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preop management Flashcards

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1
Q

Continue antihypertensive meds until

A

day of surgery and resume postoperatively UNLESS PATIENT IS TAKING ACE INHIBITORS OR ARBS.

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2
Q

Why don’t you want to follow the same rules with ACE or ARBS

A

Renally excreted. Don’t want them to take it on the day of surgery bc these drugs tend to lower BP a lot and anesthesia lowers BP as well. So in some cases we can’t control this low BP and have to get pressors involved

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3
Q

pts with DM usually present in this manner PreOp

A

Usually hyperglycemic preop due to stress (increase of cortisol and epinephrine) or unrecognized infection

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4
Q

what do we do to manage pts with DM in surgery

A

need tight glucose control

usually book very early in the morning

usually not on PO because need insulin to monitor very carefully

Fasting Glucose above 200 may be treated with insulin by anesthesiologist

usually put them on a sliding scale of insulin depending on BG

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5
Q

when should pts with DM discontinue there medications before surgery

A

Patients with well-controlled diabetes taking oral agents should continue meds until day BEFORE surgery – will manage with insulin if needed during surgery

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6
Q

how should analgesics be managed in pts with DM why?

A

Preoperative sedatives or analgesics should be as low dose as possible due to increased sensitivity

cortisol, catecholamines and glucagon oppose

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7
Q

Patients with non-insulin dependent diabetes should stop taking long-acting sulfonylureas (Glyburide) due to

what would you recommend they take instead

A

should stop taking a couple days before due to risk of intraoperative hypoglycemia

Use short-acting (Repaglinide) or sliding scale insulin (preferred during hospitalization).

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8
Q

pts taking metformin have a risk of

A

lactic acidosis (increased lactic acid and low ph)

with renal insufficiency

need to watch out for this

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9
Q

how do you test a pt pre op to insure good glycemic control

A

FBS= less than 100
random blood sugar < 200
or hemoglobin A1C <6.5

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10
Q

what if you don’t have good glycemic control in a DM pt scheduled for surgery

A

refer back to PCP or endocrinologist for stabalization

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11
Q

Preoperative HTN increases risk of perioperative complicationsi.

A

increase Incidence of stroke

increase Incidence of arrhythmia

increase Incidence of myocardial ischemia/myocardial infarction

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12
Q

Complications related to heart disease is the major cause of perioperative deaths sometimes you can monitor with

A

arterial line

Should be monitored with arterial line or subclavian if significant heart disease

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13
Q

how should pts with valvular dz be monitored preop

A

Antibiotic prophylaxis for patients with valvular disease

Up to a week to 5 days before surgery

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14
Q

when would we stop heparin presurg

A

Heparin stopped 5 days prior to surgery – resumed 12 hours post op

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15
Q

Serious cardiac event or death during procedure is based on the

A

Goldman’s Index

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16
Q

concerns with renal disease

A

Risk of dehydration

Risk of infection

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17
Q

medications that can be nephrotoxic

A

. Gentamycin (aminoglycosides)
Methicillin (PCNs)
Toradol (NSAIDS)

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18
Q

what should we always check before a surgery scheduled for renal pt

when would a pt need dialysis before surgery

A

Look at potassium -if high needs dialysis before surgery

Consult with nephrologist to order dialysis day before surgery

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19
Q

If alcohol intake is high or history of alcohol abuse in pt awaiting surgery

A

patient will need medical intervention for withdrawal symptoms

Management – Give ETOH to pt’s pre-op
Alternative –>Ativan

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20
Q

Presence of umbilical hernia may indicate

A

ascites

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21
Q

when would we test PT/PTT/INR

A

done for longer cases where you might need to transfuse patients)

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22
Q

LFT cause for concern in preop liver pt when

A
  1. AST (aspartate aminotransferase)
  2. ALT (alanine aminotransferase)
  3. Alkaline phosphatase
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23
Q

preop testing for pt with liver dz

A

A BEAP P L

A albumin <3.5

B bili direct >.3 total>1.0
E encephalopathy
A acities
P Pt/INR

PTT used to monitor heparin therapy

LDH (lactate dehyrogenase) >90 elevated with cell injury/death

AFP (alpha fetoprotein)–>CA/cirrhosis

Also elevated in testicular cancers, particularly seminomas

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24
Q

LDH when elevated indicated

A

Indicates poor perfusion of one of the organs

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25
obese pts are at risk for
poor wound healing BMI>30 obese BMI>40 morbid obese
26
how do you prevent DVT in obese pt (meds)
TX with 5000 units Heparin subq perioperatively Perioperative timeline = ~ 90 days around surgery i Continue heparin 5k subq q 12hr while hospitalized
27
modifications to help prevent DVT in obese pt
Get up to bathroom before surgery/walk to operating room Early ambulation after surgery helps prevent DVT’s as well
28
co-morbidities often seen in obese pts
``` Comorbidities of HTN, Diabetes, Obstructive Sleep Apnea, GERD Stress Incontinence ``` Consider each comorbidity as a separate underlying disease
29
Lung compromise including patients with
COPD Emphysema have increased risk of pneumonia atelectasis and hypoxia
30
atelectasis is a complication of what
partial or complete collapse (pulling at) that can result from being on a ventilator
31
pre-op tx for pts with productive cough
Preop tx with bronchodilators and antibiotics for productive cough
32
what are the recommendations around smoking preop
Don’t cut back or quit smoking 2-3 days before surgery b/c there is increased mucus production which makes it harder to manage the airway
33
Asthma patients should get what before surgery
Asthma patients should get steroids/bronchodilator treatment before surgery Example: Albuterol MDI (patient can use their own home inhaler)
34
when should you recommend a pt stop smoking before surgery
SMOKING cessation 8 weeks before surgery will decrease sputum production
35
risk of bleeding with these 6 meds
``` NSAIDS Plavix ASA Cuomadin Warfarin OTC ```
36
when should NSAIDS be stopped
i. Should be discontinued 5 days preop
37
when should plavix and ASA be stopped
i. Should be discontinued 10 days preop
38
when should coumadin and warfarin be stopped***
i. Should be discontinued 5 days preop | ii. Switch to Heparin if necessary
39
when should OTC meds be stopped
should be discontinued 10 days preop
40
Determinants of malnourished pt
Weight loss of 15% over last 3-4 months Albumin less than 3.0 g/dl Protein less than 6.0 g/dl Serum transferrin level of less than 150 mg/dl Increased RBC size (macrocytic) Decreased B-12, Folic Acid
41
malnutrition bMI And preop tx
<18 PREOP TREATMENT: 25% ALBUMIN IN 100cc soln IV 120cc/h
42
who is at risk of poor wound healing
Elderly, malnourished and cancer patients have a high incidence of being immunocompromised pts on corticosteroids -usually if chronic use will try to get them off 2 week sbefore
43
Pt receiving corticosteroids within 3 days of surgery is at risk of
Risk of poor wound healing Steroids reduce inflammation, epithelialization and collagen synthesis Leads to wound breakdown and infection Pt will need additional dose of steroids on day of surgery if taking more than 5mg prednisone for 2 weeks
44
GERD complications
Patients have a high incidence of postoperative nausea
45
TX considerations for a pt with GERD
Require aggressive antiemetic treatment preop and postop
46
Workup for pt with GERD
Hx of H.pylori, PUD, hiatal hernia
47
Meds to consider for pt with GERD
``` i. H2 Blocker – “dines” Cimetidine (Tagamet) Ranitidine (Zantac) ii. Antacids – Gaviscon, Mylanta iii. PPIs (proton pump inhibitor) – “prazole” Lansprazole (Prevacid) Omeprazole (Prilosec) ```
48
hypovolemia
b. Bleeding c. Vomiting/diarrhea d. Bowel obstruction-Shock e. Dehydration
49
Hypovolemia sxs and PE
Symptoms -->Dizziness, weakness, anxiety | PE --> Cold skin, pallor, capillary refill > 2sec, diaphoretic
50
Orthostatic hypotension definition
fall in systolic pressure of more than 10mm Hg when patient sits up from lying position)
51
this is an early sign of hypovolemia
Tachycardia is early sign of Fever Low urine output also seen
52
you really want to control this to prevent hypovolemia
PAIN will allow for assessment of true blood pressure
53
Hyponatremia hypovolemia commonly caused by
diuretics loss of NA excess vomiting diarrhea, sweating, diuretics all cause this
54
hyperthyroid pt at risk of
i. Risk of HTN ii. Risk of hyperthermia iii. Risk of cardiac arrhythmia iv. Risk of CHF
55
Tx for pt with hyperthyroid prop (how many weeks pre op)
Treat with PPU/PTU (propylthiouracil) 1-6 weeks preop If emergency, treat with propranolol, PPU and potassium iodide propranolol lowers BP
56
hypothyroidism
i. Risk of hypotension ii. Risk of shock iii. Risk of hypothermia
57
preop tx for adrenal insufficiency
Preop tx with cortisol and NS (normal saline) | ADD cortisol
58
what are we considered about with allergies in surgery
Intraoperative anaphylaxis occur 1/4500 surgeries with 3%-6% mortality
59
Most allergies are to
Most allergies are to muscle relaxants, anesthesia drugs (etomidate/propofol) and narcotics LATEX ALLERGIES second most common cause of anaphylactic allergies (first is muscle relaxants)
60
when would you need to consider a transfusion in a pt with anemia awaiting surgery
Hemoglobin below 7 (or HCT below 21) will likely require blood transfusion of 1 unit
61
1 unit of PRBC will raise HCT by
by approx 3 points
62
anemia is of concerned with hemoglobin below
i. Hemoglobin below 10 | ii. Hematocrit below 30 does not increase risk for surgery
63
vi. Low Hemoglobin Determinants:
1. MCV (mean corpuscular volume) | 2. MCHC (mean corpuscular hemoglobin conc)
64
Normocytic/normochromic concerned about
1. Acute blood loss 2. Early FE-deficiency 3. Chronic illness/cancer 4. Hemolytic anemia
65
viii. Microcytic/hypochromic concerned for
1. Late FE-deficiency 2. Thalassemia 3. Lead poisoning
66
Macrocytic/normochromic concerned for
1. Malnutrition 2. B-12 deficiency 3. Folic Acid deficiency
67
Platelets below _____does not increase risk for surgery
50,000 u/l
68
Platelets below _____consider the need for blood transfusion
30,000,
69
Platelets below _____ require blood transfusion
10,000 platelets are usually this low because of chemo
70
platelet counts needing a transfusion (<10,000) would replace with
Replace with platelets (not PRBC!)
71
e. Surgery increases risk of DVT (deep vein thrombosis) 21 times! In the following patients --
ii. Hx of DVT iii. Hx of prolonged immobilization iv. Hypercoagulable states such as
72
Hypercoagulable states such as
1. Factor V Leiden 2. TTP (thrombotic thrombocytopenic purpura) 3. SLE 4. Polycythemia Vera
73
f. PREOP TREATMENT FOR DVT RISK:
i. WALK TO OPERATING ROOM ii. SEQUENTIAL COMPRESSION DEVICE (SCD) iii. ELASTIC STOCKINGS iv. HEPARIN 5000 units SUBQ q 8-12h
74
risks witH the alcoholic pt
a. Risk of malnutrition b/c ETOH is empty calories, can cause seizures & delirium tremens (rapid onset confusion caused by withdarawal from alcohol)
75
LABS WITH alcoholic pt
``` increase LFTs decrease Albumin decrease FE/transferrin decrease B-12/Folic Acid increase Bilirubin ```
76
may have ____ PT/INR/PTT
h. May have increased PT/INR/PTT
77
treatment for alcoholic pt
Type and Screen for blood transfusion if needed i. Preop tx with ativan, thiamine, B-12
78
goldman criteria
age of 70 MI in the last 6 months S3 gallop or JVD valvular aortic stenosis rhythm other than sinus on last pre-op exam >5PVC on any EKG know the lab values abdominal thoracic or aortic surgery planned emergency operation
79
DM more sensitive to anesthesia because
increased cortisol increased sensitivity because surgery evokes a stress response that release of growth hormone and glucagon these hormones oppose glucose hemostasis more sedated more easily
80
More important than the BP is the
EKG managed by the anesthesiologist if you have an EKG that is diufferent than the prior consider a cardiology consult
81
intraoperative HTN is associated
stokes MI death
82
how to we manage the pain meds of DM pts
usally lower the amount of analgesics because they are more sensitive to them and it can mess with their blood sugar
83
what would be the benefits of an arterial line to avoid complications from heart disease
Arterial line – can check blood gases and can also check very accurate BP’s manage fluid
84
why would you use a subclavian line to monitor over an arterial line
Subclavian line has more ports so can check blood
85
what is the total score with goldman's index
Total score is 53
86
what is this risk of having a cardiac event with goldman's index
Risk of serious cardiac event or mortality is from .9% to 63.6%
87
what are the lab values on goldman cardiac index | K
K<3
88
what are the lab values on goldman cardiac index HCO3
<20
89
what are the lab values on goldman cardiac index bun
>50
90
what are the lab values on goldman cardiac index Cr
Cr>30
91
what are the lab values on goldman cardiac index PO2
<60`
92
what are the lab values on goldman cardiac index pc02
>50
93
what, other than the lab values would add to the cardiac risk index with regards to liver and disease
increased liver enzymes or bedridden wiht chronic disease
94
stop NSAIDS
a week before surgery ok to take Tylenol with codeine NORCO
95
preop testing for a pt with renal disease labs and nml ranges
BUN >20 (>100 CRITICAL!) Creatinine >1.2 Albumin < 3.5 LDH (lactate dehyrogenase) > 90 U/L LDH is an enzyme released by cells with injured or destroyed Urinanalysis Proteinuria CASTS
96
most common cause of prolonged PTT
most common cause of prolonged PTT
97
use to asses pts with chronic liver disease
Child–Pugh score
98
what OTC meds cause complications
``` echinachea -allergy and immunocompremis ephredra-MI HTN STOKRE GARLIC-bleeind ginko- bleeding ginseng-hypoglcemia and risk of bleeding Kava-increase effet of aneshesia St. John's -alter effects valerian-increase risk of anesthesia fish oil- bleeding ```
99
risk of bleeding with these OTC
garlic and ginseing (hypoglycemia as well) stop 7 days before
100
when should you stop ephredra and Kava
24 hours before
101
st johns wart should be stopped
5 days before
102
immunocompromised pts have a lymphocyte count
Determination by total lymphocyte count less than 800
103
hypovolemia labs
```  glucose  BUN  Creatinine Albumin BUN:CR >20:1 ```  NA  K  CL  Co2 (bicarb)

Surgery (18 decks)

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