perioperative medical management

Question 1

how long to delay surgery after following cardiac procedures:

• balloon angioplasty
• bare metal stent
• drug eluting stent

Answer 1

• balloon angioplasty: 14 days
• bare metal stent: 30 days
• drug eluting stent: 6-12 months

Question 2

what are the stroke risks of ranges of CHADS-VASC scores?

Answer 2

0 -> 0%
1 -3-> 1-3%
4-7 -> 4-9%
12-15 -> 12-15%

Question 3

what is typical peri-operative management for:

• plavix
• warfarin

Answer 3

• plavix: stop 3-5 days before, restart 24-48 hours after surgery
• warfarin: for a-fib, typically does not need bridging. stop 5 days before, restart 24-48 hours after. if bridging needed, usually LMWH until 24-48 hours before surgery, then restart after with warfarin

Question 4

when should pulmonary testing be ordered pre-operativley?

Answer 4

• rarely; primarily to establish new diagnoses or capture a significant clinical change
• (peri-operative pulmonary morbidity risk factors are FEV1 < 1 liter, FVC 70% of predicted).

Question 5

what risks exist for patients with cirrhosis? what pre-op assessment should be done?

Answer 5

• bleeding dysfunction due to lack of coagulation factor production
• risk of death
• risk of portal hypertension-> ascites, SBP, hepatorenal syndrome
• ecephalopathy
• preop assessmetn of coags, albumin
• Child-Pugh scoring for cirrhosis offers risk of mortality (includes bilirubin, albumin, INR, ascites, encephalopathy). Class A - 10%, class B- 30%, class C- 70%

Question 6

periop management in pts with COPD

Answer 6

poorly controlled COPD/asthma: 40% risk PNA, 70% risk atelectasis

• smoking cessation 8 weeks prior to surgery
• delay 2-3 weeks if ongoing infection
• consider steroids if PEF < 80%
• NXA when possible
• post-op: early ambulation, non-opioid pain control, lung expansion therapy, CPAP if OSA

Question 7

DM

Answer 7

• If HA1c above 200, increased risks
• For diabetics, reasonable goal less than 180
• Med management: hold metformin AM of surgery, hold sulfonylurea agents x 24 hours
• AM of surgery: 50% NPH dose, 60-80% long acting or basal pump. if combination regimen, should be converted peri-operatively
• when NPO q4-6 hr checks with SSI