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IM RCPSC 2024 > Pre Op > Flashcards

Pre Op Flashcards

1
Q

pre op medicine management of ACE/ ARB

A

Hold 24hours before noncardiac surgery.
increased risk of hypotension especially with with spinal anesthesia
Restart day 2 post op if no AKI

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2
Q

pre op medicine management of Beta blockers

A

Continue it if already taking
Do NOT initiate it within 24 hours of non cardiac surgery if patient is not routinely taking (POISE, 2008)

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3
Q

pre op medicine management of Statins

A

If they are on a statin you continue
If they have MINS so start post op

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4
Q

which patients require screening for cardiac periop Risk?

A

45 or over
18 and over with significant cardiovascular disease
non-cardiac surgery requiring overnight hospital stay

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5
Q

Major/Significant CVD pathologies that increase cardiac risk post op

A

Known CAD
Cerebral vascular disease
peripheral artery disease
CHF
Severe pulmonary hypertension
Intracardiac obstruction ( Severe AS, MS, HOCM)

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6
Q

How to screen patients for MINs if going for Class A/ emergency surgery (life or limb surgery)

A

post op troponin 48-72 hours
PACU ECG (recovery room)
Shared Care management
Discuss Goals Of Care if you have time

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7
Q

how to screen patients for cardiac risk if going for class B surgery
(hip fracture, bowel obstruction etc / cancer surgery)

A

Consider pre op tests IF:
- obstructive cardiac diasease (AS, MS, HOCM)
- severe pulmonary hypertension
- unstable cardiac condition (ACS, Arrhythmia)
If no ECHO availability, alert Anesthesia of risk and monitor for MINS
Post op troponin 48-72 hours
PACU ECG (recovery room)
Shared Care management

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8
Q

How to screen patient for cardiac risk for elective surgeries

A

Pre op BNP if 65 or older, RCRI 1 or over, 45-64 w/ Major CVD
normal BNP - no monitoring
Abnormal BNP or BNP unavailable:
post op trop 48-72h
PACU ECG
Shared care management

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9
Q

RCRI score

A

(1 point for each)
High risk surgery
History of CAD (MI, ECG with q waves etc)
History of CHF
History of stroke or TIA
Diabetic on insulin
Preop Creatinine >177umol/l

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10
Q

why do we order a pre-op BNP in patients with RCRI 1 or over

A

BNP is independently associated with MACE and improves risk estimation compared to RCRI alone

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11
Q

CCS Recommends AGAINST which pre-op Cardiac testing?
(to enhance perioperative cardiac risk estimation)

A

Exercise stress test
Cardiopulmonary exercise testing
pharmacological stress echocardiography
pharmacological stress radionuclide imaging.

Would do these if patient was suspicious for ACS/ angina, would need to delay surgery if able.

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12
Q

Definition of Myocardial Injury after Noncardiac Surgery (MINS)
(CCS definition)

A

Elevated Troponin T > 0.03ng/ml with supply-demand not due to another cause (e.g. PE, renal failure)

> 65% of patients with post op MI do NOT experience Ischemic symptoms and have SAME risk of dying as those rolling into ER with ACS.

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13
Q

Who should get a pre-op BNP

A

65 or older or
RCRI 1 or over
45-64 with major CVD

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14
Q

appropriate post op monitoring if BNP abnormal or unavailable

A

Post op trop 48-72h
PACU ECG
Shared care management

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15
Q

CCS 2016 guideline for treating MINS

A

Counsel patient and optimize medications
Start ASA
Start Statin
shared care follow up with cardio and IM (ongoing research)

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16
Q

AHA position statement on treating MINS
(not a guideline, scientific position statement)

A

Identify Type 1 vs Type 2 MI
T1 - Atherosclerotic plaque rupture - consider revascularization. DAPT, stain, BB, ACE
T2 - demand ischemia - treat with antithrombotic if appropriate, statin, noninvasive testing

Everyone should have non pharmacological management

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17
Q

CCS 2018 Guideline for minimum DAPT duration for stents prior to surgery
(CCS 2023 guideline did not update this recommendation)

A

Urgent surgery: do not delay ( No neuroaxial anesthesia) restart DAPT ASAP (common oral scenario)
Semi-urgent surgery delay at least 1 month post PCI
Elective surgery:
Bare metal stents - wait 1 month
Drug Eluding stent - wait 3 months
balloon angioplasty - wait 14 days
Continue ASA wherever possible
Hold Clopidogrel/ ticagrelor 5-7 days

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18
Q

pre op medicine management of ticagrelor

A

hold 5-7 days
consider initiating ASA 81 if needed

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19
Q

pre op medicine management of Clopidogrel

A

hold 5-7 days
consider initiating ASA 81 if needed

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20
Q

pre op medicine management of prasugrel

A

hold 7-10 days pre op
consider initiating ASA 81 if needed

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21
Q

Timing of surgery post stroke

A

AHA position statement - delay elective surgery for at least 6 months (unless for carotid endarterectomy).
Continue ASA wherever possible

22
Q

when to order ECHO pre-op

A

suspect moderate-severe stenosis/ regurgitation

23
Q

Criteria for severe AS on ECHO

A

Abnormal systolic AV opening with Vmax 4 m/s or Pmean gradient >40mmHg

24
Q

Class 1 indications for Aortic Valve replacement

A

Severe Aortic stenosis, symptomatic
Severe Aortic Stenosis, asymptomatic with EF<50%
Severe Aortic stenosis going for other cardiac surgery

25
when to order a dobutamine stress ECHO pre op
Patients with Moderate aortic Stenosis and symptoms fitting with severe Aortic stenosis. i.e. at risk of having low flow low gradient Aortic stenosis - Vmax 3-3.9 - Pmean 20-39 Classically seen in reduced EF but can occur with preserved EF and low stroke volume. The low output results in pseudonormalization of gradients and will underestimate AS severity
26
CCS Guideline on ASA pre-op (2016,2018)
Do not start ASA pre op to prevent cardiac events Discontinue ASA 3 days prior to non-cardiac surgery unless recent cardiac stent or pre-op major vascular surgery (POISE 2, 2014)
27
pre op medicine management of DMARDS/ non biologics
Can be continued
28
pre op medicine management of biologics
held for 1 dosing cycle i.e. surgery to be timed to be furthest day away from last dose
29
when to order a C-spine Xray Pre-op
a patient with rheumatoid arthritis WITH neck pain
30
pre op medicine management of Metformin
Hold day of surgery
31
pre op medicine management of DPP4i
Hold day of surgery
32
pre op medicine management of Sulfonureas
Hold day of surgery
33
pre op medicine management of SGLT2i
Hold 72 hours pre op (ertugliflozin 4 days)
34
pre op medicine management of GLP1 Ras
hold 1 week, increased risk of aspiration (except liraglutide - 1 day)
35
pre op medicine management of Insulin
hold prandial when fasting Dose reduce basal by half to 2/3
36
pre op medicine management of anticoagulants
Low bleeding risk - continue High bleeding risk - Hold (including neuraxial anesthesia)
37
who requires anticoagulation bridging pre op ( warfarin)
High peri op risk of thromboembolic events: Mechanical valves Afib + Stroke within 3 months Afib + CHADS 5, 6 Afib + Rheumatic valve VTE within 3 months VTE + High risk thrombophilia (APLA, Protein C/S/ ATIII def)
38
pre op medicine management of Anti Xa drugs (Apixaban, Edoxaban, Rivaroxaban)
Low risk bleeding: hold day before surgery and restart 24h post op High risk bleeding: hold 2 days before + POD 1
39
pre op medicine management of Dabigatran
CrCl > 50 low bleeding risk: hold day before, restart 24h post op, High risk bleeding hold 2 days pre op, hold POD1 CrCl<50 low bleeding risk hold 2 days pre op high bleeding risk hold 4 days pre op
40
pre op medicine management of Warfarin
Not bridging - hold 5 days Do INR day before surgery, restart 12h post op Bridging - hold 5 days before surgery start LMWH 3 days before surgery 1/2 dose LMWH vs. last dose 24h pre op no LMWH day of surgery VKA 12h post op + LMWH POD1 and continue both until therapeutic INR
41
Post op VTE Prophylaxis for Total hip replacement or knee replacement (ASH, 2019)
high risk of DVT knee 14 days, hip 35 days Post op DOACs > LMWH (Apix 2.5 BID, Riva 10 OD, Dabig 220 OD)
42
Post op VTE Prophylaxis for hip fracture (ASH, 2019)
Need LMWH for 30-35 day post op DOACs have NOT been studied in this population and therefore are NOT recommended
43
Recommendations for elective joint arthroplasties in poorly controlled diabetes
ACR 2023 guideline Recommend delaying Joint surgery to improve glycemic control ( Set A1c, or specific target not mentioned in guideline) Also state we should delay for smoking cessation!
44
When to order Pulmonary function tests pre-op
If result would affect management If anesthesia requests (e.g. Neuromuscular disease to predict post op ventilation) 1 lung ventilation planned lung resection surgery
45
AHA 2023 pulmonary Hypertension guideline for non-cardiac surgery
High RISK - elective surgery should be evaluated in a high risk center
46
pre op medicine management of steroids
No evidence Clinical gestalt / consensus HPA Axis likely NOT suppressed: Prednisone < 5 mg/d or Any dose < 3 wks – Uncertain: 5-20 mg prednisone > 3 wks (*some say > 5 mg for 3 wks = probably suppressed) Consider ACTH stim test/consult Endo, or just give steroids as if suppressed (esp. if no time for testing and major surgical stress) – HPA Axis Suppressed: Prednisone ≥ 20 mg/d for 3+ weeks or Cushingoid – STRESS DOSE (this is “art of medicine” not evidence based – pick a number 50 or 100 and you will be fine in oral exam ;) * Major surgery – Usual AM dose + HC 100 mg IV X 1 pre-op, then 50 mg q8h X 3 doses, then 25 mg q8h X 3 doses then back to usual dose * Moderate surgery – Usual AM dose + HC 50 mg X 1 pre-op, 25 mg q8h X 3, then usual dose * Minor surgery – Usual AM dose
47
When to screen for anemia pre-op
All patients undergoing surgery high risk for bleeding 6 weeks prior to OR date
48
How to manage anemia pre-op
Hb <100: consider delay, investigate, refer Hb 100-130: Investigate, IV iron (PO if >8wks till OR), +/- ESA Hb>130: ESA support if high risk for bleeding, consider TXA * Note: IV iron still minimum 3-4 days for any effect
49
How to manage Cirrhosis Pre/peri op
Child Pugh C, elective surgery discouraged decompensated cirrhosis have a high 1 year mortality rate in general, so elective surgeries are generally not offered Considerations if undertaking surgery: * Bleeding risk – pre-op Vit K, FFP, ensure blood bank ready, avoid neuraxial anesthesia * VTE risk – high despite coagulopathy (elevated INR) and thrombocytopenia * Infection risk – higher at all surgical sites * Encephalopathy – common postop, esp w high doses of peri-op opioid analgesia or sedatives
50
ICD management pre op
* ICD should be re-programed pre-op if the surgery will be above the umbilicus with cautery use (monopolar electrosurgery unit). – Avoids shocking patient and surgeon * Suspend anti-tachyarrhythmia therapy and/or initiate asynchronous pacing in pacing dependent patient – programming machine and can sometimes be accomplished by applying a magnet * Before emergency external defibrillation or cardioversion of a patient with a magnet applied to an ICD, the magnet should be removed to permit reactivation of the ICD's anti-tachyarrhythmia function

IM RCPSC 2024 (9 decks)

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