Consultative co management

Question 1

Guide the preoperative management of direct thrombin inhibitors and factor Xa inhibitors.

Answer 1

in Patients With Nonvalvular Atrial Fibrillation, factor Xa inhibitor therapy can be interrupted at least 48 hours before surgeries with an intermediate or high bleeding risk when the estimated glomerular filtration rate is 30 mL/min per 1.73 m2 or greater.

Question 2

Guide the preoperative management of direct thrombin inhibitors and factor Xa inhibitors.

Answer 2

Before neuraxial procedures, factor Xa inhibitors should be discontinued at least 3 days prior (depending on specific agent) and direct thrombin inhibitors (dabigatran) should be discontinued at least 4 days prior,

Question 3

Recommend an appropriate management plan for the prevention of venous thromboembolism in a patient undergoing major joint arthroplasty.

Answer 3

Mechanical compression devices plus apixaban, 2.5 twice daily beginning 12 hours after surgery and continued for 35 days on high risk DVT patient

considering filter insertion in patients at high risk of VTE who are also at high risk of bleeding, making chemoprophylaxis potentially unsafe.

When aspirin is used, the American Academy of Orthopedic Surgeons recommends treatment for 6 weeks after surgery.

Question 4

Manage mild, persistent asthma in a patient scheduled to undergo surgery

Answer 4

Add inhaled corticosteroids controller medication 7 days before surgery

Question 5

Identify undiagnosed obstructive sleep apnea as a risk factor for postoperative respiratory compromise.

Answer 5

Perioperative management recommendations include nonsupine position and continuous pulse oximetry for postoperative monitoring of patients at risk for obstructive sleep apnea. Regional anesthesia should be considered to reduce the use of systemic opioids

Continuous positive airway pressure should be continued for patients with known obstructive sleep apnea

Question 6

Determine risk factors and identify clinical tools and risk indices to predict postoperative pulmonary complications.

Answer 6

An American College of Physicians systematic review found that the odds ratios for postoperative pulmonary complications for individuals aged 50 to 59 years, 60 to 69 years, 70 to 79 years, and older than 79 years were 1.5, 2.3, 3.9, and 5.6, respectively.

Despite pulmonary physiologic changes associated with obesity, obesity in the absence of hypoventilation and obstructive sleep apnea has not been shown to be an independent predictor of perioperative pulmonary complications.

Cigarette use ( is associated with a modest increase

Similarly, well-controlled asthma is not a known risk factor for perioperative pulmonary complications.

Question 7

Interpret the signs and symptoms of undiagnosed heart failure to determine whether elective surgery should be delayed to optimize the patient’s condition and reduce the risk of major adverse cardiac events

Answer 7

Delay surgery for 3 months to evaluate and treat the patient for newly diagnosed heart failure

Question 8

Manage postoperative atrial fibrillation.

Answer 8

BB can be started and consideration for surgery when to begin anticoagulation

Question 9

Recommend appropriate management of ß-adrenergic blockers before surgery.

Answer 9

patients who are already on ß-adrenergic blocker therapy should continue their home dosage on the day of surgery, provided vital signs are stable.

ß-Adrenergic blockers should not be started on the same day as surgery because they can cause harm (eg, increased all-cause mortality, stroke, hypotension, and bradycardia)

most perioperative providers, if electing to start a ß-adrenergic blocker, prefer to do so 2 to 4 weeks in advance of surgery to properly monitor response.

Question 10

List diagnostic criteria for and diagnose postoperative acute myocardial infarction

Answer 10

1. Symptoms of MI
2. New significant ST-T segment/T-wave changes or new left bundle branch block on electrocardiography
3. Development of pathologic Q waves on electrocardiography
4. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
5. Identification of an intracoronary thrombus by angiography or autopsy

Question 11

Diagnose peripartum cardiomyopathy and formulate a treatment plan.

Answer 11

Diuretic plus hydralazine and nitrate

Question 12

Diagnose and treat hyperthyroidism in pregnancy.

Answer 12

clinical manifestations include hyperemesis, dehydration, ketosis, and weight loss.
Propylthiouracil

Question 13

Identify effective interventions to reduce postoperative delirium.

Answer 13

Encourage use of home eyeglasses and hearing aids

Measures to prevent delirium should include efforts to normalize sleep-wake cycles. Promoting daytime arousal may include use of phototherapy and exposure to sunlight, whereas efforts to facilitate nocturnal sleep may include maintaining a dark and quiet environment, providing earplugs, and avoiding overnight interruptions when possible. Furthermore, the daytime affords opportunities to institute orientation protocols, including the provision of clocks and calendars, frequent verbal reorientation, family at bedside whenever possible, and orientation to day/night with windows providing outside views to facilitate physiologic sleep.

Question 14

In a patient with cirrhosis and hepatitis, use the Child-Turcotte-Pugh score and Model for End-Stage Liver Disease score to predict perioperative risk

Answer 14

Both cirrhosis and acute hepatitis portend an elevated risk of perioperative complications and mortality. Complications include hemodynamic compromise and renal injury, encephalopathy, bleeding, infections, poor wound healing, and worsening liver function. In many cases, high perioperative risk contraindicates surgery altogether. In other cases, each of the potential complications should be individually anticipated and addressed.

Question 15

Recommend an approach to bridging anticoagulation therapy before a procedure associated with a high bleeding risk.

Answer 15

Discontinue warfarin 5 days before surgery and admit the patient for intravenous unfractionated heparin 2 days before surgery

“Bridging” anticoagulation refers to the process of discontinuing long-acting oral anticoagulants and substituting shorter-acting anticoagulants in their place in the time leading up to a procedure.

Question 16

Apply appropriate perioperative management in a patient with chronic obstructive pulmonary disease.

Answer 16

Advise smoking cessation, postoperative lung expansion maneuvers

Question 17

American Heart Association guidelines on the prevention of infective endocarditis

Answer 17

The administration of prophylactic antibiotics solely to prevent endocarditis is not recommended for patients who undergo GU or GI tract procedures, including diagnostic esophagogastroduodenoscopy (EGD) or colonoscopy”

The guidelines also list a number of conditions involving prosthetic material warranting consideration of antimicrobial prophylaxis with dental procedures, including prosthetic cardiac valves and some repaired and unrepaired congenital heart diseases with prosthetic patches, devices, or palliative shunts and conduits.

Question 18

Recommend perioperative insulin use to avoid hyperglycemia in preventing surgical site infection

Answer 18

Administering insulin as needed to maintain serum glucose levels below 200 mg/

Question 19

Identify indications for perioperative statin use.

Answer 19

The American College of Cardiology and the European Society of Cardiology both report initiation of statin therapy to be reasonable for patients undergoing vascular surgery

Question 20

Assess functional capacity in the clinical evaluation of the cardiac risk of noncardiac surgery.

Answer 20

Revised Cardiac Risk Index or the National Surgical Quality Improvement Program risk assessment tool.

Patients with limited functional capacity, defined as inability to achieve 4 METs (metabolic equivalents) (eg, climbing a flight of stairs or walking 2 blocks at a normal pace), are at increased risk for perioperative cardiac complications. In contrast, good functional capacity predicts a favorable outcome, and generally makes preoperative stress testing unnecessary.

Question 21

asymptomatic abdominal aortic aneurysm that meets criteria for operative intervention

Answer 21

diameter ≥5.5 cm and expansion of >1 cm over 12 months)

Question 22

pre-op for a patient with a stent -safety of discontinuing DAPT

Answer 22

a decision that should be made in concert with cardiologist input, especially for borderline cases (ie, <12 months DAPT, complex coronary anatomy, unknown type of stent).

Question 23

Appropriately manage glucose control around the time of surgery.

Answer 23

In patients with well-controlled type 2 diabetes who are taking oral agents, these should be stopped and the hyperglycemia should be managed with a sliding scale (correction insulin) every 6 hours. For patients with type 2 diabetes who are treated with insulin or for patients with type 1 diabetes, the general rule is to give one-half to two-thirds of their home insulin as a basal rate along with a corrective insulin scale. Patients with type 1 diabetes must receive a basal rate of insulin to prevent ketosis and cannot be managed solely with a sliding scale.
In any case, treating for BG over 140-180 is not recommended—given evidence that aiming for lower BG targets result in more frequent hypoglycemia episodes.

Question 24

Apply the best available evidence regarding the risk of perioperative adrenal insufficiency to specific clinical scenarios and recommend the safest steroid management plan

Answer 24

On the basis of case reports of postoperative adrenal insufficiency in patients taking corticosteroids for inflammatory conditions, many clinicians have adopted the practice of providing stress-dose steroids to patients undergoing surgery.
More recent literature has demonstrated that this may not be appropriate for all patients, particularly those who are taking less than 20 mg of prednisone (or equivalent) daily and those who have been on steroids for less than 2 weeks in the past 6 to 12 months.
The duration and risk of the surgical procedure should also be considered, with minor interventions requiring no increase in the patient’s usual steroid dosage.
Intermediate- and high-risk procedures may warrant stress-dosing for 24 to 48 hours before returning to the patient’s usual dosage.

Question 25

Explain how spinal anesthesia can be the cause of postoperative hypotension

Answer 25

Hypotension occurs in as many as 47% of patients who receive spinal anesthesia as a result of decreased systemic vascular resistance, peripheral blood pooling with decreased venous return to the heart, or both. These 2 effects result from the sympathetic block that accompanies spinal anesthesia and from block of adrenal medullary secretion.

Question 26

Differentiate among the causes of postoperative hypertension.

Answer 26

It usually occurs within 30 minutes after surgery and lasts for 3 to 4 hours. Preexisting hypertension is the single greatest predictor of postoperative hypertension. Pain, anxiety, excitement due to emergence from anesthesia, and hypercarbia are the most frequent causes. Urinary retention is also a common cause, especially in men. Hypoventilation (hypoxia or hypercapnia), hypervolemia (intraoperatively), acute alcohol withdrawal, pheochromocytoma, thyrotoxicosis, and abrupt β-adrenergic blocker withdrawal are other potential etiologies. Certain surgeries (eg, vascular, cardiac, intracranial, endocrine, or neck) are more likely to be associated with the development of postoperative hypertension.

Question 27

Manage ACE inhibitors and angiotensin-receptor blockers before surgery

Answer 27

Stopping these medications for the day of surgery may be reasonable for patients at high risk for intraoperative hypotension, high operative blood loss, or acute kidney injury, but there are no data to support stopping ACE inhibitors or angiotensin-receptor blockers more than 1 day preoperatively
If ACE inhibitors and angiotensin-receptor blockers are held preoperatively, these medications should be restarted as soon as it is deemed clinically safe postoperatively.

Question 28

Diagnose a perioperative peripheral nerve injury.

Answer 28

Perioperative peripheral nerve injuries can occur as a result of nerve compression or stretch from intraoperative positioning and inadequate padding, as well as from direct trauma during regional blocks.

. Once suspected, electrophysiologic studies should be obtained without delay to confirm localization of the lesion and reveal the extent and type of injury .A neurology consult is also indicated.

Question 29

Manage mild, persistent asthma in pregnancy.

Answer 29

Low-dosage inhaled corticosteroids (Answer B) are indicated for mild, persistent asthma. The goal of treating asthma in pregnancy is to achieve and maintain asthma control by preventing exacerbations and maintaining optimal pulmonary function. Low-dosage inhaled corticosteroids should be continued or prescribed during pregnancy because asthma exacerbations in pregnancy can lead to worse outcomes.

Question 30

Consider the risks and benefits of delaying nonemergent, noncardiac surgery

Answer 30

American Heart Association guidelines recommend that nonemergent surgeries be delayed in patients with active cardiac conditions (decompensated heart failure, significant arrhythmia, severe valvular disease, and acute coronary syndromes within 30 days).

Question 31

Manage postoperative urinary retention

Answer 31

most common causes of postoperative urinary retention are exacerbation of known benign prostatic hypertrophy, various medications, anesthesia (particularly spinal anesthesia), and constipationAcute urinary retention has been associated with the use of medications that have anticholinergic effects, including first-generation histamine-receptor antagonists, antipsychotics, and tricyclic antidepressants.

Question 32

Differentiate among the multiple potential causes of postoperative hypoxia

Answer 32

pulm edema, PE, Aspiration, atelectasis and PNA, OSA,

Question 33

Diagnose HELLP syndrome in pregnancy.

Answer 33

hemolysis (schistocytes on peripheral smear and lactate dehydrogenase >600 U/L), elevated liver function tests (AST ≥70 U/L), and low platelet count (<100 x 103/µL). Clinical diagnosis can be difficult given nonspecific symptoms of right upper-quadrant and upper-abdominal pain associated with hypertension and proteinuria (>300 mg/24 h

Question 34

Recommend insulin therapy for women with gestational diabetes mellitus

Answer 34

when they are unable to achieve fasting glucose values less than 95 mg/dL and 1-hour postprandial glucose values less than 140 mg/dL.

This patient’s 1-hour postprandial glucose values are consistently above the target of less than 140 mg/dL recommended in pregnancy despite lifestyle modifications of reduced carbohydrate intake (30%-40% of calories) and exercise (at least 150 minutes per week). Insulin is the preferred first-line therapy for gestational diabetes mellitus (GDM), as it does not cross the placenta and multiple studies have demonstrated reduced complications in both mothers (reduced risk of preeclampsia) and infants (reduced risk of perinatal death, shoulder dystocia, and birth trauma).

Question 35

Manage asymptomatic bacteriuria in the preoperative setting.

Answer 35

no indication to treat with antibiotics. She has no dysuria, increased frequency, or suprapubic pain.