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
Describe the Obturator sign and and what it can be indicative of?
The patients thigh is flexed to a right angle and gently rotated, first internally and then externally.
Appendicitis, Diverticulitis, PID
MC site for breast malignancy
Upper outer quadrant, slightly more on left boob.
What are the three positions someone should be in for a breast exam?
upright with arm above head
sitting upright with arms at her side
lying down with arm above head
What ABI is indicative of Arterial disease?
0.9
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 heart disease
- 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
common in cancer patients and those w/ intestinal disorders
When would a screening workup include PT/INR, PTT, and CBC?
any h/o bleeding tendencies (Epitaxis, gingival bleeding, easy bruising, menorrhagia, excessive bleeding with other surgeries)
Fam h/o bleeding disorders (Hemophilia, VWD)
Drug history (ASA, NSAIDS, Clopidogrel, Warfarin, Pradaxa, Xarelto)
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 workup would you do for someone high risk for post operative pulmonary complications?
Heavy smoking, SOB/DOE, Chronic cough, Pulm disease, COPD, Asthma, OSA
CXR, ECG
ABG-poorly controlled COPD
PFTs-undiagnosed DOE, COPD/Asthma not at baseline
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 preoperative treatment can significantly decrease incidence of surgical site infections?
high flow oxygen
What is associated with a very low sugrical cardiac risk?
- absense of symptoms (chest pain, palpitations, DOE, syncope)
- good functional assesment (METs)
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
What is the reversal agent for each of these:
Warfarin
Plavix
Xarelto/Eliquis
Pradaxa
Warfarin: Vit K, Kcentra
Plavix: NO, give them platelets
Xarelto/Eliquis: prothrombin complex concentrate or Andexxa
Pradaxa: Praxbind
How do we manage glycemic control perioperatively for DM pts?
Sliding scale insulin
Goal: tight glycemic control before surgery
If a preop workup is needed for a DM pt, what would it include?
What should be checked morning of surgery?
workup: ECG, CXR, UA, CMP, CBC, BG
Blood glucose checked morning of!
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
- admit 1-2 days prior to sx, IVF and sodium replacement
- Correction of any electrolyte abnormalities PRIOR to surgery
What is the mainstay of treating addisonian crisis?
High dose corticosteroids
What is the preop workup for a patient with pulmonary disease?
CXR, ABG, PFTs, CT (if abnormal CXR)
What is the best predictor of airway function test with PFTs?
FEV1
FEV1<50% is associated with high rate of pulmonary complication
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
If a patient had a PCI, how long should they wait before undergoing an elective surgery?
- 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 prophylaxis do patients with a prosthetic heart valve require prior to surgery?
Endocarditis prophylaxis with Amoxicillin 2gm single dose 30-60 min pre op
should also be given to patients with prior endocarditis, cyanotic congenital heart disease, cardiac transplantation recipients who developed cardiac 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
What is no abdominal exam complete without?
a rectal exam!
