Pre and Perioperative Eval of Patient

Question 1

What pre-operative labs are indicated for treatment of the patient?

Answer 1

• CBC, Basic Metabolic Panel, Urinalysis, Coagulation Studies (PT, PTT, INR), pregnancy screening where appropriate
• Chest X-Ray
• Electrocardiogram

Question 2

What needs to be considered in the cardiopulmonary eval of a preoperative patient?

Answer 2

o	Cardiopulmonary Evaluation:
•	Age
•	Male
•	Heredity
•	Tobacco abuse
•	Obesity
•	DM
•	HTN
•	Hyperlipidemia
•	Sedentary lifestyle
•	Stress

Question 3

patients without significant medical problems, especially those under 50, are a very low chance for…

Answer 3

perioperative complications.

Question 4

what are the two most important cardiac complications to screen for prior to surgery?

Answer 4

MI and cardiac death are MOST important

however, also ask about CHF, LV dysfunction, arryhthmias, and unstable angina.

Question 5

What does the RCRI help to evaluate for?

Answer 5

pre-op cardiac risk assessment

Question 6

should emergency surgery be delayed because of cardiac problems in the patient?

Answer 6

NO

Question 7

who should get a resting EKG?

Answer 7

A resting EKG should be obtained in patients with at least one RCRI predictor prior to major surgery.

Question 8

When do you need to consider stopping surgery or continuing surgery in regard to cardiac problems?

Answer 8

If there is a known valve correction surgery, it should be done FIRST before other elective surgery. Surgery should consider being delayed in severe hypotension, but not in mild to moderate. Drugs can be taken day of. Diuretics and ACEIs should probably be stopped due to increased risk of hypotension and hypovolemia and electrolyte disorders.

Question 9

What is the ASA score?

Answer 9

surgery score that correlates with the potential for death in the patient. •
ASA Score
o 1 through 5 with an E added for emergency surgery
o 1=Healthy
o 5=Moribund—Not expected to survive with or without the surgery
o Postoperative mortality correlates with this score.

Question 10

What is the appropriate urine output for an adult? child? on average it should be no less than..?

Answer 10

.5-1 ml/kg/hr, 1 ml/kg/hr, 30 ml/kg/hr…

These all came from 3 different lectures and sources.

Question 11

What do you need to consider for the fluid status?

Answer 11

Get a preoperative Hgb, they need to be NPO for AT LEAST 6 HOURS!, bowel prep may be necessary

Question 12

What are three ways to monitor fluid status?

Answer 12

o Triple lumen catheter—Central venous pressure. Usually less than 8 you want to give more fluid. 8-12 is normal.
o Swan-Ganz catheter—Pulmonary capillary wedge pressure
o Arterial line—Blood pressure (usually go through radial artery)

Question 13

What are some ways to reduce infections?

Answer 13

Reducing Infections:
o	Preoperative antibiotics
o	Hair removal
o	Preoperative shower with chlorhexadine soap
o	Preoperative bowel prep
o	Good sterile technique
o	Patients immune system

Question 14

How are wounds categorized based on infection status?

Answer 14

I. Clean:
- Uninfected, no inflammation
- Resp, GI, GU tracts not entered
- Closed primarily
Examples: Ex lap, mastectomy, neck dissection, thyroid, vascular, hernia, splenectomy
II. Clean-contaminated:
- Resp, GI, GU tracts entered, controlled
- No unusual contamination
Examples: Chole, SBR, Whipple, liver txp, gastric surgery, bronch, colon surgery
III: Contaminated:
- Open, fresh, accidental wounds
- Major break in sterile technique
- Gross Spillage from GI tract
- Acute nonpurulent inflammation
Examples: Inflamed appy, bile spillage in chole, diverticulitis, Rectal surgery, penetrating wounds
IV: Dirty:
- Old traumatic wounds, devitalized tissue
- Existing infection or perforation
- Organisms present BEFORE procedure
Examples: Abscess I&D, perforated bowel, peritonitis, wound debridement, positive cultures pre-op

Question 15

How can hemodynamics be assessed on a physical exam? What can you LOOK AT?

Answer 15

Fluid status can be assessed by looking at
•	Blood pressure
•	Heart rate
•	Intake and Output
•	Mental status
•	Skin perfusion
•	CVP
•	Weight

Question 16

What are IV fluids that can be used to replace losses?

Answer 16

Types of Intravenous Fluid
Crystalloid
•	Lactated Ringer’s
•	Normal saline (0.9%)
•	Half normal saline (0.45%)
•	D5 and half normal saline
Colloid
•	Albumin
•	Dextran

Question 17

What is the difference between crystalloid and colloid fluids?

Answer 17

Both crystalloids and colloids increase intestinal blood flow and systemic arterial pressure; however, colloids may have a longer duration of effect. Colloids also result in a net movement of fluid from the intestinal lumen to the blood, whereas crystalloids can exacerbate transmucosal fluid movement into the intestinal lumen.

Question 18

How do you calculate how much fluid a patient should get post-op?

Answer 18

Maintenance IVF Calculations
•	100/50/20 Rule
•	100mL/kg for first 10kg
•	50mL/kg for next 10kg
•	20mL/kg for every kg over 20
•Gives total fluid for 24 hours
•	4/2/1 Rule
•	4mL/kg for the first 10kg
•	2mL/kg for next 10kg
•	1mL/kg for every kg over 20.
•Gives hourly IVF rate

Question 19

What are risks faced by someone with diabetes and surgery?

Answer 19

If diabetes is controlled on DIET:
-measure glucose every 4 hours, while fasting or NPO and give SC regular insulin as needed to maintain blood glucose between 140-200. Avoid glucose containing solution during surgery.
if diabetes is controlled on ORAL medication
- last dose should be taken the evening before surgery. measure glucose every 4 hours while fasting or NPO and give SC regular insulin as needed to maintain blood glucose between 140-200. Measure every 4 hours during surgery. resume oral therapy when patient returns to baseline diet.

Question 20

what needs to be considered in a patient with hyperthyroidism? hypothyroidism?

Answer 20

hyperthyroidism is at risk for thyroid storm.
hypothyroidism is at risk for hypotension, HF, cardiac arrest and death.

Endocrinologist should be consulted.

Question 21

What are several ways to prevent surgical site infections?

Answer 21

wash hands, wash patient when antiseptic agents, remove hair, give antibiotics

Question 22

what is a common finding in liver enzymes post-op?

Answer 22

Postoperative elevation of serum aminotransferase levels is relatively common finding after major surgery. Most are common, and tend to go away with time.

Question 23

What is an important pulmonary post-op complication?

Answer 23

atelectesis and pneumonia (most people die from pneumonia)

Question 24

What are the risks for pulmonary complications

Answer 24

a. Upper abdominal or cardiothoracic surgery
b. Prolonged anesthesia time
c. Emergency surgery
d. Age > 60
e. COPD
f. Heart failure
g. Severe systemic disease
h. Tobacco use
i. Impaired cognition
j. Functional dependcy or prior stroke
k. Sepsis
l. Low serum albumin
m. Obstructive sleep apnea

Question 25

Current recommendations for perioperative anticoagulation management:

Answer 25

Current recommendations for perioperative anticoagulation management:

If thromboembolic risk is…LOW:
Then…stop warfarin 5 days before surgery
Measure INR the day before to make sure it is below 1.6
If hemostasis permits, start warfarin 12-24 hours post op
No bridging needed

If risk is HIGH
Then you need to do bridging with medications. Stop warfarin 5 days before surgery and start on heparin 2 days after stopping warfarin. Make sure INR is <1.6 day before surgery. Can continue bridging or go back to warfarin post op