Perioperative Care Flashcards
True or False: decreased urine output after major abdominal surgery is associated with AKI and increased hospital length of stay?
False; decreased urine output is a physiologic response to surgical stress and urine output goal of 0.2cc/kg/hr is not associated with any injury to the kidney and does not effect length of stay
What is the most common malignancy encountered during pregnancy?
melanoma
Rivaroxaban: Mechanism? Half life? When should you discontinue it prior to a procedure in a normal patient vs. reduced creatinine clearance? When do you restart?
Mechanism: direct oral anticocoagulation that inhibits Factor Xa Half life: 9 to 13 hours Discontinued prior to surgery: AT LEAST 24 hours (normal CrCl) vs. 3 to 5 days (reduced CrCl) Excreted via urine
How many half lives does it take for a medication to wear off?
4 to 5 half lives
patient with a.fib on warfarin and moderate risk for perioperative stroke base on CHADS-Vasc… what kind of anticoagulant bridging for a lap chole?
NO BRIDGING THERAPY [Moderate risk for stroke vs. increased risk of bleeding]
Patient > 65 y/o. post-operative complication risk is best predicted by…? What categories does this cover?
the Frailty Index [covers comorbidities, activities of daily living, attitude and nutrition]
What are the 5 surgical/invasive procedure reportable invents as listed by the National Quality Forum?
1) Wrong Site 2) Wrong patient 3) Wrong surgery/procedure 4) Unintended retention of a foreign object in a patient after surgery/procedure 5) Intraop or immediate Postop death in ASA Class 1 patient
If you have to hold plavix (or another P2Y12 receptor inhibitor) for surgery, when is the recommended time to restart plavix? Give with or without a loading dose?
24 to 72 hours WITH a loading dose.
What general, orthopedic and urology surgeries are considered LOW hemorrhagic risk surgeries (11)?
- Hernioplasty - Plastic surgery of Incisional Hernias - Cholecystectomy - Appendectomy - Colectomy - Gastric resection - Intestinal rescetion - Breast surgery - Hand Surgery - Arthroscopy - CYstoscopy/Ureteroscopy
What general, orthopedic and urology surgeries are considered INTERMEDIATE hemorrhagic risk surgeries (10)?
- Hemorrhoidectomy - Splenectomy - Gastrectomy - Bariatric Surgery - Rectal Resection - Thyroidectomy - Proesthetic Shoulder/knee/foot - Major Spine Sugery - Prostate biopsy - Orchiectomy
What general, orthopedic and urology surgeries are considered HIGH hemorrhagic risk surgeries (8)?
- Hepatic Resection - Duodencefalopancreasectomy - Hip Surgery - Major pelvic/proximal femur fracture surgery - Nephrectomy - Cystectomy - TURP/TURBT - Proastectomy
What are LOW hemorrhagic risk Vascular surgeries?
- Carotid Endarterectomy (CEA) - Bypass or Endarterectomy of Lower Extremity - EVAR - TEVAR - Limb amputation
What are INTERMEDIATE hemorrhagic risk Vascular surgeries?
Open abdominal aorta surgery
What are HIGH hemorrhagic risk Vascular surgeries?
Open thoracic or thoracoabdominal surgery
What are INTERMEDIATE hemorrhagic risk Cardiac surgeries?
- Mini thoracotomy - TAVR (apical approach) - OPCAB - CABG - Valve Replacement
What are HIGH hemorrhagic risk Cardiac surgeries?
- Any reintervention - Endocarditis - CABG in PCI failure - Aortic dissections
Patient on dual anti-platelet therapy (DAPT) s/p PCI… When are they LOW risk for thrombosis (<1%) if stop their DAPT given they had a plain old balloon angioplasty vs. bare metal stent vs. drug eluting stent?
PCI w/ POBA: > 4 weeks PCI w/ BMS: > 6 months PCI w/ DES: > 12 months
Patient on dual anti-platelet therapy s/p PCI… When are they INTERMEDIATE (1-5%) risk for thrombosis if stop their DAPT given they had a plain old balloon angioplasty vs. bare metal stent vs. drug eluting stent?
PCI w/ POBA: 2 to 4 weeks PCI w/ BMS: 1 to 6 months PCI w/ DES: 6 to 12 months OR > 12 months after complex PCI with DES
Patient on dual anti-platelet therapy s/p PCI… When are they HIGH risk for thrombosis (>5%) if stop their DAPT given they had a plain old balloon angioplasty vs. bare metal stent vs. drug eluting stent?
PCI w/ POBA: <= 2 weeks PCI w/ BMS: <= 1 months PCI w/ DES: <=6 months OR <=12 months after complex PCI with DES OR <= 6 months after PCI for MI with previous stent thrombosis
True or False: Hypoglycemia is associated with an increased risk of SSI. What is your target perioperative blood glucpse in almost all patients? well.. what about cardiac patients?
FALSE; HYPERglycemia is associated with increased risk of SSI Target perioperative blood glucose: 110 to 150 mg/dL Cardiac surgery patients: < 180mg/dL
When do you administer prophylactic antibiotics? Are there any exceptions to this?
Prophylactic antibiotics should be administered < 1 hour prior incision [EXCEPTION: < 2 hours for vancomycin or fluoroquinolones]
When do you redose antibiotics during surgery?
- Redose based on half life to maintain adequate tissue levels OR for every 1500 cc blood loss
True or False: There is no high-quality evidence about delayed primary closure vs. primary closure and SSI for contaminated and dirty incisions
TRUE
What is the recommend stoma closure method?
Purse string >> primary closure
What is the recommended supplemental oxygen level in the immediate postoperative period after surgery is performed under general anesthesia?
supplemental oxygen of 80%
True or False: There is no evidence in the timing of dressing removal increases SSI risk
TRUE
True or False: There is no evidence showing the use of wound vacuum therapy over stapled skin can reduce SSI in colorectal abdominal and vascular groin cases.
FALSE. THe use of wound vacuum therapy over staple skin CAN reduce SSI in open colorectal abdominal and vascular groin cases
True or False: You should probe the wound daily in contaminated wounds to decrease SSI.
TRUE
Y/N: Does preoperative removal of hair from surgical sites reduce the incidence of surgical site infections?
NO; preoperative removal of hair from surgical sites DOES NOT reduce the incidence of surgical site infections
In the ERAS protocol, what is the effect of preoperative oral carbohydrate loading?
Decreases insulin resistance.
72 year old female taking clopidogrel for prior stroke is planned for right hemicoletomy for cecal cancer. What is the appropriate perioperative management of her anticoagulation?
Continue clopidogrel without interruption. There are higher rate of transfusion in plavix, but no higher risk to perioperative complications; whereas if you hold plavix.. there is a higher rate of cardiac complications.
Direct Factor Xa inhibitor recommended for patients with low creatinine clearance? half life?
Apixaban [hepatic clearance] Half life: 8 to 12 hours
Oral factor Xa inhibitor to avoid in patients with low creatinine clearance
Rivaroxaban
Oral direct thrombin inhibitor metabolized by the kidneys
Dabigatran [the only one!]
Parenteral direct thrombin inhibitor
Argatroban, bivalirudin, desirudin
Reversal agent for dabigatran
Idarucizumab [monoclonal antibody that binds dabigatran]
Antibiotic of choice for elective low risk laparoscopic biliary tract procedure
NONE!!
Antibiotic of choice for uncomplicated appendicitis?
Cefoxitin (or cefazolin + metronidazole)
For direct oral anti-coagulation, how many half lives do you hold for minor surgery vs. major surgery?
Minor surgery: 2-3 half lives Major surgery: 4-5 half lives
Half life for… Rivaroxaban? Apixaban? Dabigatran?
Rivaroxaban: 6 to 9 hours (healthy), 11-13 hours (elderly)
Apixaban: 8 to 12 hours
Dabigatran: 12 to 17 hours
How long would you have to hold rivaroxaban for a major surgery? vs. minor surgery? very high risk surgery?
Rivaroxaban half life is 6 to 9 hours, thus… major surgery: at least 24 hours minor surgery: at least 12 hours very high risk surgery: 3 days?
How long would you have to hold apixaban for a major surgery? vs. minor surgery?
Apixaban half life is 12 hours, thus… major surgery: at least 48 hours minor surgery: at least 24 hours
How long would you have to hold dabigatran for a major surgery? vs. minor surgery?
Dabigatran half life is 12 to 17 hours, thus… major surgery: at least 48 hours minor surgery: at least 24 hours
Place in order of least to greatest for risk of bleeding: apixaban, rivaroxaban, dabigatran
apixaban < dabigatran < rivaroxaban
ASA class 1 patient undergoing minor or intermediate risk surgery, what is their preoperative assessment include? What is the exception to the above preoperative assessment?
H&P only. No labs, urinalysis, CXR, coags Exception: men > 45 y/o and women > 50 y/o require an EKG
What is the mechanism and half life of clopidogrel?
Mechanism of clopidogrel: inhibitor ADP receptor of P2Y12 Half life: 6 hours
Stress dose steroids are not indicated for patients undergoing minimal stress procedures that are have been on steroids for less than how many weeks? or how many mg/day?
Stress-dose steroids are not indicated for patients on short-term steroids (< 3 weeks) and for those on low-dose (< 5 mg/d) steroids and undergoing procedures with minimal stress.
In patients with equivocal concern for HPA axis suppression from history of large dose/short treatment duration of steroids, what test and level would screen for HPA axis suppression?
An EARLY-morning random cortisol level < 5 mcg/dL is an impaired HPA axis
What induction agent should be avoided in patients with HPA axis suppression? why?
Etomidate == Can further suppress adrenal function and reduce serum cortisol level
When do you stop warfarin before surgery?
5 days prior to surgery
When do you stop oral antithrombin and factor Xa agents prior to surgery?
2 days prior to surgery
When can you operate on a patient with a bare metal coronary stent vs. drug-eluting stent?
bare metal stent = after 4 weeks drug eluting stent = after 6 months
Surgical patient with DVT, how long should they be on anticogaulation?
DVT with inciting stimulus: 12 weeks DVT w/o inciting stimulus: 6 months
What is the recommended antibiotic(s) for a cardiac procedure? What if the patient has a penicillin allergy?
cefazolin, cefuroxime Penicillin allergy: clindamycin, vancomycin
What is the recommended antibiotic(s) for a thoracic procedure? What if the patient has a penicillin allergy?
1) cefazolin 2) ampicillin-sulbactam Penicillin allergy: clindamycin, vancomycin
What is the recommended antibiotic(s) for a bariatric, pancreatic or antireflux/vagotomy procedure? What if the patient has a penicillin allergy?
cefazolin Penicillin allergy: clindamycin or vancomycin + aminoglycoside (ex. gentamicin) or fluoroquinolone (ex - floxacin)
What is the recommended antibiotic(s) for a biliary tract procedure? What if the patient has a penicillin allergy?
1) cefazolin 2) ceftriaxone 3) ampicillin-sulbactam Penicillin allergy: clindamycin or vancomycin + aminoglycoside (ex. gentamicin) or fluoroquinolone (ex - floxacin)
What is the recommended antibiotic(s) for an appendectomy? What if the patient has a penicillin allergy?
cefazolin and metronidazole Penicillin allergy: clindamycin + aminoglycoside or fluoroquinolone
What is the recommended antibiotic(s) for a non-obstructed small bowel surgery? What if the patient has a penicillin allergy?
cefazolin Penicillin allergy: clindamycin + aminoglycoside or fluoroquinolone
What is the recommended antibiotic(s) for an obstructed small bowel surgery? What if the patient has a penicillin allergy?
cefazolin + metronidazole Penicillin allergy: metronidazole + aminoglycoside or fluoroquinolone
What is the recommended antibiotic(s) for colorectal surgery? What if the patient has a penicillin allergy?
1) cefazolin + metronidazole 2) ampicillin - sulfactam 3) ceftriaxone + netronidazole, 4) ertapenem Penicillin allergy: 1) clindamycin + aminoglycoside or fluoroquinolone 2) metronidazole + aminoglycoside or fluoroquinolone
What is the recommended antibiotic(s) for hernia surgery? What if the patient has a penicillin allergy?
cefazolin Penicillin allergy options: 1) clindamycin 2) vancomycin
What is the recommended antibiotic(s) for head and neck surgery? (clean vs. clean-contaminated) What if the patient has a penicillin allergy?
Clean: cefazolin Clean contaminated: 1) cefazolin + netranidazole 2) cefuroxime + metronidazole 3) ampicillin-sulbactam Penicillin allergy: Clean: Clindamycin+ aminoglycoside Clean-contaminated: Clindamycin or vancomycin + aminoglycoside or fluoroquinolone
What is the antibiotic(s) recommended for orthopedic surgery? What if the patient has a penicillin allergy?
cefazolin Penicillin allergy: clindamycin, vancomycin
What is the antibiotic(s) recommended for urology surgery? (clean vs. lower tract instrumentation) What if the patient has a penicillin allergy?
Clean: cefazolin Lower tract instrumentation: fluoroquinolone, TMP-SMX, cefazolin Penicillin allergy: Clean: Clindamycin, vancomycin Lower tract instrumentation: Aminoglycoside ± clindamycin
What is the antibiotic(s) recommended for vascular surgery? What if the patient has a penicillin allergy?
cefazolin Penicillin allergy: clindamycin, vancomycin
In patients with history of prior cardiac surgery, what patients require consideration of endocarditis prophylaxis? Antibiotic of choice?
- Prosthetic heart valves - Prosthetic material used for other cardiac valve repair (annuloplasty rings or chords) - Prior history of infectious endocarditis - Unrepaired cyanotic congenital heart disease - Repaired congenital heart disease with residual shunts or valvular regurgitation at or adjacent to the site of the prosthetic patch or prosthetic device - Transplanted heart with valve regurgitation due to a structurally abnormal valve Patients must be undergoing: 1) Dental work 2) Procedures involving incision or biopsy of respiratory mucosa Antibiotic of choice amoxicillin
What are the factors that go into the cardiac risk index system (CRIS) to help assess the risk of underoing noncardiac surgery?
Functional status/capcity is positively associated with postoperative outcomes. What are some functional activities and relative METs (metabolic equivalents; 1 MET = 3.5mL O2 uptake/kg/min = resting oxygen uptake in sitting position)
- Can take care of self, such as eat, dress, or use the toilet (1 MET)
- Can walk up a flight of steps or a hill or walk on level ground at 3 to 4 mph (4 METs)
- Can do heavy work around the house, such as scrubbing floors or lifting or moving heavy furniture, or climb two flights of stairs (between 4 and 10 METs)
- Can participate in strenuous sports such as swimming, singles tennis, football, basketball, and skiing (>10 METs)
What evidence-based risk factors determine pulmonary risk stratification for noncardiothoracic surgery?
In HIV patients:
1) do you continue antiretroviral therapy (ART) perioperatively?
2) What abx prophylaxis is required if CD4 count is <200? <100?
YES, continue antiretroviral therapy (ART) perioperatively. If you need to stop it for a few days there are usually no deleterious effects
- Give TMP-SMX (trimetoprim-sulfamethoxazole) = prevent pneumocystis infection if CD4<200, prevents toxoplasmosis if CDR < 100 cell/ul
What are risk factors for invasive fungal infection?
How is invasive fungal infection different than colonization?
Solid organ transplantation
ICU stay > 7 days
Prolonged antibiotic therapy
TPN
GI perforation (UGI tract)
Hemodialysis
Colonization = isolated fungal pathogen w/o signs or symptoms of clinical infection
What is the rate of seroconversion for
1) HIV?
2) Hepatitis C
3) Hepatitis B
HIV: 0.3% / percutanoeus exposure to HIV+blood
Hepatitis C: 1.3% / percutaneous exposure to HCV+ blood
Hepatitis B: 23-62%/percutanous exposure to HBV+blood
In what type of surgeries are there recommendations for MRSA decolonization?
How do you do a MRSA decolonziation?
What other therapy can you give to help reduce postop MRSA surgical site infections in colonized patients?
Cardiothoracic and orthopedic surgeries
Decolonization methods:
1) intranasal mupirocen two to three times/day x 5 days prior to procedure
2) Chlorhexidine baths x 5 days if colonization in axilla, groin or perineum
Can give abx (vancomycin) to reduce postop MRSA SSI
What is the postexposure prophylaxis (PEP) recommendations for HIV?
Two drug PEP regimen of two nucleoside analogues (zidovudine and lamivudine) starting < 72 hours of exposure x 28 days; Consider 3rd nucleoside analogue if inc. risk of transmission.
What is the postexposure prophylaxis (PEP) recommendations for HBV?
If nonresponder to vaccination [HBSAg negative]: Hepatitis B immune globulin within 24 hours of exposure
What is the postexposure prophylaxis (PEP) recommendations for HCV?
No immune globulin or antiviral agent after exposure!
HOWEVER, you should get baseline testing of anti-HCV and alanine aminotransferase activity w/ FOLLOW-UP of levels at 4 to 6 months
What is the screening and confirmatory test for HIV?
Screening test = Enzyme-linked immunosorbent assay (ELISA) [aka. enzyme immunoassay (EIA)]
Confirmatory Test: HIV-1/HIV-2 antibody differentiation immunoassay (aka. Nucleic acid test)
Historically, the western blot test was previously used to confirm ELISA (but has not been recommended by CDD since 2014)
Name at least 3 AIDS-defining conditions
Bacterial infections, multiple or recurrent
Candidiasis of bronchi, trachea, lungs, or esophagus
Coccidioidomycosis, disseminated or extrapulmonary
Cryptosporidiosis, chronic intestinal
Cytomegalovirus disease (other than liver, spleen, or nodes)
HIV-related encephalopathy
Herpes simplex with chronic ulcers (> 1 month) or bronchitis, pneumonitis, or esophagitis
Histoplasmosis
Isosporiasis
Kaposi sarcoma
Lymphoid interstitial pneumonia
Lymphoma (Burkitt, immunoblastic, or brain primary)
Mycobacterium avium complex, disseminated or extrapulmonary
Mycobacterium tuberculosis of any site
Pneumocystis jirovecii pneumonia
Recurrent pneumonia
Progressive multifocal leukoencephalopathy
Salmonella septicemia
Toxoplasmosis of the brain
Wasting syndrome attributed to HIV
Per NSQIP, what factor contributes the most to moratlity in a surgical patient?
INPATIENT STATUS!
Moreso than age, functional status, obesity, sepsis, etc
At what age is a cardiac screening EKG required for otherwise healthy adults?
> 40 years old
What is the half-life of warfarin?
40 hours
What is the mechanism and half life of aspirin?
Mechanism: Cyclooxygenase inhibitor
Half life: 2.5 to 4 hours
In someone with early-morning random cortisol level < 5mcg/dL, what anesthetic induction agent should not be used? Why?
Don’t use Etomidate!!
Patient has hypothalmic-pituitary-adrenal (HPA) axis suppression (as indicated by early-morning cortisol level)
Etomidate can FURTHER SUPPRESS adrenal function and reduce serum cortisol level.
