Dr. Smith preop lecture Flashcards

1
Q

What does a preop eval allow you to do?

A
Assess the medical condition
Evaluate the pt's overall health status
Determine RFs
Educate the pt
Explain the procedure in detail
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2
Q

Advantages of pt education

A

Pt can:
Understand the procedure and ask questions
Consider alternatives
Realize which complications may occur

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3
Q

Emergency

A

Life-threatening situation requiring immediate intervention (trauma, ruptured aneurysm)

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4
Q

Urgent- examples

A

Intestinal obstruction
Appendicitis
Wounds

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5
Q

Elective surgery

A
Can be done when convenient and sometimes not at all
Hernia
Varicose veins
Breast CA
Breast implants
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6
Q

What are the goals of the preop eval?

A

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

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7
Q

What is part of preop?

A
Hx and PE
Special investigation
Informed consent
Specific orders
DVT prophylaxis
Abx prophylaxis
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8
Q

What specific questions and components should be asked?

A

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)

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9
Q

What should you look for in FHx?

A

Hypercoagulable disorders more prevalent than bleeding disorders
Malignant hyperthermia
Pseudocholinesterase deficiency

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10
Q

What to ask about in social hx?

A

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

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11
Q

How to do a PE

A

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

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12
Q

What does an emergency PE consist of?

A
Airway
Breathing
Circulation
Pupils
GCS
Exposure of body for something glaringly obvious
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13
Q

What preoperative investigations should be performed?

A
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
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14
Q

When should you get a CBC?

A

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

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15
Q

When to get electrolytes and BUN/creatinine

A
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
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16
Q

When to get amylase/lipase

A

Anyone with suspected abdominal pathology

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17
Q

When to get glucose

A

Acute abdomen or sepsis
Age >60
Anyone with obesity, DM, malnourished

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18
Q

When to get liver enzymes

A

Excessive alcohol use
RUQ pain or known gallbladder or liver dz
Suspected hepatitis
Jaundice

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19
Q

When to get coagulation studies?

A
Cardiothoracic procedure
Vascular procedure
Neuro procedure
Known anticoagulant use
Hx of coagulation problems
Alcohol abuse
Liver dz or jaundice
Cannot get a hx
20
Q

When to get a type and crossmatch

A

Emergency surgery
Anyone with anemia
Cases with known opportunity for large blood loss
Pregnancy

21
Q

When to get pregnancy test

A

Any female with a uterus over the age of 9 unless hysterectomy or menopausal

22
Q

When to get CXR

A
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
23
Q

When to get EKG

A

Age >50
Morbid obesity
Known cardiac dz

24
Q

Major predictors of increased risk?

A
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
25
Intermediate predictors of increased risk
``` Mild angina Previous MI by hx or by Q waves Compensated heart failure DM Renal insufficiency (Cr >2.0) ```
26
Minor predictors of increased risk
``` Advanced age Abnl EKG (LVH, LBBB, ST changes) Low functional capacity Hx of stroke Uncontrolled systemic HTN ```
27
ASA grade I
Nl healthy individual
28
ASA grade II
Mild systemic dz that doesn't limit activity
29
ASA grade III
Severe systemic dz that limits activity
30
ASA grade IV
Severe systemic dz that is constant threat to life
31
ASA grade V
Moribund, not expected to survive 24 hrs with or without surgery
32
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
33
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
34
What surgeries are considered intermediate risk?
``` Carotid endarterectomy Endovascular AAA repair Head and neck Intraperitoneal and intrathoracic Orthopedic Prostate ```
35
What surgeries are considered low risk?
Endoscopic procedures Superficial procedures Cataract surgery Breast surgery
36
How is DVT prophylaxis performed?
Done preoperatively and intraoperatively Compression hose Mechanical prophylaxis Chemical prophylaxis
37
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
38
Abx prophylaxis and class I
May not require prophylaxis unless a foreign body is inserted
39
Abx prophylaxis and class II
Single perioperative antibiotic given within 30 mins of incision
40
Abx prophylaxis and classes III and IV
Depends, but should at least have a dose prior to incision
41
Common abx for cardiac
Cefazolin | Vancomycin
42
Common abx for esophageal, gastroduodenal
High risk only: cefazolin
43
Common abx for biliary tract
High risk only: cefazolin
44
Common abx for colorectal
Oral: neomycin-erythromycin or metronidazole Parenteral: cefazolin + metronidazole or ampicilin-sulbactam
45
Common abx for GU
High risk only: ciprofloxacin
46
Common abx for neurosurgery
Cefazolin | Vancomycin
47
Common abx for thoracic (non-cardiac)
Cefazolin OR Cefuroxime OR Vancomycin