Exam 1 Reading 2 (B.Ch23) Flashcards
Best way to screen for occult CV disease
Inquire about the patient’s ability to exercise at 4 METs.
Exercise considered 4 METS
climbing 1-2 flight of stairs
Watching TV how many mets
MET 1
Eating dressing
MET 2
Walking on ground level 2-3mph, light housework
MET 3
METS> 10
Playing strenuous sports
CV questions to ask
Exercise tolerance
Angina
DOE
HTN
Pulmonary questions to ask
Smoking
COPD
Asthma , OSA
GI questions to ask
Reflex, obstruction
Endocrine questions to ask
Diabetes, thyroid
Vascular questions to ask
Peripheral vascular, aneurysm.
Hepatic questions to ask
Liver disease, alcohol
Musculo questions to ask
RA
Drugs known to have interactions with anesthetics
MAOIs
Some medication with knonw rebound effects
Propranolol
Clonidine
Patients on chronic beta blocker should they continue? why>?
Patient on chronic beta blocker should continue their meds because abrupt withdrawal may lead to angina, ischemia dysrhythmias
Which one may be continued perioperatively CCB or BB
CCB
Can you continue ACEI and ARBs, why or why not?
You cannot because it they have been know to cause refractory hypotension
When do you D/C diuretics?
Night before surgery to avoid intravascular volume depletion
What about statins and peri-operative?
Statins reduces the morbidity and mortality risk so should be continue perioperatively especially for patient undergoing vascular surgery. .
What dose of prednisone would the patient be at risk for adrenal suppression?
> 5mg ; you have to administer supplemental glucocorticoids
Perioperatively: What about oral hypoglycemic drugs and short acting insulin?
Withheld the morning of surgery
Perioperatively: What about Intermediate and long acting insulin?
Reduced dose on the day of surgery
Perioperatively: Metformin; should it be discontinued and when?
Associated with an increased risk of lactic acidosis in the contxt of severe dehydration. Yes 24 hours prior to surgey
When do yo D/C oral contraceptives and prior to surgery and why ?
4-6 weeks , because high risk for Thromboembolism.
For minor surgeries what perioperative supplementation?
Take usual morning dose of steroid
For moderate surgeries what perioperative supplementation?
Take usual morning dose of steroid
Administer 50 mg hydrocortisone IV prior to induction
25mg IV every 8 hours for 24 hours
For severe surgeries what perioperative supplementation?
Take usual morning dose of steroid
Administer 100 mg hydrocortisone IV prior to induction
50mg IV every 8 hours for 24 hours
Why are MAOIs bad?
Inhibit breakdown of monoamine neurotransmitters including dopamine, serotonin, epinephrine and NE.
Giving an MAOI, with indirect acting sympathomimetic agents?
Hypertensive crisis
Serotonin syndrome
How long do you hold ASA before surgeries?
7-10 days ( action of aspiring is to decrease platelet aggregation, therefore, put the patient at risk for increase surgical bleeding.
How long do you hold clopidogrel and ticagrelor should be stopped?
5 days
How long do you hold prasugrel should be stopped?
7 days
How long do you hold should be stopped?
10 days
How long do you stop ibuprofen and naproxen
3-5 days
How long do you hold warfarin ?
5 ays
LMW heparin last dose should be administered
24 hours before the start of the procedure.
Dabigatran shoud be stopped when ? what indicates how long you stop for
1-2 days prior to surgery with normal CrCl
and 3-5 day for patients with CrCl < 50
When should diabetic surgery be scheduled for?
First case of the day to avoid prolonged fasting
For patient with Type I Diabetes, how should you manage insulin?
Give half the usual dose of intermediate to long acting insulin on the morning of surgery.
Patients with type I diabetes with an insulin pump?
Continue on basal rate; start dextrose containing insulin infusion upon arrival to surgical suite
WHen should herbal and complementary drugs be discontinued 1 week prior to surgery
discontinued 1 week prior to surgery
Effects of garlic
Inhibits platelet aggregation
Effects of St John’s Wort
Inhibits serotonin, NE, dopamine,reuptake
Induces CYP 450 , leading to increased drugs metabolism
Effects of Feverfew
Inhibits platelet aggregation
PCN allergy and cephalosporins
2% of patients with a documented penicillin allergy will have an allergic reaction to a cephalosporin.
Smoking and perioperative outcomes
Smoking is also associated with an increased risk of perioperative respiratory complications, including airway hyperreactivity
Malignant hyperthermia is a rare but potentially life-threatening
anesthetic-triggered disorder of skeletal muscle metabolism that is often inherited in an autosomal dominant fashion.
Patients heterozygous or homozygous for the atypical plasma cholinesterase gene may
describe prolonged hospital stays or ventilator dependence after brief surgical procedures.
A thyromental distance of_______Indicate possible difficult intubation
6 cm is suggestive of possible difficult intubation.
Preoperative evaluation of dentition is important to determine the presence of
prosthetics that should be removed prior to anesthesia and to identify pre-existing loose, chipped, or fractured teeth that might later be erroneously attributed to airway manipulation.
The risk of major adverse cardiac event can be stratified by
Revised Cardiac Risk Index (RCRI)
RCRI identified six independent predictors of cardiac complications:
- history of ischemic heart disease;
- history of congestive heart failure;
- history of cerebrovascular accident;
- preoperative insulin-requiring diabetes;
- creatinine >2.0 mg/dL; and those presenting for
- high-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular surgery).
The best available evidence suggests that preoperative noninvasive stress testing should be reserved for patients with
cardiac risks factors who demonstrate poor (<4 METS) or unknown functional capacity and are undergoing anything other than low risk surgery (MACE risk ≥1%)
Surgery time to wait for bare metal stent
postponing elective surgery for a minimum of 4 weeks after placement of a bare-metal stent and
Surgery time to wait for drug- eluting stent
12 months after placement of a drug-eluting stent
ICD WHat may cause interference
Electromagnetic interference (EMI) from devices in the operating suite, most commonly monopolar electrocautery,
ICD Anesthetic interview includes the
Reason for device implantation Device type and manufacturer Date of last interrogation Current programming, whether the patient is pacemaker dependent, and the device’s response to application of a magnet
When is a MAGNET recommended?
When the site of surgery is within 6 inches (15 cm) of the pacemaker, application of a magnet is recommended when there is a risk of EMI
When is a magnet unnecessary?
When the site of surgery is more than 6 inches from the pacemaker, application of a magnet is
How does Induction affects HTN
Induction of anesthesia results in sympathetic stimulation that manifests as a rise in blood pressure of about 20 to 30 mm Hg and heart rate of about 15 to 20 beats per minute.
Risk factors for Perioperative Pulmonary complications
Smoking Older age COPD Obesity OSA
Effect of smoking of sputum production, ciliary function, and CV? what does it increase ? when should the patient stop smoking to facilitate procedure?
Tobacco and nicotine increase sputum production, reduce ciliary function, stimulate the cardiovascular system, and increase carboxyhemoglobin levels. Although smoking cessation for as little as 2 days decreases carboxyhemoglobin levels and improves mucociliary clearance, most studies suggest it takes at least 8 weeks of smoking cessation to reduce the rate of postoperative pulmonary complications.
Symptoms suggestive of OSA include a
history of snoring, daytime sleepiness, and headaches.
What is the most important factor related to the risk of developing pulmonary complications postoperatively?
The site of surgery (thoracic and upper abdominal more likely to suffer pulmonary complications)
3 implications of having diabetes with the perioperative process?
Autonomic neuropathy may predispose those with diabetes to intraoperative hemodynamic instability.
Gastroparesis makes the risk of pulmonary aspiration relatively more likely.
Poorly controlled diabetic patients are also at greater risk of developing postoperative infections.
Therefore, in general, guidelines recommend a perioperative glycemic target
between 140 and 180 mg/dL.
S/s of Hypothyroidism
Bradycardia
Cold intolerance
Hypoventilation
Hyponatremia
S/S of Hyperthyroidism
Atrial fibrillation Tachycardia Tremor Weight loss Heat intolerance
Pt with hyperparathyroidism
hyperparathyroidism, preoperative determination of serum calcium concentration is prudent.
RA and its implications on perioperative period
cervical joint instability, which must be taken into consideration during intubation. Patients are often maintained on long-term glucocorticoid therapy and may require supplementation perioperatively.
Pt with parkinson’s disease
Increase risk for hypotension
Aspiration
Post op pulmonary complications
Clinical features suggestive of liver disease include a
history of heavy alcohol use, hepatitis, illicit drug use, or sexual promiscuity.
Patients who are dialysis dependent should ideally be dialyzed
as soon prior to surgery as feasible (usually the day before surgery) to optimize preoperative fluid and electrolyte status.
2 meds to be continued parkinson and seizure patients
Antiepileptic drugs
Parkinson’s drugs.
NOnhuman milk how long to wait
6 hours
Light meal (toast clear liquids)
6 hours
Infant formula, how long to wait
6 hours
Breast Milk how long to wait
4 hours
Role of antacids in reducing risk of pulmonary aspiration
Raise gastric pH
Example of nonparticulate antacids
Sodium citrate (bicitra)
Examples of particulate antacids
Maalox
Compare nonparticulate with particulate
nonparticulate antacids, do not cause pulmonary damage if aspirated
Role of H-2 Antagonists in reducing risk of pulmonary aspiration
Reduce gastric Volume
Increase gastric pH
Role of PPIs in reducing risk of pulmonary aspiration
Reduce gastric acid secretion
Reduce gastric colume
PPI blocks proton pmp on
Parietal cells
Role of Prokinetic agents in reducing risk of pulmonary aspiration
Increase gastric motility
Increase Gastroesophageal sphincter tone.
Benzodiazepines commonly used and why?
Midazolam
rapid onset 1-2 mintes
Short half life 1-4 hours
Drugs given before end of surgery
ondansetron, phenothiazines such as perphenazine, butyrophenones such as droperidol, and antihistamines such as dimenhydrinate. These drugs are best administered just prior to the end of surgery for optimal onset of action.
Pre-emptive analgesia involves the
Administration of analgesics prior to an expected noxious stimuli.
Ketamine, opioids, Gabapentin and pregabalin may be given .
What is the most commonly used antibiotic for prophylaxis against SSIs (surgical site infections).
Cefazolin, a first-generation cephalosporin, i
Antibiotic infusions should be administered within_____what is an exception?
1 hour of incision, with the exception of vancomycin and fluoroquinolones, which may be administered within 2 hours of incision.
What is the half life of cefazolin
2 hours
Which factor, discovered during the preoperative interview, warrants delaying a noncardiac surgery?
Hx of medically managed MI within the past 45 days.
The major clinical predictors of increase perioperative CV risk that warrant further investigation?
Hx of CV disease
DM
CVA.
How long should noncardiac surgery be delayed
at least 60 days following an MI
Risk factors for PONV
Female NON-SMOKER Large body habitus Young age Prior hx of PONV motion sickness Procedure longer than one hour
How long prior to inducion of anesthesia should an antacid be adminsitered
15-30 minutes
Lab studies associated with increase risk of pulmonary morbidity?
Reduced serum albumin levels
Increase Creatinine level
2 conditions with highest risk of silent MI
DM
HTN
PAtient with OSA typically develop those 3 thingsq
Hypercabia
Polycythemia (not anemia)
Pulmonary HTN
Right sided HF
Surgical sites with the highest risk for postop pulmonary complications?
Thoracic
Open aortic
Upper abdominal
Select two risk factors predictive of postoperative nausea and vomiting after inhalation anesthesia.
Non-smoker
Female
Which is the best method for defining coronary anatomy and evaluating ventricular and valvular function?
coronary angiography. assess ventricular and valvular function.
2 tests that can assess cardiac ejection fraction at rest and under stress.
Echocardiography and radionuclide angiography can evaluate cardiac EF at rest and under stressful conditions.
The advantages of echocardiography are that it is less invasive, and it is able to check for
wall abnormalities, wall thickness, valvular function, and valve area.
