1: Preoperative Care Flashcards
What general categories of active cardiac conditions require cardiology workup and treatment before elective noncardiac surgery? (3)
- Unstable coronary syndromes (recent MI, unstable antina, severe angina)
- Decompensated HF (class IV, worsening, or new-onset)
- Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with HR > 100 bpm)
What are “significant arrhythmias” that count as active cardiac conditions requiring cardiology workup and treatment prior to elective surgery?
High-grade AV block (Mobitz II or 3rd-degree)
Symptomatic ventricular arrhythmia
Supraventricular arrhythmias with HR > 100 bpm
What is a systemic risk of spinal anesthesia?
Who is at high risk of this complication? (3)
Hypotension (due to loss of peripheral vasoconstriction and ability to increase CO)
At-risk: CAD, low EF, diabetic PAD with neuropathy
How long should ibuprofen be discontinued prior to surgery (if indicated)? Aspirin?
Ibuprofen and other NSAIDs: 2 days
Aspirin: 7-10 days
What is indicated if a screening indicates a Q wave with no known MI history?
Cardiology consult. (Depending on other risk factors and METs, a stress test may also be indicated)
How should DM patients on oral hypoglycemic agents be managed on surgery day?
What range should perioperative glucose levels be in?
Hold oral hypoglycemics on surgery day, manage with glucose measurements, insulin, and dextrose.
Glucose should be 100-250 mg/dL, or else surgery should be delayed until brought into that range.
Other than dehydration, what can lead to polycythemia?
Polycythemia vera, COP, and EPO-secreting RCC or HCC
What should be done if a DM patient is discovered to have a toe infection on the day of elective surgery? UTI?
Postpone until infection treated (increased risk of surgical site infections if have active infection elsewhere)
What blood pressure is associated with increased risk of CV complications and indicates delay of elective surgery?
Diastolic >110.
How long should a patient abstain from smoking before surgery?
6-8 weeks
What is a potential early sign of a COPD exacerbation?
What should be done if this is discovered prior to elective surgery?
Change in sputum color (e.g. to green or brown).
Treat with antibiotics, reschedule surgery after treatment
What tests should be performed in a patient with COPR prior to surgery?
CXR, ABG. Also CBC and EKG per table 1-4.
What is a warning value of PaO2 on ABG? PaCO2?
PaO2 < 60 mm Hg suggests pulmonary HTN.
PaCO > 45 associated with high perioperative morbidity.
What are indicators of increased perioperative risk of pulmonary complications?
Highly increased risk: FEV1 <35% of predicted
Moderately-to-highly increased risk: Pulmonary artery pressure >25 mm Hg
Moderately increased risk:
FEV1 <70% predicted
FVC <50-75% predicted
PaCO2 > 45 mm Hg:
How can a patient with severe COPD be managed when urgent surgery is required?
Bronchodilators, corticosteroids, antibiotics.
What is a contraindication for laparoscopic surgery?
Poor cardiopulmonary reserve (pneumoperitoneum can exacerbate hypercapnea and lead to secondary tachycardia)
How should acute cholecystitis be managed in a patient with contraindications to surgery but who is not responding to medical management?
Cholecystotomy
How long should elective surgery be delayed after an MI?
At least 60 days
Which BBB can be a normal variant?
RBBB. LBBB is always indicative of underlying disease.
How many PVCs per minute is considered significant? What should be done if this is found on preoperative workup?
More than 5.
Workup for underlying ventricular disease. Prophylactic aniarrhythmics have not been proven benificial
What test should be performed in a patient with a loud carotid bruit?
Duplex US
What degree of carotid stenosis indicates possible benefit of preoperative carotid endarterectomy before vascular surgery if they have a stroke history? No stroke history?
Stroke history: >70% stenosis
No stroke history: >80% stenosis
What factors are included in the Child classification of liver failure? MELD score?
Child’s: Bilirubin, albumin, ascites, encephalopathy, nutrition
MELD: Bilirubin, INR, creatinine
How should prolonged prothrombin time be managed in a liver failure patient prior to surgery?
Normalization with vitamin K, if possible
