Pre-op H&P

Question 1

What is the goal of a pre-op H&P?

Answer 1

Reduce complications

Health care costs

Question 2

Role of Medical Consultant Prior to Surgery

Answer 2

Define co-morbidities
Evaluate severity of co-morbidities
Optimize all medical conditions
Provide surgical risk assessment
Recommend peri-op measures to reduce risk

Question 3

Surgical Physiology

Answer 3

Peripheral dilation
Reduced myocardial contractility
Decrease in tidal volume
Epi & norepi elevated
Cortisol elevated
ADH elevated

Question 4

Complete ROS with Special Attention to

Answer 4

Undiagnosed or inadequately controlled chronic disease
Cardiac & pulmonary
Bleeding disorders
Hx of DVT

Question 5

What all needs to be included in the medication history of a pre-operative patient?

Answer 5

Anticoagulants
Aspirin
NSAIDs
Echinacea
Ginsent
Garlic
Gingko
St. John's Work
Kava

Question 6

Effects of Echinacea Important for Surgery

Answer 6

Hepatotoxicity

Question 7

Effects of Ginseng Important for Surgery

Answer 7

Platelet inhibitor

Hypoglycemia

Question 8

Effects of Garlic Important for Surgery

Answer 8

Platelet inhibitor

Preload reduction

Question 9

Effects of Gingko Important for Surgery

Answer 9

Platelet inhibitor

Alters vasoregulation

Question 10

Effects of St. John’s Wort Important for Surgery

Answer 10

Up-regulates P450

Drug-drug reactions

Question 11

Effects of Kava Important for Surgery

Answer 11

Potentiates sedation

Drug-drug reactions

Question 12

Important Factors of Functional Status

Answer 12

Exercise tolerance

Activity level

Question 13

Lee Index Risk Factors for Major Cardiac Complications

Answer 13

High-risk surgery
Hx of ischemic HD
Hx of congestive HF
Hx of stroke/TIA
Insulin-dependent DM
Serum Cr >2 mg/dL

Question 14

Major Cardiac Complications with Lee Index

Answer 14

MI
Pulmonary edema
V-fib
Primary cardiac arrest
Complete heart block

Question 15

When is noninvasive cardiac testing performed?

Answer 15

Intermediate clinical predictor
Poor functional capacity
High risk surgery

Question 16

Examples of Intermediate Clinical Predictors

Answer 16

Class 1 or 2 angina
Prior MI or pathologic Q waves
Compensated or prior HF
DM

Question 17

Management of Low Risk Patient with CAD

Answer 17

4-5% risk of major cardiac complication
Considered for prophylactic revascularization if indications for revascularization exist independent of non cardiac surgery
Preoperative anti-anginal meds should be continued
Prophylactic IV nitro may reduce ischemia

Question 18

Evaluation of High Risk Patient with CAD

Answer 18

Surgery delayed until CAD is treated

Delay surgery 3-6 months of recent MI

Question 19

What do you need to know with a CHF patient for surgery?

Answer 19

Ejection fraction

Question 20

How is decompensated CHF indicated?

Answer 20

Elevated JVP
Audible 3rd heart sound
Evidence of pulmonary edema on exam or CXR

Question 21

Pre-op Necessities with CHF Patients

Answer 21

Pre-op control of CHF
Electrolytes & digoxin levels
Anesthesiologist & surgeon aware of severity of CHF

Question 22

Valvular HD & Pre-op Evaluation

Answer 22

Echo to determine nature & severity of disease

Severe systemic aortic stenosis are high risk for complications

Question 23

Arrhythmias & Pre-op Evaluation

Answer 23

Determine any arrhythmias
A-fib: control with Lovenox window
Symptomatic SVT & VT should be controlled
Indications for pacemaker: placed prior to surgery

Question 24

HTN & Surgery

Answer 24

Should be controlled prior to surgery

Question 25

Pulmonary Evaluation & Surgery

Answer 25

Highest risk in cardiac, thoracic, & upper abdominal surgery Patient specific factors associated with increased risk Highest risk: FEV1 less than 500 mL or arterial pCO2 >45 mmHg Well controlled asthma?

Question 26

Pulmonary Evaluation: Patient Specific Factors Associated with Increased Risk

Answer 26

Chronic lung disease Morbid obesity Tobacco use

Question 27

Peri-operative Management of Patients with Lung Disease

Answer 27

DVT prophylaxis | Antibiotics

Question 28

Bleeding Risk Assessment

Answer 28

History | Hx unavailable: PT, PTT, platelet count, & bleeding time

Question 29

2 Most Common Serious Neurologic Problems After Surgery

Answer 29

Acute delirium | Stroke

Question 30

DM & Surgery

Answer 30

Increased risk of infection & MI Regulation of blood sugar CMP measured & corrected prior to surgery

Question 31

Hypothyroidism & Surgery

Answer 31

Severe symptomatic should be corrected | Mild or asymptomatic generally okay

Question 32

Risk of Renal Disease & Surgery

Answer 32

Peri-operative complications: hyperkalemia, pneumonia, & fluid overload Dialysis 24 hours prior to surgery Monitor volume status closely

Question 33

Medication Recommendations & Surgery

Answer 33

Most Rx meds continued morning of surgery ACEI & diuretics withheld day of surgery DM: No oral hypoglycemics day of surgery Discontinue herbals 2 weeks prior Refrain from ASA, NSAIDs, & Plavix 2 weeks prior Warfarin: use lovenox window USE BETA-BLOCKERS