3 - Preop Eval Flashcards
Purpose of the pre-op H and P:
Determine overall health and risk factors
Discover / stabilize issues prior to surgery
Promote safety / prevent adverse outcomes
Order and interpret pre-op tests
Standard informed consent form contains:
The procedure in both medical and layman’s terms
Site of procedure
Primary surgeon
Relative procedural risks
Blood products
What are RBA’s?
Risks, benefits, alternatives
Must be explained to pt prior to surgery
Informed consent form is signed by:
Surgery team member
Patient
Witness (not on the surgery team)
When can the informed consent form be waived?
In an emergency
Signed by two docs
Pre-op labs include:
CBC (WBC’s, H/H, platelets)
CMP (liver enzymes, kidney, electrolytes, glucose, bilirubin, albumin)
PT/INR (true liver function when combined with total bilirubin and albumin)
UA (infection, dehydration, protein, glucose, HCG)
NPO for how many hrs prior to surg?
6 to 8 hrs
What is it’s emergent surgery and patient was not NPO?
NG tube, suction stomach to prevent aspiration risk
Universal protocol includes:
Site and sign operative site
Prevents injury on wrong site
“time out” just prior to first cut
Pt’s normally receive ABX prophylaxis within ___ hrs of surgery:
1 hr
Prophylactic ABX normally discontinued how long after surgery?
Within 24 hrs of surgery
Selection of surgical ABX prophylaxis is based on:
The facility’s antibiogram and expected contamination sites (skin, GI tract, etc)
Prophylactic ABX are more likely to be used in which surgeries?
GI tract
Implantation of foreign body
Contaminated wounds
Immunocompromised patients
Features of anesthesia consultation:
Assessment of airway (Mallampati classification)
Prior tracheal intubation
Assign ASA category
Previous anesthesia reactions
Underlying metabolic dz
Rx/allergies
The Mallampati classification:
Class I through IV
I = healthy
II - slightly obscured
III - almost entirely obscured
IV - entirely obscured
The ASA category I
Healthy patient
The ASA category II
Mild to moderate systemic disorder that need not be associated with the surgical problem
Ex COPD, controlled DM, age extremes, controlled HTN, moderate obesity
The ASA category III:
Severe systemic dz that limits activity but it not incapacitating
Ex. Insulin-dependent DM, morbid obesity, stress-induced angina
The ASA category IV
Incapacitating, life-threatening systemic dz
Ex. Cardiac ischemia (active), advanced hepatic, pulmonary, or renal dz, CHF, unstable angina
The ASA category V
Moribund patient - not expected to survive 24 hrs without an operation
Ex. Major brain trauma with increased ICP, shock secondary to major trauma, massive PE (saddle), ruptured AAA, etc
Respiratory system risk factors for surg
> 60 yrs old Smoker Obese Symptomatic respiratory dz Abnormal exam Abnormal CXR
Ways to mitigate surg-related pulm issues:
PRN bronchodilators
Smoking cessation
Post-op spirometer (prevent atelectasis)
Post-op deep breathing
Compression devices and anticoagulation (DVT prevention)
CV pre-op eval elements:
Risks: CHF Valvular dz Frequent PVC’s on ECG Any dysrhythmia Pulmonary edema or cardiomegaly on CXR Exercise capability
In general, try to postpone surgery until how many months after an MI?
6 months
GI complications of surg:
Aspiration
Increased ABD pressure
Ileus
Post-op GI bleed (mitigate with antacids, PPI’s)
H2RA’s and PPI’s can interact with:
CYP450 - look up interactions with lidocaine, warfarin, benzos
Pre-op hepatic considerations:
Hepatomegaly, cirrhosis
Spider hemangiomata
Jaundice (T. Bili > 3)
Hepatic encephalopathy
- restraints
- Haldol preferred over benzos
- lactulose binds ammonia
Baseline labs (bili, alb, PT/INR, NH3)
Child-Pugh-Turcotte Chart
Slide 18
Parameters: ascites, bilirubin, albumin, PT, seconds over control, INR, encephalopathy
Elevated BUN usually indicated:
Dehydration
Elevated creatinine is correlated with increased ______ in surgery patients
Mortality
Renal consideration pre-op:
BUN/Creatinine
GFR
UA
Initial txt for post-op oliguria:
IV fluids, NOT diuretics
Be mindful of third spacing (CHF - pulmonary edema, peripheral edema)(ascites)(abdominal compartment syndrome)
Why avoid over-stretching joints during surgery?
Can lead to neuropraxia
Optimum glucose level pre-surgery:
80-110mg/dL
Pre-op considerations for DM:
Increased A1C’s associated with poor outcomes - get that sugar under control before surgery!
Patients should not be controlling their own glucose in-hospital (all interventions - meds, diet - should be in the orders)
Pain can cause the posterior pituitary to secrete _____ leading to decreased urine output
ADH
Pain can stimulate the adrenals to release:
Epi
Norepi
Cortisol
Common cause of intravascular volume loss with surg?
3rd-spacing
Causes vasoconstriction -> decreased renal blood flood -> renin release -> angiotensin -> aldosterone -> Na and water retention
All of that ^ leads to decreased urine output and dilute serum (low Na) due to water retention
Sudden stoppage of steroids can cause:
Addisonian crisis (HOTN, hyponatremia, hyperkalemia)
Use “stress dose” steroids” in lieu of stopping abruptly
More than 12 percent weight loss with surg can lead to:
Delayed wound healing
Anergy (immune response failure)
Decreased pulmonary reserve
Albumin < 3g/dL suggests:
Chronic malnutrition
Prealbumin < 16mg/dL suggests:
Acute malnutrition
Prior to surgery, correct physiologic abnormalities - examples:
Restoring circulatory volume
Correcting coagulopathies
Correcting acid-base imbalances
Repleting electrolytes
How will a cirrhotic liver feel?
Small and fibrotic , hard
Does not present as hepatomegaly
MC cause of post-op oliguria
Dehydration
Did you hear about the guy whose whole left side was cut off?
He’s all right now.
