4: Peri-operative - Smith

Question 1

ASA classification of physical status

Answer 1

I - normal healthy
II - mild systemic disease
III - severe systemic disease that limits activity but is not incapacitating
IV - incapacitating systemic disease that is a constant threat to life
V - moribund pt not expected to survive 24 hr with or without surgery
E - emergency surgical procedure

Question 2

how does surgery affect DM?

Answer 2

• surgical stress creates endocrine metabolic rxn that results in glucagon, Ne, Epi and cortisol secretion
• blood glucose levels rise
• resultant insulin production in response to hyperglycemia inhibited by feedback loop
• albumin status inhibits healing

Question 3

elective surgery should be avoided when blood sugar greater than ______

Answer 3

200 mg/dl

• schedule surgery in am
• get ECG if considering general anesthesia (increased insulin demand increases risk of silent MI)

Question 4

dosing of insulin for surgery ***

Answer 4

give one half insulin dose preoperatively and second half of insulin after surgery and give 5% dextrose during surgery

Question 5

who needs to be worked up for atlantoaxial subluxation

Answer 5

surgical candidate with RA

• present in 40% rheumatoid pts
• marked flexion of neck can cause fracture or neurological interruption

Question 6

when do you stop ASA and NSAIDs before surgery?

Answer 6

stop ASA 2 wks prior to surgery

stop NSAIDs 3-5 d prior to surgery

Question 7

corticosteroid use and the steroid suppressed pt: if oral cortisone used w/i last year …

Answer 7

do not need to supplement if less than 5 mg/d or intra-articular injection

Question 8

corticosteroid (hydrocortisone) supplementation for pt on long term steroid therapy

Answer 8

minor surgery - 25 mg/d 1 d
moderate surgery - 50-75 mg/d - 1-2 d
major surgery - 100-150 mg/d - 2-3 d

ex: hydrocortisone 100mg IV/IM evening prior to surgery, another dose directly before surgery, continue every 8 hr for next day postop

Question 9

should a pt continue to take immunosuppressive drugs?

Answer 9

yes - benefits (decrease arthritic flare ups) outweigh risks

Question 10

what uses prophylactic antibiotics?

Answer 10

joint replacement and immunosuppression

ancef 1-2 mg IV 30 min before surgery
vancomycin 1 mg IV 1 hr before surgery

Question 11

what should you do if your surgical candidate is taking coumadin?

Answer 11

• stop coumadin 3-5 d prior to surgery
• may start on heparin or levonox
• post surg continue coumadin until PT is therapeutic with heparin

Question 12

reversal of coumadin

Answer 12

vitamin K and/or FFP

Question 13

reversal of heparin

Answer 13

protamine sulfate

Question 14

risk of postop gout attacks due to trauma, dehydration and interruption of uricosuric meds during surgery. what should you do?

Answer 14

oral colchicine 0.6 mg BID for two days before surg and one day postop

colchicine 2 mg VI preop to avoid GI side effects

Question 15

what should be evaluated preop for a pt with HTN

Answer 15

potassium (greater than 3.5 mEq)

- HTN is controlled by anestheis if the pt has not taken oral meds

Question 16

avoid elective surg if pt has had an MI w/i _________

Answer 16

last 6 months

- cardiac consult for ANY surgery with pre-existing ischemic heart disease

Question 17

why would you ask someone during your pre-op workup if they get prophylaxis at the dentist?

Answer 17

• rhematic heart disease and mitral valve prolapse prone to bacterial endocarditis
• need to be prophylaxed with antibiotics
• in office: amoxicillin

Question 18

what sedatives should be avoid due to hepatotoxicity ?

Answer 18

halothane and amides

Question 19

why do patients with renal/hepatic dz have increased bleeding tendency?

Answer 19

due to decreased platelets and extrinsic pathway

Question 20

clarks rule for dosing general anesthesia to ped pt

Answer 20

weight/150 = fraction of adult dose