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aaaabbbb > 4 - Peri-operative Evaluation of Surgical Patient > Flashcards

4 - Peri-operative Evaluation of Surgical Patient Flashcards

1
Q

Patient work up

A
  • History and Physical
  • Preoperative laboratory studies
  • Vascular workup
  • Radiographs
  • Special studies
  • Medical problems
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2
Q

History and physical

A
  • Concentrate on major organ systems and rule out medical contraindications to surgery
  • Identify true allergies and potential drug interactions
  • Anesthesia risks

Social history
o Convalescence and rehabilitation
o Tobacco (“before I will do the surgery, you have to stop smoking” – ↓ bone healing)
o Recreational drugs (certain anesthetics can interact with cocaine –> heart attack)

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3
Q

American society of anesthesiologists - classificaiton system of patienst

A 
ASA Class I
ASA Class II
ASA Class III
ASA Class IV
ASA Class V
E
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4
Q

ASA Class I

A

A normal healthy patient

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5
Q

ASA Class II

A

A patient with mild systemic disease

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6
Q

ASA Class III

A

A patient w/ severe systemic disease that limits activity, but is not incapacitating

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7
Q

ASA Class IV

A

A patient with incapacitating systemic disease that is a constant threat to life

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8
Q

ASA Class V

A

A moribund patient not expected to survive 24 hours with or without surgery

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9
Q

E

A

Designates an emergency surgical procedure

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10
Q

Laboratory studies

A
  • Follow hospital protocol
  • CBC
  • ESR (sed rate)
  • Electrolytes
  • PT/PTT
  • Chemistry Panel (LFT, BUN, creatinine, cardiac enzymes)
  • UA pregnancy test
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11
Q

Vascular workup

A 
When there is doubt about adequacy of arterial or venous circulation, order the appropriate vascular studies
o	Doppler with segmental pressures
o	Ankle/arm indices
o	Transcutaneous oximetry
o	Angiography (MRI)
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12
Q

Radiographs

A
  • Foot and ankle radiographs for soft tissue and osseous evaluation
  • Templates
  • Chest x-ray (especially if patient is a smoker)
  • Cervical spine films
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13
Q

Special studies

A

Nuclear scans

CT scans
o Osseous affinity
o Fracture and tumor evaluation

MRI
o Soft tissue affinity
o Evaluation of tumors, infection and tendon pathology

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14
Q

Medical problems

A
  • Assess circulatory status of lower extremity
  • Treat underlying medical conditions
  • Adjust medical therapy
  • Inform members of healthcare team about potential problems
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15
Q

Diabetes mellitus

A
  • DM is a complex systemic disease that affects multiple organ sites that include vascular, neurologic and dermatologic
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16
Q

Surgical stress in diabetes mellitus

A

Surgical stress creates endocrine metabolic reaction that results in glucagon, norepinephrine, epinephrine and cortisol secretion
o Blood glucose levels rise
o Resultant insulin production in response to hyperglycemia inhibited by feedback loop

17
Q

Other surgical considerations for diabetes mellitus

A
  • Albumin status inhibits healing
  • Elective surgery should be avoided when blood sugar greater than 200 mg/dl
  • Schedule surgery early in am
  • ECG, especially when considering general anesthesia (Increased insulin demand increases risk of silent MI)
  • Give one half insulin dose preoperatively and second half of insulin after surgery and give D5W
18
Q

Arthritis

A
  • Includes all forms of arthritis

- Avoid joint surgery during flare-ups

19
Q

Surgery in rheumatoid patient

A

Surgery in the rheumatoid patient should be goal oriented
o PAIN RELIEF
o IMPROVEMENT OF OVERALL FUNCTION
o CORRECTION OF THE DEFORMITY

Note: one of the goals is NOT cosmetic

20
Q

Patient management in rheumatoid arthritis

A
  • ASA or NSAID discontinuation
  • Pre-operative corticosteroid supplementation
  • Adjustment of antirheumatic drugs
  • Prophylactic antibiotics (joint replacement)
  • Prophylaxis for DVT
  • Workup for atlantoaxial subluxation (C1, C2)
21
Q

ASA and NSAIDs

A
  • Preoperative Labs = PT, PTT, bleeding time, serum transaminase, BUN, creatinine, uric acid
  • Stop ASA 2 weeks prior to surgery
  • Stop NSAIDs 3-5 days prior to surgery
22
Q

Corticosteroid use and steroid suppressed patient

A
  • HPA-Axis suppression

- Oral cortisone has been used within last year ***Do not need to supplement if

23
Q

Corticosteroid supplementation

A

Recommended perioperative hydrocortisone dosage for patients on long-term steroid therapy

General
o Hydrocortisone 100mg IV/IM evening prior to surgery
o Another dose directly before surgery
o Continue every 8 hours for the next day postoperatively

24
Q

Surgery type and stress dose for corticosteroid supplementation

A
  • Minor (hernia) = 25 mg/day for 1 day
  • Moderate (total joint) = 50-75 mg/day for 1-2 days
  • Major (cardio bypass) = 100-150 mg/day for 2-3 days
25
Q

Immunosuppressive drugs

A

Antimalarials, gold salts, penicillamine and methotrexate should be CONTINUED to decrease arthritic flare-ups

Do NOT stop immunosuppressive drugs when taking someone to surgery

26
Q

Prophylactic antibiotics

A

Used for joint replacement and immunosuppressed patients

  • Ancef 1-2 mg IV 30 minutes before surgery
  • Vancomycin 1 gm IV 1 hour before surgery
27
Q

DVT and atrial fib

A
  • Stop Coumadin 3-5 days prior to surgery
  • May start on Heparin or Lovenox
  • Start Coumadin for 3-5 days until PT is therapeutic, continue heparin during this time
  • Reversal of Coumadin with vitamin K and/or FFP
28
Q

Atlantoaxial subluxation

A
  • Present in 40% of rheumatoid patients

- Marked flexion of neck can cause fracture or neurological interruption

29
Q

Evidence based medicien

A
  • Large analysis of literature that reviews various aspects of RA medications and surgery
  • Level 3 systematic review of literature
  • Found that methotrexate is safe and does not need to be discontinued
30
Q

Gout

A
  • Risk for post-operative gout attack due to surgical trauma, dehydration and interruption of uricosuric medication
  • Oral colchicine 0.6 mg BID for two days before surgery and one day postoperatively
  • Colchicine 2 mg IV preoperatively to avoid GI side effects
31
Q

Cardiovascular disease

A
  • Hypertension
  • Ischemic heart disease
  • Rheumatic heart disease
  • Mitral valve prolapse
32
Q

Hypertension

A
  • Increased medical and surgical risk
  • Controlled by anesthesia if patient has not taken oral medication
  • Mild hypertension will often resolve with induction medication and pain medication
  • Evaluate preoperative potassium (>3.5 mEq)
33
Q

Ischemic heart disease

A
  • Avoid elective surgery if patient has had an MI within the last 6 months
  • Cardiac consult for any surgery with pre-existing ischemic heart disease
34
Q

Rheumatic heart disease and mitral valve prolapse

A
  • Prone to bacterial endocarditis
  • Prophylaxis with antibiotics (ask “do you get prophylaxis when you go to the dentist?” If yes, need to look into it and figure out why)
  • In office prophylaxis with amoxicillin
35
Q

Renal and hepatic disease

A
  • Previously discussed in renal course
  • LFTs, alkaline phosphatase, albumin, bilirubin, PT, CBC
  • Increased bleeding tendency due to decreased platelets and extrinsic pathway
  • Avoid halothane and amides because of hepatotoxicity
36
Q

Pediatric pateints

A
  • Parental presence during anesthesia induction and in recovery room is beneficial
  • General anesthesia favored
  • Prevent hypothermia due to poor thermoregulation created by large surface area/weight ratio
  • Clark’s rule: Weight/150 = fraction of adult dose (or you can always contact pharmacy)
37
Q

Geriatric pateints

A
  • Multiple medications and possible drug interactions
  • Decreased renal function with age
  • Inability to clear medications
  • Respiratory depression with medications
  • Rehabilitation concerns –> Recovery time often doubled
  • Avoid preventable ulcerations

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