Pre-op

Question 1

Ejection fraction

• Normal %
• % of prohibitive cardiac risk for noncardiac operations & what is the patient at risk for?

Answer 1

Normal: 55%

Prohibitive: 75-80% incidence of perioperative MI, with 55-90% mortality

Question 2

Goldman’s Index

1. What is it?
2. Elements involved

Answer 2

1. Risk of cardiac complications

2. Different points for each element (worst predictor to least bad):
JVD (e/o CHF)
Recent MI (w/in 6mo)
Premature ventricular contrxns (5+/min) or non-sinus rhythm
Age >70
Emergency surgery
Aortic stenosis
Poor medical condition
Surgery w/in chest or abdomen

Question 3

Worst single finding predicting high cardiac risk & what to do before surgery:

Answer 3

• JVD (indicates CHF)

- Pre-op tx with ACE-I’s, beta-blockers, digitalis, & diuretics if at all possible

Question 4

Second worst predictor of cardiac complications

Answer 4

Recent transmural or subendocardial MI

• -> operative mortality up to 3mo after MI = 40%
• -> drops to 6% after 6mo
• —> best to defer surgery until after 6mo, or if surgery necessary, admit to ICU to “optimize cardiac variables” the day before surgery

Question 5

Most common cause of increased pulmonary

–>how does it cause problems

Answer 5

Smoking!

–> compromised ventilation (high PCO2, low FEV1) rather than compromised oxygenation

Question 6

Hepatic risk: predictors of mortality with surgery

Answer 6

~40% mortality with either:

• bilirubin >2 (reflects hepatocellular fxn)
• serum albumin 16
• encephalopathy

~80-85% mortality with three of the above present (~100% if all four) or with either

• bilirubin >4
• albumin 150

*ascites also risk factor

Question 7

Severe nutritional depletion:

1) Definition
2) What to do pre-op

Answer 7

1) Definition:
- loss of 20% of body weight over a couple of months
- serum albumin multiplies surgical risk manyfold

2) What to do pre-op
- 4-5 days nutritional support (best via gut) makes big difference; 7-10 days optimal if possible

Question 8

Diabetic coma and surgery

• level of risk
• what to do

Answer 8

=absolute contraindication to surgery