Perioprative Managment Flashcards
Predictors of major cardiac complications with noncardiac surgery (Revised Cardiac Risk Index)
Clinical risk factors
High-risk surgery (eg, vascular) History of ischemic heart disease Heart failure History of stroke Diabetes mellitus treated with insulin Preoperative creatinine >2 mg/dL Rate of cardiac death, nonfatal cardiac arrest, or nonfatal MI
No risk factors: 0.4% (low risk) 1 risk factor: 1.0% (low risk) 2 risk factors: 2.4% (moderate risk) ≥3 risk factors: 5.4% (high risk) MI = myocardial infarction.
Cardiac risk stratification for noncardiac surgical procedures
Risk of cardiac death
or nonfatal MI depends on type of surgery
Type of surgery:
High risk (>5%)
- Aortic or other major vascular
- Peripheral vascular
Intermediate risk (1%-5%)
- Carotid endarterectomy
- Head & neck
- Intraperitoneal & intrathoracic
- Orthopedic
- Prostate
Low risk (<1%)
- Ambulatory or superficial procedure
- Endoscopic procedure
- Cataract
- Breast
Would you proceed with low risk surgery for Fatal/no fatal cardiac complication in high RCRI patient?
patients undergoing low-risk surgeries (eg, breast or cataract surgery) have <1% risk of experiencing cardiac death or nonfatal myocardial infarction (MI).
In the absence of acutely active cardiac disease (eg, decompensated heart failure, unstable angina), patients undergoing these low-risk surgeries require no further cardiac workup regardless of underlying comorbidities
How do you approach preoperatively for patient with high RCRI undergoing intermediate or high risk procedure?
For intermediate- or high-risk surgeries, patients should be evaluated using a validated prediction model such as the Revised Cardiac Risk Index (RCRI).
Moderate- or high-risk patients (ie, with an estimated risk of cardiac death, nonfatal cardiac arrest, or nonfatal MI >1%) may need additional evaluation depending on their functional status: Those able to perform >4 metabolic equivalents (METs) of activity (eg, brisk walking, climbing 2 flights of stairs) generally do not require additional evaluation, but those with poor functional status (exercise capacity <4 METs) are recommended to undergo further evaluation prior to surgery
When to stop OCP and restart for elective surgery?
1 month before and resume 1 month after (because risk of thromboembolism)
Average blood glucose if only Hgb A1c known?
Hgb A1c x 20
Sever Aortic stenosis signs on PE?
The presence of a low-intensity, single second heart sound during inspiration is consistent with severe aortic stenosis.
Other findings suggestive of severe AS include delayed and diminished carotid pulse and loud and late-peaking systolic murmur.
(severely stenotic aortic valve creates a low-intensity sound during closure. High intensity of S2 is more consistent with mild to moderate AS)
Screening question for unhealthy alcohol use
How many times in the past year you had 5 (4 if women) or more dink’s in a day?
If one time or more then positive.
CAGE questions detects more sever alcohol problem and for withdrawal (not screening)
Indication for preop PFT?
1) prior lung resection to estimate postop lung volumes
2) to optimize COPD patient if baseline clinical status cannot be determined.
3) to evaluate the cause of dyspnea or exercise intolerance (EF, cardiac vs deconditioning).
Active cardiac conditions that increase perioperative cardiovascular risk (requires further evaluation and treatment before noncardiac surgery)
Unstable angina or recent MI Decompensated heart failure Significant arrhythmia - Symptomatic bradycardia - High-grade AV block - Supraventricular tachycardia - Symptomatic or new-onset VT Severe valvular disease - Severe aortic stenosis - Symptomatic mitral stenosis
