Lecture 1: Intro to Surgery Flashcards
What are the MC complaints in surgical candidates?
- Pain
- Emesis
- Change in bowel habits
- Hematemesis/hematochezia
- Trauma
What are the goals of Pre-op testing?
- Screening for asymptomatic disease that may affect surgical result
- Appraising current diseases that may affect course of surgery
- Dx of disorders that may require sx
- Evaluate any metabolic or septic complications
What INR level is needed to do an elective procedure?
Lower than 1.5
How long ago can previous labs be for pre-op diagnostic work-up?
Within past 4 months
When is CXR recommended for pre-op diagnostic work-up?
- Cardiopulmonary disease
- > =50 undergoing AAA or upper abd/thoracic sx
Who gets a Beta-hCG lab in pre-op diagnostic work-up?
Any pre-menopausal women
What kind of pre-op pts would require a nutritional assessment?
Cancer or intestinal disorders
MC site for breast malignancy
Upper outer quadrant, slightly more on left.
What is the recommendation regarding labs for pre-op diagnostic work-up in surgical pts?
Do not routinely screen if healthy or recent within 4 months.
Who gets an EKG for pre-op workup?
- Known CAD/arrhythmia/PVD/CVD/Structural
- Intermediate or high risk sx
What METs level is considered good for surgery prognosis?
At least 4 without symptoms.
Higher is better
Physiologic age > chronologic age
Ex: walking up a small incline, single flight of stairs, 3-4mph on flat ground
What physical activity is considered 4 METs?
- Walking up a small incline
- Single flight of stairs
- 3-4 mph walking speed on ground
What weight loss is considered very high risk in surgical candidates?
> 10% wt loss from their baseline
What is the screening tool for obstructive sleep apnea?
- Snoring
- Tiredness
- Observed apnea
- Pressure (BP)
- BMI > 35
- Age > 50
- Neck > 40cm circumference
- Gender (Male)
STOP-BANG
What screening tool determines risk of postop pulmonary complication?
ARISCAT Calculator
How do we pre-op prep someone with compromised pulmonary function?
- No smoking 8 weeks prior
- Bronchodilators/Chest physiotherapy
- Pre-op/post-op supplemental O2
Pre-op high flow helps with reducing site infections!
What are the major predictors of cardiovascular risk?
- Recent MI (6months)
- Unstable angina
- Recent PCI
- Active CHF
- VTach or AV Blocks
What are the minor predictors for cardiovascular risk?
- AFib
- Age > 70
- LVH or LBBB
- Poorly controlled HTN
What are the intermediate predictors for cardiovascular risk?
- CAD
- Stable angina
- Remote MI
- Compensated CHF
- Renal insufficiency
- DM
- CVD
- Obesity
What is NSQIP for?
National Surgical Quality Improvement Program to measure risk stratification
ACS-NSQIP-SRC (surgical risk calculator)
How are no risk, low risk, and intermediate cardiovascular risk patients managed/worked up per AHA/ACC guidelines?
- No risk = no workup
- Low risk = EKG
- Intermediate = EKG + pertinent labs
How are high risk and very high cardiovascular risk patients worked up prior to surgery?
- High = 3+ intermediate factors or high risk surgery = EKG + labs + echo + cardiac consult
- Very high = 1+ major = Cardiac consult + postpone until stabilized.
What do all anesthesias cause?
- CNS depression
- Respiratory depression
- Cardiac depression
ASA Classifications (1-6)
ASA is classified based on presence of systemic disease and its threat to life.
Pre-anesthesia classification
What is mallampati classification?
Classification of oropharynx to predict ease of intubation
What are the two parts of informed consent for surgery?
- Operative consent (patient and surgeon sign)
- Anesthesia consent (patient and anesthesia sign)
What medications must be stopped 5-7 days prior to surgery?
- Oral AC (pradaxa only 2 days prior)
- NSAIDs
- OTC vitamins with vitamin E
- Herbals
How do we manage glycemic control perioperatively for DM pts?
Sliding scale insulin
What is the goal of surgery for thyroid complications?
Achieving euthyroid state PRIOR to surgery
For hyperthyroidism, what are the main drugs for emergency surgery?
- BBs like propranolol
- Potassium iodide
PTU for non-emergent
What can occur in addisonian crisis that is a danger in surgery?
- Hypovolemia
- Hypotension
- Shock
- Death
Risk is present during the entire surgery
How do we pre-op manage adrenal insufficiency?
- IV/IM cortisol injections
- 1-2 days prior to sx, IVF and sodium replacement
- Correction of any lyte abnormalities PRIOR to surgery
What is the mainstay of treating addisonian crisis?
High dose corticosteroids
What PFT value correlates with high risk of pulmonary complications?
FEV1 < 50%
Any acute pulmonary disease should be treated prior to surgery.
What is the MCC of perioperative death?
MI
How long do you wait to do surgery post angioplasty?
- Angioplasty: 2-4 weeks
- Angioplasty + metal stents: 4-6 weeks
- Angioplasty + Drug-eluting stent: 1 year
Stenting = wait longer
For surgical pts with prosthetic heart valves, what is the ABX for endocarditis prophylaxis?
Amoxicillin 2gm single dose 30-60 preop
Prevention of strep viridans
Who is highest risk for infective endocarditis due to surgery?
- Prosthetic heart valves
- Prior endocarditis
- Cyanotic congenital heart disease (The T diseases)
- Cardiac transplantation with recent development of valvulopathy
What is the MCC of spontaneous bacteremias?
Gingivitis
Can cause severe cardiovascular complications.
What surgical procedures does oral hygiene affect the most?
Cardiovascular surgery
