Pre and Perioperative Eval of Patient Flashcards
What pre-operative labs are indicated for treatment of the patient?
- CBC, Basic Metabolic Panel, Urinalysis, Coagulation Studies (PT, PTT, INR), pregnancy screening where appropriate
- Chest X-Ray
- Electrocardiogram
What needs to be considered in the cardiopulmonary eval of a preoperative patient?
o Cardiopulmonary Evaluation: • Age • Male • Heredity • Tobacco abuse • Obesity • DM • HTN • Hyperlipidemia • Sedentary lifestyle • Stress
patients without significant medical problems, especially those under 50, are a very low chance for…
perioperative complications.
what are the two most important cardiac complications to screen for prior to surgery?
MI and cardiac death are MOST important
however, also ask about CHF, LV dysfunction, arryhthmias, and unstable angina.
What does the RCRI help to evaluate for?
pre-op cardiac risk assessment
should emergency surgery be delayed because of cardiac problems in the patient?
NO
who should get a resting EKG?
A resting EKG should be obtained in patients with at least one RCRI predictor prior to major surgery.
When do you need to consider stopping surgery or continuing surgery in regard to cardiac problems?
If there is a known valve correction surgery, it should be done FIRST before other elective surgery. Surgery should consider being delayed in severe hypotension, but not in mild to moderate. Drugs can be taken day of. Diuretics and ACEIs should probably be stopped due to increased risk of hypotension and hypovolemia and electrolyte disorders.
What is the ASA score?
surgery score that correlates with the potential for death in the patient. •
ASA Score
o 1 through 5 with an E added for emergency surgery
o 1=Healthy
o 5=Moribund—Not expected to survive with or without the surgery
o Postoperative mortality correlates with this score.
What is the appropriate urine output for an adult? child? on average it should be no less than..?
.5-1 ml/kg/hr, 1 ml/kg/hr, 30 ml/kg/hr…
These all came from 3 different lectures and sources.
What do you need to consider for the fluid status?
Get a preoperative Hgb, they need to be NPO for AT LEAST 6 HOURS!, bowel prep may be necessary
What are three ways to monitor fluid status?
o Triple lumen catheter—Central venous pressure. Usually less than 8 you want to give more fluid. 8-12 is normal.
o Swan-Ganz catheter—Pulmonary capillary wedge pressure
o Arterial line—Blood pressure (usually go through radial artery)
What are some ways to reduce infections?
Reducing Infections: o Preoperative antibiotics o Hair removal o Preoperative shower with chlorhexadine soap o Preoperative bowel prep o Good sterile technique o Patients immune system
How are wounds categorized based on infection status?
I. Clean:
- Uninfected, no inflammation
- Resp, GI, GU tracts not entered
- Closed primarily
Examples: Ex lap, mastectomy, neck dissection, thyroid, vascular, hernia, splenectomy
II. Clean-contaminated:
- Resp, GI, GU tracts entered, controlled
- No unusual contamination
Examples: Chole, SBR, Whipple, liver txp, gastric surgery, bronch, colon surgery
III: Contaminated:
- Open, fresh, accidental wounds
- Major break in sterile technique
- Gross Spillage from GI tract
- Acute nonpurulent inflammation
Examples: Inflamed appy, bile spillage in chole, diverticulitis, Rectal surgery, penetrating wounds
IV: Dirty:
- Old traumatic wounds, devitalized tissue
- Existing infection or perforation
- Organisms present BEFORE procedure
Examples: Abscess I&D, perforated bowel, peritonitis, wound debridement, positive cultures pre-op
How can hemodynamics be assessed on a physical exam? What can you LOOK AT?
Fluid status can be assessed by looking at • Blood pressure • Heart rate • Intake and Output • Mental status • Skin perfusion • CVP • Weight
What are IV fluids that can be used to replace losses?
Types of Intravenous Fluid Crystalloid • Lactated Ringer’s • Normal saline (0.9%) • Half normal saline (0.45%) • D5 and half normal saline Colloid • Albumin • Dextran
What is the difference between crystalloid and colloid fluids?
Both crystalloids and colloids increase intestinal blood flow and systemic arterial pressure; however, colloids may have a longer duration of effect. Colloids also result in a net movement of fluid from the intestinal lumen to the blood, whereas crystalloids can exacerbate transmucosal fluid movement into the intestinal lumen.
How do you calculate how much fluid a patient should get post-op?
Maintenance IVF Calculations • 100/50/20 Rule • 100mL/kg for first 10kg • 50mL/kg for next 10kg • 20mL/kg for every kg over 20 •Gives total fluid for 24 hours • 4/2/1 Rule • 4mL/kg for the first 10kg • 2mL/kg for next 10kg • 1mL/kg for every kg over 20. •Gives hourly IVF rate
What are risks faced by someone with diabetes and surgery?
If diabetes is controlled on DIET:
-measure glucose every 4 hours, while fasting or NPO and give SC regular insulin as needed to maintain blood glucose between 140-200. Avoid glucose containing solution during surgery.
if diabetes is controlled on ORAL medication
- last dose should be taken the evening before surgery. measure glucose every 4 hours while fasting or NPO and give SC regular insulin as needed to maintain blood glucose between 140-200. Measure every 4 hours during surgery. resume oral therapy when patient returns to baseline diet.
what needs to be considered in a patient with hyperthyroidism? hypothyroidism?
hyperthyroidism is at risk for thyroid storm.
hypothyroidism is at risk for hypotension, HF, cardiac arrest and death.
Endocrinologist should be consulted.
What are several ways to prevent surgical site infections?
wash hands, wash patient when antiseptic agents, remove hair, give antibiotics
what is a common finding in liver enzymes post-op?
Postoperative elevation of serum aminotransferase levels is relatively common finding after major surgery. Most are common, and tend to go away with time.
What is an important pulmonary post-op complication?
atelectesis and pneumonia (most people die from pneumonia)
What are the risks for pulmonary complications
a. Upper abdominal or cardiothoracic surgery
b. Prolonged anesthesia time
c. Emergency surgery
d. Age > 60
e. COPD
f. Heart failure
g. Severe systemic disease
h. Tobacco use
i. Impaired cognition
j. Functional dependcy or prior stroke
k. Sepsis
l. Low serum albumin
m. Obstructive sleep apnea
Current recommendations for perioperative anticoagulation management:
Current recommendations for perioperative anticoagulation management:
If thromboembolic risk is…LOW:
Then…stop warfarin 5 days before surgery
Measure INR the day before to make sure it is below 1.6
If hemostasis permits, start warfarin 12-24 hours post op
No bridging needed
If risk is HIGH
Then you need to do bridging with medications. Stop warfarin 5 days before surgery and start on heparin 2 days after stopping warfarin. Make sure INR is <1.6 day before surgery. Can continue bridging or go back to warfarin post op
