5. The preoperative management of surgical patients

Question 1

Surgical risk formula

Answer 1

Surgical risk = risk of surgery + anesthesilogical risk

Question 2

Surgical risk classifications

Answer 2

Based on expected blood loss

Low risk: <200ml
Medium risk: <1000ml
High risk: >1000ml

Question 3

Premedication is used for…

Answer 3

• Anxiolysis
• Reduction of secretion
• Reduction of vagal and sympathoadrenal reflexes
• Decrease of gastric pH
• Prevention of post-operative nausea and vomiting

Question 4

Fasting

Answer 4

• 8 hours prior: fatty meals
• 6 hours prior: light meals
• 4 hours prior: breastfeeding
• 2-3 hours prior: clear fluids only

Question 5

GI-tract preparation

Answer 5

• Mechanical bowel cleansing:
  
  • Purging
  • Enema
• Decontamination with non-absorbable, local antibiotics

Question 6

Urinary catheter indications

Answer 6

• Surgical indications: pelvic procedures, laparoscopic colon resections
• Anaesthesiological indications: easy monitoring of renal function and circulatory
parameters

Question 7

Antibiotic prophylaxis

Answer 7

• Necessary in the case of abdominal emergencies, elective colon resection and
malignancies of the upper GI-tract
• Also considered in cholecystectomy, vascular graft surgeries, plastic surgeries and
hernioplasties

Question 8

Thrombosis prophylaxis - mechanical

Answer 8

• Early mobilisation, movement of the limb by either active or passive movement
• Graded compression stocking
• Intermittent pneumatic compression devices

Question 9

Pharmacological prevention of venous thromboembolism in surgery

Answer 9

• Heparin (unfractionated and LMWH)
• Xa inhibitors, direct blockers of thrombin
• Vit K antagonists

Question 10

•Pharmacological prevention of arterial thromboembolism in surgery

Answer 10

• COX-inhibitors

Question 11

Cardiac evaluation: asymptomatic patients

Answer 11

a baseline test of cardiac function may be performed to asses risks with the surgery

• History: ask for a detailed personal/family history of cardiac disease and interventions
• Check vital signs
• Evaluate carotid artery function: measure pulse and auscultate for bruits
• Check for jugular vein distension (indicate severe heart failure and increased risk in
surgery)
• Aucsultate: rubs, S3 and systolic murmurs indicate higher risk.

Question 12

Cardiovascular conditions: increased risk (excluding danger symptoms)

Answer 12

• MI
• CABG/PCI
• Valve replacement
• Pacemaker

Question 13

Cardiovascular danger symptoms

Answer 13

syncope, arrhythmias, palpitations, cerebrovascular incidents

Question 14

Renal evaluation markers and methods

Answer 14

BUN and serum creatinine monitoring
Urine electrolytes
ECG
CXR

Question 15

Chronic metabolic acidosis complication

Answer 15

chronic metabolic acidosis due to low clearance -> gets worse in post-operative state associated with increased H+ levels

Question 16

Hepatic risk factors

Answer 16

• Anaemia
• Ascites
• Encephalopathy
• Hypoalbuminaemia
• Hypoxaemia
• Infection
• Malnutrition
• Portal hypertension
• Increased INR, non-correctable with vitK

Question 17

Hepatic risk stratification

Answer 17

MELD (model for end-stage liver disease)

Child-Pugh score

Question 18

Diabetic conciderations

Answer 18

Surgery is associated with an increase in all insulin-counteracting hormones (glucagon,
epinephrine, cortisol and growth hormone) thus insulin control becomes even more
important.

Usually the patient is given a continuous infusion of insulin.

Question 19

Diabetic Preoperative evaluation

Answer 19

• Ensure normoglycemia
• Asses complications of disease: neuropathy, nephropathy
• Asses cardiovascular function
• Check the feet for cuts and ulcers
• Diabetic patients are at increased risk of infection!

Question 20

main reason to fast before surgery?

Answer 20

To decrease risk of aspiration