Perioperative Medicine Flashcards
What to do for patient at high cardiac risk (>65 or 18-64 and known CAD, cerebrovascular dz, PAD, CHF, PH, AS/MS/HoCM) going for emergency “A Case” Surgery ie life/limb in 6 hrs (trauma, AAA rupture, nec fasc)
DO NOT DELAY
Continue ASA if on already and okay’d by surgeon
Continue BB
Post-op: PACU ECG, Trop x72 hrs daily, shared care
What to do for patient at high cardiac risk going for Urgent (w/i 24-48h eg SBO, hip #) or Semi-Urgent (eg cancer) OR?
Delay only if:
- ACS
- Unstable arrhythmia
- Unstable CHF exacerbation
- Suspicious of severe pHTN or AS (try to get echo 1st)
Continue ASA (if surgeon permits) + BB if already on Post-op: PACU ECG, Trop x72 hrs daily, shared care
What do for patient at high cardiac risk going for elective OR?
If high risk stress test or unstable CAD or suspicion of severe AS - delay OR for testing
If not:
If RCRI = 0 + Age <65 + No CVD - proceed with OR
If RCRI>0 or Age>=65 or major CVD: Obtain pre-op BNP
- If elevated or not avail: PACU ECG, Trop x72 hrs daily, shared care
- If not elevated: Proceed to OR with no further testing
RCRI Score and cardiac risk assessment
Surgical risk + 4C’s and a D:
- High risk OR (intra-thoracic, intra-abdominal, supra-inguinal vascular)
- CHF (S3, crackles, pulm edema, PND, +CXR)
- CAD - +stress test, Q waves, angina, nitrate use, hx MI (NO points if asx w/ PCI/CABG)
- CVD - TIA/stroke
- CKD - Cr > 177
- DM - insulin dependent
0 = 4% risk peri-op CV event (MI, CHF, VF, death) 1 = 6% 2= 10% 3+= 15%
Management of anti-platelets with stents peri-op for elective OR
Delay 14 ds post POBA, 1 mo post BMS, 3 mo post DES
Continue ASA if possible (if permitted by surgeon)
Stop 2nd anti-plt 5-7 days pre-op
Management of anti-platelets with stents peri-op for urgent or emergent OR
Continue ASA
Hold 2nd anti-platelet
Monitored bed post-op
Management of suspected severe stenotic valve disease pre- elective surgery
- Obtain TTE if suspected mod-sev stenosis/regurg and no TTE on record within 1 year or change in status since last echo
- If meets criteria for valve surgery –>replace/repair before elective surgery
- If demonstrates low flow low gradient severe AS (AVA <1cm, MG <40, Vp <4, LVEF <50%) –> refer for dobutamine stress test (and for AVR if +) pre-op
Management of suspected severe stenotic valve disease pre- urgent surgery
Do not delay, but attempt to obtain TTE while OR awaits
Inform anesthesia
Intra-operative monitoring
Post-op monitored bed
Treatment of Myocardial Injury after Non-Cardiac Surgery (MINS)
Type 1 (plaque): revasc, DAPT, high dose statin, BB, ACE/ARB Type 2 (demand mismatch): ASA, statin, noninvasive testing Shared care - surgeons, IM, cardio
Risk factors for post-operative respiratory failure
Lung dz: COPD/asthma (continue pufers), pHTN
Comorbidities: CHF, COVID, OSA/Obesity, Smoking (>4wks cessation = benefit),
Frail: Age >60, Alb <35, poor health/fcnal health status
Surgery:
- Intrathoracic > Intraabdo surgery
- Surgery under GA
- Long OR
Mitigating resp risk post-op
Pain control
DVTp
Incentive spirometry
Early mobilization
NG decompression
Continue home CPAP
Consider extubating to NIPPV
Management of BB peri-op
Continue if already on
Don’t start within 24 hrs of OR (except if unstable arrhythmia)
Management of ASA peri-op
Don’t initiate
Continue if going for CEA
Continue if cardiac stents (definitely if <1m BMS/3m DES, beyond - shared discussion)
Otherwise, discontinue at least 3 days pre-op
Resume as soon as safe per surgeons
Management Plavix/Ticag peri-op
Hold 5-7 days pre-elective surgery (7 if neuraxial anesthesia)
If urgent OR and new stent - discuss continuation with surgeon
If urgent OR and old stent - hold
Resume as soon as safe per surgeons
If <3-5 days = no neuraxial anesthesia
for prasugrel (7-10 dep on neuraxial anesthesia)
Management of statin peri-op
Continue
Management of ACE/ARB peri-op
Hold 24 hrs pre-op
Resume on POD2 if eating/drinking well, not hypotensive and no AKI
Indications to hold anti-coagulation before elective OR
All procedures except:
- Minor dental (<=2 teeth extraction, periodontal, root canal, teeth cleaning) - use oral prohemostatic agent
- Minor derm eg skin bx
- Cataracts
- Endoscopy WITHOUT biopsy
Indications to bridge warfarin peri-operatively for elective surgery
1) Afib with:
- CHADS2 5/6
- rheumatic or mechanical valve
- stroke in last 3 months
2) Valves (all mechanical, all mitral, old AVR eg ball/cage, tilting disk) if 1+ of:
- Afib
- LV dysfunction
- Past embolism
- Hypercoagulable state
- Stroke w/i 6 mo
3) VTE :
- Within 3 months
- High-risk thrombophilia: APLA, Protein C/S/ATIII def, or multiple
Management of DOAC Pre-elective surgery
Apix/Riva/Edox
Hold x48 hrs pre-op if high risk bleed (OR day -2)
Hold x24 hrs low risk bleed (OR day -1)
Dabi
Hold x4 days pre-op if high risk bleed
Hold 2 days (48 hrs) pre-op if low risk bleed
*If CrCl <30 - add 24 hours to hold
Resume as soon as safe per surgeons
Management of Warfarin Pre-elective surgery
Hold for 5 days pre-op (OR Day -5), check INR pre-op D1
If bridging / high risk of thrombosis:
- Start LMWH 3 days pre-op - therapeutic dose on pre-op day 3 and 2, 1/2 therapeutic dose pre-op D1
- Hold LMWH on day of OR
Start warfarin at 1.5x home dose 12 hours post-op and resume LMWH 24 hrs post-op (if ok by surgeons)
Continue LMWH until INR therapeutic
Management of anti-rheumatic drugs peri-op elective OR
Continue all DMARDs
Hold biologics 1 dosing cycle pre-op and resume once evidence of adequate wound healing
Management of SGLT-2 inhibitors peri-op
Hold 3 days pre-operatively
Management of all non-SGLT2 oral anti-glycemics peri-op
Hold on day of OR and use SS
Management of insulin peri-operatively
Take 70-100% qhs or 1/2 of AM basal insulin dose (lantus/ tuojeo/ tresiba/ nph/ levemir/ mix 70:30)
-Hold all short acting
IV insulin infusion peri-op if:
- Long OR (1-2h) in IDDM or T1DM
- CABG or major OR (target 5.5-11.1 vs minor OR 5-10)
- Intrapartum for IDDM
VTE Prophylaxis post-op
NO meds, use IPC>compression stocking for:
- Neurosurg,
- CV/Vasc surg (equivocal),
- Urologic,
- Major Trauma,
- Lap Chole
- All other inpatient surgeries: LMWH/UFH x 19-42 days (or until D/C for minor)
- Postop ppx for all pregnant patients
- No LMWH for 4 hours, Fonda for 6-12h, Heparin for 1h after neuraxial anesthesia removed
Indications to give stress dose steroids perioperatively
Major surgery +
1) Prednisone >=20 mg/day for >=3 weeks
2) Prednisone 5-20 mg x >=3 wks (consider)
3) Cushingoid features
Stress steroid dosing
- Major surgery (CV, liver resection, whipple): Usual AM dose +HC 100mg IVX1 pre-op, then 50 mg q8hX3doses, then 25 mg q8h X 3 doses then back to usual dose
- Moderate surgery (chole, hemicolectomy): Usual AM dose+HC 50mg X 1 pre-op, 25mg q8hX3, then usual dose
- Minor surgery–Usual AM dose
Peri-operative care for dialysis patients
Elective: Schedule for 1 day post-IHD, obtain K day of OR, should be <5.5 (otherwise no paralysis)
Urgent/Emergent: K pre-op, post-op monitored bed
High risk features on noninvasive stress test
- > 2mm ST depression
- ST elevation,
- VT/VF,
- Failure of sBP >120 or BP drop >10 mmHg,
- Ischemia >3min into recovery
- EF<35%
- Severe stress induced LV dysfunction - EF <45% or decrease with stress by over 10%
MINS Definition
Troponin increase >99th percentile of ULN w/i 30d of surgery
Increase in 4th gen trop >0.03ng/mL, hsTnT 20-65ng/L w/ absolute change of >5, or any abs change >14 or any elevation over 65ng/L
Symptoms/ECG changes not required
Screening for MINS
Adults >65y o adults >45 w established CAD/PAD
Preop baseline trop and postop 48-72h
Managing AC for emergent/urgent/nonurgent surgeries
Emergent:
- VKA: Vit K 5-10IV +/- PCC/aPCC
- DOAC: antidote or PCC/aPCC if unavail
Urgent:
- VKA: defer 12-24h if possible, give Vit K 2.5-5mg
- DOAC: defer surgery 12-24h (if possible)
Nonurgent:
- Decide if need to bridge
Preop/Intraop Anemia Mx
Optimize Hgb preop if <115 (F), <130 (M), <130 before major arthroplasty:
- Iron: min 3-4d for effect
- EPO: min 2-4wk for effect. Use in CKD, anemia chronic dz, refusing transfusion
Intraop:
- TXA or ortho/liver sx or postpartum hemorrhage
- Autologous transfusion
Indication for pre-op CXR/PFT
- PFT if one lung ventilation planned
- To predict need for postop ventilation in neuromuscular dz
Jehovah’s Witness Blood Approach
- Decrease phelebotomy (freq, pediatric tubes)
- Autologous blood donation, Fe, EPO preop
- TXA, DDAVP
- Acute normovolemic hemodilution (for high risk bleed OR: major cardiac, ortho, thoracic, liver)
- RBC salvage (not if sepsis, Ca, bone cement)
- Hgb based O2 carriers
OSA Periop
- Anesthesia and Surg to decide if delay for sleep study (eg invasive surgery or post-op opioid needed)
- In vs outpatient OR
- Bring CPAP if on it, if unresponsive, consider BIPAP
- Regional/local anesthetic to limit sedation and post-op opioids
- Non-supine position post-OR if possible
ICD Mx
- Reprogram pre-op if surgery above umbilicus w/ cautery use to avoid shocking patient/surgeon
- Suspend anti-tachy therapy and/or initiate asynchronous pacing with magnet
