Pre-op H&P Flashcards
What is the goal of a pre-op H&P?
Reduce complications
Health care costs
Role of Medical Consultant Prior to Surgery
Define co-morbidities Evaluate severity of co-morbidities Optimize all medical conditions Provide surgical risk assessment Recommend peri-op measures to reduce risk
Surgical Physiology
Peripheral dilation Reduced myocardial contractility Decrease in tidal volume Epi & norepi elevated Cortisol elevated ADH elevated
Complete ROS with Special Attention to
Undiagnosed or inadequately controlled chronic disease
Cardiac & pulmonary
Bleeding disorders
Hx of DVT
What all needs to be included in the medication history of a pre-operative patient?
Anticoagulants Aspirin NSAIDs Echinacea Ginsent Garlic Gingko St. John's Work Kava
Effects of Echinacea Important for Surgery
Hepatotoxicity
Effects of Ginseng Important for Surgery
Platelet inhibitor
Hypoglycemia
Effects of Garlic Important for Surgery
Platelet inhibitor
Preload reduction
Effects of Gingko Important for Surgery
Platelet inhibitor
Alters vasoregulation
Effects of St. John’s Wort Important for Surgery
Up-regulates P450
Drug-drug reactions
Effects of Kava Important for Surgery
Potentiates sedation
Drug-drug reactions
Important Factors of Functional Status
Exercise tolerance
Activity level
Lee Index Risk Factors for Major Cardiac Complications
High-risk surgery Hx of ischemic HD Hx of congestive HF Hx of stroke/TIA Insulin-dependent DM Serum Cr >2 mg/dL
Major Cardiac Complications with Lee Index
MI Pulmonary edema V-fib Primary cardiac arrest Complete heart block
When is noninvasive cardiac testing performed?
Intermediate clinical predictor
Poor functional capacity
High risk surgery
Examples of Intermediate Clinical Predictors
Class 1 or 2 angina
Prior MI or pathologic Q waves
Compensated or prior HF
DM
Management of Low Risk Patient with CAD
4-5% risk of major cardiac complication
Considered for prophylactic revascularization if indications for revascularization exist independent of non cardiac surgery
Preoperative anti-anginal meds should be continued
Prophylactic IV nitro may reduce ischemia
Evaluation of High Risk Patient with CAD
Surgery delayed until CAD is treated
Delay surgery 3-6 months of recent MI
What do you need to know with a CHF patient for surgery?
Ejection fraction
How is decompensated CHF indicated?
Elevated JVP
Audible 3rd heart sound
Evidence of pulmonary edema on exam or CXR
Pre-op Necessities with CHF Patients
Pre-op control of CHF
Electrolytes & digoxin levels
Anesthesiologist & surgeon aware of severity of CHF
Valvular HD & Pre-op Evaluation
Echo to determine nature & severity of disease
Severe systemic aortic stenosis are high risk for complications
Arrhythmias & Pre-op Evaluation
Determine any arrhythmias
A-fib: control with Lovenox window
Symptomatic SVT & VT should be controlled
Indications for pacemaker: placed prior to surgery
HTN & Surgery
Should be controlled prior to surgery
Pulmonary Evaluation & Surgery
Highest risk in cardiac, thoracic, & upper abdominal surgery
Patient specific factors associated with increased risk
Highest risk: FEV1 less than 500 mL or arterial pCO2 >45 mmHg
Well controlled asthma?
Pulmonary Evaluation: Patient Specific Factors Associated with Increased Risk
Chronic lung disease
Morbid obesity
Tobacco use
Peri-operative Management of Patients with Lung Disease
DVT prophylaxis
Antibiotics
Bleeding Risk Assessment
History
Hx unavailable: PT, PTT, platelet count, & bleeding time
2 Most Common Serious Neurologic Problems After Surgery
Acute delirium
Stroke
DM & Surgery
Increased risk of infection & MI
Regulation of blood sugar
CMP measured & corrected prior to surgery
Hypothyroidism & Surgery
Severe symptomatic should be corrected
Mild or asymptomatic generally okay
Risk of Renal Disease & Surgery
Peri-operative complications: hyperkalemia, pneumonia, & fluid overload
Dialysis 24 hours prior to surgery
Monitor volume status closely
Medication Recommendations & Surgery
Most Rx meds continued morning of surgery
ACEI & diuretics withheld day of surgery
DM: No oral hypoglycemics day of surgery
Discontinue herbals 2 weeks prior
Refrain from ASA, NSAIDs, & Plavix 2 weeks prior
Warfarin: use lovenox window
USE BETA-BLOCKERS
