Pre and Post-Op Management Flashcards
How to evaluate a patient’s risk for a procedure?
- Nature of procedure
- Overall health of the pt
- What risks can we control?
- Which risks can we NOT control?
- How can we reduce risk?
If risk is high and benefit low:
Reconsider surgery
When is surgery deemed appropriate for a patient?
When benefit is high and risk is low
What does the pre-op evaluation consist of?
Complete medical history
- Allergies
- Meds
- Prior surgeries, problems w/anesthesia
- Family hx of anesthesia problems
- ROS
- Physical exam
What are pre-op red flag disorders?
- Cardiac, lung, DM
- Bleeding, liver, renal
- Seizures, infections, pregnancy
- Substance abuse
- HIV
How should diabetes patients be prepped pre-op?
- NPO
- Hold or reduce hypoglycemic agents
- Better if glucose is higher rather than low
What should a surgical patient receive if they are on steroid treatment?
Pre and post-op solumedrol (IV)
Why does a patient on steroids require pre and post-op solumedrol (IV)?
- Chronic steroids can suppress endogenous steroid production
- During times of stress (aka surgery), the adrenals may not respond appropriately
How are labs ordered for the pre-op evaluation?
Fine tuned to the nature of the surgery as well as age/health of patient
Which pre-op labs are necessary only if indicated?
- Clotting studies
- LFTs
- EKG
- CXR
When is a pre-op EKG indicated?
If patient is over 40 yo OR has cardiac history
Effects of general anesthesia
- Increases cardiac irritability
- Decreases: systemic vasc resistance, myocardial contractility, stroke volume
What type of anesthesia carries the least risk?
Local
What type of anesthesia carries the most risk?
General
Describe post-op MI
50% mortality risk
related to age and pre-existing conditions
What are considered major cardiac risks to surgery?
- Unstable coronary syndrome
- Decompensated CHF
- Significant arrhythmia
- Severe valvular disease
What are considered intermediate cardiac risks to surgery?
- Mild angina
- Previous MI
- Compensated or prior CHF
- DM
- Renal insufficiency
What are considered minor cardiac risks to surgery?
- Advanced age
- Abnormal echo
- Rhythm other than sinus
- Prior hx of stroke
- Uncontrolled HTN
- Low cardiac functional capacity
What makes a surgery high risk and what are examples?
- Over 5% chance of MI or death
- Emergent surgery in elderly
- Aortic surgery
- Peripheral vascular
- Procedures w/prolonged blood loss
What makes a surgery intermediate risk and what are examples?
- 1-5% chance of MI or death
- Carotid endarterectomy
- GU and uncomplicated abd
- Ortho
- Head and neck
- Thoracic
What makes a surgery low risk and what are examples?
- Less than 1% chance of MI or death
- Cataracts
- Endoscopy
- Superficial procedures
Purpose of pre-op testing for cardiac risk patients
- To measure functional capacity and predict risk
- Identify existing or potential myocardial ischemia
Cardiac pre-op tests
- EKG
- Dobutamine stress ECHO
- Dipyridamole thallium imaging
- Coronary angiography
- Exercise stress testing not always used
What decreases the absolute cardiac risk of surgery by 15%?
Beta blockers started 1 week pre-op
What is the result of starting Beta Blockers 1 week pre-op?
Reduces absolute cardiac risk by 15%
How does post-op cardiac ischemia present?
Asymptomatic in up to 90% of cases
When does post-op cardiac ischemia present?
NOT during surgery, but post-op day 1 and 2
What are the % risks of cardiac ischemia pre-op, intra-op, and post-op?
- Pre-op risk = 20%
- Intra-op risk = 25%
- Post-op risk = 55%
- Highest risk of cardiac ischemia AFTER surgery
The MC post-op complication is ____ in origin
Pulmonary
atelectasis and PNA
Risk factors for pulmonary post-op complications?
Age
Obesity
Smoking
COPD, asthma, sleep apnea
Risk of pulmonary post-op complication in smokers?
2X higher even if they don’t have COPD
Ways to reduce pulmonary post-op complications?
- Stop smoking more than 8 wks prior
- Delay elective surgery for poorly controlled COPD pts
How to prevent post-op atelectasis?
- Deep breathing
- Incentive spirometry
- Pre-op teaching
- Avoid supine positioning
When does oxygen delivery diminish?
HCT under 30
HCT under 30 causes:
Reduced oxygen delivery
What can intra-operatively lower HCT?
IV hydration
HCT under ___ will increase MI risk
28
HCT under 28 will increase:
MI risk
Which surgeries carry higher infection risk?
Oral
Trauma
Bowel
Vaginal
When are proph abx used for surgical patients?
If risk is over 2%
How often should a diabetic surgical patient’s blood glucose be measured?
Every 6 hours
What doses of prednisone (and hydrocortisone) can be suppressive?
- Prednisone 7.5 mg/day
- Hydrocortisone 30 mg/day
How long may partial adrenal insufficiency last after d/c chronic steroids?
As long as 9 months
What are the 5 Ps for post-op patients?
- Pain control
- Prevent pus (post op abx)
- Pillow (sleeper PRN)
- Poop
- Previous meds
Mobilization of a post-op patient
Get pt out of bed and ambulating ASAP to avoid pressure sores, PNA, DVT, etc.
How often should post-op wound be checked?
At least QD or QOD
What does a pre-op note consist of?
- Date of planned procedure
- Pre-op diagnosis
- Name of procedure
- Consent obtained/risks discussed
- Lab results including EKG
- Confirmation of blood in blood bank
