Pre/Post Op Flashcards
(29 cards)
What factors independently predict cardiac risk factors for surgery? Revised Goldman Cardiac Risk Index
- High Risk Surgery itself
- Hx ischemic heart disease
- CHF
- CVD
- DM requiring insulin
- Creatinine 2.0+
Factoring the cardiac risk factors for perioperative cardiac complications, how do you calculate risk for surgery?
Zero Factors – 0.4%
One Factor – 1.0%
Two Factors – 2.4%
Three or more – 5.4%
What patients with how many cardiac risk factors can be considered low risk?
Low Risk is considered Score of 0 or 1 – RCRI
– No further cardiac testing is required or risk stratification
What is the index used to gauge cardiac risk factor for surgery?
Revised Goldman Cardiac Risk Index (RCRI)
What kind of patients require further risk stratification for surgery?
- 2 or more RCRI factors
- - Considered elevated risk for major adverse event
What has been found to be an accurate predictor of perioperative or long term events from surgery?
Functional Status
– Metabolic Equivalents
What are metabolic equivalents that can be used to stratify risk for surgery and not require any further evaluation?
- – Climbing a flight of stairs
- – Walking up a hill
- – Performing heavy household work
- – Rigorous Sports activities
When should a patient undergo a cardiac stress test or echocardiogram before surgery?
A patient who already needs one.
- Unstable Angina
- Arrhythmia
- Uncompensated CHF
- Severe valvular disease
If a patient has recently had an MI and recovering, but was scheduled for a cholecystectomy, when should it be rescheduled?
8 weeks after the MI at the minimum
Who should receive a EKG prior to surgery?
– Any patient undergoing intermediate-risk procedures with at least 1x RCRI risk factor, this is in order to compare it to an EKG afterward to know if any events occurred during the procedure.
If a patient with CHF and DM is undergoing cataracts removal, what needs to be done prior to that procedure?
No EKG needs to be performed for any patients undergoing an low-risk surgery.
What hepatic functions are measured to assess the hepatic risk for surgery using the Child-Pugh score?
- Albumin
- Bilirubin
- Encephalopathy
- Ascites
- PT (INR)
What is a hepatic risk factor that is an absolute contraindication for elective surgery?
Acute Hepatitis
What should be evaluated and corrected in a patient with liver disease before they undergo surgery?
- Renal Function
- Electolytes
- Bleeding Time (PT/PTT)
- Encephalopathy
- Nutritional status
If a patient has prolonged bleeding time, what can be used to correct it for surgery?
Bleeding Time –> Desmopressin
If INR Elevated
– Vitamin K
– Fresh Frozen Plasma
If a patient has Afib and is going to undergo an elective cholecystectomy, what should you instruct the patient to do before surgery?
Discontinue taking Warfarin 3-4 days before surgery and to check INR to ensure it is below 1.5 before proceeding with surgery.
If a patient has a history of PE after surgery before in the past and is on Warfarin, how should you manage the patient differently?
The patient should be bridged with Heparin after stopping Warfarin (LMWH) before surgery, then resuming warfarin immediately post-op and Heparin is resumed 12 hours after surgery.
What are the increased surgical complications associated with diabetes mellitus?
- Increased risk of infection
- Delay in wound healing
- Increased cardiac complications
- Increased mortality post-operatively
What might need to be adjusted in diabetic patients post operatively?
Insulin dose should go up. This is due to the body being under stress and elevated cortisol that releases more glucose
What should be done with a patient who has renal insufficiency preoperatively and will be receiving intraoperative contrast?
- Ensure proper hydration and give Isotonic fluids prior to surgery to prevent volume loss
- Acetylcysteine can be used to limit contrast induced nephropathy
What are indicators of severe nutritional depletion?
- Anergy to skin antigens
- Albumin less than 3g/dL
- Serum transferrin less than 200 mg/dL
- Significant weight loss (more than 20% body weight) over the span of several months
If patient has signs of severe nutritional depletion how should surgeries be handled?
Should be postponed until patient is optimized nutritionally in order for them to heal properly
What is the best indicator of nutritional status?
Prealbumin, malnutrition indicated by less than 16 mg/dL
– Short half-life 2-3, so can be a good snapshot of nutritional status
What are conditions that can cause prealbumin to be decreased, despite normal nutrition?
Physiologic Stressors
Infections
Liver Dysfunction
Over-hydration
