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Surgery > Approach to the Surgical Patient: Preoperative Care > Flashcards

Approach to the Surgical Patient: Preoperative Care Flashcards

1
Q

What are the phases of surgical management?

A
  1. Preoperative care
  2. Operative care and anesthesia
  3. Postoperative care
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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
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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
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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
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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

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6
Q

What are components of a emergent physical exam?

A

Focused physical exam
ALWAYS perform airway assessment, heart, lungs, abdomen

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7
Q

What is the order of the abdominal exam PE?

A
  • Inspection
  • Auscultation
  • Palpation- light and deep
  • Special tests and signs
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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

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9
Q

What is the psoas sign?

A

Thigh flexed against resistance of examiner’s hand
Appendicitis

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10
Q

No abdominal exam is complete without a what?

A

Rectal exam

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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
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12
Q

What is the most common site for breast malignancy?

A

Upper outer quadrant on L side

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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)
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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

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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
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16
Q

What diagnostic labs should be considered preoperatively?

A
  • CBC, CMP, PT/INR/PTT, BHCG
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17
Q

What additional tests (other than labs) should be considered preoperatively?

A
  • Imaging
  • ECG
  • Echo
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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

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19
Q

When is a CXR recommended preoperatively?

A
  • For cardiopulmonary disease or pt >50 undergoing AAA sx or upper abdominal/thoracic sx
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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

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21
Q

When would you order bHCG preoperatively?

A

all pre-menopausal women

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22
Q

What diagnostic work-up is needed in an otherwise healthy child undergoing adenoidectomy?

A

none (unless otherwise indicate ie family history)

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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

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24
Q

What diagnostic work up is required for an otherwise healthy 30 y/o female undergoing a lap chole?

A

bHCG

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25
Q

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?

A

CXR, EKG, labs

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26
Q

How are surgical patients assessed in terms of age?

A

Physiologic age based on functional mets

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27
Q

What are functional mets based on?

A

how active pt is

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28
Q

What does each MET mean?

A

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

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29
Q

What functional MET level is a good prognostic indicator?

A

4 METs

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30
Q

What are special general health assessment considerations for the surgical patient?

A
  • Physiological age
  • Nutrition
  • Weight assessment
  • Immune competence
  • Wound healing
  • Hemostasis
  • Thromboembolism
  • Pulmonary Function
  • CV risk
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31
Q

What does preoperative malnutrition increase the risk of?

A
  • Increased operative death
  • Increased infection
  • Prolonged recovery
  • May require pre/post hyperalimentation
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32
Q

How do you assess nutritional status preoperatively?

A
  • Questions about weight loss
  • Questions about diet and eating habits
  • Labwork: CBC with diff, serum albumin/prealbumin, vitamin B12
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33
Q

What is the greatest nutritional risk with preop care?

A

> 10% weight loss from baseline

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34
Q

What does obesity increase the risk of?

A
  • Post-op infections and wound complications
  • Cardiopulmonary complications
  • DVT
  • Concomitant chronic diseases
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35
Q

What does underweight increase the risk of related to surgery?

A
  • Malnutrition/vitamin deficiencies
  • delayed wound healing
  • concomitant chronic diseases
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36
Q

If a patient is obese, what is recommended prior to surgery?

A

Weight loss

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37
Q

What are factors that can impair immune function and increase risk of infection post surgery?

A
  • Malnutrition
  • Elderly patients
  • Severe trauma and burns
  • Cancer
  • Certain meds
  • Uncontrolled DM
  • CKD
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38
Q

What does immune issues in surgery require?

A
  • Strict antiseptic techniques and wound care
  • Proper perioperative abx
  • Postoperative abx when indicated
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39
Q

What are factors that lead to delayed wound healing in surgical patients?

A
  • Malnutrition
  • Anemia
  • Marked dehydration
  • Marked edema
  • Poorly controlled DM
  • Smoking
  • Radiation
  • Corticosteroids
  • Chemo
  • CVD
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40
Q

What H&P should be taken for hemostasis assessment (work up also depends on H&P and type of surgery)

A
  • 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
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41
Q

What is screening work up for hemostasis assessment?

A

PT/INR, PTT, CBC

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42
Q

What are risk factors for thromboembolism that should be considered preoperatively?

A
  • 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)
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43
Q

What would you do if a patient is at risk for thromboembolism?

A

Mechanical and/or chemical DVT prophylaxis (therapeutic agent depends on surgery and risks)

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44
Q

Impaired pulmonary function preop increases risk of what?

A

Pulmonary complications post op

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45
Q

What are risk factors for pulmonary complications?

A
  • Heavy smoking
  • SOB/DOE
  • Chronic cough
  • Pulmonary diseases
  • COPD
  • Asthma
  • Restrictive lung diseases
  • OSA
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46
Q

What are physical exam findings that suggest impaired pulmonary function?

A
  • LS: wheezing, rhonchi, crackles
  • Prolonged expiration
  • Low O2 sat
  • Obesity
  • Advanced age
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47
Q

What is included in a preop pulmonary work up?

A
  • CXR
  • EKG
  • ABG for poorly controlled COPD
  • PFTs for undiagnosed DOE, COPD/asthma not at baseline
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48
Q

What are OSA patients at increased risk for post op?

A
  • Atelectasis
  • Aspiration
  • Resp failure
  • Cardiac event
  • Post op delirium
  • Reintubation
  • Prolonged hospital stay
  • Death
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49
Q

What is a questionnaire that can be used to screen for OSA?

A

STOPBANG

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50
Q

What is used to determine risk of postop pulmonary complications?

A

ARISCAT calculator

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51
Q

How are patients with compromised pulmonary function prepared preop?

A
  • Abstinence from smoking (ideally 8 weeks prior)
  • Bronchodilators/chest physiotherapy to optimize chronic issues
  • Pre-op/post-op supplemental O2
52
Q

What treatment for pulmonary problems can reduce the incidence of surgical site infections?

A

Preop treatment with high flow oxygen therapy

53
Q

What are pulmonary postoperative complications?

A
  • Atelectasis
  • Hypoxia
  • Pneumonia
  • Respiratory failure
  • PE
54
Q

What factors increase risk of perioperative cardiac complications?

A
  • CVD
  • Symptomatic patients without cardiac disease: CP, palpitations, DOE, syncope
  • Advanced age
  • Smokers
  • Obesity
  • Concomitant chronic medical conditions
55
Q

What are historical questions to assess cardiac function preop?

A
  • Symptoms: CP, DOE, syncope?
  • METs (ability to walk up stairs/hill, household chores, sports)
56
Q

What cardiovascular assessment findings are associated with low surgical cardiac risk?

A

Absence of symptoms and good functional assessment

57
Q

What are components of a cardiovascular risk PE?

A
  • BP
  • Heart auscultation for murmur/irregularity (need further eval prior to elective surgery)
  • Carotid auscultation for bruits
58
Q

What does a preop CV diagnostic work up include?

A

ECG
Echo
Stress test
Carotid doppler

59
Q

What are indications for a ecg, echo, doppler preop? Just ecg?

A

ecg, echo, doppler: positive h&p findings (depends on specific findings)
ecg: known disease or intermediate/high risk procedure

60
Q

what are major predictors of cardiovascular risk?

A
  • recent MI
  • Unstable angina
  • Recent PCI
  • Active CHF
  • V. tach, AV blocks
61
Q

What are intermediate predictors of cardiovascular risk?

A
  • CAD
  • Stable angina
  • Remote MI
  • Compensated CHF
  • Renal insufficiency
  • DM
  • Cerebrovascular disease
  • Obesity
62
Q

What are minor predictors of CV risk?

A
  • A. fib
  • Age >70
  • Abnormal EKG findings: LVH, LBBB
  • Poorly controlled HTN
63
Q

What calculators are used to determine surgical risk of cardiovascular complications?

A

ACS NSQIP calculator
Revised cardiac risk index

64
Q

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?

According to the AHA/ACA guidelines

A

No work up needed

65
Q

If a patient is at low risk (with 1 or more minor predictors) what work up should be done prior to surgery?

A

ECG

66
Q

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?

A

ECG, pertinent labs

67
Q

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?

A

ECG, labs, echo, cardiac consult

68
Q

How should a very high risk patient (1 + major predictors) be worked up prior to surgery?

A

cardiac consult, surgery potponed until condition stable unless emergency

69
Q

What are the components of preop preparations?

A
  • Pre-anesthesia assessment
  • Medical clearance/consultations
  • Patient education/preoperative orders
  • Informed consent/operative permit
70
Q

What can anesthetics cause?

A
  • CNS depression/loss of consciousness
  • Respiratory depression
  • Cardiac depression
71
Q

What are components of preanesthesia testing or preanesthesia care?

A
  • 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
Q

What is the ASA classification?

A
  • 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
Q

What are components of airway assessment pre-anesthesia?

A
  • Neck ROM
  • Neck circumference
  • Mouth opening/jaw protrusion
  • Dentition
  • Mallampati classification: oropharyngeal assessment used to predict ease of intubation
74
Q

What does it mean if a patient has a mallampati score of class I? Class IV?

A
  • Class I: complete visualization of soft palate
  • Class IV: soft palate not visible
75
Q

What is medical clearance?

A

Surgeon or anesthesiologist requires patient to obtain medical clearance prior to surgery (ie cardiac, pulmonary, medical (DM, CKD), social work)

76
Q

What are components of operative consent?

A
  • Description of surgery/operation
  • Reason for surgery
  • Alternatives
  • Risks
  • Benefits
  • Signature of patient or POA
  • Signature of provider
  • Signature of witness
77
Q

What are components of anesthesia consent?

A
  • Description of anesthesia process
  • Different types of anesthesia and type used for specific surgery
  • Risks of anesthesia
  • Signature of patient, anesthesiologist, witness
78
Q

What is included in preop instructions?

A
  • 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
Q

What CV meds can be continued on day of surgery?

A
  • Beta blockers
  • ACE
  • CCB
  • Nitrates
  • Clonidine
  • Antiarrhythmics
  • Digoxin
80
Q

What anticonvulsants can be taken on the day of surgery?

A
  • Phenytoin
  • Tegretol
81
Q

What anti-parkinsons and psych meds can be taken on the day of surgery?

A
  • Anti-Parkinsons: sinemet
  • Lithium
82
Q

What asthma/COPD meds can be taken on the day of surgery?

A
  • Singulair
  • Theophylline
  • Inhalers
83
Q

What thyroid medications and GU meds can be taken on day of surgery?

A
  • Synthroid
  • OCPs
  • BPH: Terazosin
84
Q

What GI meds can be taken on the day of surgery?

A
  • GERD meds: prilosec, prevacid, zantac
85
Q
A
86
Q

What medications can be taken up until the day of surgery?

A
  • Statins
  • Diuretics: Lasix, HCTZ
  • Antidepressants: SSRIs, TCAs
  • Insulins
  • Oral hypoglycemics: Metformin, Glucotrol
  • Opioids: hydrocodone, oxycodone

May be able to take anxiety meds/opioids day of surgery

87
Q

How are insulins adjusted leading up to surgery?

A
  • Adjustment to evening dose
  • If ok glucose in morning, skip morning dose and if elevated can take half dose of intermediate/long acting
88
Q

What medications should be stopped before surgery (typically 5-7 days before)

A
  • Oral anticoagulants: Coumadin, Plavix, Pradaxa, Eliquis, Xarelto, Aspirin (off 2 days with pradaxa)
  • NSAIDs
  • OTC vitamins containing vitamin E
  • Herbal preparations
89
Q

What can you do if a patient is on a medication that should be stopped prior to surgery and needs emergent surgery?

A

Reversal agents!

  • Vitamin K: Coumadin
  • Plavix: give platelets (no reversal agent)
  • Xarelto/Eliquis: prothrombin complex concentrate
  • Pradaxa: Praxbind
90
Q

What are risks of operating on a DM patient?

A
  • Infections
  • Delayed wound healing
  • Cardiopulmonary events
  • Electrolyte disturbances
  • Renal insufficiency
91
Q

What is preop work up of a DM patient?

A
  • 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
Q

What is the preop goal when dealing with a DM patient?

A

Tight glycemic control

93
Q

What can cause hyperglycemia in a DM patient?

A
  • Trauma
  • Illness
  • Physical and emotional stress
94
Q

What can cause hypoglycemia preop in a DM patient?

A

Preop fasting and preps

95
Q

What do you need to check in a DM patient the AM of the surgery?

A

Blood glucose (fingerstick)

96
Q

How are DM patients managed perioperative?

A
  • Meticulous wound care
  • Longer postop observation
  • Resume regular meds once normal diet is tolerated and glucose stable, often with consult of medical service
97
Q

What are risk of hyperthyroidism in a patient with thyroid disease?

A
  • Thyrotoxicosis and thyroid storm
  • hypertension
  • Cardiac arrhythmias
  • CHF
  • Hyperthermia
  • Airway difficulty with goiters
98
Q

What are risks of hypothyroidism in a patient with thyroid disease perioperatively?

A
  • Myxedema coma
  • Acute hypotension
  • Hypothermia
  • Shock
  • Hypoventilation/CO2 retention
  • Poor wound healing
99
Q

What is the goal of preop management of a patient with thyroid disease?

A
  • Euthyroid state prior to surgery
100
Q

How is a patient with hyperthyroidism managed prior to surgery?

A
  • Propylthiouracil (PTU) x 1-6 weeks
  • For emergency surgery: B-blocker (propranolol), potassium iodine
  • Monitor TSH levels
101
Q

How is a patient with hypothyroidism managed prior to surgery?

A
  • Levothyroxine (Synthroid): start at low dose and titrate up. Takes several weeks
  • Monitor TSH levels
102
Q

What is preop work up for thyroid disease?

A
  • Complete H&P/General assessment
  • Diagnostic work-up: TSH/free T4
  • Medical clearance/endocrine consult if not controlled
103
Q

What are risks associated with adrenal insufficiency perioperatively?

A
  • 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
Q

What is preoperative management of a patient with adrenal insufficiency?

A
  • 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
Q

What may be required for an acute flair of adrenal insufficiency and what are risks of this?

A

Corticosteroids
* Severe electrolyte abnormalities/hyperglycemia
* Hypertension
* Postop infections
* Renal problems

106
Q

What is required for the treatment of addisonian crisis preop?

A

High dose corticosteroids

107
Q

What are risks of operating on someone with asthma, COPD, restrictive lung disease, or OSA?

A
  • Hypoxia
  • Hypercapnia
  • Pneumonia
  • Bronchospasm/Laryngospasm
  • Prolonged extubation/difficulty waking up
  • Increased risk for continued post-operative ventilation
  • Respiratory failure
108
Q

What is the preop work-up for someone with pulmonary disease?

A

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
Q

What is an FEV1 of <50% associated with?

A

high rate of pulmonary complications

110
Q

How is an FEV1 of >80% staged?

A

stage 1

111
Q

How is an FEV1 of 50-79% staged? 30-49%? <30%?

A

Moderate (stage 2)
Severe (stage 2)
Very severe (stage 2)

112
Q

How is pulmonary disease managed before surgery?

A
  • 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
Q

Surgery increases the risk of what cardiovascular disease?

A

MI

114
Q

What is the most common cause of perioperative death?

A

MI

115
Q

What are components of the preop evaluation of cardiovascular disease patient?

A
  • 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
Q

How is cardiovascular disease preop managed?

A
  • 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
Q

What are the time frames that must elapse prior to being able to do an elective surgery with PCI?

A
  • Angioplasty alone: 2-4 weeks
  • Angioplasty with metal stents: 4-6 weeks
  • Angioplasty with drug-eluting stent: 1 year
118
Q

What do MVP/Prosthetic heart valves require preoperatively?

A
  • endocarditis prophylaxis with amoxicillin 2 gm single dose 30-60 min preop
119
Q

What should you do if a surgical candidate patient has an acute exacerbation of CHF?

A

Treat prior to surgery

120
Q

What should be done if a surgical candidate has a pacemaker/defib device prior to surgery?

A

Should be checked within 3-6 months

121
Q

When is endocarditis prophylaxis done prior to surgery?

A
  • High risk patients for IE and only procedures with higher likelihood of bacteremia
122
Q

Which patients are at risk for infective endocarditis (and therefore should receive preop prophylaxis in high risk procedures)?

A
  • Prosthetic heart valves
  • Prior endocarditis
  • Cyanotic congenital heart disease (unrepaired, repaired, or partially repaired)
  • Cardiac transplantation recipients who develop cardiac valvulopathy
123
Q

What questions should be asked about prior surgical experiences to guide premedication and selection of anesthesia?

A
  • Personal history of reaction to anesthesia
  • Family history of severe reaction to anesthesia
  • Severe post-operative N/V
  • Severe peri-operative anxiety
124
Q

What is an important factor in successful surgical outcomes?

A

Good oral hygiene

125
Q

What type of procedures is dental hygiene particularly important for?

A

Cardiovascular surgical procedures

126
Q

What is the most common source of spontaneous bacteremias?

A

Gingivitis

127
Q
A

Surgery (7 decks)

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