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Flashcards in Pre Op Jill Deck (79):
1

goals of prep assessment

1. detect unrecognized disease and risk factors

2. optimize preoperative medical condition

2

ASA 1 health status

healthy, non smoking

no or minimal alcohol use

3

ASA 2 health status

mild systemic disease (well controlled HTN, DM, stable asthma)

w/o functional limitation

social drinker, prego, obese, current smoker

4

ASA 3 health status

severe systemic dz/functional limitation

hx of cardiac complication
COPD
active hepatitis, alcohol dependence/abuse
ESRD + dialysis
premature infant
BMI >40

5

ASA 4 health status

severe systemic disease w/constant threat to life


recent MI, CVA, TIA, CAD
Ongoing ischemia or valve dysfunction
sepsis
dic
ards
esrd - dialysis

6

ASA 5 health status

moribund, not expected to survive w.o operation

ruptured aortic aneurysm
massive trauma
intracranial bleed w/mass effect
ischemic bowel in face of significant pathology

7

ASA 6 health status

brain dead, just going in to harvest organs

8

risk assessment - RCRI

6 primary indicators of cardiac complications

1. high risk surgery (vascular, open peritoneal, intrathoracic procedure)

2. hx of heart disease (MI, postive stress Tess, pathologic Q waves, nitrate use)

3. Hx of compensated or prior HF

4. hx of CVA

5. DM tx with insulin

6. CKD w. Cr >2 mg/dl

9

factors to take into account preoperative risk assessment

1. exercise capacity

2. age

3. medications used

4. obesity

5. obstructive sleep apnea

6. alcohol misuse

7. smoking

8. personal/fh of anesthetic complications

10

exercise functional capacity to consider pre op

poor exercise capacity = inability to perform >4 METS

strong predictor of all cause mortality, more than RCRI

11

age pre-op

not a significant risk factor for cardiac complications

should not be a SOLE eliminator of surgery

12

obstructive sleep apnea pre-op

OSA increases risk for post-operative pulmonary applications

most pts are undiagnosed

STOP BANG, high obese pts

13

alcohol use in pre op considerations

misuse increases risk of post op complications (esp. surgical site infection, cardiopulmonary infection)


also at risk for seizure and delirium tremens

14

assessing alcohol use pre op

emergent or urgent surgery will req. treatment to prevent symptoms of withdrawal

should stop drinking at least 4 weeks before physiologic abnormalities occur

AUDIT-C, CAGE, SBIRT

15

smoking use pre op

increased risk of ICU admission and mortality

cessation preoperatively should reduce post op issues BUT increased risk if stop <8 weeks prior to surgery

if they are current smokers at time of sx, nicotine patch should be given

16

when is ideal time to stop smoking prior to sx?

ideally cessation should be done months prior to surgery and not within a few weeks of tx

17

rare complication of anesthesia

malignant hyperthermia

must asses for family hx

occurs when pts are exposed to succinylcholine or volatile anesthetic

18

malignant hyperthermia epidemiology

autosomal dominant

2x more common in males (half of rxns are <19 yrs of age)

19

malignant hyperthermia patho

calcium accumulation occurs causing sustained muscle contraction (generates heat, consuming O2, depleting ATP)

once energy stores depleted = rhabdomyolysis of muscle = hyperkalemia and spilling myoglobin in blood

leads to CO2 production and DIC

20

malignant hyperthermia Clinical Presentation:

- Sustained muscular contraction, rhabdomyolysis, anaerobic metabolism and mixed metabolic and respiratory acidosis

-Early hypercarbia not amenable to increased minute volume

-Sinus tachycardia

- Masseter or generalized muscle rigidity

21

malignant hyperthermia management

Optimize oxygenation, end surgery

Dantrolene


ICU management, Pt counseling

22

Dantrolene

blocks accumulation of calcium

tx malignant hyperthermia

23

Indications of Preoperative Diagnostic Testing

HgB/Hct

pts age >65 undergoing major surgery

younger patients going for surgery where large blood loss is expected

24

Indications of Preoperative Diagnostic Testing

Cr/Chem Panel

Pts > 50, undergoing intermediate or high risk surgery

Young patients with suspected renal disease or nephrotoxic drug use

25

Indications of Preoperative Diagnostic Testing

Urine Pregnancy Test/beta HCG

All females of child bearing age

26

Indications of Preoperative Diagnostic Testing

CXR

Pts > 50 who are undergoing:
- AAA
- Upper abdominal surgery (GB, liver, stomach, pancreas)
- Thoracic surgery


+/- obese pts

27

Indications of Preoperative Diagnostic Testing

EKG

Preexisting cardiovascular dz

Pt undergoing any

Severely obese pts with poor exercise tolerance and 1 addition CVD/RCRI risk actor

28

Indications of Preoperative Diagnostic Testing

PFTs

Pts w/symptoms of unexplained dyspnea

Exercise intolerance

COPD or asthma pts without optimal tx

Abnormal pulm exam

Pts undergoing pulm resection surgery

29

Pulm Complications MC

atelectasis
bronchospasm
pneumonia

30

risk of pulm complications and FEV1

risk increases with FEV1 <1.5 L

high risk of prolonged ventilation/mortality FEV1 <1

31

NSQUIP calculator

online calculation of risk

Takes into account type of surgery, functional status of pt, increased ages, abnormal Cr, ASA class

32

ex. of 1 MET

take care of self

eat/dress/use toilet

walk indoors

walk on level @2 mph

washing dishes

33

ex of > 4 MET

climb 1 flight of stairs

walk on level @ 4mph

run a short distance

scrubbing floors

golf, bowl, dance

34

>10 MET s

singles tennis
football
basketball
skiing

35

when to do further cardiac tests?

Less than 4 Mets
Greater than 4 METs + high risk surgery

36

low risk surgeries

endoscopic procedures

superficial procedures

cataract sx

breast sx

ambulatory sx

37

intermediate risk surgeries

carotid endarterectomy

endovascular abdominal aortic aneurysm repair

head and neck

intraperitonela sx

intrathoracic sx

orthopedic sx

prostate sx

38

high risk vascular surgery

peripheral vascular surgery

aortic/major vessel sx

emergency surgery

39

what anti-hypertensives can't be taken day of surgery

diuretics (hydrochlorothiazide, furosemide)

ACE Inhibitors

ARBs (HoTN, CV, renal outcomes)

40

who gets beta blockers as pre op management

CAD or 2+ cardiac risk factors

titrated to HR 60-80

41

why are BB continued to surgical patients

decreased oxygen demand

acute withdrawal, may cause ischemia

42

alpha 2 agonistis and surgery

continue to day of surgery but dont initiate

abrupt withdrawal can cause rebound HTN

43

CCB and surgery

continue, can initiate if needed

44

Digoxin

continue preoperatively

45

H2 Blockers/PPI:

considered safe, continue if pt is already taking, may be used empirically

46

Inhaled Beta Agonists/Anti Cholinergics:

continue use, reduce periop pulmonary complications

47

Theophylline:

may cause serious arrhythmias and neurotoxicity = hold evening prior

48

Statin:

continue perioperatively, initiate if prior to cardiac surgery

49

Niacin and fibric acid derivatives:

hold 24hrs prior, rhabdo and myopathy risk

50

estrogen and surgery OC

continue if low risk surgery

may choose to stop 4-6 weeks prior to surgery due to increased VTE risk

51

HRT and surgery

stop 4-6 weeks if having procedure with high risk of VTE

low risk is ok to conintue

52

SSRI’s/SNRIs:

increased bleeding risk, hold 3 weeks pre op

53

Psych Med management

continue with caution

Lithium, antipsychotics, anxiolytics

54

diabetes surgery

pro op eval

EKG, A1C, serum Cr, fasting glucose (goal b/t 110-180)

PTS should have surgery in the morning

55

DM
control is diet alone

no therapy, SSI possible/avoid D5W fluids

56

DM control is oral agent/non insulin injectable

continue meds,
hold morning of surgery

57

DM long acting insulin

take 1/3 to ½ normal dose day of up until pt resumes full diet post op

58

surgery risk with DM
Sulfonylureas:

increase hypoglycemia

59

surgery risk with DM
Metformin:

contraindicated if increased risk of renal hypoperfusion, lactate accumulation, tissue hypoxia

60

surgery risk with DM
TZD:

may worsen fluid retention/ peripheral edema = HF risk

61

surgery risk with DM
DDP-IV/GLP-1:

decrease GI motility, worsening post op ileus

62

surgery risk with DM
SGLT2:

increase risk of hypoglycemia, reports of AKI and DKA

63

thyroid disease surgical management
Subclinical Hypothyroidism:

(elevated TSH, normal T4) continue surgery

64

thyroid disease surgical management
Overt Hypothyroidism:

urgent/emergent sx is ok, postpone elective surgeries until patient is euthyroid

65

thyroid disease surgical management

Severe Hypothyroidism:

risk of myxedema coma, ok for emergent surgeries (high risk), hold other surgeries

consider stress dose steroid, tx with IV levothyroxine

66

thyroid disease surgical management
Overt Hyperthyroidism:

increased risk of thyroid storm, ok for emergent surgeries, hold others

67

Adrenal insufficiency surgical risk

(inadequate mineral corticoid and cortisol) are at risk for adrenal crisis (HoTN, HoGlycemia, shock)


inability to increase production of adrenal hormones in response to stress

68

who needs stress dose management

adrenal insufficiency
chronic disease

69

stress dose management

minor surgical procedure

(hernia repair, colonoscopy, bx)
usual steroid dose morning of

70

stress dose management

Moderate surgery:

(joint replacement, vascular surgery)

usual morning dose + 50mg Hydrocortisone IV prior to procedure, 25 mg IV q8/24hrs until normal regimen resumed

71

stress dose management

Major surgery:

(CABG, emergency)

usual morning dose, 100 mg IV prior, 50 mg IV q8/24 hrs then taper dose 1/2 per day until maintenance dose is reached

72

when do you stop heparin prior to procedure

5hrs prior

73

when do you stop LMWH prior to surgery

24hrs prior

74

goal INR before surgery

< 1.5

stop Coumadin 5 days prior or give vitamin K for urgent sx

75

bleeding character of vWF dz

delayed bleeding, unstable clot forms following procedure but the will break open/not heal

76

vWF dz surgical management

DDAVP or vWF infusions

77

who gets endocarditis prophylaxis? what meds?

high risk cardiac condition AND high risk procedure

Either Amox, Cephalexin or Clinda/Azithromycin

78

High Risk Procedures:

Dental procedures that manipulate gingiva (routine cleaning, tooth extraction, drainage of abscess)

Invasive procedures of respiratory tract (incision or biopsy of mucosa, bronchoscopy w/bx, tonsillectomy, adenoidectomy)

Invasive procedures of infected skin or soft tissue

79

High Risk Conditions:

Prosthetic heart valve

Prosthetic material in valve repair

Prior hx of infective endocarditis

Pulmonary conduit

Valve regurgitation in transplanted heart