chapter 6 preoperative evaluation Flashcards
surgical morbidity and mortality fall into one of three categories:
cardiac, respiratory, or infectious complications.
risk factors for preoperative MI, heart failure, or arrhythmias:
angina, recent myocardial infarction (MI), arrhythmias, congestive heart failure (CHF), and diabetes.
an increased risk for cardiac complications is also present in elderly patients and those with abnormal electrocardiograms (ECGs), low functional capacity, history of stroke, and uncontrolled HTN.
surgeries may be classified as high, intermediate, or low risk procedures.
high risk for cardiac complications (>5%) cardiac risk include vascular surgeries, emergency surgeries, and surgeries associated with increased blood loss or large fluid shifts.
intermediate risk surgeries
1-5% cardiac risk include intrathoracic, intraperitoneal, and orthopaedic procedures
low risk procedures
<1% cardiac risk include cosmetic procedures, cataract operations, and endoscopies.
patients at risk for pulmomary complications include those with lung disease ex. asthma, chronic obstructive pulmonary disease (COPD), obesity, hx of smoking, undiagnosed cough or dyspnea.
procedures that increase risk for pulmonary complications are primarily abdominal or thoracic surgeries, the closer the surgery is to the diaphragm, the higher the risk of complications.
medication dosing may have to be adjusted in the perioperative period. aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDS( should generally be d/c 1 week prior to surgery to avoid excessive bleeding).
true
patient should quit smoking 8 or more weeks preoperatively to minimize risk of pulmonary complications.
true.
must pay particular attention during physical examination to the bedside cardiopulmonary assessment. more than 20% of patients undergoing elective surgery have some form of CV disease. key features that may warrant further eval include
elevated bp, heart murmurs, chest pain, signs of CHF, shortness of breath, and lung disease
DIAGNOSTIC EVALUATION preop eval: routinely includes:
complete blood count (CBC) chemistry profile urinalysis (UA) prothrombin time (PT) partial thromboplastin time (PTT) an ECG and chext x-rays BUT recent studies demonstrate that extensive testing does not reduce morbidity and mortality.
PREOP EVAL RECENTLY in general will contain
hemoglobin, UA and in pts over age 40 a serum glucose and ECG.
URINE PREGNANCY test should be considered in women of childbearing age and a chest x-ray, blood urea nitrogen (BUN), creatinine, and CBC in patients above 75 years of age.
patients with risk factors for cardiac complications undergoing elective or semielective surgeries may require preoperative cardiac evaluation.
true
in addition to ECG, echocardiogram may be used to evaluate murmurs, left ventricular (LV) function, hypertrophy, and wall motion abnormalities.
eval of LV function is not warranted in all pts. it is reasonable to assess LV function in pts with dyspnea of unknown function, those with current or prior heart failure and those with a questionable hx of a cardiomyopathy.
patients with good functional capacity can
climb 2 flights of stairs, walk up a hill effortlessly, or walk four or more blocks easily.
pts with poor functional capacity are limited to activities such as personal care, walking indoors around the house, or walking slowly on level ground.
for most surgeries, cefazolin or vancomycin is used to cover
skin flora, specifically staphylococcus aureus, which is commonly responsible for wound infections.
gram negative coverage should be provided for
gastroingestinal, oral, head and heck, and genitourinary surgeries
anerobic coverage provided for
gastrointestinal and oral surgeries.
cefoxitin is commonly used for
gastrointestinal
ciprofloxacin for
genitourinary procedures.
combination of gentamicin and clindamycin is commonly recommended for
head and neck procedures.
cardiac conditions associated with highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures/medical procedures is reasonable
- prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- previous infective endocarditis
- congenital heart disease (CHD)
- unrepaired cyanotic CHD, including palliative shunts and conduits
- repaired CHD with residual defects
- cardiac transplantation recipients who develop cardiac valvulopathy.
planning for surgery should also include deep venous thrombosis (DVT) prophylaxis and efforts to maximize patient’s pulmonary function.
t
risk for developing DVT approximately _ in the general surgical patient and increases to 50-60% for patients undergoing hip surgery
15-30%
50-60%
risk factors for developing DVT include
age >40
obesity, orthopaedic surgery, chf, prior family hx of DVT, stroke, malignancy, immobilization, trauma, and estrogen use.
prophylactic therapies for lower-risk patients include
early ambulation, gradient compression stockings, pneumatic compression stockings, low dose subcutaneous unfractionated or low-molecular weight heparin.
prophylactic therapies for high risk patients:
low molecular weight heparin or warfarin should be considered.
