Preop H&P Flashcards
1
Q
What is the most impt thing about the preop hx and physical?
A
- assessing cardiac risk
- CV events are leading cause of perioperative death
2
Q
Joint commission for accreditation of hospitals requrires what for all surgical pts?
A
- reqrs all surgical pts to have a H and P documented in the medical record w/in 30 days b/f surgery
- the goal is to reduce complications and health care costs
- a standard preop eval hasn’t been defined
- routine lab, cv and pulm tests are often performed w/o justification
3
Q
Serious morbidity during surgical procedures usually is a result of what? What is the role of the medical consultant b/f surgery?
A
- 3-10% of pts undergoing surgical procedures experience serious morbidity, most of which results from cardiac, pulmonary or infectious complications
Role of medical consultant b/f surgery is:
- clearly defining the pt’s medical conditions
- eval severity and stability of these conditions, -optimizing all medical conditions
- providing a surgical risk assessment
- recommending perioperative measures to reduce the risk
4
Q
Physiologic changes during aneshesia and surgery?
A
- physiologic effects of anesthesia: peripheral vasodilation leading to hypotension, most of the anesthetic agents also lead to reduced myocardial contractility
- the decrease in tidal volume caused by general and spinal epidural anesthesia can cause atelectasis
- epi and NE levels are elevated during surgery and the 1st and 2nd postop days
- the serum cortisol is generally elevated for 1-3 days (increases sugar, suppresses immune system)
- serum ADH may be elevated for up to 1 wk postop
5
Q
What is the most impt aspect of the preop eval?
A
a thorough hx including:
- thorough ROS
- extensive med hx, OTC
- allergies
- surgical and anesthetic hx
- fxnl status
6
Q
What should you pay attention to in the ROS?
A
- undx or inadequately controlled chronic disease
- cardiac and pulm (recent chest pain or exertional SOB esp impt)
- bleeding disorders (hemophilia, von willebrands)
- hx of DVT
7
Q
What do you need to ask about in medication hx?
A
- not just Rx meds that are impt
- recent use of anticoagulants, aspirin, and nonselective NSAIDs
- don’t forget supplements, herbs
8
Q
Potential effects of preop use of common herbal therapies?
A
- echinacea: hepatotoxicity
- ginseng: PLT inhibitor, hypoglycemia
- garlic: PLT inhibitor, preload reduction
- gingko: PLT inhibitor, alters vasoregulation
- St. John’s wort: upregulates P450, drug-drug rxns
- kava: potentiates sedation, drug-drug rxns
9
Q
What are impt allergies to ask about?
A
- allergies to rubber product? Latex?
- allergies to any foods assoc w/ latex rxns such as bananas, avocados, kiwis, apricots, melons, and chestnuts?
10
Q
Impt surgical and anesthetic hx ?s to ask about?
A
- hx of bleeding complications during surgery
- personal or family hx of major rxns to anesthetics
11
Q
Impt fxnl status eval of pt?
A
- what is pt’s self reported exercise tolerance?
- what is pt’s activity level?
- a great tool to use for assessing fxnl status is the duke activity status index (ability to perform greater than 4 metabolic equivalents has been assoc w/ a lower CV risk)
12
Q
Preop eval of cardiac risk?
A
- cardiac complications of noncardiac surgey are perhaps major cause of perioperative morbidity and demise
- approx 1 mill pts undergoing surgery each year suffer a cardiac complication, 50,000 pts have MI
- pts w/o a hx of CAD are at extremely low risk (less than 0.5%) for perioperative ischemic complications
13
Q
What are the RFs for major cardiac complications (lee index)?
A
1 pt for each of the following:
- high risk surgery
- hx of ischemic heart disease
- hx of CHF
- hx of stroke or TIA
- insulin-dependent DM
- serum Cr over 2 mg/dL
pts and complication rate:
- 0 pts, 0.4% complication rate
- 1 pt, 1% complication rate
- 2 pts, 7% complication rate
- greater or equal to 3 pts, 11% complication rate
- complications include MI, pulmonary edema, Vfib or primary cardiac arrest, complete heart block
14
Q
Is there a routine noninvasive cardiac test done preop?
A
- no, there is no convincing evidence that routine noninvasive cardiac stress testing improves periop care
15
Q
When is noninvasive cardiac testing preop indicated?
A
if 2 of the following factors are present:
1) intermediate clinical predictor
- class 1 or 2 angina
- prior MI based on hx or pathologic Q waves
- compensated or prior herat failure
- diabetes
2) poor fxnl capacity (less than 4 metabolic equivalents)
3) procedure w/ high surgical risk (emergency surgery, aortic repair or peripheral vascular surgery, prolonged procedure w/ large fluid shifts or blood loss)
16
Q
Management of low risk pt w/ CAD perioperatively?
A
- these pts have 4-5% risk of major cardiac complication
- they should be considered for prophylactic revascularization only if indications for revascularizaiton exist independent of noncardiac surgery
- preop anti-anginal meds should be continued preop and in post op period
- prophylactic IV nitro may reduce ischemia but hasn’t been shown to reduce the rate of postop complications
17
Q
Management of high risk pts w/ CAD for surgery?
A
- in these pts surgery should be delayed until CAD is tx, if possible
- for pts w/ recent MI, delaying the surgery for 3-6 months may be useful
18
Q
Preop eval for CHF pts?
A
- decompensated CHF as indicated by elevated JVP, an audible 3rd heart sound or evidence of pulmonary edema on exam or CxR significantly increases risk of perioperative pulmonary edema (15%) and death (2-10%)
- preop control of CHF w/ diuretics and afterload reducing agents decreases the risk but diuretics can increase risk of intraop hypotension
- electrolytes and digoxin level should be checked
- the anesthesiologist and surgeon should be made aware of presence and severity of CHF
19
Q
What would you do if you heard a murmur in a pt who has come in for a routine preop history and physical?
A
- get an echo
20
Q
Preop eval for pt w/ valvular heart disease?
A
- pts w/ heart murmurs should have echos to define the nature and severity of valvular lesions. Pts w/ sig lesions may need abx prophylaxis and appropriate fluid management and consideration of invasive intraop monitoring
- pts w/ severe sx aoritc stenosisare at especially high risk for complications
21
Q
Preop eval of arrhythmias?
A
- finding of a rhythm disturbance during preop eval should prompt consideration of further cardiac eval, especially if the finding of structural heart disease would alter perioperative management. Pts found to have a rhythm disturbance w/o structural heart disease are at very low risk for perioperative complications
- in pts w/ a fib, rate should be controlled and they should be covered w/ lovenox window
- sx supraventricular and ventricular tachycardia should be controlled b/f surgery
- pts who have indications for permanent pacemaker should have these placed b/f surgery
22
Q
Preop eval of HTN?
A
- severe HTN (greater tahn 180/110) has been assoc w/ higher risk of cardiac complications
- therefore BP should be controlled b/f surgery if possible
23
Q
Preop eval for pulm complications?
A
- risk of developing pulm complications is highest in pts undergoing cardiac, thoracic, and upper abdominal surgery
- the 3 pt specific factors assoc w/ increased risk of postop pulmonary complications are: chronic lung disease, morbid obesity and tobacco use
- pts w/ chronic lung disease, esp those w/ FEV1 less than 500ml or an arterial pCO2 greater tahn 45mmHg are at highest risk
- CXR for pts older than 60 good preop eval
- pts w/ asthma at optimal pulm fxn at time of surgery don’t appear to be at increased risk
- smoking cessation for at least 8 wks has been show to reduce risk of pulm complications in pts undergoing CABG
- the use of incentive spirometry and deep breathing exercises begun preop and continued for 3-5 days in postop period reduces the incidence of postop atelectasis
24
Q
Periop management of pts w/ lung disease?
A
- DVT prophylaxis is impt, esp in pt undergoing or hip surgery
- abx may be useful in pts coughing purulent sputum
- pts who take theophylline should be maintained on IV theophylline when necessary (narrow therapeutic window)
25
Preop heme eval- what if blood work shows that the pt has some anemia?
- does this pt need preop eval for anemia: certain types of pts (with immune hemolytic anemia and sickle cell disease need to be eval b/f surgery) are at high risk
- does this pt need transfusions: usually pts w/ hemoglobin of 8-9 g/dL do well though in some situations like pts w/ CAD, CHF and PVD we like to see a higher hemoglobin
26
Bleeding risk assessment preop?
- hx is most impt part of eval
- when the hx is unavailable a formal eval should be done and should consist of PT, PTT, platelet count and bleeding time
27
What ?s should you ask to eval risk of bleeding?
- have you ever bled a long time or developed a swollen tongue or mouth after cutting or biting your tongue, cheek or lip?
- do you develop bruses larger than a silver dollar w/o being able to remember how you injured yourself?
- has bleeding ever started again the day after a tooth extraction?
- was bleeding after surgery ever hard to stop? Have you had unusual bruising around an area of surgery or injury?
- has any 1st degree blood relative had a problem w/ unusual bleeding or bleedin after surgery?
28
Neuro eval - preop?
- 2 MC serious SEs of surgery in the area are acute delirium and stroke
- it is impt to avoid meds that can cause delirium. Meperidine, anticholinergics, and benzos have all been assoc w/ delirium
- postop stroke is a relatively infrequent complication. Older age, sx carotid stenosis and the occurence of postop afib and RFs for development of stroke
29
Preop eval for DM?
- pts w/ diabetes are at increased risk for postop infections and MIs
- regulation of blood sugar can also be difficult in these pts: generally, the goal should be to keep the sugar b/t 100-250 mg/dL
- all pts w/ diabetes should have their renal fxn, and electrolytes measured and corrected b/f surgery.
30
When should glucocorticoid replacement be considered?
- in any pt who has been on 7.5 mg of prednisone for 3 wks or 20 mg prednisone for a wk
- if there is evidence of adrenocortical insufficiency, these pts should receive 100mg of hydrocortisone every 8 hrs beginning on morning of surgery and continuing for 48-72 hrs. Tapering the dose is not necessary
31
Preop eval of hypothyroidism?
- severe sx hypothyroidism should be corrected b/f surgery
| - pts w/ mild or asx hypothyroidism generally tolerated surgery well
32
Preop eval for renal disease?
- these pts are at high risk for periop comlications such as postop hyperkalemia, pneumonia and fluid overload
- dialysis dependent pts should be dialyzed 24 hrs b/f surgery. Their electrolytes should be carefully monitored in periop period
- pts w/ renal insufficiency, defined as elevated serum Cr or BUN should have their volume status monitored as hypovolemia can increase the risk of postop deterioration in renal fxn
33
Physical exam preop?
- ensure thorough CV and pulm exam
| - unexpected abnormal findings on physical exam should be fully characterized and investigated b/f elective surgery
34
What are the med recommendations perioperatively?
- most Rx meds should be continued on morning of surgery w/ small sips of water ,unless CI
- ACEI and diuretics usually withheld day of surgery (increases risk for renal failure and hypotension)
- pts w/ diabetes: no metformin or oral hypoglycemics day of surgery, whether or not and how much insulin a diabetic takes largely dependent on pt
- d/c herbal supplements 2 wks prior to surgery
- pts whose risk of bleeding from preop use of ASA for 7-10 days, nonselective NSAIDs for 3-5 days, and thienopyridine (such as plavix) for 2 wks
- although much more complicated, as a general rule, a pt taking warfarin may have surgery as long as INR is less than 1.5
- all pts w/ CV RFs should receive bbs perioperatively unless strongly CI
35
Best tool to use when performing preop eval?
- hx
