Pre and Post-Op Management Flashcards

1
Q

How to evaluate a patient’s risk for a procedure?

A
  • Nature of procedure
  • Overall health of the pt
  • What risks can we control?
  • Which risks can we NOT control?
  • How can we reduce risk?
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2
Q

If risk is high and benefit low:

A

Reconsider surgery

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3
Q

When is surgery deemed appropriate for a patient?

A

When benefit is high and risk is low

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4
Q

What does the pre-op evaluation consist of?

A

Complete medical history

  • Allergies
  • Meds
  • Prior surgeries, problems w/anesthesia
  • Family hx of anesthesia problems
  • ROS
  • Physical exam
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5
Q

What are pre-op red flag disorders?

A
  • Cardiac, lung, DM
  • Bleeding, liver, renal
  • Seizures, infections, pregnancy
  • Substance abuse
  • HIV
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6
Q

How should diabetes patients be prepped pre-op?

A
  • NPO
  • Hold or reduce hypoglycemic agents
  • Better if glucose is higher rather than low
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7
Q

What should a surgical patient receive if they are on steroid treatment?

A

Pre and post-op solumedrol (IV)

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8
Q

Why does a patient on steroids require pre and post-op solumedrol (IV)?

A
  • Chronic steroids can suppress endogenous steroid production
  • During times of stress (aka surgery), the adrenals may not respond appropriately
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9
Q

How are labs ordered for the pre-op evaluation?

A

Fine tuned to the nature of the surgery as well as age/health of patient

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10
Q

Which pre-op labs are necessary only if indicated?

A
  • Clotting studies
  • LFTs
  • EKG
  • CXR
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11
Q

When is a pre-op EKG indicated?

A

If patient is over 40 yo OR has cardiac history

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12
Q

Effects of general anesthesia

A
  • Increases cardiac irritability

- Decreases: systemic vasc resistance, myocardial contractility, stroke volume

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13
Q

What type of anesthesia carries the least risk?

A

Local

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14
Q

What type of anesthesia carries the most risk?

A

General

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15
Q

Describe post-op MI

A

50% mortality risk

related to age and pre-existing conditions

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16
Q

What are considered major cardiac risks to surgery?

A
  • Unstable coronary syndrome
  • Decompensated CHF
  • Significant arrhythmia
  • Severe valvular disease
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17
Q

What are considered intermediate cardiac risks to surgery?

A
  • Mild angina
  • Previous MI
  • Compensated or prior CHF
  • DM
  • Renal insufficiency
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18
Q

What are considered minor cardiac risks to surgery?

A
  • Advanced age
  • Abnormal echo
  • Rhythm other than sinus
  • Prior hx of stroke
  • Uncontrolled HTN
  • Low cardiac functional capacity
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19
Q

What makes a surgery high risk and what are examples?

A
  • Over 5% chance of MI or death
  • Emergent surgery in elderly
  • Aortic surgery
  • Peripheral vascular
  • Procedures w/prolonged blood loss
20
Q

What makes a surgery intermediate risk and what are examples?

A
  • 1-5% chance of MI or death
  • Carotid endarterectomy
  • GU and uncomplicated abd
  • Ortho
  • Head and neck
  • Thoracic
21
Q

What makes a surgery low risk and what are examples?

A
  • Less than 1% chance of MI or death
  • Cataracts
  • Endoscopy
  • Superficial procedures
22
Q

Purpose of pre-op testing for cardiac risk patients

A
  • To measure functional capacity and predict risk

- Identify existing or potential myocardial ischemia

23
Q

Cardiac pre-op tests

A
  • EKG
  • Dobutamine stress ECHO
  • Dipyridamole thallium imaging
  • Coronary angiography
  • Exercise stress testing not always used
24
Q

What decreases the absolute cardiac risk of surgery by 15%?

A

Beta blockers started 1 week pre-op

25
What is the result of starting Beta Blockers 1 week pre-op?
Reduces absolute cardiac risk by 15%
26
How does post-op cardiac ischemia present?
Asymptomatic in up to 90% of cases
27
When does post-op cardiac ischemia present?
NOT during surgery, but post-op day 1 and 2
28
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
29
The MC post-op complication is ____ in origin
Pulmonary | atelectasis and PNA
30
Risk factors for pulmonary post-op complications?
Age Obesity Smoking COPD, asthma, sleep apnea
31
Risk of pulmonary post-op complication in smokers?
2X higher even if they don't have COPD
32
Ways to reduce pulmonary post-op complications?
- Stop smoking more than 8 wks prior | - Delay elective surgery for poorly controlled COPD pts
33
How to prevent post-op atelectasis?
- Deep breathing - Incentive spirometry - Pre-op teaching - Avoid supine positioning
34
When does oxygen delivery diminish?
HCT under 30
35
HCT under 30 causes:
Reduced oxygen delivery
36
What can intra-operatively lower HCT?
IV hydration
37
HCT under ___ will increase MI risk
28
38
HCT under 28 will increase:
MI risk
39
Which surgeries carry higher infection risk?
Oral Trauma Bowel Vaginal
40
When are proph abx used for surgical patients?
If risk is over 2%
41
How often should a diabetic surgical patient's blood glucose be measured?
Every 6 hours
42
What doses of prednisone (and hydrocortisone) can be suppressive?
- Prednisone 7.5 mg/day | - Hydrocortisone 30 mg/day
43
How long may partial adrenal insufficiency last after d/c chronic steroids?
As long as 9 months
44
What are the 5 Ps for post-op patients?
1. Pain control 2. Prevent pus (post op abx) 3. Pillow (sleeper PRN) 4. Poop 5. Previous meds
45
Mobilization of a post-op patient
Get pt out of bed and ambulating ASAP to avoid pressure sores, PNA, DVT, etc.
46
How often should post-op wound be checked?
At least QD or QOD
47
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