1: Preoperative Care

Question 1

What general categories of active cardiac conditions require cardiology workup and treatment before elective noncardiac surgery? (3)

Answer 1

1. Unstable coronary syndromes (recent MI, unstable antina, severe angina)
2. Decompensated HF (class IV, worsening, or new-onset)
3. Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with HR > 100 bpm)

Question 2

What are “significant arrhythmias” that count as active cardiac conditions requiring cardiology workup and treatment prior to elective surgery?

Answer 2

High-grade AV block (Mobitz II or 3rd-degree)
Symptomatic ventricular arrhythmia
Supraventricular arrhythmias with HR > 100 bpm

Question 3

What is a systemic risk of spinal anesthesia?

Who is at high risk of this complication? (3)

Answer 3

Hypotension (due to loss of peripheral vasoconstriction and ability to increase CO)

At-risk: CAD, low EF, diabetic PAD with neuropathy

Question 4

How long should ibuprofen be discontinued prior to surgery (if indicated)? Aspirin?

Answer 4

Ibuprofen and other NSAIDs: 2 days

Aspirin: 7-10 days

Question 5

What is indicated if a screening indicates a Q wave with no known MI history?

Answer 5

Cardiology consult. (Depending on other risk factors and METs, a stress test may also be indicated)

Question 6

How should DM patients on oral hypoglycemic agents be managed on surgery day?
What range should perioperative glucose levels be in?

Answer 6

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.

Question 7

Other than dehydration, what can lead to polycythemia?

Answer 7

Polycythemia vera, COP, and EPO-secreting RCC or HCC

Question 8

What should be done if a DM patient is discovered to have a toe infection on the day of elective surgery? UTI?

Answer 8

Postpone until infection treated (increased risk of surgical site infections if have active infection elsewhere)

Question 9

What blood pressure is associated with increased risk of CV complications and indicates delay of elective surgery?

Answer 9

Diastolic >110.

Question 10

How long should a patient abstain from smoking before surgery?

Answer 10

6-8 weeks

Question 11

What is a potential early sign of a COPD exacerbation?

What should be done if this is discovered prior to elective surgery?

Answer 11

Change in sputum color (e.g. to green or brown).

Treat with antibiotics, reschedule surgery after treatment

Question 12

What tests should be performed in a patient with COPR prior to surgery?

Answer 12

CXR, ABG. Also CBC and EKG per table 1-4.

Question 13

What is a warning value of PaO2 on ABG? PaCO2?

Answer 13

PaO2 < 60 mm Hg suggests pulmonary HTN.

PaCO > 45 associated with high perioperative morbidity.

Question 14

What are indicators of increased perioperative risk of pulmonary complications?

Answer 14

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:

Question 15

How can a patient with severe COPD be managed when urgent surgery is required?

Answer 15

Bronchodilators, corticosteroids, antibiotics.

Question 16

What is a contraindication for laparoscopic surgery?

Answer 16

Poor cardiopulmonary reserve (pneumoperitoneum can exacerbate hypercapnea and lead to secondary tachycardia)

Question 17

How should acute cholecystitis be managed in a patient with contraindications to surgery but who is not responding to medical management?

Answer 17

Cholecystotomy

Question 18

How long should elective surgery be delayed after an MI?

Answer 18

At least 60 days

Question 19

Which BBB can be a normal variant?

Answer 19

RBBB. LBBB is always indicative of underlying disease.

Question 20

How many PVCs per minute is considered significant? What should be done if this is found on preoperative workup?

Answer 20

More than 5.

Workup for underlying ventricular disease. Prophylactic aniarrhythmics have not been proven benificial

Question 21

What test should be performed in a patient with a loud carotid bruit?

Answer 21

Duplex US

Question 22

What degree of carotid stenosis indicates possible benefit of preoperative carotid endarterectomy before vascular surgery if they have a stroke history? No stroke history?

Answer 22

Stroke history: >70% stenosis

No stroke history: >80% stenosis

Question 23

What factors are included in the Child classification of liver failure? MELD score?

Answer 23

Child’s: Bilirubin, albumin, ascites, encephalopathy, nutrition
MELD: Bilirubin, INR, creatinine

Question 24

How should prolonged prothrombin time be managed in a liver failure patient prior to surgery?

Answer 24

Normalization with vitamin K, if possible

Question 25

What should be assessed for in a patient with liver disease presenting with new AMS? (5)

Answer 25

1. Electrolyte abnormalities
2. GI bleed
3. Sepsis / SBP
4. Subdural hematoma
5. Hepatic encephalopathy

Question 26

What test should be performed if SBP is suspected? What is a positive?

Answer 26

WBC count on ascites tap. >250 WBC/mm3 indicates SBP

Question 27

How long should an alcoholic abstain from alcohol prior to surgery?

Answer 27

6-12 weeks

Question 28

What can lead to a bleeding risk in a renal failure patient?

Answer 28

Platelet dysfunction due to uremia

Question 29

How can platelet dysfunction in renal disease be treated?

Answer 29

HD (to correct uremia)
Desmopressin (increases vWF release)
FFP
Conjugated estrogens

Question 30

What is a key EKG sign of early hyperkalemia? Late?

Answer 30

Early (5.5-6.5): Peaked T waves

Late (>6.5): QRS widening

Question 31

How should severe hyperkalemia be treated in a renal failure patient be treated?

Answer 31

1. Calcium gluconate to stabilize cardiac membranes
2. IV insulin and glucose to shift K+ into cells
3. Bicarbonate
4. Hemodialysis

Question 32

What invasive monitoring may be performed in a patient with severe AV stenosis who needs urgent surgery? MV stenosis?

Answer 32

AV stenosis: A-line, TEE, PA catheter
MV stenosis: A-line and TEE, but PA catheter not useful because pressure gradient across MV distorts relationship between pulmonary capillary wedge pressure and LV end-diastolic pressure.

Question 33

What cardiac conditions are considered high-risk for endocarditis?
What types of procedures do these patients require antibiotic prophylaxis for?

Answer 33

Patients: Prosthetic valves, previous infective endocarditis, unrepaired cyanotic heart disease, heart transplant with valve disease.
Procedures: Dental, incision/biopsy of respiratory mucosa, infected skin or MSK tissue