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Clin Specialties Surgery Exam > Lecture 2: DONT STUDY > Flashcards

Lecture 2: DONT STUDY Flashcards

1
Q

If a pregnant woman is preparing to have a cholecystectomy should you order baseline labs and an EKG?

A

NO - they are not indicated in pregnancy

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2
Q

When should you order an EKG as part of pre-op testing?

A

If pt >50 y/o or they have a pertinent PMH

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3
Q

What are the 4 types of surgery, classified by urgency?

A
  1. Emergent - OR w/in 6 hrs
  2. Urgent - OR w/in 24 hrs
  3. Time Sensitive - delaying 1-6 weeks negatively affects the outcome
  4. Elective - can delay up to 1 yr
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4
Q

What are the names of the tools used to assess cardiac risk?

A

RCRI, NSQIP - risk stratification

DASI - functional classification

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5
Q

What is the ASA assessing?
What is the problem w/it?
What is the better alternative to it?

A

Assessing Anesthesia risk
Subjective, not specific, vague categories
Alternative - NSQIP

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6
Q

What does the RCRI assess?

A

The risk of cardiac complications after surgery

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7
Q

What are the 6 factors the RCRI uses to determine a pt’s risk?

A

Surgery risk category, peri-op Tx w/insulin, peri-op Cr >2
Hx of: CHF, CVD, ischemic heart dz

(note: lower score/ASA class = lower risk)

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8
Q

How is the DASI measured?

A

Measured in MET - metabolic equivalent task

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9
Q

What is the MET requirement needed to be able to proceed with surgery?

A

> or equal to 4 METS

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10
Q

What is the only risk tool that is procedure specific and uses pt predictors and the planned procedure to predict the chance of various outcomes w/in 30 days of surgery?

A

NSQIP - Natl Surgical Quality Improvement Program

Note - 9 outcome predictors: Death, Complication, PNA, cardiac event, SSI, UTI, VTE, Renal failure, Expected LOS

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11
Q

What disease is considered a CV disease equivalent, shown to increase the risk of cardiac complications?

A

DM

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12
Q

What is the most important prognostic marker for heart failure?

A

Functional Capacity

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13
Q

What is the MC reason to postpone surgery?

A

Pre-existing HTN

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14
Q

A patient is preparing to have surgery, what HTN medications should you tell him he is NOT allowed to take the morning of surgery?

A

ACEs & ARBs (HoTN risk)
Diuretics (fluid shift risk)

Note: most BP meds okay to take the morning of surgery

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15
Q

When is it reasonable to start peri-op beta-blockade prophylaxis?

A

In pts w/intermed or high cardiac risk or pts w/ >3 RCRI risk factors

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16
Q

What is the typical length of therapy for Beta blockade prophylaxis?

A

Pre-op period until POD #30

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17
Q

When is reasonable to start peri-op statin prophylaxis?

A

In pts having vascular surgery

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18
Q

What is the most important pt-related predictor of pulmonary risk?

A

Age

19
Q

For patients undergoing pulmonary surgery is pulmonary catheterization, TPN or total enteral nutrition encouraged?

A

NO

20
Q

How soon should you tell patients to quit smoking before surgery to promote favorable outcomes and wound healing?

A

at least 4 weeks before surgery

note: smokers = higher risk for PNA, SSI, death

21
Q

What is an independent risk factor for developing pulmonary complications?

A

Sleep Apnea

22
Q

What of the components of the OSA questionnaire?

A 
STOP BANG 
Snoring 
Tired during day 
Obstructed breathing at night 
High BP
BMI 
Age >50
Neck Circumference > 16 in
Gender (Male)
23
Q

Which is more important for determining the risk post-op complications: pre-op or post-op blood sugar control?

A

PRE-op

note: goal = 140-180, too tight of control not good

24
Q

What can general anesthesia ultimately cause in DM patients due to a neuroendocrine stress response?

A

Hyperglycemia and ketosis

25
Q

What 3 types of DM meds are typically NOT given the morning of surgery?

A
  1. PO antihyperglycemics
  2. Regular insulin
  3. Lispro

(note: give 1/2 NPH dose the AM of surgery & if BS >200 give regular insulin)

26
Q

What can chronic use of glucocorticoids cause post-operatively?

A

Adrenal Insufficiency

- they suppress the HPA axis & production of cortisol

27
Q

Why is the ACTH stimulation test delivered pre-operatively in patients on long term steroids?

A

Need to determine if they need a steroid stress dose

28
Q

A patient was provided stress dosing prior to surgery however the patient is now presenting with weakness, fatigue, confusion, and HoTN… what is occurring and why is this happening?

A

Addisonian crisis

- b/c the stress dose was inadequate

29
Q

For what drugs is Pre-op bridge therapy recommended?

A

Warfarin - must hold 5 days pre-op

+/- Clopidogrel - hold 5-7 days

30
Q

For what drugs is Pre-op bridge therapy NOT recommended?

A
  1. Factor Xa inhibitors (-xabans)
  2. Direct Thrombin Inhibitors (Dabigatran/Pradaxa)
  3. DOACs/NOACs
31
Q

What is the reversal agent for Dabigatran/Pradaxa?

A

Praxbind

only DOAC w/reversal agent

32
Q

What other medications should be stopped prior to surgery?

A
  1. ASA (7-10 days before)
  2. NOACs (2-3 days before)
  3. NSAIDs & COX 2 inhibitors (3 days before)
  4. OCPs/HRT (4-6 weeks before)
33
Q

When is the only time Heparin preferred over Lovenox for bridge therapy?

A

Renal insufficiency or pts on hemodialysis

34
Q

What is bridge therapy risk stratification based on?

A
  1. A-fib (CHA2DS2 VASc)
  2. Mechanical heart valve
  3. VTE Hx
35
Q

Components of CHA2DS2 VASc?

A

CHF, HTN, Age >65, DM, Prior Stroke, VASCular dz, Sex (F)

36
Q

When should you strongly consider bridge therapy for anti-coagulation?

A

High risk pts (CHA2DS2 VASc 2-9)

37
Q

What are 4 procedures that may not require Warfarin interuption?

A
  1. Dental procedures - if INR < 3
  2. Endoscopy - w/out Bx
  3. Cystoscopy - w/out Bx
  4. Cataracts`
38
Q

What can predict post-op mortality risk in geriatrics patients, and what is the name of the tool associated with it?

A

Frailty Score

Tool: Charlson Comorbidity Index

39
Q

What can be given to decrease bleeding risk in pts on NSAIDs?

A

Platelets - inhibit NSAIDs

40
Q

What is the reversal agent for Warfarin (Coumadin)?

A

Vitamin K

41
Q

Is obesity a major risk factor for NON-cardiac surgery?

A

NO

42
Q

A pregnant patient comes, who is in her 1st trimester and requires an non-urgent surgery, when should the surgery be preformed?

A

Non-urgent - wait til the 2nd trimester

(note: urgent - do it regardless of trimester
elective - wait til after deliver)

43
Q

What are adaptations that can be done during anesthesia to minimize risk to the fetus?

A
  1. LLD (15 degrees)
  2. Give neuraxial anesthesia
  3. Avoid HoTN
44
Q

What type of medication should be avoid in pregnancy after 32 weeks gestation and why?

A

NSAIDs - risk of premature closing of the fetal ductus arteriosus
(note: opioids okay to give during pregnancy)

Clin Specialties Surgery Exam (13 decks)

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