PreSurgicalOptimization Flashcards
(32 cards)
What should a history for preop consist of
- Review of physical health
- functional status and history of falls (frailty)
- Cognitive ability
- competency
- risk factors for postop delirium
- screen of alcohol or other abuse/dependence
- Availability of social support
- symptoms of depression
- cardiac eval
- risk factors for postop pulmonary complications
- nutritional status
- Medication assessments
- determine treatment goals and expectations
- appropriate preop diagnostic tests
How to do a minicog test
-say three words and have them remember and repeat
-have them draw a clock, starting with large circle, numbers and then hands at 11:10
(3 min)
-ask them to repeat the three words again
- 1 pt for ea word correct
- 2 for normal clock
- 0-2 pt is possible impairment
CAGE questions
- have you ever felt you should cut down on your drinking or drug use?
- have people annoyed you by crtizing you drinking or drug use>
- have you ever feld bad or Guilty about your drinking or drug use?
- have you ever had a drink or drug first thing in the morning to steady your nerves or to get rid of a hangover?
Criteria and score for frailty
- Shrinkage
- weakness
- exhaustion
- low physical activity
- slowe
Criteria and score for frailty
- Shrinkage (unintentional weight loss >10 lb in past year)
- weakness (decreased grip strength)
- exhaustion (self-reported poor energy and endurance)
- low physical activity (low weekly energy expenditure)
- slowness(slow walking)
4-5: frail
2-3: prefrail
Medications to discontinue before surgery
- nonessential that may inc surgical risk
- drugs with potential f interactions with anesthesia
- herbal medications 7 days b4
meds to consider periop
- those with withdrawal potential
- angiotensin-converting enzyme inhibitors
Recommended preop tests
Hemoglobin
Renal function test
Serum albumin
Tests for selected patients
- urinalysis
- chest radiograph
- electrocardiograms
- pulmonary function tests
- noninvasive stress testing
key questions when deciding to perform surgery of someone who is at risk or has CAD
- determine it is urgent
- determine acute coronary syndrome
- estimated perioperative risk of mobile acute care of elderly
- less than 1% (proceed)
- greater than 1% (dependent on functional capacity)
- functional capacity greater than 4 (proceed)
- less than 4 or unknown (will further testing/treatment imapact decision?)
- no (proceed or alternate)
- yes (stress test)
- abnormal (no surgery-intervention)
- normal (proceed or alternate)
algorithm for cardiac eval for noncardiac surgery
- emergency?
- active cardiac conditions?
- low risk?
- functional capaicty
- risk factors?
- risk rank of surgery
look at chart
patient related risk factors for postop pul complications
- advanced age
- presence of COPD
- american society of ane class
- fucntional dependence
- impaired sensorium
- frailty
- cigarette smoking
procedure-related factors for postop pul complications
- emergency surgery
- thoracic and upper ab procedures
- prolonged op
- type of ane and ane agent
- periop transfusion
risk factors for noncardiac surgical procedures
- history of ischemic heart disease
- history of compenstaed or prior heart failure
- history of cerebrovascular disease
- diabetes
- renal insufficiency
what are low risk procedures
-endoscopice, superficial procedures, cataract surgery, breast surgery, anbulatory
what are intermediate risk surgeries
intraperitoneal and intrathoracic, cardiac endarterectomy, head and neck, orthopedic, prostate
what are vascular surgies
aortic/other major vascular surgery, peripheral vascular surgery
1 MET
- take care of yourself?
- eat, dress, use toilet?
- walk indoors around the house
- walk a block or two at ground level at 2-3 mph
4 METs
- do light work around the house like dusting or washing dishes
- climb flight of stairs
- walk at ground level at 4 mph
- run short distance
- do heavy work around the house like scrubbing floors or lifting or moving
10 METs
participate in moderate rec acivity like golf, bowling, dancing, doubles tennis, or throwing baseball or football
-participate in strenuous sports like swimming, singles tennis, football, basketball or skiing
risk for post op venous thromboembolism (VTE)
- Hypercoagulability (congential hypercoag, cancer, cancer therapy, history of VTE, inflamm bowel disease, oral contraceptives, polycythemia, pregnancy, smoking, thrombocytosis)
- venous statsis (congestive heart failure, immobility, increasing age, obesity, varicose veins, venous compression or obstruction)
- endothelial injury (recent surgery, severe infection, trauma)
risk factors for postoperative delirium
- strongest: preexisting cognitive impairment and dementia
- untreated or inadequately controlled pain
- depression
- alcohol use
- sleep deprivation
- severe illness/comorbidities
- renal insufficiency
- anemia
- hypoxia
- poor nutrition
- dehydration
- electrolyte abnormalities
- poor funct status
- immobilization
- hearing or vision impairment
- over 70
- polypharm
- risk of urinary retention or constipation, presence of catheter
code of medical ethics on consent
- assess patients ability to understand
- present relevant information
- document the informed consent conversation
conditions that must be met for valid informed consent in presurgical patients
- patient must have the capacity to make health care decision
- patients receive adequate information
- patient consents freely
