Approach to the Surgical Patient: Preoperative Care Flashcards
1
Q
What are the phases of surgical management?
A
- Preoperative care
- Operative care and anesthesia
- Postoperative care
2
Q
What are components of preoperative care?
A
- Preop evaluation- complete H&P
- Diagnostic work up- labs/imaging (if pertinent)
- Pre-operative preparation- education/medication/optimization
3
Q
What is the purpose of the general health assessment (H&P pre-op)?
A
- Identify risk
- Dictate other diagnostic procedures, consults, etc. need to be addressed before surgery
- Identifies conditions that need to be treated or addressed prior to surgery
4
Q
What are the most common presenting symptoms for general surgery?
A
- Pain/Claudication
- N/V/Hematemesis
- Change in bowel habits/blood in stool
- Lump or mass
- Injury or trauma
- Numbness/weakness
5
Q
What are components of a elective/urgent physical exam?
A
Complete physical exam with at minimum: general survey, CV, resp, abd, and ext
More depending on CC
6
Q
What are components of a emergent physical exam?
A
Focused physical exam
ALWAYS perform airway assessment, heart, lungs, abdomen
7
Q
What is the order of the abdominal exam PE?
A
- Inspection
- Auscultation
- Palpation- light and deep
- Special tests and signs
8
Q
What is the obturator sign?
A
Thigh flexed to right angle and rotated internally then externally
* Test for appendicitis, diverticulitis, PID
peritoneal inflammation
9
Q
What is the psoas sign?
A
Thigh flexed against resistance of examiner’s hand
Appendicitis
10
Q
No abdominal exam is complete without a what?
A
Rectal exam
11
Q
How should a patient be positioned during a rectal exam and what are you looking for?
A
- On side with knees flexed
- Rectal masses, prostate masses in men
- Can perform hemoccult test for occult blood
12
Q
What is the most common site for breast malignancy?
A
Upper outer quadrant on L side
13
Q
What are components of extremity physical exam preoperatively?
A
- Inspection (color, hair, dryness, muscle tone, lesions/ulceration)
- Skin temperature
- Sensory testing
- Peripheral pulses- palpation/handheld doppler US
- Ankle-brachial index (ABI)
14
Q
At what ABI is moderate arterial disease that should be referred to a vascular specialist?
A
<.9 = arterial disease
<.8 refer to specialist
15
Q
What are objectives of laboratory testing preoperatively?
A
- Screen for asymptomatic disease that may impact surgical result (ie anemia or diabetes)
- Appraisal of diseases that may contraindicate elective surgery or require treatment before surgery
- Diagnosis of disorders that require surgery
- Evaluation of the nature and extent of metabolic or septic complications
16
Q
What diagnostic labs should be considered preoperatively?
A
- CBC, CMP, PT/INR/PTT, BHCG
17
Q
What additional tests (other than labs) should be considered preoperatively?
A
- Imaging
- ECG
- Echo
18
Q
When is an EKG recommended preoperatively?
A
- Known CAD
- Arrhythmia
- PVD
- CVD
- Structural heart disease
- Intermediate/high risk surgery
Basically any known heart problems
19
Q
When is a CXR recommended preoperatively?
A
- For cardiopulmonary disease or pt >50 undergoing AAA sx or upper abdominal/thoracic sx
20
Q
When are labs (CBC, CMP, PT/PTT) recommended preoperatively?
A
Depends on patient and surgery
Can use labs from previous 4 m
Recommended against routine screening in healthy patients
21
Q
When would you order bHCG preoperatively?
A
all pre-menopausal women
22
Q
What diagnostic work-up is needed in an otherwise healthy child undergoing adenoidectomy?
A
none (unless otherwise indicate ie family history)
23
Q
What diagnostic work up is needed in a 30 y/o female with a history of diabetes and a recent DVT requiring coumadin use undergoing a lap chole?
A
PT/INR and bHCG
24
Q
What diagnostic work up is required for an otherwise healthy 30 y/o female undergoing a lap chole?
A
bHCG
25
What diagnostic work up is required for a 56 y/o male who denies any medical conditions and "never has to go to the doctor" undergoing AAA repair?
CXR, EKG, labs
26
How are surgical patients assessed in terms of age?
Physiologic age based on functional mets
27
What are functional mets based on?
how active pt is
28
What does each MET mean?
1 MET: basic ADLs
4 METs: can walk up small incline, single flight of stairs, walk at 3-4 mph on level ground
5-10 METS: heavy house work, scrubbing floors, climbing stairs
>10 METS: participates in sports
29
What functional MET level is a good prognostic indicator?
4 METs
30
What are special general health assessment considerations for the surgical patient?
* Physiological age
* Nutrition
* Weight assessment
* Immune competence
* Wound healing
* Hemostasis
* Thromboembolism
* Pulmonary Function
* CV risk
31
What does preoperative malnutrition increase the risk of?
* Increased operative death
* Increased infection
* Prolonged recovery
* May require pre/post hyperalimentation
32
How do you assess nutritional status preoperatively?
* Questions about weight loss
* Questions about diet and eating habits
* Labwork: CBC with diff, serum albumin/prealbumin, vitamin B12
33
What is the greatest nutritional risk with preop care?
>10% weight loss from baseline
34
What does obesity increase the risk of?
* Post-op infections and wound complications
* Cardiopulmonary complications
* DVT
* Concomitant chronic diseases
35
What does underweight increase the risk of related to surgery?
* Malnutrition/vitamin deficiencies
* delayed wound healing
* concomitant chronic diseases
36
If a patient is obese, what is recommended prior to surgery?
Weight loss
37
What are factors that can impair immune function and increase risk of infection post surgery?
* Malnutrition
* Elderly patients
* Severe trauma and burns
* Cancer
* Certain meds
* Uncontrolled DM
* CKD
38
What does immune issues in surgery require?
* Strict antiseptic techniques and wound care
* Proper perioperative abx
* Postoperative abx when indicated
39
What are factors that lead to delayed wound healing in surgical patients?
* Malnutrition
* Anemia
* Marked dehydration
* Marked edema
* Poorly controlled DM
* Smoking
* Radiation
* Corticosteroids
* Chemo
* CVD
40
What H&P should be taken for hemostasis assessment (work up also depends on H&P and type of surgery)
* History of bleeding tendencies: epistaxis, gingival bleeding, easy bruising, menorrhagia
* Family history of bleeding disorders: Hemophilia, VWD
* Drug history: ASA, NSAIDS, clopidogrel, warfarin, pradaxa, xarelto
* PE: Ecchymosis
41
What is screening work up for hemostasis assessment?
PT/INR, PTT, CBC
42
What are risk factors for thromboembolism that should be considered preoperatively?
* Hx of DVT or PE
* Cardiac conditions
* Cancer patients
* Smokers
* Drug history (OCPs)
* Obesity
* Advanced age
* Sedentary condition
* H/O clotting disorders (lupus, protein c/s deficiency, factor V)
43
What would you do if a patient is at risk for thromboembolism?
Mechanical and/or chemical DVT prophylaxis (therapeutic agent depends on surgery and risks)
44
Impaired pulmonary function preop increases risk of what?
Pulmonary complications post op
45
What are risk factors for pulmonary complications?
* Heavy smoking
* SOB/DOE
* Chronic cough
* Pulmonary diseases
* COPD
* Asthma
* Restrictive lung diseases
* OSA
46
What are physical exam findings that suggest impaired pulmonary function?
* LS: wheezing, rhonchi, crackles
* Prolonged expiration
* Low O2 sat
* Obesity
* Advanced age
47
What is included in a preop pulmonary work up?
* CXR
* EKG
* ABG for poorly controlled COPD
* PFTs for undiagnosed DOE, COPD/asthma not at baseline
48
What are OSA patients at increased risk for post op?
* Atelectasis
* Aspiration
* Resp failure
* Cardiac event
* Post op delirium
* Reintubation
* Prolonged hospital stay
* Death
49
What is a questionnaire that can be used to screen for OSA?
STOPBANG
50
What is used to determine risk of postop pulmonary complications?
ARISCAT calculator
51
How are patients with compromised pulmonary function prepared preop?
* Abstinence from smoking (ideally 8 weeks prior)
* Bronchodilators/chest physiotherapy to optimize chronic issues
* Pre-op/post-op supplemental O2
52
What treatment for pulmonary problems can reduce the incidence of surgical site infections?
Preop treatment with high flow oxygen therapy
53
What are pulmonary postoperative complications?
* Atelectasis
* Hypoxia
* Pneumonia
* Respiratory failure
* PE
54
What factors increase risk of perioperative cardiac complications?
* CVD
* Symptomatic patients without cardiac disease: CP, palpitations, DOE, syncope
* Advanced age
* Smokers
* Obesity
* Concomitant chronic medical conditions
55
What are historical questions to assess cardiac function preop?
* Symptoms: CP, DOE, syncope?
* METs (ability to walk up stairs/hill, household chores, sports)
56
What cardiovascular assessment findings are associated with low surgical cardiac risk?
Absence of symptoms and good functional assessment
57
What are components of a cardiovascular risk PE?
* BP
* Heart auscultation for murmur/irregularity (need further eval prior to elective surgery)
* Carotid auscultation for bruits
58
What does a preop CV diagnostic work up include?
ECG
Echo
Stress test
Carotid doppler
59
What are indications for a ecg, echo, doppler preop? Just ecg?
ecg, echo, doppler: positive h&p findings (depends on specific findings)
ecg: known disease or intermediate/high risk procedure
60
what are major predictors of cardiovascular risk?
* recent MI
* Unstable angina
* Recent PCI
* Active CHF
* V. tach, AV blocks
61
What are intermediate predictors of cardiovascular risk?
* CAD
* Stable angina
* Remote MI
* Compensated CHF
* Renal insufficiency
* DM
* Cerebrovascular disease
* Obesity
62
What are minor predictors of CV risk?
* A. fib
* Age >70
* Abnormal EKG findings: LVH, LBBB
* Poorly controlled HTN
63
What calculators are used to determine surgical risk of cardiovascular complications?
ACS NSQIP calculator
Revised cardiac risk index
64
If a patient has no cardiac symptoms or mild cardiac symptoms with good functional capacity undergoing a low risk surgery, how should they be worked up?
## Footnote
According to the AHA/ACA guidelines
No work up needed
65
If a patient is at low risk (with 1 or more minor predictors) what work up should be done prior to surgery?
ECG
66
If a patient is at intermediate risk (1 or 2 intermediate predictors) according to AHA/ACC guidelines, how should they worked up prior to surgery?
ECG, pertinent labs
67
How should a high CV risk patient (3 + intermediate AHA/ACC risk predictors) or those undergoing high risk surgery be worked up prior to surgery?
ECG, labs, echo, cardiac consult
68
How should a very high risk patient (1 + major predictors) be worked up prior to surgery?
cardiac consult, surgery potponed until condition stable unless emergency
69
What are the components of preop preparations?
* Pre-anesthesia assessment
* Medical clearance/consultations
* Patient education/preoperative orders
* Informed consent/operative permit
70
What can anesthetics cause?
* CNS depression/loss of consciousness
* Respiratory depression
* Cardiac depression
71
What are components of preanesthesia testing or preanesthesia care?
* Typically one week before surgery (low risk surgery or patient can be day of)
* Preop labs and diagnostic tests ordered by surgeon performed
* Evaluated by healthcare provider (PA/NP) and anesthesia provider (CRNA/anesthesiologist): PA/NP performs H&P and anesthesia reviews and performs airway exam and counsels on anesthesia
Operative and anesthesia consent are signed
72
What is the ASA classification?
* ASA I: normal healthy patient
* ASA II: mild systemic disease
* ASA III: severe systemic disease
* ASA IV: severe systemic disease that is constant threat to life
* ASA V: moribund patient not expected to survive operation
* ASA VI: declared brain-dead patient whose organs are being removed for donation
73
What are components of airway assessment pre-anesthesia?
* Neck ROM
* Neck circumference
* Mouth opening/jaw protrusion
* Dentition
* Mallampati classification: oropharyngeal assessment used to predict ease of intubation
74
What does it mean if a patient has a mallampati score of class I? Class IV?
* Class I: complete visualization of soft palate
* Class IV: soft palate not visible
75
What is medical clearance?
Surgeon or anesthesiologist requires patient to obtain medical clearance prior to surgery (ie cardiac, pulmonary, medical (DM, CKD), social work)
76
What are components of operative consent?
* Description of surgery/operation
* Reason for surgery
* Alternatives
* Risks
* Benefits
* Signature of patient or POA
* Signature of provider
* Signature of witness
77
What are components of anesthesia consent?
* Description of anesthesia process
* Different types of anesthesia and type used for specific surgery
* Risks of anesthesia
* Signature of patient, anesthesiologist, witness
78
What is included in preop instructions?
* NPO after midnight before surgery (nothing to eat, drink. smoke, or chew); can take meds with sip of water
* List of meds to stop and meds can take prior to surgery, list of premedications before surgery
* Surgery specific patient prep
79
What CV meds can be continued on day of surgery?
* Beta blockers
* ACE
* CCB
* Nitrates
* Clonidine
* Antiarrhythmics
* Digoxin
80
What anticonvulsants can be taken on the day of surgery?
* Phenytoin
* Tegretol
81
What anti-parkinsons and psych meds can be taken on the day of surgery?
* Anti-Parkinsons: sinemet
* Lithium
82
What asthma/COPD meds can be taken on the day of surgery?
* Singulair
* Theophylline
* Inhalers
83
What thyroid medications and GU meds can be taken on day of surgery?
* Synthroid
* OCPs
* BPH: Terazosin
84
What GI meds can be taken on the day of surgery?
* GERD meds: prilosec, prevacid, zantac
85
86
What medications can be taken up until the day of surgery?
* Statins
* Diuretics: Lasix, HCTZ
* Antidepressants: SSRIs, TCAs
* Insulins
* Oral hypoglycemics: Metformin, Glucotrol
* Opioids: hydrocodone, oxycodone
## Footnote
May be able to take anxiety meds/opioids day of surgery
87
How are insulins adjusted leading up to surgery?
* Adjustment to evening dose
* If ok glucose in morning, skip morning dose and if elevated can take half dose of intermediate/long acting
88
What medications should be stopped before surgery (typically 5-7 days before)
* Oral anticoagulants: Coumadin, Plavix, Pradaxa, Eliquis, Xarelto, Aspirin (off 2 days with pradaxa)
* NSAIDs
* OTC vitamins containing vitamin E
* Herbal preparations
89
What can you do if a patient is on a medication that should be stopped prior to surgery and needs emergent surgery?
Reversal agents!
* Vitamin K: Coumadin
* Plavix: give platelets (no reversal agent)
* Xarelto/Eliquis: prothrombin complex concentrate
* Pradaxa: Praxbind
90
What are risks of operating on a DM patient?
* Infections
* Delayed wound healing
* Cardiopulmonary events
* Electrolyte disturbances
* Renal insufficiency
91
What is preop work up of a DM patient?
* Complete H&P/General assessment
* Diagnostic work-up if indicated: ECG, CXR, UA, CMP, CBC, blood glucose monitoring
* Medical clearance/consultation
* Patient education: be sure they understand how to take med
92
What is the preop goal when dealing with a DM patient?
Tight glycemic control
93
What can cause hyperglycemia in a DM patient?
* Trauma
* Illness
* Physical and emotional stress
94
What can cause hypoglycemia preop in a DM patient?
Preop fasting and preps
95
What do you need to check in a DM patient the AM of the surgery?
Blood glucose (fingerstick)
96
How are DM patients managed perioperative?
* Meticulous wound care
* Longer postop observation
* Resume regular meds once normal diet is tolerated and glucose stable, often with consult of medical service
97
What are risk of hyperthyroidism in a patient with thyroid disease?
* Thyrotoxicosis and thyroid storm
* hypertension
* Cardiac arrhythmias
* CHF
* Hyperthermia
* Airway difficulty with goiters
98
What are risks of hypothyroidism in a patient with thyroid disease perioperatively?
* Myxedema coma
* Acute hypotension
* Hypothermia
* Shock
* Hypoventilation/CO2 retention
* Poor wound healing
99
What is the goal of preop management of a patient with thyroid disease?
* Euthyroid state prior to surgery
100
How is a patient with hyperthyroidism managed prior to surgery?
* Propylthiouracil (PTU) x 1-6 weeks
* For emergency surgery: B-blocker (propranolol), potassium iodine
* Monitor TSH levels
101
How is a patient with hypothyroidism managed prior to surgery?
* Levothyroxine (Synthroid): start at low dose and titrate up. Takes several weeks
* Monitor TSH levels
102
What is preop work up for thyroid disease?
* Complete H&P/General assessment
* Diagnostic work-up: TSH/free T4
* Medical clearance/endocrine consult if not controlled
103
What are risks associated with adrenal insufficiency perioperatively?
* Addisonian crisis (triggered by illness or stress of surgery): hypovolemia, hypotension, shock, death
* Increased risk of infection
* Delayed wound healing
* Electrolyte abnormalities
* Blood glucose abnormalities
104
What is preoperative management of a patient with adrenal insufficiency?
* Admit 1-2 days preop for IV fluids, sodium replacement, and cortisol therapy
* IV or IM cortisol throughout surgery and post op
* Diagnostic work-up: BMP, cortisol levels, glucose levels; correct electrolytes prior to surgery
* Medical/endocrinology consult
105
What may be required for an acute flair of adrenal insufficiency and what are risks of this?
Corticosteroids
* Severe electrolyte abnormalities/hyperglycemia
* Hypertension
* Postop infections
* Renal problems
106
What is required for the treatment of addisonian crisis preop?
High dose corticosteroids
107
What are risks of operating on someone with asthma, COPD, restrictive lung disease, or OSA?
* Hypoxia
* Hypercapnia
* Pneumonia
* Bronchospasm/Laryngospasm
* Prolonged extubation/difficulty waking up
* Increased risk for continued post-operative ventilation
* Respiratory failure
108
What is the preop work-up for someone with pulmonary disease?
Complete H&P/General Assessment
* Assess control of disease, meds for control, responsiveness to meds, hospitalizations, oral steroids
* Assess functional status
* Assess lung sounds
Diagnostic work-up
* CXR, ABG, PFTs, CT (if abnormal CXR)
* Best predictor of airway function with PFTs: FEV1
Medical/Pulmonology consult if not well controlled
109
What is an FEV1 of <50% associated with?
high rate of pulmonary complications
110
How is an FEV1 of >80% staged?
stage 1
111
How is an FEV1 of 50-79% staged? 30-49%? <30%?
Moderate (stage 2)
Severe (stage 2)
Very severe (stage 2)
112
How is pulmonary disease managed before surgery?
* Acute pulmonary disease treated preop
* Good control of underlying disease/exacerbations via bronchodilator therapy, inhaled/oral steroids, antibiotics, and chest physiotherapy
* Smoking cessation: optimal if quit >8 weeks prior to surgery
* Peak flow/preop incentive spirometry
113
Surgery increases the risk of what cardiovascular disease?
MI
114
What is the most common cause of perioperative death?
MI
115
What are components of the preop evaluation of cardiovascular disease patient?
* H&P/General Assessment with thorough CV risk assessment and assessment of functional capacity
Diagnostic work-up:
* ECG: with risk factors
* 1 or more cardiac risk factors in a patient undergoing an intermediate/major surgery with elevated NSQIP score and low METS warrants more thorough workup (ECG, stress testing, echo, cardiology consult)
116
How is cardiovascular disease preop managed?
* HTN treated to within normal limits
* Patient continues CV meds throughout
* B-blockade typically continued during surgery
* Any new cardiac factors found on testing treated prior to surgery
* If PCI, specified time must elapse prior to elective surgery
117
What are the time frames that must elapse prior to being able to do an elective surgery with PCI?
* Angioplasty alone: 2-4 weeks
* Angioplasty with metal stents: 4-6 weeks
* Angioplasty with drug-eluting stent: 1 year
118
What do MVP/Prosthetic heart valves require preoperatively?
* endocarditis prophylaxis with amoxicillin 2 gm single dose 30-60 min preop
119
What should you do if a surgical candidate patient has an acute exacerbation of CHF?
Treat prior to surgery
120
What should be done if a surgical candidate has a pacemaker/defib device prior to surgery?
Should be checked within 3-6 months
121
When is endocarditis prophylaxis done prior to surgery?
* High risk patients for IE and only procedures with higher likelihood of bacteremia
122
Which patients are at risk for infective endocarditis (and therefore should receive preop prophylaxis in high risk procedures)?
* Prosthetic heart valves
* Prior endocarditis
* Cyanotic congenital heart disease (unrepaired, repaired, or partially repaired)
* Cardiac transplantation recipients who develop cardiac valvulopathy
123
What questions should be asked about prior surgical experiences to guide premedication and selection of anesthesia?
* Personal history of reaction to anesthesia
* Family history of severe reaction to anesthesia
* Severe post-operative N/V
* Severe peri-operative anxiety
124
What is an important factor in successful surgical outcomes?
Good oral hygiene
125
What type of procedures is dental hygiene particularly important for?
Cardiovascular surgical procedures
126
What is the most common source of spontaneous bacteremias?
Gingivitis
127
