Perioperative medicine Flashcards
What systems should be assessed prior to surgery? What “checklist” should you go through?
- Cardiac risk assessment
- Dont forget endocarditis prophylaxis
- Delirium risk and frailty
- Meds and withdrawal
- Anticoagulants and antiplatelets
- Heme considerations
- VTE. Px
- Anemia optimization
- Coagulopathies
- Liver
- ITP
- VWD
- …
- Metabolic
- DM
- Stress steroids
In the case of emergency surgery, who should have their cardiac risk assessed, and what should be done before and after surgery?
- NO preop assessment
- If patient >65 or 18-64 with significant cardiovascular disease*
- Daily post-op troponins x48-72hrs
- ECG in PACU
- COnsider shared care management
*Significant cardiovascular disease:
- Known CAD
- CVD
- PAD
- CHF
- severe pulmonary hypertension
- Intracardiac obstruction
- Severe AS
- Severe MS
- HOCM
In the case of urgent surgery, who should get extra cardiac investigations in the pre-op setting.
- Severe obstructive cardiac condition
- Severe pulmonary hypertension
- Unstable cardiac condition – active ACS or arrythmia
In the case of urgent surgery, who should get increased post-op cardiac monitoring, and what should be done?
- If patient >65 or 18-64 with significant cardiovascular disease*
- Daily post-op troponins x48-72hrs
- ECG in PACU
- COnsider shared care management
*Significant cardiovascular disease:
- Known CAD
- CVD
- PAD
- CHF
- severe pulmonary hypertension
- Intracardiac obstruction
- Severe AS
- Severe MS
- HOCM
What pre-operative cardiac workup should be done in patients undergoing elective surgery requiring overnight hospital stay and which patients should get this work up
How is the RCRI calculated?
Name high risk features on non-invasive cardiac stress testing that would prompt further perioperative testing
- ≥2mm ST depression, ST elevation, VT/VF, sBP not greater than 120 or decrease by >10
- EF <35%
- Severe stress-induced LV dysfunction - EF<45%or decrease with stress by over 10%
What is MINS and how is it diagnosed?
Miocardial Infarction after Non-cardiac Surgery
- Elevation of troponin T >0.03 ng/ml due to ischemic mechanism
- Not due to other cause (Renal failure, PE…)
How is MINS treated
ASA + Statin
“shared care”
If evidence of type I MI, treat as such
Pursue non-invasive stress testing s/p type II MINS
Hoow is valvular heart diseased managed before elective surgery?
If the patient meets standard criteria for valve intervention, this should be done prior to the elective surgery
What should be done prior to urgent, emergent surgery if there is suspicion for severe valve disease?
- Get echo
- Inform anesthesia
- Get intraop monitoring
- post-op monitored bed
Perioperative atrial fibrillation is associated with a higher risk for the following 3 conditions
- Stroke
- MI
- Vascular and all cause mortality
Should patients with perioperative Afib be anticoagulated
This is highly controversial. Consider bleeding risk and thrombotic risk and prolonged post-op monitoring or clinic follow-up
How should beta blockers be managed perioperatively
- Don’t start beta-blockers 24hrs before surgery
- If patients are on beta-blockers chronically, continue throughout surgery
*Exceptions if beta blockers are clearly indicated such as angina or arrhythmia… Give the BB then proceed to surgery when appropriate
How should ASA be managed perioperatively in patients who have not had a recent coronary stent
- D/C 3 days before surgery
- Unless undergoing carotid endarcterectomy
- Do not initiate ASA before surgery
* In surgeries with low risk bleeding, it may be reasonable to continue ASA perioperatively
How should ASA and plavix be managed preoperatively in the setting of elective surgery and recent stent
- POBA
- Delay surgery to 14 days after POBA
- BMS
- Delay surgery to 1 month after BMS
- DES
- Delay to 3 months after DES
- Delay at least 1 month if semi-urgent
- Whenever possible continue ASA
- Hold clopidogrel 5-7 days pre-op, prasugrel 7-10 days
How should antiplatelets be managed perioperatively in patients who had a recent coronary stent and require urgent or emergent surgery?
- Do not delay surgery
- Get monitored bed post-op
- No neuraxial anesthesia
- Restart DAPT as soon as deemed safe by surgeon
How should statins be managed perioperatively?
Continue perioperatively
Start if MINS
How should ACE/ARBs be managed perioperatively?
- Hold 24hrs before non-cardiac surgery
- Restart 2 days after surgery if patient is hemodynamically stable
How should DMARDs be managed perioperatively for patients undergoing THA or TKA
Continue throughout surgery
How should biologics be managed perioperatively in patients undergoing TKA or THA?
Operate around when the patient is due for his next dose
Restart once there is evidence of wound healing
Name low bleeding risk procedures in which anticoagulation can be continued
- Minor dental procedures
- Up to 2 teeth removal
- root canal
- periodontal surgery
- teeth cleening
*consider oral prohemostatic agent
- Minor derm procedures such as skin biopsy
- Cataract surgery
- Endoscopic procedures not requiring biopsy
Name surgeries that are high risk for bleeding complications
- Any procedure with neuraxial anesthesia
- Neurosurgery (intracranial or spinal)
- Cardiac surgery
- Major vascular surgery (bypass, aortic aneurysm repair)
- Major urological surgery (prostatectomy, bladder tumor resection)
- Major lower limb ortho surgery
- Lung resection surgery
- Intestinal anastomosis surgery
- Selected procedures
- Renal Bx
- Prostate Bx
- Cervical cone Bx
- Pericardiocentesis
- Colonic polypectomy
How should warfarin be managed perioperatively?
- Stop 5 days prior to surgery
- Restart on day of OR or post-op day 1
- COnsider 2 days of 1.5X regular dose then back to usual dose
In which patients on VKAs being held for surgery should bridging be considered?
Describe how perioperative bridging is performed
How should Anti Xa anticoagulants be managed perioperatively in elective surgeries
- For low/moderate bleed risk procedures
- hold 1 day before surgery
- Resume on day 1 after. surgery
- For high bleed risk procedures
- Hold 2 days before surgery
- Resume day 2 after surgery
* ADD 1 extra preop day if CrCl<30
How should dabigatran be managed perioperatively in elective surgeries
How should DOACs be managed perioperatively in emergent surgeries
- Give PCC or idarucizumab and proceed to surgery
How should warfarin be managed prior to emergent surgery
Give vitamin K, consider PCC
How should Warfarin be managed prior to urgent surgery
Give vitamin K and defer surgery for 12-24 hours
How should DOACs be managed prior to urgent surgery
Defer surgery 12-24 hours if possible
If on dabigatran and can’t delay surgery consider idarucizumab
How long does ticagrelor need to be held prior to non-urgent surgery?
5 days prior to most surgeries
7 days prior to neuraxial
List the amount of time the following medications should be held before and after neuraxial anesthesia:
- Warfarin
- UFH IV
- SC UFH
- LMWH- Px dose
- LMWH-Tx dose
- Dabigatran
- Rivaroxaban, apixaban, edoxaban
- Prasugrel
- ASA, NSAIDS
- Fondaparinux
What are the 2 prefered DVT prophylaxis strategies in the post-op setting
- Pharmacological prophylaxis: standard bleeding rrisk
- Mechanical prophylaxis: High bleed risk
*If high thrombotic risk can consider both
What sort of VTE prophylaxis should be offered after cardiac or major vascular surgery?
Pharmacological or no pharmacological prophylaxis (paucity of evidence)
What sort of VTE prophylaxis should be used after neurosurgery?
Use mechanical
No pharmacological prophylaxis unless high risk situations, IE prolonged immobilisation
What sort of VTE prophylaxis should be used after urological surgeries such as TURP or prostatectomy
No pharmacological Px
What sort of VTE prophylaxis should be used after gynecological surgeries
Use Pharmacological Px
What sort oof VTE prophylaxis should be used after trauma surgery
- Low to medium bleed risk: Pharmacological Px
- High bleed risk: Mechanical Px
What sort of VTE prophylaxis should be used after a laparoscopic cholecystectomy
No pharmacological Px (usually day surgery)
What agent should be used for VTE prophylaxis in patients undergoing a TKA or THA, and for how long
- DOACS
- Apixaban 2.5mg BID
- Rivaroxaban 10mg daily
- dabigatran 220mg daily
- Duration 14-35 days! Go for 3 weeks as per ASH
- Rivaroxaban for 5 days then ASA also an option (thrombosis canada)
What agent should be used for VTE prophylaxis after hip fracture surgery and for how long?
- LMWH or LDUH at Px doses
- use for 14-35 days, Go for >3 weeks as per ASH
What type of VTE prophylaxis should be used for lower leg bellow knee surgery and arthroscopy of the knee?
- None if done as day surgery
- If inpatient DVT Px pharmacological until D/C
Can edoxaban be used for VTE prophylaxis?
No, not indicated/liscenced by health canada
Are graduated compression stockings helpful in preventing DVTs in patients on Px dose LMWH after surgery?
No
In which conditions should an intraoperative insulin infusion be considered in diabetic patients?
- Major surgery or CABG
- T1DM and procedure >1-2hours
- Prolonged OR in insulin dependant patient
- Intrapartum for diabetics on insulin in pregnancy
How should antidiabetic medications be managed in the period settings. Give a management plan for the following meds:
- Oral agents in general
- GLP1 agonists
- SGLT2 inhibitors
- Long acting insulins
- Twice daily mix insulins
- Rapid acting insulins
How should a patient with anemia be worked up and managed prior to surgery?
- Men with Hb<130 and women with Hb<115 benefit from pre-op Hb optimization
- COnsider:
- IV iron (if deficient)
- EPO
- TXA to reduce blood loss
- Intraop:
- Acute normovolemic hemodilution
- Cardiac, ortho, thoracic, liver surg.
- Cellsaver
- Acute normovolemic hemodilution
What characteristics make a patient high risk for surgery from a resp perspective?
- Patient related risks:
- Acronym COUGHS
- COPD
- Older than 60
- Underlying lung disease-ASA>II
- General health (functional class)
- Heart failure
- Smoking
- Biochemical
- Albumin<35 (nutritional status)
- Also
- Obesity
- Asthma
- OSA
- Pulmonary hypertension
- Acronym COUGHS
- Procedure related risks
- Surgical site
- Duration of surgery
- Route of anesthesia
- Type of neuromuscular blockade
What respiratory complications can arise from surgery
- Respiratory failure
- Infection
- Atelectasis
- Exacerbation of underlying lung disease
- VTE
- Pneumothorax
When should a pre-op PFT and CXR be considered?
- No role for routine
- COnsider if
- One lung ventilation is planned
- Anesthesia requests it for neuromuscular disease (predicts the need for post-op ventilation)
- If the results would affect management (ex. signs of undiagnosed asthma)
What can be done pre-operatively to manage the risk of post-op resp complications?
- Optimize COPD/Asthma (continue puffers)
-
Smoking cessation
- >4 weeks cessation shows increased benefit
- Discuss non GA options with anesthesia
- Recent URTI – No evidence to inform management
What can be done postoperatively to manage the risk of respiratory complications?
- Deep breathing exercises or incentive spirometry
- Early mobilisation
- Good pain control
- NG decompression
- DVT Px
- Use home CPAP machine
For patients on steroids, at what dose of prednisone (or equivalent dose) is the HPA axis suppressed, maybe suppressed and not suppressed?
- NOT suppressed
- Prednisone < 5mg/day
- ANY dose of prednisone < 3 weeks
- Uncertain
- 5-20 mg prednisone >3 weeks
- Suppressed
- Prednisone >20mg for >3 weels or patient with cushingoid features
What can be done if we are unsure wether the HPA axis is suppressed
- ACTH stim. test or consult endo
- Just give steroids
- Esp. if no time for testing and/or major surgical stress
In patients requiring stress doses of corticosteroids preoperatively, What doses should be used?
- Major surgery:
- Take usual AM dose
- HC 100mg IV pre-op
- HC 50mg IV q8hrs x 3 doses then 25mg IV q 3 doses then back to normal dose post-op
- Moderate surgery
- Usual AM dose
- HC 50mg IV pre-op
- 25mh IV q8hrs x3 post-op then back to normal dose
- Minor surgery
- Usual AM dose
What strategies should be employed in the period setting in Jehovah’s witnesses who do not want transfusions
- Discuss patient preferences and involve the surgeon.
- Determine likelihood and magnitude of blood loss and discuss wether or not these risks can be mitigated surgically
- Clearly express possible consequences of not having transfusion and enquire if patient understands the risks
- If patient is anemic pre-op, delay surgery if possible to optimize anemia
- Document strategies and treatments available for this surgery
- decrease phlebotomies (frequency, volume [pediatric tubes])
- Autologous blood donations pre-op
- TXA, consider DDAVP
- Acute normovolemic hemodilution (defer to anesthesia)
- RBC salvage (cellsaver)
- Iron, EPO pre op
- New possibilities: Hemoglobin-based oxygen carriers
How can anemia secondary to renal insufficiency or chronic disease be optimized pre-operatively to reduce the risk/burden of transfusions preoperatively?
Iron optimization
EPO
TXA can be considered in any surgery with high risk of bleeding. Name surgeries where it might be particularly beneficial
- Certain orthopedic procedures (such as knee replacement)
- liver surgery
How should OSA be managed perioperatively
- Preanesthetic consultation in anyone suspected of OSA
- Review of previous records, Hx and examination to determine likelihood of complicated airway
- Joint decision between surgeon and anesthesia on whether to delay surgery for sleep study
- COnsider inpatient rather than outpatient OR if high index of suspicion for OSA
- Bring CPAP in, If not responsive to CPAP, consider BIPAP
- Consider regional/local anesthesia to limit sedation and opiates post-op
- If possible, position the patient in a non-supine position during recovery
- Consider continuous pulse oximetry
When during pregnancy should semi-urgent surgeries be planned for, ideally?
2nd trimester
What extra precautions should be taken during surgery in patients who are in the 3rd trimester of pregnancy?
- Anatomical changes must be considered in upper abdo or head and neck surgery as well as the risk of pre-term labor
- Continuous foetal monitoring intraoperatively
What extra precautions should be taken post-operatively in pregnant patients
- All should get VTE prophylaxis
- Carefull with ABx, NO VANCO - teratogenic
When should you consider NOT proceeding with elective surgeries in patients with Cirrhosis
Childs pugh score C
What should be considered in patients with cirrhosis undergoing surgery
- Manage bleeding risk
- Pre-op vitamin K, FFP
- Ensure blood bank is ready
- Avoid neuraxial anesthesia
- Manage VTE risk
- High risk of VTE despite coagulopathy
- Infection risk
- Higher at all surgical sites
- Encephalopathy
- Common post-op
What considerations should be given to patients with ESRD on dialysis undergoing low risk elective surgeries
- Generally safe, follow these general guidelines
- Ideally do surgery the day after HD
- Potassium <5.5 the day of OR
- Appropriate pre-op optimization of DM, anticoagulants,
- Get nephrology involved post-op
How should ICDs be programmed for surgery
Reprogram pre-op if surgery above the umbilicus with cautery use
Suspend anti-tachyarrythmia therapy and/or initiate asynchronous pacing. in pacing dependant patient
Can sometimes be achieved by applying a magnet
Before emergency external defibrillation or cardioversion of a patient with a magnet applied to their ICD, remove the magnet to permit reactivation of the ICD’s anti-tachyarrhythmia function
