Perioperative Medicine

Question 1

When should you measure BNP preop?

Answer 1

ELECTIVE surgery
Age >= 65 OR
RCRI >=1 OR
Age 45-64 with major CVD

Major CVD:
Known CAD
Cerebral vascular dx
PAD
CHF
Severe pHTN
Intracardiac obstruction
Severe AS, MS, HOCM

Question 2

What are components of the RCRI index?

Answer 2

1) High risk surgery (intraperi, intrathor, suprainguinal vascular)
2) Ischemic CAD
3) CHF hx
4) Hx of stroke or TIA
5) Diabetes ON INSULIN
6) Preop Cr > 177

Question 3

What should you do with beta blockers perioperatively?

Answer 3

Don’t start new BB within 24 hours before surgery.

If new BB indicated (angina or arrhythmia), consider delay surgery and start BB unless urgent surgeries.

If taking chronically, continue throughout perioperative period.

Question 4

What do you do with perioperative ASA?

Answer 4

Stop at least 3 days prior to surgery unless:

1) Recent stent (6 weeks BMD, 3-12 months DES)
2) Underlying carotid endarterectomy

Question 5

What do you do with ACEi/ARB perioperatively?

Answer 5

Holding 24 hr before non cardiac surgery

Restart day POD2 IF stable

Question 6

What do you do with SGLT2 inhibitors perioperatively?

Answer 6

Hold for 48 hrs due to risk of euglycemic DKA

Question 7

What do you do with DAPT and recent stent perioperatively?

Answer 7

Continue ASA whenever possible

Hold Plavix/Ticag 5-7d, Prasugrel 7-10d

Question 8

When can you continue perioperative anticoagulation?

Answer 8

Minor surgeries
Cataracts
Endoscopic procedures not requiring biopsy

Question 9

Who should you bridge for anticoagulation perioperatively?

Answer 9

1. VTE: within 3 months, high risk thrombophilia (APLA, Protein C/S/ATIII def).
2. Afib: CHADS5-6, rheumatic valve, stroke within 3 months.
3. Mechanical valve:
   MVR, old AVR, stroke within 6 months.

Question 10

How do you bridge warfarin perioperatively?

Answer 10

Stop 5 days pre-op
-3 start LMWH
-1 last dose LMWH 24 hr before OR
POD1 restart warfarin + LMWH. Continue until INR therapeutic

Question 11

How long do you hold DOACs pre-op?

Answer 11

Standard risk: 2 days (3 days if CrCL <50 for dabi, <30 for others)

If high risk bleed, 3 days (5 days if Cr Cl < 50 for dabi, 4 days if <30 for others)

Question 12

When do you start DVT prophylaxis post spinal catheter removal?

Answer 12

12 hours if prophylaxis dose

24 hours if full dose anticoagulation

Question 13

What surgeries post op do you not use pharmacological DVT prophylaxis?

Answer 13

Neurosurg (unless prolonged immobility post op with low bleeding risk)
Urological

Question 14

How long should you quit smoking prior to surgery?

Answer 14

4 weeks at least

Question 15

What are glucose targets periop?

Answer 15

5.5-11.1 for major surgery/CABG

5-10 for minor to moderate

Question 16

What do you do with diabetic meds periop?

Answer 16

Oral agents - hold AM of OR
GLP1 agonist - hold day of OR
SLGT2 inhb - hold 2 days prior to OR
Long acting insulin - 2/3 dose night prior or AM of
Short acting insulin - omit
Insulin mix - 1/2 usual dose in AM

Question 17

What is a pre-operative test needed to be considered for people with Down’s, RA, or ank spond?

Answer 17

Pre-op C spine xrays
Anesthesia consult

Consider Neurosurgical referral if:
C1-C2 separate 9mm
Posterior atlanto-dental distance < 14mm
Any neuro symptoms

Question 18

What do you do with chronic steroids perioperatively?

Answer 18

Stress dose:

Major surgery: usual AM + 100mg IV HC preop x1, then 50mg Q8H x3, then 25 Q8H x3 then back to home dose

Moderate: usual AM + HC 50 x1 preop, then 25mg Q8H x3, then back to home dose

Minor: usual dose

Question 19

When should you idealy have surgery during pregnancy?

Answer 19

2nd trimester

Question 20

What is your management for perioperative ICD?

Answer 20

reprogrammed preop if surgery is above the umbilicus with cautery use

Suspend ATP and/or initiate VOO mode