Preoperative Evaluation Flashcards
(133 cards)
1
Q
one MET is approximately …
A
the rate of O2 consumption at rest
(3.5 mL/kg/min)
2
Q
Walking 1 or 2 blocks on level ground is equivalent to how many METs?
A
3
3
Q
Climbing 1 flight of stairs, dancing, or bicycling is equivalent to how many METs?
A
5
4
Q
Swimming quickly, running or jogging briskly is equivalent to how many METs?
A
10
5
Q
In a French prospective cohort study of 1501 patients, the following characteristics were identified as independent predictors of difficult bag-mask ventilation: …
These risk factors are largely consistent with those identified in an American retrospective cohort study of 22,660 patients: …
Other possible risk factors for difficult ventilation include …
A
- Age more than 55 years
- BMI more than 26 kg/m2
- Absence of teeth
- Presence of a beard
- History of snoring
———————————— - Age 57 years or more
- BMI 30 kg/m2 or greater
- Presence of a beard
- Mallampati classification III or IV
- Severely limited mandibular protrusion
- History of snoring
————————————————— - An increased neck circumference
- Face and neck deformities (i.e., prior surgery, prior radiation, prior trauma, congenital abnormalities)
- Rheumatoid arthritis
- Trisomy 21 (Down syndrome)
- Scleroderma
- Cervical spine disease
- Previous cervical spine surgery
6
Q
Components of the Airway
Examination
A
1) Length of upper incisors (concerning if relatively long)
2) Condition of the teeth
3) Relationship of maxillary incisors to mandibular incisors (concerning
if there is prominent overbite)
4) Ability to advance mandibular incisors in front of maxillary incisors
(concerning if unable to do this)
5) Interincisor or intergum (if edentulous) distance (concerning if <
3 cm)
6) Visibility of the uvula (concerning if Mallampati class is 3 or more)
7) Shape of uvula (concerning if highly arched or very narrow)
8) Presence of heavy facial hair
9) Compliance of the mandibular space (concerning if it is stiff, indurated,
occupied by mass, or nonresilient)
10) Thyromental distance (concerning if < 6 cm)
11) Length of the neck
12) Thickness or circumference of the neck
13) Range of motion of the head and neck (concerning if unable to
touch tip of chin to chest or cannot extend neck)
7
Q
These risks associated with hypertension appear to increase once blood pressure exceeds … mmHg, with each subsequent … mmHg increase in systolic blood pressure and … mm Hg increase in diastolic
blood pressure being associated with a two-fold increase in
the risk of stroke and cardiovascular death.
In the perioperative setting, hypertension is associated with increased
risks of…, but the magnitude of this association is relatively weak (odds
ratio 1.35; 95% confidence limits, 1.17-1.56)
A
117/75
20
10
postoperative death and myocardial infarction
8
Q
While preoperative hypertension is associated with an
increased risk of cardiovascular complication, this association
is generally not evident for systolic blood pressure values
less than … mm Hg or diastolic blood pressure values
less than … mm Hg
A
180
110
9
Q
There is no compelling data that delaying surgery to optimize blood pressure control will result in improved outcomes
T or F
A
T
10
Q
Coronary revascularization— specifically with CABG—improves survival compared to medical therapy (pooled relative risk 0.80,
95% limits 0.70-0.91) in several high-risk IHD states,
namely …
A
- left main coronary artery stenosis
- triple-vessel coronary artery disease
- two-vessel coronary artery disease with proximal left anterior descending artery stenosis
11
Q
In patients who meet indications for revascularization, CABG and PCI improves survivel similarly in multivessel disease that is associated with either diabetes mellitus or higher coronary artery lesion complexity
T or F
A
F
In patients who meet indications for revascularization, CABG improves survival more than PCI in multivessel disease that is associated with either diabetes mellitus or higher coronary artery lesion complexity
12
Q
Aside from high-risk states (e.g., triple vessel coronary artery disease), PCI has not been shown to convincingly improve survival in stable IHD
T or F
A
T
13
Q
A
14
Q
Describe the Simplified cardiac evaluation algorithm for noncardiac surgery proposed by the 2014 American Heart Association and American College of Cardiology guidelines
A
Step 1: Emergency Surgery:
-> Proceed to surgery with clinical risk stratification and perioperative surveillance
Step 2: Active Cardiac Conditions (* acute coronary syndrome; * decompensated heart failure; * significant arrhythmia; * severe valvular disease):
-> Postpone planned surgery until condition is first evaluated and then treated using guidelinedirected
therapy
Step 3: Estimate risk of perioperative death or MI (ACS-NSQIP risk calculator - determine risk using www.riskcalculator.facs.org; Revised Cardiac Risk Index (elevated risk based on score of 2 or more):
- > Proceed to surgery if estimated risk is less than 1%
Step 4: Assess functional capacity:
- > Proceed to surgery if functional capacity is 4 or more metabolic equivalents
Step 5: Assess whether further testing will impact care:
- > Pharmacological stress testing if results would affect decision making or care. If results are abnormal, consider guideline-indicated revascularization strategies
Step 6: Proceed to surgery or consider alternative strategies
* Alternatives included less-invasive or palliative treatment
15
Q
The 2014 ACC/AHA guidelines define an emergency procedure as one where …; an urgent procedure as one where …; and a time-sensitive procedure as one where …
A
life or limb would be threatened if surgery did not proceed within 6 hours or less
life or limb would be threatened if surgery did not proceed within 6 to 24 hours
delays exceeding 1 to 6 weeks would adversely affect outcomes (e.g., most oncology surgery).
16
Q
Simple subjective assessment of functional capacity based on the usual preoperative history accurately estimate true exercise
capacity
T or F
A
F
Simple subjective assessment of functional capacity based on the usual preoperative history does not accurately estimate true exercise
capacity, and does not accurately predict postoperative cardiovascular complications. Thus, in clinical practice, anesthesiologists should generally use a structured questionnaire, especially the DASI
17
Q
Correlate the Revised Cardiac Risk Index Score with the Risk of Major Cardiac Events
A
0 - 0,4%
1 - 1%
2 - 2,4%
3 - 5,4%
18
Q
A preoperative high-sensitivity troponin T concentration above … is associated with increased risks of death and cardiovascular complications after major noncardiac surgery
A
14 ng/L
19
Q
The choice of pharmacologic stress modality is generally immaterial, but there are some exceptions.
For example, since dobutamine uncovers ischemia by increasing contractility, heart rate, and blood pressure, it may not be the best choice in patients with …
While adenosine and dipyridamole rely on their vasodilatory properties and do not depend on a heart rate response, they may exacerbate …
A
pacemakers, significant bradycardia, aortic aneurysms, cerebral aneurysms, or poorly controlled hypertension
bronchospasm in patients taking theophylline
20
Q
At present, both American and European guidelines only recommend consideration for revascularization in …, while the CCS guidelines recommend …
A
patients who meet usual nonoperative indications (e.g., left main coronary artery stenosis, triplevessel coronary artery disease)
against preoperative revascularization in any patient with stable IHD
21
Q
Whenever possible, surgical procedures should be performed following critical time windows (i.e., … after bare metal stent , or … after DES), aspirin should be continued throughout the perioperative period, and any P2Y12 inhibitor therapy should be restarted …
The importance of continuing aspirin perioperatively is
supported by the substudy of the …
In this subgroup analysis of 470 patients with prior PCI, aspirin … (hazard ratio, 0.50; 95% confidence limits, 0.26-0.95) without any significantly increased bleeding risk.
A
30 days
3-6 months
as soon as possible after surgery
POISE-2 randomized trial
reduced the risk of death or myocardial infarction
22
Q
Unfractionated heparin and low-molecular-weight
heparin (LMWH) should be used to “bridge” patients
who have been withdrawn from antiplatelet therapy
T or F
A
F
Unfractionated heparin and low-molecular-weight
heparin (LMWH) should not be used to “bridge” patients
who have been withdrawn from antiplatelet therapy,
especially since heparin can paradoxically increase platelet aggregation
23
Q
Decompensated heart failure is a very high-risk condition that warrants postponement of surgery for all except lifesaving emergency procedures.
No consensus exists on how long nonemergent surgery should
be deferred after resolution of acute decompensated heart
failure, although a reasonable approach is to delay elective
procedures (including most time-sensitive procedures) for…, and urgent procedures for …
A
1 month
24 hours
24
Q
Loop diuretics (e.g., furosemide) can not be continued on the
day of surgery because of high rates of hypotension during surgery
T or F
A
F
Loop diuretics (e.g., furosemide) can be continued on the
day of surgery for most procedures since this strategy does
not increase risks of intraoperative hypotension or adverse
cardiac events. The exception is lengthy high-risk procedures with projected significant blood loss or fluid requirements, in which potent diuretics should be held on the
morning of surgery
25
A Valsalva maneuver ... right and left-heart filling, thereby ... the intensity of most murmurs except those of ...
Standing ... preload, and thereby increases the intensity of murmurs of ...
decreases
reducing
mitral valve prolapse and hypertrophic cardiomyopathy
decreases
mitral valve prolapse and hypertrophic cardiomyopathy
26
Having the patient repeatedly perform a hand grip ... heart rate and arterial blood pressure, thereby augmenting murmurs of ...; conversely, this maneuver decreases murmurs of ...
increases
mitral regurgitation and aortic insufficiency
aortic stenosis and hypertrophic cardiomyopathy
27
Severe aortic stenosis parameters
Transvalvular Jet Velocity (m/s): ≥ 4
Mean Pressure Gradient (mm Hg): ≥ 40
Valve Area (cm2): < 1
28
Can individuals with asymptomatic severe
aortic stenosis do a noncardiac surgery before valvar surgery?
Moderate to severe aortic stenosis is associated with
increased risk of perioperative cardiovascular complications.
Nonetheless, contemporary studies suggest that noncardiac surgery can be performed with acceptable mortality risks in individuals with asymptomatic severe aortic stenosis
Thus, guidelines support proceeding with major elective noncardiac surgery in patients with asymptomatic severe aortic stenosis, provided that appropriate intraoperative and postoperative hemodynamic monitoring is available
29
Patients with moderate to severe aortic stenosis
have an increased risk of bleeding from ...
The underlying pathophysiology is ...
an acquired von Willebrand syndrome, which occurs in 67% to 92% of patients with severe stenosis
mechanical disruption of von Willebrand multimers during turbulent blood flow through the narrowed valve
30
Prophylaxis for infective endocarditis is not
recommended for patients with severe aortic stenosis
T or F
T
31
Can individuals with asymptomatic severe
aortic insufficiency do a noncardiac surgery before valvar surgery?
Expert consensus from current guidelines is supportive of patients with asymptomatic severe aortic insufficiency to proceed with major noncardiac surgery accompanied by careful perioperative management, including hemodynamic monitoring, afterload control, and fluid balance
32
Mitral stenosis involves progressive reduction of this area, with shortness of breath with exertion occurring when the area falls below ..., and symptoms at rest occurring once the area falls below ...
Severe mitral stenosis is defined by a valve area less than ... and is typically associated with a pulmonary artery systolic pressure > 50 mm Hg, and a resting mean transvalvular gradient ≥ 10 mm Hg
2.5 cm2
1.5 cm2
1 cm2
33
Estenose aortica + sangramento em TGI por lesões angiodisplasicas
Síndrome de Heyde
34
Cardiac Conditions for Which Endocarditis Prophylaxis Is Recommended
1) Previous infective endocarditis
2) Prosthetic cardiac valves, including transcatheter-implanted prostheses, and homografts
3) Prosthetic material used for cardiac valve repair, such as annulo-plasty rings and chords
4) Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
5) Repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device
6) Cardiac transplant with valve regurgitation due to a structurally abnormal valve
35
is a rare cause of sudden cardiac arrest that occurs in the absence of structural heart disease. It is an autosomal dominant disorder that is more common in men, rarely diagnosed in children, and often affects individuals of Asian ethnicity. Patients usually have normal findings on echocardiography, stress testing, and cardiac magnetic resonance imaging (MRI). The most significant clinical manifestations are ventricular arrhythmias, syncope, and sudden death. Patients may also be at increased risk of atrial arrhythmias, especially atrial fibrillation. Is characterized by an ECG with pseudo-RBBB and persistent ST-segment elevation in leads V1 to V3
Brugada syndrome
36
Drugs used in anesthesia that should be avoided in the Brugada syndrome
Bupivacaine
Procaina
Propofol
37
Drugs used in anesthesia that may be associated with events in the brugada syndrome (low evidence)
Lidocaine
Ketamine
Tramadol
38
Effect of a magnet in a cardiovascular implantable electronic device
In general, a magnet suspends antitachyarrhythmia therapy in most ICDs, and switch pacemakers (but not ICDs) to an asynchronous pacing mode
39
Basic recommendations for procedures in patients with cardiovascular implantable electronic devices
□ Inactivation of ICDs is not absolutely necessary for all procedures
□ Not all pacemakers need to be altered to pace asynchronously in all patients or for all procedures
□ Pacemakers can be reprogrammed or magnets can be used to force pacemakers to pace asynchronously to prevent inhibition
□ ICDs can be reprogrammed or magnets can be used to inhibit ICD arrhythmia detection and tachyarrhythmia functions
□ Magnets can/will not force pacemakers in ICDs to pace asyn- chronously
□ Inactivation of ICDs is recommended for all procedures above the umbilicus involving electrocautery or radiofrequency ablation
□ It is preferable to change to asynchronous pacing in pacemak- er-dependent patients for procedures involving electrocautery or radiofrequency ablation above the umbilicus
40
selective continuation of aspirin should be considered in which patients?
selective continuation of aspirin should be considered in patients undergoing vascular surgery (to mitigate risks of bypass graft occlusion), as well as those with high-risk IHD, prior PCI, or recent stroke (i.e., previous 9 months)
41
There are no benefits to using oral corticosteroids preoperatively in an asthmatic patient
T or F
F
Asthma therapy can be supplemented with a short preoperative course of oral corticosteroids (prednisone 20 mg-60 mg daily for 3-5 days) in any newly diagnosed or poorly controlled asthmatic patient
42
T or F
Measurement of both FEV1 and diffusing capacity for carbon monoxide (DLCO) is recommended in all patients being considered for lung resection surgery
T
43
How the predicted postoperative FEV1 (PPO FEV1) is calculated? And the PPO DLCO?
The predicted postoperative FEV1 (PPO FEV1) is calculated by multiplying the preoperative FEV1 by the percentage of perfusion to the nonoperative lung or lung region:
PPO FEV1 =Preoperative FEV1 × (Perfusion to nonresected lung / Total perfusion to lungs)
The PPO DLCO is calculated using an analogous equation
for preoperative DLCO
44
Patients with both PPO FEV1 and PPO DLCO values exceeding 1...% of predicted are considered low-risk and can generally proceed directly to surgery.
If either value is within the range of 2...% of predicted,
3... is recommended.
For individuals with poor performance on these tests (4...), as well as for individuals with either PPO FEV1 or PPO DLCO values less than 5...% predicted, the ACCP guidelines recommend Cardiopulmonary Exercise Testing to measure peak oxygen consumption (VO2 peak)
A preoperative VO2 peak greater than 6... mL/kg/min is consistent with low perioperative risk, 7... mL/kg/min is consistent with moderate risk, and less than 8... mL/kg/min is consistent with high risk
1) 60
2) 30% to 60
3) simple objective exercise testing with a shuttle walk test or
symptom limited stair climbing test
4) i.e., < 400 m on shuttle walk test or < 22 m on stair climbing test
5) 30
6) 20
7) 10 to 20
8) 10
45
How deal with Upper Respiratory Tract Infections in the preoperative period?
For patients with severe symptoms (e.g., high fever), especially in the presence of other health conditions (e.g., significant asthma, heart disease, immunosuppression), elective surgery should be postponed until 4 weeks after resolution of the infection.
Conversely for mild or uncomplicated infections in otherwise healthy patients, it is reasonable to proceed with the planned surgery and avoid the inconvenience of a last-minute cancellation. The dilemma lies with patients between these two extremes, for whom decisions regarding the suitability to proceed should be made on an individualized basis
46
Abbott and colleagues identified four standard outcome measures that are appropriate for widespread use in clinical trials of postoperative pulmonary complications, namely, ...
pneumonia, atelectasis, acute respiratory distress syndrome, and aspiration
47
Potential Patient-related Risk Factors for Postoperative Pulmonary Complications
Advanced age
ASA-PS Class 2 or more
Congestive heart failure
Functionally dependent
Chronic obstructive pulmonary disease
Weight loss
Impaired sensorium
Cigarette use
Alcohol use
Abnormal findings on chest examination
Preexisting pulmonary disease (e.g., recent infection, low oxygen saturation)
Pulmonary hypertension
Anemia
Heart failure
Preexisting sepsis
Poor nutritional status (e.g., albumin concentration)
Obesity (BMI > 30 kg/m2)
48
Potential Procedure-related Risk Factors for Postoperative Pulmonary Complications
Aortic aneurysm repair
Thoracic surgery
Abdominal surgery
Upper abdominal surgery
Neurosurgery
Head-and-neck surgery
Emergency surgery
Vascular surgery
General anesthesia
Perioperative transfusion
Long-duration procedures
Residual neuromuscular blockade
49
Potential Laboratory test related Risk Factors for Postoperative Pulmonary Complications
Albumin concentration < 3,5 g/dL
Chest radiograph abnormalities
BUN concentration > 7.5 mmol/L (> 21 mg/dL)
50
Arterial blood gases are useful in predicting pulmonary function
after lung resection operations and can be used to estimate perioperative pulmonary risk
T or F
F
Arterial blood gases are useful in predicting pulmonary function
after lung resection operations, but do not estimate perioperative pulmonary risk
51
Describe the Scoring Scheme for the ARISCAT* Perioperative Pulmonary Risk Index
Components of ARISCAT Score Points Assigned
Age
□ ≤50 years: 0
□ 51–80 years: 3
□ >80 years: 16
Preoperative oxygen saturation
□ ≥96%: 0
□ 91%–95%: 8
□ ≤91%: 24
Respiratory infection in prior month: 17
Preoperative anemia (<10 g/dL): 11
Surgical incision location
□ Peripheral: 0
□ Upper abdominal: 15
□ Intrathoracic: 24
Duration of surgery
□ ≤2 h: 0
□ >2–3 h: 16
□ >3 h: 23
Emergency procedure: 8
ARISCAT Score
Low-risk: < 26 points -> 1.6%
Intermediate risk: 26–44 points ->13.3%
High-risk: ≥ 45 points -> 42.1%
Estimates risk of composite endpoint of respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, or aspiration pneumonitis
52
Management of oral antidiabetics medication for surgery
Normal treatment regimen for most noninsulin diabetic medications (metformin, sulfonylureas, repaglinide, GLP-1 agonists, DPP-4 inhibitors) should be continued until (and inclusive of) the day before surgerybut held on the morning of surgery.
The possible exception pertains to SGLT2 inhibitors, which have been associated with euglycemic diabetic ketoacidosis in the postoperative setting. Thus, some guidelines recommend that the medications be discontinued at least 24 hours before elective surgery (up to date diz 3-4 dias antes da cirurgia)
53
Perioperative corticosteroid supplementation is needed only when a patient is likely to have suppression of
the hypothalamic-pituitary-adrenal axis. Thus, supplementation is not required for individuals who have received less than ... mg prednisone (or its equivalent) daily, or less than ... weeks of corticosteroids (regardless of dose)
5
3
54
Recommendations for Perioperative Corticosteroid Coverage
1) Superficial procedure (e.g., biopsy, dental procedure): usual daily dose
2) Minor procedure (e.g., inguinal hernia repair, colonoscopy, hand surgery):
- Hydrocortisone 50 mg IV before incision
- Hydrocortisone 25 mg IV every 8 h for 24 h
- Then usual daily dose
3) Moderate procedure (e.g., colon resection, total joint replacement, lower extremity
revascularization):
- Hydrocortisone 50 mg IV before incision
- Hydrocortisone 25 mg IV every 8 h for 24 h
- Then usual daily dose
4) Major (e.g., esophagectomy, pancreatoduodenectomy, major cardiac, major vascular, trauma):
- Hydrocortisone 100 mg IV before incision
- Continuous IV infusion of 200 mg of hydrocortisone
over 24 h
- Then usual daily dose
OR
- Hydrocortisone 50 mg IV every 8 h for 24 h
- Taper dose by 50% per day until usual daily dose is
reached*
- Then usual daily dose
55
In a patient with phechromocytoma that is going to surgery, effectiveness of medical preparation is assessed by ...
(UP TO DATE)
twice-daily orthostatic blood pressure (BP) measurements, typically aiming for a seated BP of 120/80 mmHg, a standing systolic blood pressure (SBP) ≥90 mmHg, and a heart rate between 60 and 70 beats/minute (bpm) seated and 70 to 80 bpm standing
56
How to do the preparation for surgery in a patient with pheochromocytoma?
1) alfa-adrenergic blokckade: The preferred drug at many centers is phenoxybenzamine, which is
an irreversible, long-acting, nonspecific α-adrenergic blocking drug. The initial dose is 10 mg once or twice daily, and the dose is increased by 10 to 20 mg every 2 to 3 days as needed. Most patients eventually need doses ranging from
20 to 100 mg daily.
Given these side effects, as well as higher rates
of postoperative hypotension after preoperative phenoxybenzamine treatment, some centers instead use selective α1-adrenergic blocking drugs (e.g., prazosin, terazosin, doxazosin)
2) beta-adrenergic blockade: After adequate α-adrenergic blockade, β-adrenergic blockade may be started cautiously with short-acting drugs.
As an example, 10 mg of propranolol every 6 hours can be used. After 24 to 48 hours, a long-acting preparation (e.g., metoprolol, atenolol) can be substituted, provided that the patient tolerates β-adrenergic blockade. The dose is then
adjusted to achieve a heart rate between 60 and 80 beats/ min
*** Alternatives to perioperative α-adrenergic blockade include calcium channel blockers and metyrosine
57
The renal reserve of a normal 80-yearold person is less than... that of a 40-year-old person
half
58
Current KDIGO guidelines recommend using erythropoiesis stimulating agents to treat hemoglobin concentrations less than ..., but avoid increasing the concentration to above ...
9 g/dL
13 g/dL
59
Ideally, elective surgery should be performed about ...
after dialysis. Performance of surgery shortly after dialysis
should be avoided, because of the risks of ...
24 hours
acute volume depletion and electrolyte alterations
60
Preventative strategies to avoid contrast-induced nephropathy include
avoiding volume depletion, discontinuing NSAIDs for 24 to 48 hours,
using a low-risk contrast administration protocol (i.e., low volume of a low-osmolal or iso-osmolal agent), and periprocedure intravenous volume administration with normal saline
61
Predictors of poor perioperative outcome in patients with liver disease
include the following
□ Child-Turcotte-Pugh class C cirrhosis;
□ Model for end-stage liver disease (MELD) score of 15
or more;
□ Acute hepatitis (viral or alcoholic);
□ Chronic active hepatitis with jaundice, encephalopathy,
coagulopathy, or elevated liver enzymes;
□ Abdominal surgical procedures;
□ PT prolongation of 3 seconds or more that is refractive to
vitamin K therapy.
62
Extrahepatic bile duct obstruction may be caused by gallstones, tumors (e.g., pancreatic, gallbladder, bile duct, ampulla of Vater), or scarring. Patients can present with jaundice, pruritus, and abdominal pain. Risk factors for postoperative mortality in these patients include a ...
These patients are at elevated risk for postoperative AKI, which
may be prevented using bile salts or lactulose
hemoglobin concentration less than 10 g/dL, serum bilirubin exceeding
20 mg/dL, and serum albumin lower than 2,5 g/dL.
63
Primary biliary cirrhosis (or primary biliary cholangitis) is an autoimmune disorder characterized by ... obstruction and ...
antibodies. Affected patients are predominantly ...[gender], may have other autoimmune disorders (e.g.,...), and can
progress to end-stage liver disease.
intrahepatic biliary
antimitochondrial
female (> 90%)
Sjögren syndrome, autoimmune thyroid disease, limited
cutaneous scleroderma, rheumatoid arthritis
64
Primary sclerosing cholangitis is characterized by ... that can progress to cirrhosis and end-stage liver disease. The disease mainly affects ...[gender] and may be idiopathic or associated with ...
bile duct destruction
males
inflammatory bowel disease (i.e., ulcerative colitis, Crohn disease)
65
What is the hemoglobin threshold that indicates trasfusion?
There is no consistent hemoglobin concentration threshold that defines elevated perioperative risk. While data from noncardiac surgery performed in Jehovah’s Witness patients suggest that risk increases substantially once preoperative hemoglobin concentrations fall below 10 g/dL (especially in the presence of concomitant IHD), simply
increasing hemoglobin concentrations to this threshold
with RBC transfusion is not consistently beneficial.
Importantly, transfusion itself has also been associated with poor
outcomes in observational studies. In a multicenter
randomized trial of 2016 patients undergoing hip fracture
surgery, a strategy of transfusing in response to a 10 g/dL
threshold in hemoglobin concentration was not superior to
a strategy of transfusing in response to a 8 g/dL threshold
or symptoms of anemia.
Similarly, in a multicenter randomized trial of 5243 patients undergoing cardiac surgery, a strategy of transfusing in response to a 7,5 g/dL threshold was noninferior to a strategy of transfusing in response to
a 9,5 g/L threshold.
These data suggest that the optimal perioperative hemoglobin concentration threshold varies between 7,5 g/dL and 10 g/dL across individuals, with interindividual differences largely explained by comorbid conditions (e.g., cardiopulmonary disease)
66
Preoperative considerations for patiens with sickle cell disease
The preoperative examination focuses on the frequency,
severity, and pattern of vasoocclusive crises. In addition,
the anesthesiologist should evaluate the degree of pulmonary, cardiac, renal, and central nervous system damage.
Useful tests include an ECG, chest radiograph, and blood
sampling for CBC and creatinine concentration. Additional testing (e.g., echocardiogram, arterial blood gases) may be needed.
Preoperative prophylactic transfusion is increasingly used in patients with sickle cell anemia who are undergoing any surgical procedure—other than short minor procedures (e.g., biopsy, myringotomy. The
objective of any red cell transfusion is to reduce the proportion of abnormal hemoglobin in the affected patient. A prior randomized trial found that prophylactic transfusion to a hemoglobin concentration greater than 10 g/dLresulted in fewer adverse events following intermediate-risk
surgery.This simpler approach of transfusing to a hemoglobin concentration threshold (>10 g/dL) is as effectiveas a more aggressive approach of transfusing to decrease
67
Considerations for patients with glucose-6-phosphate dehydrogenase deficiency
Glucose-6-phosphate dehydrogenase deficiency is a hereditary Coombs-positive hemolytic anemia. Since it is an X-linked hereditary condition, affected individuals are typically males. Hemolysis may be triggered by drugs (e.g., antipyretics, nitrates, sulfonamides), food (e.g., fava beans),
infection, hypoxia, hypothermia, or blood products.
Treatment involves avoidance of triggers, folic acid supplementation, and management of acute hemolytic episodes (i.e., hydration, red cell transfusion for severe anemia). The preoperative evaluation should focus
on previous hemolysis episodes, predisposing factors, and
current hematocrit
68
In patients without a history of vitamin K antagonist use, the most
common causes of a prolonged INR are ...
laboratory error, liver disease, and malnutrition
69
Hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency) are ... inherited disorders that almost exclusively manifest in...
Hemophilia B is also referred to as “Christmas disease.”
Hemophilia C is an autosomal recessive deficiency of factor ... (also called ... syndrome) that tends to affect individuals of ...
X-linked recessive
males
XI
Rosenthal
Ashkenazi Jewish descent
70
Laboratory alterations in patients with hemophilia
Patients with hemophilia have a prolonged aPTT, but a normal INR and platelet count
71
von Willebrand Disease is an inherited disorder
of von Willebrand factor (vWF) that affects both sexes. It is
the most common congenital coagulopathy, occurring in
approximately 1% of individuals.
Several types (...) are autosomal dominant, while type ... is autosomal recessive
1, 2A, 2B, 2M, 2N
3
72
Laboratory alterations in vWF
Most affected patients have a normal INR and platelet count (although type 2B can have a mild thrombocytopenia), but typically
elevated aPTT (although patients with mild disease may
have normal aPTT)
73
DDAVP (1-desamino-8-d-arginine vasopressin) increases the release of factor VIII, vWF, and plasminogen activator from endothelial cells. It is contraindicated in patients with type ... vWF disease because it ...
In addition, it is not recommended in patients with type ...
disease (since ...)
2B
increases abnormal vWF release and may cause thrombocytopenia
3
there is minimal to no vWF available to be released from endothelial cells
74
When platelet transfusions are used to treat thrombocytopenia, the
platelet count generally rises by .../mm3 for every
unit transfused
10,000
75
A steep increase in blood viscosity occurs once the hematocrit increases to more than ..., resulting in an increased thrombogenic risk
50%
76
A reasonable approach for estimating perioperative VTE risk is to use a validated clinical prediction index, a widely used example being the Modified Caprini Risk Assessment Model. What conditions score 5?
Stroke (<1 month)
Elective arthroplasty
Hip, pelvis, or leg fracture
Acute spinal cord injury (<1 month)
77
How to interpret the Modified Caprini Risk Assement score?
A Caprini score of zero indicates very low VTE risk (0.5% risk in the absence of thromboprophylaxis), scores of 1 to 2 indicate low VTE
risk (1.5% risk in the absence of thromboprophylaxis), scores of 3 to 4 indicate moderate VTE risk (3.0% risk in the absence of thromboprophylaxis), and scores of 5 or more indicate high VTE risk (6.0% risk in the absence of thromboprophylaxis)
78
For individuals with a very recent VTE episode, elective surgery should be delayed until ... have elapsed since the episode
3 or more months
79
Hereditary high-risk thrombophilias include ...
Factor V Leiden, antithrombin III deficiency, protein C deficiency, protein S deficiency, prothrombin gene mutation, and antiphospholipid antibodies.
* Factor V Leiden and prothrombin gene mutations are the most common causes, together comprising up to 60% of cases
80
Continuation of aspirin is a contraindication to performance of neuraxial blocks
T or F
F
Continuation of aspirin is not a contraindication to performance of neuraxial blocks
81
Some patients with either PAD or CVD may be on longterm therapy with dipyridamole, which causes vasodilation and impairment of platelet function.
Current ASRA guidelines recommend ... before performing any neuraxial block
discontinuing extended-release dipyridamole 24 hours
82
The risks of postoperative cardiac complications and recurrent
stroke are particularly increased when elective noncardiac
surgery is performed within ... after a prior stroke
9 months
83
When is the ideal time to perform a emergency surgery in patients who had a recent stroke?
Within 72 hours
While the risks of postoperative cardiovascular complications are very high when emergency surgery is performed within 2 weeks after an ischemic stroke, these risks were reduced when surgery proceeded within 72 hours after the stroke. This temporal pattern may be explained by progressively worsening cerebral autoregulation during the first 5 days after an ischemic stroke (which then recovers
over the next 3 months).
84
The risk of stroke in patients who have truly asymptomatic carotid bruits is ... per year, with most strokes preceded ...
1% to 2%
by transient symptoms
85
No evidence indicates that truly asymptomatic bruits increase the risk of perioperative stroke
T or F
T
86
All anticonvulsant therapy should be continued perioperatively
T or F
T
87
Considerations of anesthetics use in a patient with multiple sclerosis
No clear association has been shown between the type of anesthetic or a specific anesthetic drug and disease exacerbations. Nonetheless, regional anesthesia may offer theoretical advantages for patients with respiratory compromise or cognitive dysfunction
88
All associated medications used to treat Parkison disease should be continued
T or F
T
89
How to manage the deep brain stimulator during surgery?
Individuals with deep brain stimulators
require deactivation of the devices before any procedures in
which electrocautery will be used. The specific device should
be identified, along with the severity of disease symptoms
when the device is turned off. Perioperative management of
the device ideally should be coordinated with the surgeon
and the clinician managing the device
90
In myasthenia gravis, weakness is exacerbated by ...
stress, infections, hypokalemia, medications (e.g., aminoglycosides, propranolol, ciprofloxacin, clindamycin), and surgery
91
Osserman Classification System for Myasthenia Gravis Clinical Classification System
Class I: Ocular myasthenia
Class IIA: Mild generalized myasthenia with slow progression: no
crises, responsive to drugs
Class IIB: Moderately severe generalized myasthenia: severe
skeletal and bulbar involvement but no crises; drug response
less than satisfactory
Class III: Acute fulminating myasthenia: rapid progression of
severe symptoms, with respiratory crises and poor drug response
Class IV: Late severe myasthenia, same as III but progression over
2 years from class I to II
92
Patients with myasthenia gravis commonly have ...
other autoimmune diseases, such as
rheumatoid arthritis, polymyositis, and thyroid disorders
93
Worsening symptoms may reflect worsening disease (i.e.,
myasthenic crisis) or excessive acetylcholinesterase inhibitor treatment (i.e., cholinergic crisis). How to diferentiate?
A short-acting anticholinesterase (edrophonium) can help distinguish the
two states, since only a myasthenic crisis improves with more anticholinesterase
94
Lambert-Eaton syndrome is similar to myasthenia gravis, with muscle weakness including oculobulbar involvement and dysautonomia. It is caused by ...
It is not associated with thymic abnormalities, but commonly occurs with malignant diseases, especially...
The other distinguishing feature of this disorder is that ...
In addition to acetylcholinesterase inhibitors, typical treatments include 3,4-diaminopyridine, which is a ...
Preoperative evaluation and management are similar to
those for myasthenia gravis. All related medications should
be continued perioperatively.
antibodies against voltage-gated calcium channels that result in decreased acetylcholine release
small cell lung cancer and gastrointestinal tumors
the muscle weakness classically improves with activity
and is worse after inactivity
selective potassium channel blocker
95
Duchenne and Becker muscular dystrophies are ... [genetiscs] disorders that occur primarily in ...
Affected individuals have elevated ..., often preceding the onset of symptoms.
... patients with a family history of either Duchenne or Becker muscular dystrophy should be considered at risk (even when they have not been formally tested), and they require precautions similar to those in patients with diagnosed disease.
... are the usual causes of death
X-linked recessive
males
creatine phosphokinase levels
Male
Cardiomyopathy and respiratory failure
96
Female carriers of the abnormal gene associated with Duchenne and Becker muscular dystrophies may have ... despite having no other manifestations of the disease
dilated cardiomyopathy
97
Facioscapulohumeral muscular dystrophy (also known as faciohumeroscapular or ... muscular dystrophy) is an ... [genetics] that affects both sexes and causes a ...
... occurs much less frequently than in other dystrophies, but
... have been reported
Landouzy-Dejerine
autosomal dominant disorder
slow, progressive weakness of muscles in the shoulders and face
Cardiomyopathy
arrhythmias
98
Myotonia is characterized by ...
It is a common symptom of several dystrophies, including ...
..., which is the most common of these conditions,
is an autosomal ... inherited disorder affecting both
sexes.
... is a severe form of this disease that manifests in infancy, often in the children of affected mothers
The classic findings are severe muscle wasting, typically involving the diaphragm, face, hands, pharynx, and larynx. ... can often trigger myotonia
prolonged contraction and delayed relaxation of muscles
classic myotonic dystrophy, congenital myotonic dystrophy,
myotonia congenital, and central core disease
Myotonic dystrophy
dominant
Congenital myotonic dystrophy
Cold temperatures
99
... is a hereditary disorder that involves only skeletal muscles, causes less severe symptoms, and does not cause ... abnormalities
Myotonia congenita
cardiac
100
Central core disease is a rare disorder caused by ...
The name derives from findings of muscle biopsies, which reveal “cores” of abnormalities.
Affected individuals have...
As with myotonic dystrophy, patients are at risk for respiratory failure and aspiration
deficiency of mitochondrial enzymes
proximal muscle weakness, scoliosis, and sometimes cardiomyopathies
101
Myotonia predispose patients to malignant hyperthermia, therefore succinylcholine should be avoided in these patients
T or F
F
Myotonia was historically thought to predispose patients to malignant hyperthermia, however, current evidence indicates that they are not at increased risk. Nonetheless, succinylcholine should still be avoided in these patients because it may cause diffuse muscle contraction
102
Posterior pituitary tumors result in failure to secrete
vasopressin or ADH, which regulates renal water excretion.
A deficiency results in ..., which is characterized by excessive urine output from a failure to reabsorb water. Unless treated with ..., these patients may develop ...
diabetes insipidus
DDAVP
hypernatremia and volume depletion
103
In patients with rheumatoid arthitis, a careful history may elicit neurologic deficits, neck pain, upper extremity pain, or crunching sound with neck movement. Indications for preoperative cervical spine radiographs include neurologic findings, long-standing severely deforming disease, or procedures requiring prone positioning or manipulation of the cervical spine.
The specific radiographs required are ... and ...
Significant abnormalities (i.e., anterior atlas-dens interval >9 mm or posterior interval <14 mm) require ...
anteroposterior
lateral cervical spine films with flexion, extension, and openmouth odontoid views
consultation with a neurologist or neurosurgeon
104
In patients with rheumatoid arthitis disease duration, severity, and symptoms do correlate with cervical spine subluxation
T or F
F
disease duration, severity, and symptoms do not correlate with cervical spine subluxation
105
Ankylosing spondylitis can have important extraarticular manifestations, including
uveitis, vasculitis, aortitis, and aortic insufficiency. Affected
individuals may develop restrictive lung disease related
to pulmonary fibrosis or chest wall movement restriction
(joint fixation and kyphosis)
106
Localized scleroderma involves ...
just the skin, and no other organs
107
Limited systemic sclerosis involves ...
cutaneous manifestations “limited” to face and upper extremities, as well as systemic involvement in the gastrointestinal tract (e.g., dysphagia, reflux) and lungs (e.g., interstitial lung disease, pulmonary hypertension)
108
Diffuse systemic sclerosis is characterized by ...
generalized skin involvement and multiple end-organ damage. Manifestations include myocardial fibrosis, pericarditis, heart failure
(right-sided and left-sided), coronary artery fibrosis, severe
hypertension, ESRD, dysphagia, fatigue, weight loss, and
gastroesophageal reflux. Pulmonary hypertension, which
may result from interstitial lung disease or vasculopathy, is
a leading cause of death in systemic sclerosis and is associated with increased perioperative risk
109
Ehlers-Danlos syndrome is a disorder of collagen synthesis.
It consists of several subtypes that have various manifestations but are almost all characterized by joint hypermobility. Type ... disease is more serious because affected individuals may have …
IV
vascular fragility and skin fragility, as well as predisposition to vascular rupture, visceral rupture, and pneumothorax.
110
Important chemotherapy-associated side effects include ...
- cardiomyopathy with trastuzumab and anthracyclines (e.g., doxorubicin);
- pulmonary toxicity with bleomycin;
- nephrotoxicity with cisplatin;
- hemorrhagic cystitis with cyclophosphamide;
- and peripheral neuropathy with vincristine or cisplatin
111
Von Hippel–Lindau disease is an ... [genetics] inherited disorder characterized by a variety of benign and malignant tumors. Associated tumors include ...
During preoperative evaluation, the anesthesiologist should assess for symptoms suggestive of a … , as well as evaluate the patient’s renal function. Any further testing (e.g., electrolytes, ECG, creatinine, glucose) should be guided by findings from the initial clinical evaluation
autosomal dominant
hemangioblastomas, retinal angiomas, clear cell renal cell carcinomas, pheochromocytomas, and neuroendocrine tumors of the pancreas
pheochromocytoma or neuroendocrine tumor
112
Carcinoid tumors are rare neuroendocrine tumors that
release mediators. They are associated with ...
These tumors typically occur in the ...tract
and are the most common neoplasms of the ...; in
addition, they can also occur in the pancreas and bronchi.
Carcinoid syndrome is caused by... released by the
tumors.
Typical manifestations include ...
Nonetheless, most patients are asymptomatic because ...
Consequently, patients with gastrointestinal carcinoid tumors have manifestations of carcinoid syndrome only if they have ...
MEN type 1
gastrointestinal
appendix
vasoactive amines (e.g.,serotonin, norepinephrine, histamine, dopamine), polypeptides (e.g., bradykinin, somatostatin, vasoactive intestinal peptide, glucagon), and prostaglandins
flushing, tachycardia, arrhythmias, diarrhea, malnutrition, bronchospasm, and carcinoid heart disease
the liver inactivates the bioactive products of carcinoid tumors
hepatic metastases
113
Carcinoid heart disease is characterized by ...
Affected individuals may then develop...
They may also develop carcinoid crisis, which is associated with ...
These life-threatening episodes can occur with induction of anesthesia, intraoperative handling of a tumor, or other invasive procedure on a tumor
endocardial fibrosis of pulmonic and tricuspid valves
tricuspid regurgitation, pulmonic stenosis, pulmonic regurgitation, right-sided heart
failure, peripheral edema, and hepatomegaly
profound flushing, bronchospasm, tachycardia, and hemodynamic instability
114
Predictors of perioperative adverse events in patients with carcinoid tumors are ...
carcinoid heart disease and elevated urinary 5-hydroxyindoleacetic acid concentrations (the primary metabolite of serotonin)
115
The mainstay of pharmacologic treatment of carcinoid syndrome are
...
somatostatin analogues, namely octreotide and lanreotide.
Preoperative treatment with octreotide (300-500 μg intravenous or subcutaneously) helps mitigate the risks of intraoperative carcinoid crises. An alternative approach for high-risk major procedures is to start a continuous intravenous 50 μg /hour infusion of octreotide 12 hours before surgery and continue it for at least 24 to 48 hours after
surgery
116
Normal individuals—who are homozygous for the wild-type gene—have a dibucaine number of ... because their plasma cholinesterase is ... inhibited by dibucaine.
Individuals who are homozygous for the atypical genes have a dibucaine number of ... and can be paralyzed for ... after receiving succinylcholine.
In heterozygous individuals who have a dibucaine number of..., the duration of action of succinylcholine is prolonged by 50% to 100%
80
80%
20 (corresponding to 20% inhibition)
4 to 8 hours
60 (corresponding to 60% inhibition)
117
What is the difference between plasma cholinesterase activity and dibucaine number?
Plasma cholinesterase activity is a quantitative measure of enzyme activity, whereas the dibucaine number and fluoride number are qualitative measures
118
Patients submitted to a lung transplant are at increased risk for pulmonary edema, which has been attributed to ...
disrupted lymphatic drainage in the transplanted lung
119
Most issues relating to heart transplant recipients relate to the absence of ...
This condition has multiple physiologic effects, such as ...
autonomic innervation in the transplanted heart
a higher than normal resting heart rate (from absence of vagal tone); the absence of cardiac baroreflexes; and the lack of response to carotid sinus massage, Valsalva maneuver, laryngoscopy, or tracheal intubation
120
Cardiac denervation affects responses to medications; the allograft demonstrates a normal or augmented response to ..., a blunted response to ..., and no response to ...
direct-acting drugs
indirect-acting agents
vagolytic agents
121
The ECGs of patients submitted to a cardiac trasnplant may reveal conduction abnormalities, and two P waves ... [explain how]
a small nonconducted P wave from the native atria and a normal-sized conducted P wave from the donor atria
122
The reported incidence of perioperative anaphylaxis is about 1 in ... to procedures in large countrywide epidemiological studies, with consistent estimates based on studies from 2 different countries (France vs. United Kingdom) and time periods (2004 vs. 2016)
The overall incidence appears similar in these two epidemiological studies; however the common precipitating agents differ. In the older French study, the most common causes were ...
Conversely, in the more recent United Kingdom study, the most common precipitating agents were ...
10,000
neuromuscular blocking agents (58%), latex (20%), and antibiotics (13%)
antibiotics (53%), neuromuscular blocking agents (33%), and chlorhexidine (9%)
123
Reported allergies to vancomycin should be distinguished from...
This side effect is caused by ..., which is associated with rapid injection of vancomycin, and consists of flushing, pruritus, erythematous rash, and hypotension
“red man syndrome.”
histamine
124
Most true anaphylactic reactions following exposure
to ester local anesthetics do not involve an allergy to the
local anesthetic, but rather to ...
associated preservatives (e.g.,para-aminobenzoic acid)
125
The half-life of cocaine is about 1.5 hours but its inactive metabolites may still be detectable in the urine for ... after consumption
14 days
126
Solvents can cause ...
cardiac dysrhythmias, pulmonary edema, cerebral edema, diffuse cortical atrophy, and hepatic failure
127
Patients who are taking disulfiram because of a history of alcohol abuse may have an altered response to sympathomimetic drugs; some
authors therefore suggest that disulfiram be discontinued ... before the surgical procedure
10 days
128
For patients taking naltrexone for a history of alcohol abuse, consideration should be given to discontinuing it ... preoperatively
3 days
129
The mother should discard milk produced within the first ... after anesthesia
24 hours
130
Preoperative Management of P2Y12 inhibitors (e.g., clopidogrel, ticagrelor, prasugrel, ticlopidine)
Patients having cataract surgery with topical or general anesthesia do not need to stop taking thienopyridines.
If reversal of platelet inhibition is necessary, the time interval for discontinuing these medications before surgery is 5–7 days for clopidogrel, 5–7 days for ticagrelor, 7–10 days for prasugrel, and 10 days for ticlopidine.
Do not discontinue P2Y12 inhibitors in patients who have drug-eluting stents until they have completed 6 month of dual antiplatelet therapy, unless patients, surgeons, and cardiologists have discussed the risks of discontinuation.
The same applies to patients with bare metal stents until they
have completed 1 month of dual antiplatelet therapy.
131
Preoperative Management of Sildenafil (Viagra) or similar drugs
Discontinue 24 h before surgery
132
Preoperative Management of estrogen
Postmenopausal hormone replacement therapies that contain estrogen increase the risk of thromboembolic events. It may therefore be reasonable to discontinue these medications before operations.
Estrogens must be stopped approximately 4 weeks preoperatively for coagulation function to return to baseline.
Most modern oral contraceptives contain low doses of estrogen. Nonetheless, these medications are still associated with some elevation in thrombotic risk. Since the risk of unanticipated pregnancy may outweigh the benefits of discontinuing oral contraceptives preoperatively, it is reasonable to continue oral contraceptives in most patients during the perioperative period.
In patients who are deemed to be a high risk for postoperative VTE, consideration may be given to stopping oral contraceptives 4 weeks before surgery (and temporarily switching to other forms of contraception). This decision should be made collaboratively with the patient and must balance the risk of VTE versus the risk of unwanted pregnancy.
133
Continued perioperative use of selective serotonin reuptake inhibitors (SSRIs) are associated with increased surgical ... whereas abrupt discontinuation of SSRIs can also cause dizziness, chills, muscle
aches, and anxiety. Overall, it is still reasonable to continue SSRI perioperatively in most patients, aside from those undergoing procedures where ...
bleeding
bleeding could have significant postoperative sequalae (e.g., intracranial surgery).
