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Flashcards in Preoperative Care Deck (86)
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1

Age group that gets standard pre-op ECGs

Men over 40 and women over 50-55 years old

2

Major (>5% risk) clinical risk factors and operative risk factors for perioperative cardiac risk (MI, CHF and death)

CLINICAL: Unstable angina, MI in past 7-30 days, decompensated CHF, significant arrhythmias (AV block, symptomatic ventricular arrhythmias and uncontrolled supra ventricular arrhythmias) and severe valvular disease. OPERATIVE: emergent major operation in elderly, aortic reconstruction, major peripheral vascular procedures, major fluid shifts/blood loss.

3

Intermediate (1-5% risk) clinical risk factors and operative risk factors for perioperative cardiac risk (MI, CHF and death)

CLINICAL: Mild angina, previous MI, Q waves, compensated CHF and DM. OPERATIVE: carotid endarterectomy, major head/neck resections, laparotomy, thoracotomy, major orthopedic procedures and open prostatectomy.

4

Minor (

CLINICAL: Elderly, abnormal ECG (LVH, LBB, ST-T wave abnormalities and a-fib), poor exercise tolerance, history of stroke and uncontrolled HTN. OPERATIVE: endoscopy, breast procedures and cataract extraction.

5

Pros and cons of spinal anesthesia

Pros: fewer pulmonary complications. Cons: inability to vasoconstrict or increase CO when needed (higher risk for CAD, CHF, valvular heart disease and diabetic peripheral vascular disease)

6

Pros and cons of general anesthesia

Pros: excellent analgesia/amnesia w/good physiologic control. Cons: pulmonary complications and mild cardiodepression.

7

Pros and cons of general anesthesia

Pros: excellent analgesia/amnesia w/good physiologic control. Cons: pulmonary complications and mild cardiodepression.

8

Who should get a CBC pre-operatively?

Pts w/hx of anemia/polycythemia, procedures w/predictable blood loss and surgery for malignancy.

9

Who should get a BMP (basic metabolic panel) pre-operatively?

>50 years old or hx of fluid/electrolyte disorders (diarrhea, CKD, diuretics, DM, steroids, chronic liver disease)

10

Who should get liver enzymes tested pre-operatively?

Pts w/hepatobiliary disease or malignancy

11

Who should get coags pre-operatively?

Hx of bleeding, anticoagulant therapy and hx of liver disease.

12

Who should get a UA pre-operatively?

Procedures that involve the urinary tract

13

Who should get ECGs pre-operatively?

Men > 40 and women > 55 years old, known cardiac disorders, serious operations, systemic conditions that cause heart disease (DM, HTN), therapy w/cardiac medications and therapy w/cardiotoxic drugs like doxorubicin.

14

Who should get CXR pre-operatively?

Pts with active or hx of pulmonary disease or pts having a serious operation.

15

ASA classification of perioperative mortality

1) Normal healthy pt (.06-.08% risk) 2) Mild systemic disease, no functional limitations (.27-.4%) 3) Moderate to severe systemic disease w/some functional limitation (1.8-4.3%) 4) Pt w/severe systemic disease that is a constant threat to life and functionally incapacitating (7.8-23%) 5) Moribund pt who is not expected to survive 24 hrs w/or w/o surgery (9.4-51%)

16

ASA classification of perioperative mortality

1) Normal healthy pt (.06-.08% risk) 2) Mild systemic disease, no functional limitations (.27-.4%) 3) Moderate to severe systemic disease w/some functional limitation (1.8-4.3%) 4) Pt w/severe systemic disease that is a constant threat to life and functionally incapacitating (7.8-23%) 5) Moribund pt who is not expected to survive 24 hrs w/or w/o surgery (9.4-51%) 6) Brain dead and organs being harvested. Tag each classification with an E if the procedure is an emergency.

17

A patient presents for an elective surgery. ECG shows evidence of a previous inferior MI, but he does not recall an MI or symptoms. How should you proceed?

Cardiology consult w/possible exercise stress test to identify stress-induced ischemia. Cardiac cath may be required prior to proceeding with elective surgery.

18

Pre-operative management of patients with diabetes that have to be "NPO after midnight".

IVFs w/dextrose. No hypoglycemic agents the morning of surgery. Check sugars in the morning, if > 250 mg/dL, give 2/3 the morning dose NPH/regular. If

19

A patient presents for elective surgery with a Hct of 34%. How do you proceed?

Find the cause of anemia prior to proceeding with surgery. Note that the most common cause of anemia is colorectal cancer.

20

A patient presents for elective surgery with a Hct of 55%. How do you proceed?

Find the cause of polycythemia prior to proceeding with surgery. The most common cause is dehydration, hydrate the patient then proceed. Less common cause is polycythemia vera due to COPD or EPO-secreting tumors. Diagnose and treat these conditions prior to surgery. If hydration doesn't do the trick, phlebotomy can be considered.

21

A patient presents for elective surgery with a Hct of 55%. How do you proceed?

Find the cause of polycythemia prior to proceeding with surgery. The most common cause is dehydration, hydrate the patient then proceed. Less common cause is polycythemia vera due to COPD or EPO-secreting tumors. Diagnose and treat these conditions prior to surgery. If hydration doesn't do the trick, phlebotomy can be considered.

22

A patient presents for elective surgery with a BMI of 44. What tests should you run before proceeding with surgery?

PULMONARY: ABGs to evaluate pulmonary status. If abnormal do PFTs and encourage weight loss. If you must proceed with surgery you can use bronchodilators, epidural anesthesia and aggressive post-op pulmonary care to avoid atelectasis. CARDIOVASCULAR: SCDs and prophylactic subQ heparin for DVT prevention.

23

A patient presents for elective surgery with blood glucose of 320mg/dL. How should you proceed?

Perioperative blood glucose should be 100-250mg/dL and surgery should be delayed until blood glucose is under control with subQ/IV insulin + IV dextrose to prevent hypoglycemia.

24

Why might patients with poorly controlled DM have more post-op wound infections?

Poor circulation = decreased leukocytes to wound. High blood sugar = increased food for bacteria.

25

A patient presents for elective surgery with cellulitis from an infected hair follicle in his axilla. How do you proceed?

Cancel the surgery until there is no longer any active infection.

26

A patient presents for elective surgery with BP 180/100mmHg. He is normally in the 140s/80s range. How should you proceed?

Don't postpone the surgery because studies have shown that it will not reduce perioperative risk if the pt is mildly hypertensive (DBP

27

Which anti-hypertensive medications have a high rebound hypertension rate if withheld?

Beta-blockers

28

Which anti-hypertensive medications have a high rebound hypertension rate if withheld?

Beta-blockers

29

A patient presents needing elective surgery with a 20-pack-year smoking history and significant chronic bronchitis. How would you counsel this patient?

Counsel the patient to abstain from smoking for 6-8 weeks because perioperative mortality risk is 2-6x higher than non-smokers. This will give his body time to regain bronchial ciliary function (normal after 2 days) and decrease sputum volume (normal after 2 weeks).

30

A patient presents for elective surgery with a 3 week hx of green sputum and no fever. How do you proceed?

Prescribe oral abx and reschedule surgery for when tx is complete.