Flashcards in The Surgical Patient Deck (68)
When is preOp echo concerning?
Evidence of AS
EF less than 35%
When is a stress test positive?
ST depressions > 0.2mV or inadequate response of HR to stress or hypotension
Predicts difficulty of intubation.
Pt is seated with head in neutral position and mouth wide open with tongue out to the max.
Class 1 - 4. 4 = can't visualize soft palate.
Cardiac risk assessment: Patient less than 35 with no cardiac history
If normal, nothing more.
Cardiac risk assessment: Pt any age with cardiac history or for patient who is older
Consider stress test and echo
Contraindications to noncardiac surgery
EF less than 35%
Tool for cardiac risk assessment. More points = higher risk.
0-5 = class 1 = 1% risk of life threatening complications
6-12 = 5%
13-25 = 11%
25+ = 22%
S3 or JVD (marker of low EF) = 11
MI within 6m = 10
>5 PVCs/min = 7
Rhythm other than sinus = 7
Age > 70 = 5
Emergency = 4
Intrathoracic, intraperitoneal, aortic surgery = 3
AS = 3
Poor general med condition = 3
Which is more important? O2 or ventilation?
Ventilation. We will be make them acidotic during surgery so we care about their ability to blow off CO2
Risk factors for pulm complications
Abnormal PFTs (FEV 60
Upper abdominal or thoracic surgery
Long OR time
How do you reduce pulm risks preOp?
QUIT SMOKING. 8w before surgery (initially when you quit, bronchial secretions actually increase and ventilation gets worse)
Optimize bronchodilator therapy
ABG near day of surgery - High CO2 or low O2 are poor indicators
How do you reduce pulm complications after surgery?
DVT prophylaxis by SCD or SubQ Hep
What percentage of postOp deaths are due to pulm complications?
PFTs that are concerning
FEV1 less than 70%
VO2 more than 20 - that patient is less likely to have pulm complications
Child's Classification of risk
A = 2% op mortality
B = 10%
C = 50%
Ascites (none, controlled, uncontrolled) - look for pancreatitis
Total Bili (less than 2, 2-3, >3)
Encephalopathy (none, min, adv)
Nutrition (exc, good, poor)
Albumin (more than 3.5, 3-3.5, less)
Childs-Pugh and MELD
CP for cirrhosis. MELD for liver transplants.
Tx for elevated scores = transplant.
Pugh adds PT/PTT elevations (check for Warfarin). If Albumin, PT/PTT, Bili, Ascites, or Encephalopathy is present then 40% risk. If all are there, 100%.
How do you provide DVT prophylaxis in someone with an injured leg?
One SCD works just as well as Two (they work by helping to release tPA)
Which pulmonary complication has the highest morbidity and mortality?
Pneumonia. Mortality in elderly patients with postop pneumonia is 50%
How common are atelectasis and pneumonia as complications?
20-40% of all postop patients
PreOp Renal eval
Check BUN and Cr
Estimate Cr clearance
Maintain intravascular volume
Ensure lytes are repleted; correct acidosis
Dialysis patients should be dialyzed within 24hrs of surg
How do you calculate Cr Clearance?
[(140-age) x Ideal body weight in kg] / 72
All that x plasma creatinine (mg/dL)
Dialysis patient mortality
Overall for dialysis dependent patients = 5% regardless of when dialysis was last given
ARF that requires dialysis perioperatively = 50-80%
Morbidity = shunt thrombosis, wound infection, hemorrhage, pneumonia
Why is BUN and Cr so important?
High BUN and Cr indicates loss of at least 75% of renal reserve. Intra and postop hypotension MUST be avoided
Mortality when NH3 > 150
Mortality when INR > 2
At what BUN level does bleeding risk go up?
BUN>100 due to platelet dysfunction
Correct with desmopressin (DDAVP)
What is the most common complication of dialysis?
HyperK (33% of patients)
How do you determine source of renal problem?
FENa > 1 = intrinsic renal damage
Specific gravity = 1.010 = ATN
UNa less than 20 in prerenal
PreOp heme labs
Type and cross
Find the cause
Postpone elective procedures whenever possible. Patients who will not tolerate anemia are those with chronic hypoxia, ischemic heart disease, or cerebral ischemia
Sickle-Cell patients have higher risk of vaso-occlusive crises with operations (not sickle cell trait patients tho)
Minimize risk by maintaining euvolemia