Dr. Smith preop lecture Flashcards
What does a preop eval allow you to do?
Assess the medical condition Evaluate the pt's overall health status Determine RFs Educate the pt Explain the procedure in detail
Advantages of pt education
Pt can:
Understand the procedure and ask questions
Consider alternatives
Realize which complications may occur
Emergency
Life-threatening situation requiring immediate intervention (trauma, ruptured aneurysm)
Urgent- examples
Intestinal obstruction
Appendicitis
Wounds
Elective surgery
Can be done when convenient and sometimes not at all Hernia Varicose veins Breast CA Breast implants
What are the goals of the preop eval?
Anticipate difficulties
Made advance preparations and organize facilities, equipment and expertise
Enhance pt safety and minimize opportunity for error
Relieve fear and anxiety for the pt
What is part of preop?
Hx and PE Special investigation Informed consent Specific orders DVT prophylaxis Abx prophylaxis
What specific questions and components should be asked?
Presenting complaint dictates urgency
PMHx: look into a dz that will affect outcome
Surgical hx: may affect incision, length of operation, ability to access
Bleeding problems
Bad reaction to anesthesia, such as malignant hyperthermia, prolonged emergence, hyperemesis?
Drugs and allergy hx: esp look for anticoags, abx sensitivity, steroids (adrenal crisis)
What should you look for in FHx?
Hypercoagulable disorders more prevalent than bleeding disorders
Malignant hyperthermia
Pseudocholinesterase deficiency
What to ask about in social hx?
Smoking: increases O2 demand and decreases delivery
Alcohol: May affect dosing in OR and after, some pts may require DT prophylaxis
Illegal drugs: affects pain control post-operatively
Some pts may experience withdrawal sx
How to do a PE
Do not rely on examinations of others
Pay attention to vitals
Cardiac, resp, abdomen, neuro, peripheral vasculature
Orifice- look in or put a finger in all of them
What does an emergency PE consist of?
Airway Breathing Circulation Pupils GCS Exposure of body for something glaringly obvious
What preoperative investigations should be performed?
Confirmation of dx Exclusion of alternate dx To know the extent of the dz Assessment of fitness for surgery Risk to others Medico-legal considerations
When should you get a CBC?
All emergencies
All pts age >60
Menstruating females
Surgery where large blood loss is expected
Anytime you suspect anemia, clotting or bleeding d/o, sepsis, kidney dz
When to get electrolytes and BUN/creatinine
Age >60 On meds, such as diuretics or steroids Cardiac, pulmonary, liver, or renal dz Malnourished or has had nausea, vomiting or diarrhea Anyone receiving IVF
When to get amylase/lipase
Anyone with suspected abdominal pathology
When to get glucose
Acute abdomen or sepsis
Age >60
Anyone with obesity, DM, malnourished
When to get liver enzymes
Excessive alcohol use
RUQ pain or known gallbladder or liver dz
Suspected hepatitis
Jaundice
When to get coagulation studies?
Cardiothoracic procedure Vascular procedure Neuro procedure Known anticoagulant use Hx of coagulation problems Alcohol abuse Liver dz or jaundice Cannot get a hx
When to get a type and crossmatch
Emergency surgery
Anyone with anemia
Cases with known opportunity for large blood loss
Pregnancy
When to get pregnancy test
Any female with a uterus over the age of 9 unless hysterectomy or menopausal
When to get CXR
Trauma to neck, chest, abdomen, or pelvis Unconscious pt All elective cases over age 60 Thoracic surgery Septic pts Perforated viscous Hx of lung dz
When to get EKG
Age >50
Morbid obesity
Known cardiac dz
Major predictors of increased risk?
Acute or recent MI Unstable or severe angina Strongly positive stress test Decompensated heart failure: edema, rales, venous distention, SOB Severe valvular dz Significant arrhythmias
Intermediate predictors of increased risk
Mild angina Previous MI by hx or by Q waves Compensated heart failure DM Renal insufficiency (Cr >2.0)
Minor predictors of increased risk
Advanced age Abnl EKG (LVH, LBBB, ST changes) Low functional capacity Hx of stroke Uncontrolled systemic HTN
ASA grade I
Nl healthy individual
ASA grade II
Mild systemic dz that doesn’t limit activity
ASA grade III
Severe systemic dz that limits activity
ASA grade IV
Severe systemic dz that is constant threat to life
ASA grade V
Moribund, not expected to survive 24 hrs with or without surgery
What are some assessment tools for cardiac?
Goldman cardiac risk index
Detsky modified multifactorial index
Eagle’s criteria for cardiac assessment
Revised cardiac risk index
What surgeries are considered high risk?
Emergent major surgery
Aortic and other major vascular
Peripheral vascular
Anticipated prolonged or associated with large fluid shift and/or blood loss
What surgeries are considered intermediate risk?
Carotid endarterectomy Endovascular AAA repair Head and neck Intraperitoneal and intrathoracic Orthopedic Prostate
What surgeries are considered low risk?
Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery
How is DVT prophylaxis performed?
Done preoperatively and intraoperatively
Compression hose
Mechanical prophylaxis
Chemical prophylaxis
Class I surgical wound
Operative wound clean
Non-traumatic, with no inflammation encountered
No break in technique
Respiratory, GI and GU tracts not entered
C-section, elective, no PROM or trial of labor
Abx prophylaxis and class I
May not require prophylaxis unless a foreign body is inserted
Abx prophylaxis and class II
Single perioperative antibiotic given within 30 mins of incision
Abx prophylaxis and classes III and IV
Depends, but should at least have a dose prior to incision
Common abx for cardiac
Cefazolin
Vancomycin
Common abx for esophageal, gastroduodenal
High risk only: cefazolin
Common abx for biliary tract
High risk only: cefazolin
Common abx for colorectal
Oral: neomycin-erythromycin or metronidazole
Parenteral: cefazolin + metronidazole or ampicilin-sulbactam
Common abx for GU
High risk only: ciprofloxacin
Common abx for neurosurgery
Cefazolin
Vancomycin
Common abx for thoracic (non-cardiac)
Cefazolin OR
Cefuroxime OR
Vancomycin
