Lecture 2: DONT STUDY Flashcards
If a pregnant woman is preparing to have a cholecystectomy should you order baseline labs and an EKG?
NO - they are not indicated in pregnancy
When should you order an EKG as part of pre-op testing?
If pt >50 y/o or they have a pertinent PMH
What are the 4 types of surgery, classified by urgency?
- Emergent - OR w/in 6 hrs
- Urgent - OR w/in 24 hrs
- Time Sensitive - delaying 1-6 weeks negatively affects the outcome
- Elective - can delay up to 1 yr
What are the names of the tools used to assess cardiac risk?
RCRI, NSQIP - risk stratification
DASI - functional classification
What is the ASA assessing?
What is the problem w/it?
What is the better alternative to it?
Assessing Anesthesia risk
Subjective, not specific, vague categories
Alternative - NSQIP
What does the RCRI assess?
The risk of cardiac complications after surgery
What are the 6 factors the RCRI uses to determine a pt’s risk?
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)
How is the DASI measured?
Measured in MET - metabolic equivalent task
What is the MET requirement needed to be able to proceed with surgery?
> or equal to 4 METS
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?
NSQIP - Natl Surgical Quality Improvement Program
Note - 9 outcome predictors: Death, Complication, PNA, cardiac event, SSI, UTI, VTE, Renal failure, Expected LOS
What disease is considered a CV disease equivalent, shown to increase the risk of cardiac complications?
DM
What is the most important prognostic marker for heart failure?
Functional Capacity
What is the MC reason to postpone surgery?
Pre-existing HTN
A patient is preparing to have surgery, what HTN medications should you tell him he is NOT allowed to take the morning of surgery?
ACEs & ARBs (HoTN risk)
Diuretics (fluid shift risk)
Note: most BP meds okay to take the morning of surgery
When is it reasonable to start peri-op beta-blockade prophylaxis?
In pts w/intermed or high cardiac risk or pts w/ >3 RCRI risk factors
What is the typical length of therapy for Beta blockade prophylaxis?
Pre-op period until POD #30
When is reasonable to start peri-op statin prophylaxis?
In pts having vascular surgery
What is the most important pt-related predictor of pulmonary risk?
Age
For patients undergoing pulmonary surgery is pulmonary catheterization, TPN or total enteral nutrition encouraged?
NO
How soon should you tell patients to quit smoking before surgery to promote favorable outcomes and wound healing?
at least 4 weeks before surgery
note: smokers = higher risk for PNA, SSI, death
What is an independent risk factor for developing pulmonary complications?
Sleep Apnea
What of the components of the OSA questionnaire?
STOP BANG Snoring Tired during day Obstructed breathing at night High BP BMI Age >50 Neck Circumference > 16 in Gender (Male)
Which is more important for determining the risk post-op complications: pre-op or post-op blood sugar control?
PRE-op
note: goal = 140-180, too tight of control not good
What can general anesthesia ultimately cause in DM patients due to a neuroendocrine stress response?
Hyperglycemia and ketosis
What 3 types of DM meds are typically NOT given the morning of surgery?
- PO antihyperglycemics
- Regular insulin
- Lispro
(note: give 1/2 NPH dose the AM of surgery & if BS >200 give regular insulin)
What can chronic use of glucocorticoids cause post-operatively?
Adrenal Insufficiency
- they suppress the HPA axis & production of cortisol
Why is the ACTH stimulation test delivered pre-operatively in patients on long term steroids?
Need to determine if they need a steroid stress dose
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?
Addisonian crisis
- b/c the stress dose was inadequate
For what drugs is Pre-op bridge therapy recommended?
Warfarin - must hold 5 days pre-op
+/- Clopidogrel - hold 5-7 days
For what drugs is Pre-op bridge therapy NOT recommended?
- Factor Xa inhibitors (-xabans)
- Direct Thrombin Inhibitors (Dabigatran/Pradaxa)
- DOACs/NOACs
What is the reversal agent for Dabigatran/Pradaxa?
Praxbind
only DOAC w/reversal agent
What other medications should be stopped prior to surgery?
- ASA (7-10 days before)
- NOACs (2-3 days before)
- NSAIDs & COX 2 inhibitors (3 days before)
- OCPs/HRT (4-6 weeks before)
When is the only time Heparin preferred over Lovenox for bridge therapy?
Renal insufficiency or pts on hemodialysis
What is bridge therapy risk stratification based on?
- A-fib (CHA2DS2 VASc)
- Mechanical heart valve
- VTE Hx
Components of CHA2DS2 VASc?
CHF, HTN, Age >65, DM, Prior Stroke, VASCular dz, Sex (F)
When should you strongly consider bridge therapy for anti-coagulation?
High risk pts (CHA2DS2 VASc 2-9)
What are 4 procedures that may not require Warfarin interuption?
- Dental procedures - if INR < 3
- Endoscopy - w/out Bx
- Cystoscopy - w/out Bx
- Cataracts`
What can predict post-op mortality risk in geriatrics patients, and what is the name of the tool associated with it?
Frailty Score
Tool: Charlson Comorbidity Index
What can be given to decrease bleeding risk in pts on NSAIDs?
Platelets - inhibit NSAIDs
What is the reversal agent for Warfarin (Coumadin)?
Vitamin K
Is obesity a major risk factor for NON-cardiac surgery?
NO
A pregnant patient comes, who is in her 1st trimester and requires an non-urgent surgery, when should the surgery be preformed?
Non-urgent - wait til the 2nd trimester
(note: urgent - do it regardless of trimester
elective - wait til after deliver)
What are adaptations that can be done during anesthesia to minimize risk to the fetus?
- LLD (15 degrees)
- Give neuraxial anesthesia
- Avoid HoTN
What type of medication should be avoid in pregnancy after 32 weeks gestation and why?
NSAIDs - risk of premature closing of the fetal ductus arteriosus
(note: opioids okay to give during pregnancy)
