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Surgery > Perioperative Patients with Conditions > Flashcards

Perioperative Patients with Conditions Flashcards

1
Q

In a potential peri-operative patient, what should we do?

A

Risk-Benefit Analysis: Is the potential gain from the surgery worth the risk? If yes, what will best optimize the patients chances for a good outcome.

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2
Q

Common Pre-Existing Conditions to take into account

A
  1. Cardiac
  2. Pulmonary
  3. Renal
  4. Hepatic
  5. The sugahs
  6. Sx in Preggo
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3
Q

Why is there a higher risk for someone with cardiac issues undergoing sx?

A

Physiological stress related to sx due to fluid shifts, hypovolemia, hypotension, increased cardiac O2 demand, altered coagulation

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4
Q

What surgeries are high risk for cardiac patients (> 5%)?

A
  1. Aortic and other vascular surgeries

2. Peripheral Vascular Sx

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5
Q

What surgeries are intermediate risk for cardiac patients (1-5%) ?

A
  1. Intraperitoneal and intrathoracic surgery
  2. Carotid Endarterectomy
  3. Head and Neck Sx
  4. Ortho Sx
  5. Prostate Sx
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6
Q

What surgeries are low risk for cardiac patients (< 1%)?

A
  1. Endoscopic Procedures
  2. Superficial Procedures
  3. Cataract Sx
  4. Breast Sx
  5. Ambulatory Sx
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7
Q

What are two risk models used for cardiac risk assessment?

A
  1. Revised Cardiac Risk Index (RCRI)

2. National Surgery Quality Improvement Program (NSQUIP)

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8
Q

If a patient has cardiac history, what studies would you do?

A
  1. Labs: CBC, BMP, Type and Cross
  2. EKG - arrhythmia, Q waves, ST changes, BBB
  3. CXR
  4. Echo, Stress, Angiography
  5. Prophylactic Revasc - rare/controversial
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9
Q

Before sx what meds do you keep a cardiac patient on?

A
  1. B-Blockade (to decrease cardiac O2 demand; to decrease CV complications and mortality; to balance vs risk of hypotension and bradycardia)
  2. Statins (Stabilize plaques and anti-inflamm)
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10
Q

What do you do after sx in a patient with cardiac risk

A
  1. Restart meds gradually
  2. Restart Anticoag ASAP post-op
  3. Hemodynamic control/Fluid management
  4. Regional vs. General Anesthia/Pain Control
  5. Blood transfusions only when strictly necessary
  6. Be prompt to recognize and treat acute coronary events
  7. Control arrhythmias (rate > rhythm)
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11
Q

How do you Dx an MI?

A

2/3 : Symptoms, EKG, Cardiac Enzymes

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12
Q

How do you treat MI?

A

MONAB
Morphine, Oxygen, Nitroglycerin, Aspirin, Beta Blockers, Heparin, Statin
Potential angiography, revasc if STEMI

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13
Q

According to the NSQUIP study, perioperative what type of complications are the costliest and results in the longest hospital stay?

A

Pulmonary

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14
Q

If a patient has pulmonary history, what studies would you do?

A
  1. ABG - PaCO2 > 45 mmHg increase risk
  2. CXR - baseline, rarely changes management
  3. PFT, Exercise Testing (FEV1 < 70%, FVC <65% - increased risk)
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15
Q

How to approach pulmonary management?

A
  1. Smoking cessation! – nicotine patch, counseling
  2. Optimize chronic disease preop – bronchodialators, steroids, antibiotics (if active infection), breathing exercises
  3. Appropriate pain control
  4. Judicious fluid administration
  5. Encourage breathing exercises, incentive spirometer
  6. Chest physiotherapy, positive pressure ventilation
  7. Prompt treatment of infection
  8. Prevent aspiration
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16
Q

Why is liver failure a risk in surgery?

A

Hepatic function influences Drug metabolism (P450), coagulation, visceral-portal hemodynamics, albumin production.

17
Q

What are the risk assessments available for liver failure?

A
  1. Child-Turcotte-Pugh Classification (assesses ascites, encephalopathy, bilirubin, albumin, INR, Correlates with overall survival and surgical risk)
  2. Model for End-Stage Liver Disease (MELD)
18
Q

If you have a MELD score of greter than 15, what should you do?

A
  1. Avoid Elective Procedures

2. Consider Liver Transplant

19
Q

What work up labs will you do in a patient with Liver Dz?

A
  1. CBC
  2. PT/INR
  3. Albumin (is less than 3 you are concerned)
  4. Total Protein
  5. Creatinine
  6. Liver Profile
20
Q

Management of pt with Liver Dz

A
  1. Correct coagulopathy – vit K, FFP, factor VII, cryoprecipitate; avoid fluid overload
  2. Correct electrolyte abnormalities
  3. Aggressively treat ascites – diuretics, at time of surgery, percutaneous drainage (Administer albumin)
  4. Nutritional support – adequate protein intake, minimize sodium
  5. Treat encephalopathy – lactulose, prevent precipitating events – GI bleed, infection, excess protein
21
Q

What is the function of the kidney (aka why is it important to be aware of this before sx)?

A
  1. Fluid, electrolyte, acid base balance
  2. Drug excretion/metabolism
  3. Erythropoietin Production
22
Q

Labs to order for Renal Dz?

A
  1. CBC
  2. Coag studies
  3. CMP (creatinine, urea, electrolytes)
  4. Urinalysis
  5. Glucose
  6. HbA1C
  7. EKG
  8. CXR
  9. Echo
23
Q

Management of Renal Dz in Sx setting.

A
  1. Protect existing (if any) renal function
  2. Avoid nephrotoxins (contrast die, NSAIDs, b-lactams, vancomycin, etc.)
  3. Maintain euvolemia
  4. Sodium bicarbonate, N-acetycysteine
  5. Time hemodialysis appropriately – Usually right before surgery, PRN
  6. Adjust renally metabolized and excreted medications accordingly (Antibiotics, digoxin, muscle relaxants, opioids)
  7. Maintain fluid, electrolyte, acid/base balance
    (Surgery, anesthesia, analgesia induce metabolic/respiratory acidosis, hyperkalemia —Need thorough in/out balance, account for insensitive losses)
24
Q

What are the indications for dialysis? (AEIOU)

A 
Acidosis
Electrolytes
Intoxication
Overload
Uremia
25
Q

Potassium levels above 5 indicates?

A

Urgency/Emergency!!!

26
Q

Hyperkalemia signs/symptoms?

A
  1. Weakness
  2. Malaise
  3. Arrhythmia
  4. Cardiac Arrest
27
Q

How do you see Hyperkalemia on an EKG?

A

Peaked T wave
Small P wave
Widened QRS complx
V. Fib!

28
Q

How do you treat hyperkalemia? (C BIG K Die)

A
  1. Recheck EKG
  2. Calcium gluconate (10,10,10)/ Chloride (1-2 g)
  3. Beta agonist/Bicarb
  4. Insulin
  5. Glucose
  6. Kayexalate
  7. Diuretics (furosemide)/ Dialysis
29
Q

Risk assc with DM?

A
  1. CV
  2. CVA events,
  3. Infection
  4. Poor wound healing
  5. More hospitalizations
  6. Greater length of stay
  7. Higher morbidity and mortality
30
Q

Labs to do for DM?

A
  1. Glucose Check
  2. HbA1C
  3. Urinalysis
  4. Serum Electrolytes
  5. EKG
31
Q

P&E is important for DM, why?

A
  • CV, Renal and HTN assessment

- Home Glycemic Control

32
Q

Management of Glucose

A
  1. Stop oral hypoglycemics (Biguanides: lactic acidosis; Sulfonylureas: hypoglycemia)
  2. Commence SQ/IV insulin, decrease amount during periods of fasting/decreased nutritional intake
  3. Increased frequency of monitoring
  4. Real time glycemic control – Goal: <140-150 mg/dL
33
Q

In preggo women, what should we avoid surgically?

A

Any elective sx

34
Q

What are the most common procedures in preggo women?

A
  1. Appendicitis
  2. Biliary Dz
  3. Trauma
  4. Breast/Cervical Dz
  5. Bowel Obstruction
35
Q

Why do we avoid sx in the preggos?

A
  1. Physiologic changes: Anemia/thrombocytopenia, pro-coagulant state, relative hypotension
  2. Teratogenesis
  3. Miscariage, preterm labor
  4. Aspiration
  5. Procedure specific issues
36
Q

Management of the preggos

A
  1. Delay semi-elective sx until the 2nd trimester
  2. Communicate with surgeon, OB, anesthesia, neonatologist, etc.
  3. In 24-36 wks, prophylactic glucocorticoids
  4. Thrombophylaxis - SQ heparin, mechanical means, early ambulation
  5. Meds - look for teratogens
  6. Monitor fetal heart rate
37
Q

Intraoperative considerations if have to so sx on the preggo?

A
  1. Difficult Airway
  2. Positioning
  3. Materno-fetal hemodynamics
  4. Emergency C section

Surgery (12 decks)

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