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Clin Med - II (Surgery) > Pre-op Assessment > Flashcards

Pre-op Assessment Flashcards

1
Q

Pre-op labs are often ____ (under / over) ordered

A

Over

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2
Q

Current recommendations for pre-labs (in general)

A

Selective ordering

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3
Q

When to order

Hb / Type and Cross

A

If you anticipate major bleed

To obtain a baseline

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4
Q

When to order

Urine PG test

A

All women of childbearing age

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5
Q

When to order

Renal and Liver function

A

Based on medical hx

ie alcoholic

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6
Q

When to order

Coags

A

Based on medical hx (ex - liver dz)
Type of procedure planned
Medications

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7
Q

When to order

Cardiac Testing

A

Baseline EKG above 50 yo
Sx-related RF
Pt-related RF

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8
Q

Sx-related predictors for risk of perioperative cardiac complications - High Risk

A

Emergency Sx
Anticipated increased blood loss
Aortic or perpheral vascular sx

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9
Q

Sx-related predictors for risk of perioperative cardiac complications - Intermediate Risk

A 
Abdominal or throacic sx
Head and neck sx
Carotid endarterectomy
Orthopedic sx
Prostate sx
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10
Q

Sx-related predictors for risk of perioperative cardiac complications - Low Risk

A

Breast sx
Cataract sx
Superficial sx
Endoscopy

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11
Q

Pt-related predictors for risk of perioperative cardiac complications - Major Clinical Predictors

A

MI = 6 weeks previously
Unstable angina
Decompensated CHF
Significant arrhythmias (eg causing hemodynamic instability)
Severe valvular dz (eg aortic or mitral stenosis with valve area <1.0 cm*cm)

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12
Q

Pt-related predictors for risk of perioperative cardiac complications - Intermediate Clinical Predictors

A

Mild angina pectoris
MI > 6 weeks previously
Compensated CHF
DM

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13
Q

Pt-related predictors for risk of perioperative cardiac complications - Minor Clinical Predictors

A 
Advanced age
Abnormal EKG
Cardiac rhythm other than sinus
Low functional capacity
Hx of stroke
Uncontrolled HTN
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14
Q

METs

A

Metabolic equivalents

One MET is the energy it takes to sit quietly

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15
Q

METs scoring

A

> 7 - Excellent
4-7 - Moderate
<4 - Poor

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16
Q

Activities of an excellent METs score

A

Playing squash
Jogging 10 min mile
Scrubbing floors
Singles tennis match

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17
Q

Activities of a moderate METs score

A

Cycling
Playing golf (no cart)
Walking (4 mph)
Gardening

18
Q

Activities of an poor METs score

A

Vacuuming
ADLs
Walking 2mph
Writing

19
Q

General guideline for Pre-op

A

Pts who are poor functioning or high risk should get a stress test
Pts with positive stress test results warrant cardiology consultation before proceeding wit sx
Pts with major clinical predictors usually warrant cardiology consultation preop

20
Q

Pulmonary complications in peri-operative period

A

Atelectasis
Pneumonia
Bronchitis

21
Q

Predisposing pulmonary RF include

A 
Cough
Dyspnea
Smoking
Hx of lung dz
Obesity
Abdominal / Thoracic sx
22
Q

Most significant pulmonary RF is

A

The site of sx - abdominal / thoracic sx

As a rule, the closer the sx is to the diaphragm, the higher the risk of pulmonary complications

23
Q

Indicators of increased surgical risk for pulmonary complications

A 
Cough
Dyspnea
Pulmonary dz
Smoking obesity
Abdominal/thoracic sx
FEV1 < 2L
MC V < 50% of predicted value
PEF < 100 L or 50% of predicted value
PCO2 >/= 45 mm Hg
PO2 = 50 mm Hg
24
Q

Pulmonary Testing - Pre-op

A

Baseline CXR in >50yo and in at-risk pts
PFT in select cases
Pre-op guidelines do not define the degree of pulmonary function impairment that would prohibit sx (*other than that for lung resection)

25
Q

Malnutrition increases surgical ____ and ____.

A

Morbidity

Mortality

26
Q

Pre-op H and P should include assessment of RF or malnutrition, including

A

Social isolation
Limited financial resources
Poor dentition
Weight loss, etc.

27
Q

True or False

The best means of defining nutritional status has not been established.

A

True

28
Q

_____ has been shown to correlate with post-op morbidity.

A

Albumin

29
Q

What serum albumin level can signify increased risk of post-op complications?

A

3.2 g/dl

30
Q

In what manners may pre-op nutritional supplementation be provided?

A

Orally
Enteral tube feeding
Parenteral nutrition

31
Q

Oral Hypoglycemic agents and sx

A

Hold the morning of sx
Metformin - notorious, can cause lactic acidosis post-op
Insulin sliding scale peri-op and post-op

32
Q

Insulin - Pre-op

A

Hold PM long-acting insulin (lantus), since NPO
Hold AM dose
Check glucose in pre-op and dose accordingly
If pt feels hypoglycemic, sips of juice (clear liquid) or IV if inpatient

33
Q

Anticoagulants - Pre-op

A

Stop Plavix 7 days pre-op if possible
Postpone elective sx if not possible
ASA - depends on procedure (neurosx or retinal sx; vs. umbilical hernia or carotid endarterectomy)
Stop coumadin 3-5 days preop
Bridge with Lovenox (Lovenox only lasts 12-24h, depending on dose)

34
Q

68yo F with esophageal cancer, tolerating only liquids for the last month, 20 lb wt loss.
What labs would you check?
What are you worried about and why?
How would you optimize her preop?

A

Nutritional status

Malnourishment b/c she has not been eating for a month

Tube feeding - J-tube in this case
(G Tube vs. J Tube)

35
Q

83yo F who had an MI last week. Smokes and can’t go up 1 flight of stairs. MET =1. Cardiology has not cleared her for sx, presents wit ha perforated ulcer with free air.
Would you operate?

A

NO!!!

She will die as soon as you put her under

36
Q

42yo M with uncompensated CHF, referred to you for excision of a lipoma.
What would you do?

A

Consult the cardiologist

This is an elective sx.

37
Q

67yo M on coumadin for A.fib, presents for screening colonscopy.
How would you manage his anticoagulation prior to the procedure?

A

Give lovenox

1 mg/kg/day

38
Q

70yo F just had a coronary stend placed and is on asa/plavix. Presents for a ventral hernia repair.
What would you do?

A

She cannot stop the blood thinners b/c her stent was just placed.
Wait at least 6m-1y to consult cardiologist about stopping blood thinning medication for this procedure

39
Q

55yo M on lifelong coumadin for recurrent DVTs presents to t trauma bay s/p motorcycle accident. INR = 4.2. He needs an exploratory laparotomy for intraperitoneal injuries.
How would you handle his INR?
Do you reverse him prior to going to OR?

A

Give FFB

You can reverse and go to the OR at the same time.

40
Q

34yo M, healthy is referred for excision of a large melanoma on the back.
What pre-op labs do you order?
Any other pre-op tests?

A

No pre-op labs needed

No other pre-op testing needed

41
Q

66yo F, otherwise healthy. Referred for cholecystectomy.
What pre-op labs do you order?
Any other pre-op tests?

A

No pre-op labs needed

EKG and CXR should be ordered

42
Q

65yo M with lung ca. You plan on doing lobectomy.

What tests do you order pre-op?

A 
CXR
EKG
Type and Cross
Albumin
PFT

Clin Med - II (Surgery) (10 decks)

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