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CRRAB II Week 7 - WLB > Pre & Post Op Care - Johns > Flashcards

Flashcards in Pre & Post Op Care - Johns Deck (21)
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1
Q

What is the role of a primary care physician in the medical evaluation of surgery?

A
  • Estimate surgical risk from H&P, appropriate lab and x-ray
  • Diagnose and manage medical problems that contribute to morbidity and mortality
2
Q

What is the risk of Interoperate and Postoperative Death?

A

First 48 hours – 0.3% mortality
10% - induction of anesthesia
35% - operatively
55% - postop in first 48 hours

3
Q

What are the causes of Interoperative and Postop Death in the first 48 hours?

A
Causes – 15% each
       Failure to maintain adequate ventilation
      Aspiration
      Arrhythmia
      Drug induced myocardial depression
      Hypotension from blood loss
4
Q

How are the surgical risks associated with the Physical Status of the Patient evaluated/classified?

A
ASA Physical Status Scale
     Developed in 1940’s, modified since
     Relies on accurate H & P
     Estimates surgical risk
     More recent studies show good correlation       
        with non-cardiac mortality
5
Q

What are the three general categories of surgical risk?

A
  1. Physical status of patient
  2. Surgical factors
  3. Anesthesia factors
6
Q

What are the 6 classes of the ASA Physical Status Scale?

A

Class 1: A normally healthy individual
Class 2: Patient with mild systemic disease
Class 3: Patient with severe systemic disease that is not incapacitating
Class 4: Patient with incapacitating systemic disease that is a constant threat to life.
Class 5: A moribund patient
E: Added to any class patient with emergency surgery (doubles any class 1-5)

7
Q

What are the two major cardiologic effects of anesthetic agents?

A

1) Myocardial depression (all)
2) Arrhythmogenic properties
-Pre-op arrhythmia (PVC, a-fib)- 0.4% risk of serious
arrhythmia operatively
-Known pre-op heart disease- 3.9% risk
of serious arrhythmia operatively
-Therefore: Serious operative arrhythmias more
closely associated with underlying heart
disease than pre-op arrhythmias alone

8
Q

What are the two cardiac risk factors in patients undergoing non-cardiac surgery?

A

1) Physiology of peri-operative period
2) Disturbance of cardiac performance
Increased cardiac 02 demand (tachycardia)
Diminished O2 supply (hypoxemia)

9
Q

What are the surgical factors that affect surgical risk?

A
  • Organ involved
  • Extent of disease
  • Skill of surgeon
  • Length of surgical procedures
  • Facilities
10
Q

What are the anesthesia factors that affect surgical risk?

A

Spinal vs. general
-Risk of intraoperative hypotension same
-CHF may be worsened by general
anesthesia
-Gauthier (1983)- elderly patients with
hip surgery showed similar mortality

11
Q

According to Gloldstein, what are the surgical AND anesthesia factors that affect surgical risk?

A
Poor physical status
Poor physical fitness
Cardiac disease (angina, CHF)
Extremes of age
The adult male
Depression or anxiety
Race (non-whites)
Long duration of anesthesia and surgery
Surgery of vital organs
Complex surgery
Emergency surgery
Lack of skill, infrequent performance and excessive aggressiveness of surgeon
12
Q

When do the majority of post-op MI’s occur?

A
Post-op MI’s 
              60%  occur in first 3 days
              70%  occur by days 4-6
              50%  are silent
           The mortality overall is 50-70%
13
Q

What are the treatment goals for hypokalemia for patients going into surgery?

A

Hypokalemia
Serum K should be over 3.0
If on digitalis should be over 3.5

14
Q

What is an acceptable hemoglobin for a patient going into surgery?

A

Normal blood volume is more important than the actual hemoglobin value.

The hemoglobin should be over 10 if significant blood loss is expected during surgery.

15
Q

What are the basic rules of elective surgery?

Hint: 9 rules

A

1) No surgery within 6 months of a M.I.
2) No surgery in the patient has active
CHF or its’ signs (crackles, S3).
3) Stable angina does not carry an increased
risk, unstable angina does.
4) Hypertension with a diastolic under 110
does not carry an increased risk.
5) Pre-op arrhythmias are more significant if
associated with underlying heart disease.
6) Potassium over 3.5 if on digitalis, 3.0 if not.
7) The hemoglobin should be over 10.0 in a
patient with coronary artery disease,
over 8.5 in other patients.
8) From a medical standpoint, spinal
anesthesia is not significantly safer than
general anesthesia. They are both safe.
9) In emergency surgery you have to weigh the
benefits and the risks, there are no firm rules!

16
Q

45 year old male scheduled for an
elective hernia repair. He had a
myocardial infarction 5 months ago
and has been free of cardiac problems
since.

Should We Clear This Patient For Surgery?

A

NO, the procedure is elective. Should wait 6+ months.

***Remember the 6 month rule. The risk of
cardiac complications is highest in the
first 6 months after an MI.

17
Q

54 year old female with a blood pressure
of 166/98 is scheduled for an elective
hysterectomy.

Should We Clear This Patient For Surgery?

A

Yes- the diastolic should be under 110 for

surgery.

18
Q

65 year old female scheduled for a
mastectomy for cancer. She denies
shortness of breath but has a S3 gallop
and bilateral lung crackles.

Should We Clear This Patient For Surgery?

A

No- the presence of congestive heart failure
or its physical signs carries a high risk
of post-op CHF and pulmonary edema.

19
Q

78 year old male is scheduled for a lumbar
laminectomy and has a hemoglobin of
9.8. He has a known chronic anemia
and does not have heart disease.

Should We Clear This Patient For Surgery?

A

Yes- since his anemia is chronic, we can
assume his blood volume is normal.
Blood volume is more important than
the absolute hemoglobin. The blood
loss from a laminectomy should be
minimal.

20
Q

A 66 year old male on Lasix (furosamide)
has a potassium of 3.4 (normal 3.5-5.0).
He is scheduled for knee surgery and is
not on digitalis.

Should We Clear This Patient For Surgery?

A

Yes- his potassium is over 3.0 and he is not on

digitalis.

21
Q

89 year old female with mild CHF, stable angina, hemoglobin of 8.2, chronic renal failure with a creatinine of 2.8, and a mild myocardial infarction about 5 months ago, is scheduled for a cataract extraction.

Should We Clear This Patient For Surgery?

A

Yes- when it comes to cataract surgery done
under local anesthesia, almost every
patient is a candidate. The only real
contraindication is a bad cough which
can elevate intra-ocular pressure.