?
Potassium levels must be checked 6-8 hours before surgery.
492
What should be done if potassium levels are greater than 5.5 mEq/L?
Delay elective surgery.
493
What interventions can be used for emergency cases with high potassium levels?
Use interventions to reduce K+ (e.g., dialysis, medications).
494
What is the typical hemoglobin level in chronic renal failure patients?
Hemoglobin levels often low (5-8 mg/dL).
495
What are some causes of anemia in chronic renal failure patients?
Decreased erythropoietin production, red blood cell fragility due to uremia, chronic GI bleeding & dialysis-related blood loss.
496
What may be necessary if a chronic renal failure patient has severe anemia?
Blood transfusion may be necessary before surgery.
497
What risks are associated with frequent blood transfusions?
Risk of infections (Hepatitis, HIV).
498
What coagulopathy risk is present in chronic renal failure patients?
Prolonged bleeding time due to platelet dysfunction.
499
What can help correct coagulopathy before surgery?
Dialysis before surgery can help correct this.
500
What should be continued for renal failure patients during perioperative management?
Continue most medications (antihypertensives, digitalis, corticosteroids, insulin).
501
What should be reduced or avoided in renal failure patients preoperatively?
Reduce or avoid long-acting sedatives (e.g., diazepam).
502
What should be checked regarding vascular access sites in renal failure patients?
Check vascular access sites (AV fistulas) for infection & patency.
503
What should be avoided in dialysis-access limbs?
Avoid IV lines and blood pressure measurements.
504
What gastrointestinal preparations may be considered for renal failure patients?
Consider gastrointestinal preparations (e.g., antacids, gastrokinetics) to reduce aspiration risk.
505
What is the most common endocrine disorder affecting preoperative considerations?
Diabetes Mellitus.
506
What is the perioperative risk associated with diabetes?
Diabetic patients have a 5-10x higher morbidity & mortality risk in surgery.
507
What are the two types of diabetes?
Type 1 (Insulin-dependent) and Type 2 (Non-insulin dependent).
508
What are the risks associated with Type 1 diabetes?
Higher risk of ketoacidosis & microvascular complications.
509
What are the management strategies for Type 2 diabetes?
Often managed with diet, exercise, oral hypoglycemics.
510
What cardiovascular risks are associated with diabetes?
Higher risk of macrovascular disease (hypertension, CAD, stroke, PVD).
511
What should be assessed in diabetic patients preoperatively?
Assess metabolic control: Type, monitoring, usual glucose levels.
512
What complications should be identified in diabetic patients?
Identify cardiovascular, renal, and neurological complications.
513
What is the significance of Hemoglobin A1c (HbA1c) in diabetes?
Measures long-term glycemic control.
514
What are the HbA1c levels indicating high risk for surgery?
High Risk: 5.7-6.4%. Diabetic: ≥6.5%.
515
What should be done for poorly controlled diabetics (HbA1c >8%)?
They have higher surgical risks.
516
What should be done for uncontrolled hyperglycemia (>216 mg/dL)?
Delay elective surgery.
517
What is the risk associated with silent MI in diabetics?
Silent MI risk is high → Consider stress test, ECG.
518
What should be done to manage perioperative glucose levels?
Goal: Maintain glucose <180 mg/dL while avoiding hypoglycemia.
519
What should be done the night before surgery for diabetic patients?
Continue usual evening dose of insulin (long-acting like Glargine/NPH).
520
What should be done on the morning of surgery for fasting diabetic patients?
Withhold oral hypoglycemics and adjust insulin dosing.
521
What should be established for diabetic patients needing insulin?
IV access must be established with D5 (5% glucose) infusion available.
522
What should be determined regarding insulin pumps before surgery?
Determine type of insulin, basal rate, sensitivity factor.
523
When should the insulin pump be discontinued?
For long surgeries or procedures requiring MRI/X-ray/defibrillation.
524
What is hyperthyroidism?
Excess secretion of thyroid hormones (T3 & T4).
525
What is the goal of preoperative management for hyperthyroid patients?
Achieve a euthyroid state before elective surgery.
526
What medical therapy is used for hyperthyroid patients before surgery?
Antithyroid drugs (6-8 weeks prior to surgery).
527
What is the purpose of iodine therapy before surgery in hyperthyroid patients?
Reduces thyroid hormone release.
528
What is the goal for heart rate control in hyperthyroid patients?
Maintain HR <80 bpm.
529
What should be done if a euthyroid state cannot be achieved before surgery?
Use continuous esmolol infusion to control HR.
530
What is hypothyroidism?
Deficiency of thyroid hormones (T3 & T4).
531
What are common causes of hypothyroidism?
Hashimoto’s thyroiditis, iodine deficiency, post-surgical removal.
532
What are clinical features of hypothyroidism?
Bradycardia, fatigue, cold intolerance, weight gain.
533
What is the goal of preoperative management for hypothyroid patients?
Restore normal thyroid hormone levels.
534
What therapy is used for hypothyroid patients preoperatively?
Levothyroxine (T4) therapy.
535
What should be done for patients with mild to moderate hypothyroidism?
Elective surgery can proceed.
536
What should be done for patients with severe hypothyroidism?
Delay surgery until stabilized.
537
What is myxedema coma?
Life-threatening emergency with bradycardia, hypothermia, altered mental status.
538
What is hyperadrenocorticism (Cushing Syndrome)?
Excess glucocorticoids from prolonged steroid use or adrenal overproduction.
539
What are clinical features of Cushing Syndrome?
Hypertension, truncal obesity, moon facies, easy bruising.
540
What should be monitored in patients with Cushing Syndrome perioperatively?
Monitor blood pressure & glucose levels.
541
What is hyperaldosteronism?
Excess aldosterone production leading to sodium and water retention.
542
What are clinical features of hyperaldosteronism?
Hypertension & marked hypokalemia.
543
What should be done preoperatively for patients with adrenal insufficiency?
Assess electrolyte imbalances and correct before surgery.
544
What is the timing for routine diagnostic testing?
Normal results are valid within 6 months if no changes in health status.
545
What is the preferred method for pregnancy testing preoperatively?
Serum hCG preferred for accuracy.
546
What are the preoperative fasting guidelines for clear liquids?
Allowed up to 2 hours before surgery.
547
What is the fasting requirement for a heavy meal before surgery?
8 hours fasting required.
548
What factors increase the risk of pulmonary aspiration?
GERD, gastroparesis, obesity, diabetes, emergency surgery.
549
What is the ASA Physical Status Classification?
Developed by the American Society of Anesthesiologists to assess preoperative patient health.
550
What does ASA Class I indicate?
Healthy patient, no medical conditions.
551
What does ASA Class II indicate?
Mild systemic disease (e.g., controlled hypertension).
552
What does ASA Class III indicate?
Severe systemic disease, functionally limiting (e.g., poorly controlled diabetes).
553
How long are normal lab results valid if there are no changes in health status?
Normal results are valid within 6 months.
554
What is the validity period for serum potassium results in patients on diuretics or digitalis?
Serum potassium results are valid within 7 days.
555
When should blood glucose be tested for diabetics?
Blood glucose should be tested on the day of surgery.
556
What is the validity period for ECG results in stable cardiac disease?
ECG results are valid within 30 days.
557
How often should a chest X-ray be performed if pulmonary disease is present?
A chest X-ray is valid within 6 months.
558
When should pregnancy testing be offered?
Pregnancy testing should be offered if pregnancy status is uncertain.
559
What type of pregnancy test is preferred for accuracy?
Serum hCG is preferred for accuracy.
560
When is testing required for pregnancy risk?
Testing is required if pregnancy risk is suspected based on history or physical exam.
561
What is the recommendation for surgery in pregnancy?
Surgery in pregnancy should ideally be delayed unless necessary.
562
What is the goal of preoperative fasting guidelines?
The goal is to balance aspiration risk with minimizing patient discomfort.
563
What has replaced the traditional 'NPO after midnight' guideline?
More flexible fasting intervals have replaced the traditional guideline.
564
How long before surgery are clear liquids allowed?
Clear liquids are allowed up to 2 hours before surgery.
565
How long before surgery can a light meal be consumed?
A light meal can be consumed up to 6 hours before surgery.
566
What is the fasting requirement for a heavy meal before surgery?
8 hours fasting is required for a heavy meal.
567
What factors increase the risk of pulmonary aspiration?
Factors include GERD, gastroparesis, obesity, diabetes, emergency surgery, and pregnancy.
568
What are some preventive strategies for pulmonary aspiration?
Preventive strategies include prokinetics (Metoclopramide), acid suppression (Famotidine, Omeprazole), and antiemetics (Ondansetron).
569
What is the ASA Physical Status Classification used for?
It is used to assess preoperative patient health.
570
What does ASA I represent?
ASA I represents a healthy patient with no medical conditions.
571
What does ASA II represent?
ASA II represents a patient with mild systemic disease (e.g., controlled hypertension).
572
What does ASA III represent?
ASA III represents a patient with severe systemic disease that is functionally limiting (e.g., poorly controlled diabetes).
573
What does ASA IV represent?
ASA IV represents a patient with severe disease that is a constant threat to life (e.g., unstable angina).
574
What does ASA V represent?
ASA V represents a moribund patient unlikely to survive without surgery.
575
What does ASA VI represent?
ASA VI represents a brain-dead organ donor.
576
What does the 'E' denote in ASA classification?
'E' denotes emergency cases.
577
What is the purpose of the Joint Commission Universal Protocol?
It is developed to prevent wrong-site, wrong-procedure, and wrong-patient surgeries.
578
What are the key steps of the Joint Commission Universal Protocol?
Key steps include preoperative verification process, marking the surgical site, and 'Time-Out' before incision.
