Operative Risk Flashcards
What is the stated purpose of anesthesiology?
To control the consciousness, motion, pain and assess/support/monitor the patient’s organ systems pre-, intra-, and post-operatively.
The _______ is the peri-operative physician
anesthesiologist
What is the overall risk of anesthesia?
Very small (1:6700 to 1:200,000)
What does the risk of anesthesia correlate with?
Procedure and pt co-morbid conditions
_____ scale accurately predicts post-op morbidity and mortality
ASA (American Society of Anesthesiology )
The ASA scaleis criticized because it does not take into consideration the patient’s ____ and how difficult it is to _______.
Age; intubate
A pt has a physical status of 1, how would you best describe this pt? What is their post-op mortality? (%)
Normal, healthy patient
0.1%
A pt has a physical status of 2, how would you best describe this pt? What is their post-op mortality? (%)
Mild systemic disease
0.2%
A pt has a physical status of 3, how would you best describe this pt? What is their post-op mortality? (%)
Severe systemic disease
1.8%
A pt has a physical status of 4, how would you best describe this pt? What is their post-op mortality? (%)
Severe systemic disease that is a constant threat to life
7.8%
A pt has a physical status of 5, how would you best describe this pt? What is their post-op mortality? (%)
Moribund patient, not expected to survive without an operation
9.4%
A pt has a physical status of 6, how would you best describe this pt? What is their post-op mortality? (%)
Brain dead organ donor
umm, dead %
In general, people ____y/o without significant medical problems are at very low surgical risk
<50 y/o
Overall surgical risk is dependent upon 3 factors…
Specific surgical risk
Patient specific clinical variables
Exercise capacity/tolerance
Exercise capacity/tolerance is measured in units of _____, which is described as the amount of _____ a person consumes (or the energy expended) per unit of body weight during ___(time period)___ of rest. In surgery, exercise capacity/tolerance is measured as either >__(#)__ __(unit)__ or < __(#)__ __(unit)__
METs (metabolic equivalents)
Oxygen
1 minute
>4 MET or <4 MET
What quantity of METs is the basic ADLs equivalent to? What is 4 METs equivalent to, activity-wise?
Basic ADL: 1 MET
4 METs: Pt can walk up a flight of stairs/hill
Cardiac surgery uses separate risk assessment based on ___ database
ST
Are the following non cardiac surgeries of low/intermediate/high risk?
Non-vascular major abd Infra-inguinal vascular Carotid, head, and neck Orthopedic Prostrate
Intermediate
Are the following non cardiac surgeries of low/intermediate/high risk?
Endoscopic
Ophthalmologic
Dental
Skin/superficial
Low
Are the following non cardiac surgeries of low/intermediate/high risk?
Emergent
Major thoracic
Aortic or supra-inuginal vascular
Procedures expecting major fluid shifts/blood loss
High
What does MACE stand for?
Major Adverse Coronary Events
What are some examples of cardiac risks that would lead to a delay or cancellation of a surgery?
Unstable coronary syndromes (USA, recent AMI)
Decompensated HF, new HF, Class IV HF
Significant or new arrhythmias
Severe valvular dz: AS or symptomatic MS
Major Adverse Coronary Events (MACE), such as cardiac death or non-fatal MI, lower risk
is defined as ___% risk or less, and elevated risk is defined as ___% risk or greater.
1%
1%
Goldman’s criteria is used to predict what?
Postoperative cardiac complications
Goldman's Criteria: History of \_\_\_\_\_ \_\_\_\_\_ dz History of \_\_\_\_\_ History of \_\_\_\_ (\_\_\_/\_\_\_) Pre-op \_\_\_\_\_ tx Serum creatinine \_\_\_\_mg/dL
Goldman's Criteria: History of ischemic heart dz History of CHF History of CVD (CVA/TIA) Pre-op insulin treatment Serum creatinine >2mg/dL
_____ factors from Goldman’s Criteria generally yields a >5% risk of MACE
> 2
Why would it not be in the patient’s best interest to be on Beta Blockers prior to surgery (i.e. hip replacement)?
Beta blockers are negative inotropes and “blunt” the adrenergic response, lower HR, and therefore lower the patient’s cardiac output. Beta blockers, while appropriate after MI and in CHF, would not be recommended in a stressful response, like surgery, where good blood flow and perfusion during and after surgery are important.
What is the most important pulmonary complication of surgery? What is the % of post-op occurrence?
PNA and respiratory failure
2-19%
As the pt’s length of stay increases, the pt’s risk of _____ significantly increases too.
Mortality
Risk factors for developing post-operative pulmonary complications include: ______ _____ or _____ procedures, prolonged anesthesia >____ hours, age _____ y/o, tobacco abuse _____ years, hypo______, and impaired ____.
Other conditions that may increase a pt’s risk for developing post-operative pulmonary complications include ____, ____, ____, and pre-op _____.
Risk factors for developing post-operative pulmonary complications include: Upper abdominal or cardiothoracic procedure, prolonged anesthesia > 4 hours, age > 60 y/o, tobacco abuse >20 pack years, hypoalbuminemia, and impaired cognition
Other conditions that may increase a pt’s risk for developing post-operative pulmonary complications include COPD, HF, OSA, and pre-op sepsis.
Why does being under anesthesia for an extended period of time lead to higher incidence of post-operative pulmonary complications?
The lungs are under inflated during anesthesia, which leads to an increased incidence of atelectasis the longer the pt is under anesthesia
What might hypoalbuminemia be indicative of?
Poor nutritional status
What might impaired cognition lead to in regards to PFTs post-operatively?
Poor performance on postoperative incentive spirometry
T/F Generally, PFTs are not helpful in predicting who will have post-op issues
True
T/F PFTs can help classify patients with unexplained sx prior to big surgeries
True
T/F There is a clear cutoff for non-lung surgery in a pt with certain PFT results
False
For a pt about to undergo surgery who wants to avoid peri-operative complications, what are some pre-operative changes a pt can make to their social habits, lifestyle, and medications that can mitigate these risks?
Smoking cessation (for elective cases) Optimize pulmonary function w/ bronchodilators, corticosteroids, antibiotics, incentive spirometry and inspiratory muscle training
A pt should be diagnostically evaluated for ___(medical condition)___ prior to surgery
Anemia
Morbidity and mortality may increase with (high/low) hemoglobin and hematocrit.
Low
It is uncertain if _____ or _____ helps with anemia.
EPO or transfusion
T/F Bleeding is not a hematologic risk of surgery
False, duh
Prior to surgery, on a pt without a direct, complete, or accurate bleeding history, ensure that pre-operative lab testing for ____, ____, and _____ measurements is performed.
PT, PTT, and platelets
If a pt is at high risk for thromboembolism/CVA, what should be done prior to/during surgery? (hint: “bridge”) Would this tx be needed for a low risk pt?
Use of two anticoagulant medications simultaneously taken until desired level is achieved.
No
Acute kidney injury (AKI) is a(n) _______ risk factor for mortality, carrying a ___% risk in major surgery.
Acute kidney injury (AKI) is an independent risk factor for mortality, carrying a 1% risk in major surgery.
___-___% AKI risk in cardiac cases; ___% mortality if hemodialysis is required
10-30%; 50%
What are some risk factors of developing renal complication post-operatively?
Known renal dz, cardiac surgery, aortic surgery, DM, severe CHF, PVD, age > 70 y/o
What are tx options for post-operative renal complications?
Maintain intravascular volume, avoid kidney “poisons”
What are some examples of kidney “poisons”? (hint: medications etc)
NSAIDs, contrast media, +/- ACE/ARB
In low risk surgical pts obtaining a thorough ____, ____, ____, and ____ history should suffice. Comprehensive, routine testing (is/is not) beneficial.
In low risk surgical pts obtaining a thorough medical, bleeding, medication and anesthetic history should suffice.
Comprehensive, routine testing NOT beneficial
In low risk, healthier pts, the cases are (shorter/longer), less invasive/more invasive) and may be (outpatient/inpatient).
Cases are shorter, less invasive or outpatient
In low risk pts, anesthesia is minimal, and can be administered through three different routes: ____, ____, and ____.
Locally, regionally, MAC (monitored anesthesia care)
In intermediate or high risk patients, the goal of pre-operative screening is to….
With our major area of focus being what body system(s)?
Estimate peri-operative risk for medical complications and minimize risk without delaying surgery, causing morbidity, or creating undue expense
Cardiopulmonary
In intermediate/high risk pts, a thorough history of what 5 types of disease is important to obtain prior to surgery?
Cardiopulmonary dz Renal dz Hepatobiliary dz Metabolic/Endocrine dz CNS dz
What medications do we need to know about prior to administering anesthesia, that have possible interactions with anesthesia, but are usually continued?
beta blockers, asthma meds, antihypertensives
sorry for the weirdly worded question, very specific
What medications may be considered ‘evil bleeding humors’ and should be known about prior to administering anesthesia?
Anti-platelet therapy, warfarin, unfractionated heparin/LMWH, and any novel oral anticoagulants
T/F ‘Bridging’ is only recommended for pts at a high risk of having a stroke
True
What is a ‘normal’ thyromental distance noted upon PE of the oral airway prior to administering anesthesia?
> 6.5 cm - 7 cm
A resting 12 lead EKG should be preformed prior to administering anesthesia on pts who are (asymptomatic/symptomatic) and ____ y/o women or____ y/o men and on pts with a known ____ history.
Asymptomatic women ≥ 50 y/o or men ≥ 45 y/o
Known cardiac hx
Is a pre-op CXR helpful in asymptomatic pts w/o lung disease? Why/why not?
No, because it only changes management ~0.1%
Inability to climb stairs or walk 4 blocks yields an increased risk of______ complications.
Cardiopulmonary
In patients with known CAD and poor functional status, guidelines call for ________.
Non-invasive stress testing
Minor predictors, recognized as risk factors for CV dz, but NOT an independent peri-operative risk factor for poor outcomes include:
Advanced age >____ y/o
Abnormal EKG showing ____, _____, and ______
Uncontrolled ______
Rhythms other than NSR, i.e. ____
Advanced Age >70 y/o
Abnormal EKG showing LVH, LBBB, non-specific ST-T changes)
Uncontrolled HTN
i.e. A-fib)
