Perioperative Medicine Flashcards
When should you measure BNP preop?
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
What are components of the RCRI index?
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
What should you do with beta blockers perioperatively?
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.
What do you do with perioperative ASA?
Stop at least 3 days prior to surgery unless:
1) Recent stent (6 weeks BMD, 3-12 months DES)
2) Underlying carotid endarterectomy
What do you do with ACEi/ARB perioperatively?
Holding 24 hr before non cardiac surgery
Restart day POD2 IF stable
What do you do with SGLT2 inhibitors perioperatively?
Hold for 48 hrs due to risk of euglycemic DKA
What do you do with DAPT and recent stent perioperatively?
Continue ASA whenever possible
Hold Plavix/Ticag 5-7d, Prasugrel 7-10d
When can you continue perioperative anticoagulation?
Minor surgeries
Cataracts
Endoscopic procedures not requiring biopsy
Who should you bridge for anticoagulation perioperatively?
- VTE: within 3 months, high risk thrombophilia (APLA, Protein C/S/ATIII def).
- Afib: CHADS5-6, rheumatic valve, stroke within 3 months.
- Mechanical valve:
MVR, old AVR, stroke within 6 months.
How do you bridge warfarin perioperatively?
Stop 5 days pre-op
-3 start LMWH
-1 last dose LMWH 24 hr before OR
POD1 restart warfarin + LMWH. Continue until INR therapeutic
How long do you hold DOACs pre-op?
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)
When do you start DVT prophylaxis post spinal catheter removal?
12 hours if prophylaxis dose
24 hours if full dose anticoagulation
What surgeries post op do you not use pharmacological DVT prophylaxis?
Neurosurg (unless prolonged immobility post op with low bleeding risk)
Urological
How long should you quit smoking prior to surgery?
4 weeks at least
What are glucose targets periop?
5.5-11.1 for major surgery/CABG
5-10 for minor to moderate
What do you do with diabetic meds periop?
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
What is a pre-operative test needed to be considered for people with Down’s, RA, or ank spond?
Pre-op C spine xrays
Anesthesia consult
Consider Neurosurgical referral if:
C1-C2 separate 9mm
Posterior atlanto-dental distance < 14mm
Any neuro symptoms
What do you do with chronic steroids perioperatively?
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
When should you idealy have surgery during pregnancy?
2nd trimester
What is your management for perioperative ICD?
reprogrammed preop if surgery is above the umbilicus with cautery use
Suspend ATP and/or initiate VOO mode
