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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
Q

when to order a dobutamine stress ECHO pre op

A

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
Q

CCS Guideline on ASA pre-op (2016,2018)

A

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
Q

pre op medicine management of DMARDS/ non biologics

A

Can be continued

28
Q

pre op medicine management of biologics

A

held for 1 dosing cycle i.e. surgery to be timed to be furthest day away from last dose

29
Q

when to order a C-spine Xray Pre-op

A

a patient with rheumatoid arthritis WITH neck pain

30
Q

pre op medicine management of Metformin

A

Hold day of surgery

31
Q

pre op medicine management of DPP4i

A

Hold day of surgery

32
Q

pre op medicine management of Sulfonureas

A

Hold day of surgery

33
Q

pre op medicine management of SGLT2i

A

Hold 72 hours pre op
(ertugliflozin 4 days)

34
Q

pre op medicine management of GLP1 Ras

A

hold 1 week, increased risk of aspiration
(except liraglutide - 1 day)

35
Q

pre op medicine management of Insulin

A

hold prandial when fasting
Dose reduce basal by half to 2/3

36
Q

pre op medicine management of anticoagulants

A

Low bleeding risk - continue
High bleeding risk - Hold (including neuraxial anesthesia)

37
Q

who requires anticoagulation bridging pre op ( warfarin)

A

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
Q

pre op medicine management of Anti Xa drugs
(Apixaban, Edoxaban, Rivaroxaban)

A

Low risk bleeding: hold day before surgery and restart 24h post op
High risk bleeding: hold 2 days before + POD 1

39
Q

pre op medicine management of Dabigatran

A

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
Q

pre op medicine management of Warfarin

A

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
Q

Post op VTE Prophylaxis for Total hip replacement or knee replacement
(ASH, 2019)

A

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
Q

Post op VTE Prophylaxis for hip fracture
(ASH, 2019)

A

Need LMWH for 30-35 day post op

DOACs have NOT been studied in this population and therefore are NOT recommended

43
Q

Recommendations for elective joint arthroplasties in poorly controlled diabetes

A

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
Q

When to order Pulmonary function tests pre-op

A

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
Q

AHA 2023 pulmonary Hypertension guideline for non-cardiac surgery

A

High RISK
- elective surgery should be evaluated in a high risk center

46
Q

pre op medicine management of steroids

A

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
Q

When to screen for anemia pre-op

A

All patients undergoing surgery high risk for bleeding 6 weeks prior to OR date

48
Q

How to manage anemia pre-op

A

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
Q

How to manage Cirrhosis Pre/peri op

A

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
Q

ICD management pre op

A
  • 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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