Pre-Op Care and Morbidity Flashcards
1
Q
Preoperative care
A
Whether you are meeting your patient for the first time and completing the history and physical yourself or you just showed up at the pre-op holding area, with a written history and physical in the chart, you must ask the patient AGAIN about conditions/issues that may affect the patient even going into the operative room.
2
Q
hypertension
A
- B/P > 140/90
- Preoperative HTN increases risk of perioperative lability
- Increase incidence of stroke
- Increase incidence of arrhythmia
- Increase incidence of myocardial ischemia
- Ask the patient – what are you taking for your high blood pressure – how much – when did you last take a pill. Check the vital signs – do they support htn – is the blood pressure really low? What would you expect? High? Yes- due to anxiety….look at EKG – you are not a cardiologist – just read what the interpretation said – if abnormal let the anesthesiologist know – don’t send this patient off to surgery if there is ANY doubt of his cardiac function – many surgeries get postponed/cancelled due to abnormal ekgs - tell story about cardiologist you called that grilled you over the phone and woundn’t come in – had to get su;rgeon involved
- EKG must show no changes from previous EKG to be clear for surgery
- Consider cardiac consult
- If under care of cardiologist, should be notified and consider cardiac clearance
- Continue antihypertensive meds until day of surgery and resume postoperatively UNLESS PATIENT IS TAKING ACE INHIBITORS OR ARBS.
- More important than the BP is the EKG – anesthesiologist will manage this during operation
- These medications in conjunction with anesthesia have the propensity to make pts HoTN
3
Q
Diabetes
A
- Diabetics have more surgery than non-diabetics
- Usually hyperglycemic preop due to stress (increase of cortisol and epinephrine) or unrecognized infection
- Patient should be booked into OR as early as possible to minimize effects of fasting and ketosis.
- Fasting Glucose above 200 may be treated with insulin by anesthesiologist
- Anesthesiologist will manage the patient during operation – this will be your worry after surgery - story of pt with no hx of diabetes who had preop lab of 400!!!
- These are usually the first surgery of the day
- Preoperative sedatives or analgesics should be as low dose as possible due to increased sensitivity
- Patients with well-controlled diabetes taking oral agents should continue meds until day BEFORE surgery – will manage with insulin if needed during surgery
- Patients with insulin dependent diabetes may require insulin during surgery
- Will use insulin postoperatively as well
- Diabetics have an increased sensitivity to analgesics – surgery invokes stress response that releases cortisol
4
Q
Patients with non-insuling dependent diabetes
A
- Patients with non-insulin dependent diabetes should stop taking long-acting sulfonylureas (Glyburide) due to risk of intraoperative hypoglycemia
- use short-acting (Repaglinide) or sliding scale insulin (preferred during hospitalization).
- Patients taking metformin have risk of lactic acidosis with renal insufficiency
- PREOP TESTING:
- GLUCOSE > 100
- HbA1c to check effectiveness of medications –
- value of 7% = glucose of 80-120
- Lactic acidosis is a metabolic acidosis – increased lactic acid and low pH
- Normal random glucose <200
- Normal fasting glucose <100
5
Q
Cardiac history
A
- Complications related to heart disease is the major cause of perioperative deaths
- Should be monitored with arterial line or subclavian if significant heart disease
- Antibiotic prophylaxis for patients with valvular disease
- Heparin stopped 5 days prior to surgery – resumed 12 hours post op
- Patients should continue cardiac meds
- Why would we put in an arterial line? Its faster absorption
- Complications related to heart disease is the major cause of perioperative deaths
- Serious cardiac event or death during procedure is based on the Goldman’s Index
- Total score is 53
- Risk of serious cardiac event or mortality is from .9% to 63.6%
6
Q
Goldman’s cardiac risk
A
7
Q
Renal disease
A
- Risk of dehydration
- Risk of infection
- Medications that are nephrotoxic:
- Gentamycin (aminoglycosides)
- Methicillin (PCNs)
- Toradol (NSAIDS)
- Its ok to take Tylenol!
- Renal patients on dialysis
- Look at potassium -if high needs dialysis before surgery
- Consult with nephrologist to order dialysis day before surgery
8
Q
renal disease preop test
A
- Preop Test:
- BUN >20 (>100 CRITICAL!)
- Creatinine >1.2
- Albumin < 3.5
- LDH (lactate dehyrogenase) > 90 U/L
- Urinanalysis
- Proteinuria
- CASTS
- LDH is enzyme released by cells with injured or destroyed
9
Q
Liver disease
A
- If alcohol intake is high or history of alcohol abuse, patient will need medical intervention for withdrawal symptoms
- Presence of umbilical hernia may indicate ascites
- Cirrhosis most common cause of prolonged PTT
10
Q
Liver disease preop testing
A
- Preop Testing:
- Prolonged PT/PTT/INR –
- INR (international normalized ratio) > 1.2
- PT (prothrombin time) > 12.5 sec
- PTT (partial thromboplastin time) > 70 sec
- Elevated Liver function tests:
- AST (aspartate aminotransferase)
- ALT (alanine aminotransferase)
- Alkaline phosphatase
- CHILD PUGH “A BEAP” Albumin/bilirubin/encephalopathy/acities/PT/INR
- LDH is an enzyme found in cells that is released when cells injured/destroyed 0 used in CA
- RBC broken down into indirect bilirubin which is then conjugated in LIVER to form direct bilirubin (hemoylytic disease cause increase in indirect)
- PT/INR are the same/ PTT used to monitor heparin therapy
- PREOP TESTING
- Bilirubin (direct) > 0.3
- Total Biirubin > 1.0
- Albumin < 3.5
- LDH (lactate dehyrogenase) >90 elevated with cell injury/death
- AFP (alpha fetoprotein) – é CA/cirrhosis
11
Q
Obesity
A
- BMI > 30 obese
- BMI >40 morbidly obese
- Risk of pulmonary complication due to difficult airway, difficult ventilation, short neck
- Risk of poor wound healing
- Risk of DVT
- TX with 5000 units Heparin subq perioperatively
- Continue heparin 5k subq q 12hr while hospitalized
- Send home on Lovenox 30mg for 2-3 wks
- Due not be afraid to address their obesity - talk to them AFTER surgery about what they can do to lose weight, bariatric surgery, refer to bariatric surgeon if show interest –
- Typically lovenox is not used, its for bigger cases where they have been in the hospital for a long time
12
Q
Obesity preop tx
A
- Preop Tx: Get up to bathroom before surgery/walk to operating room
- DVT prophylaxis a must!
- Comorbidities of HTN, Diabetes, Obstructive Sleep Apnea, GERD, Stress Incontinence
- Consider each comorbidity as a separate underlying disease
13
Q
pulmonary disease
A
- Lung compromise including patients with COPD, Emphysema have increased risk of pneumonia, atelectasis and hypoxia
- Preop tx with bronchodilators and antibiotics for productive cough
- Asthma patients should get steroids/bronchodilator treatment before surgery
- Example: Albuterol MDI (patient can use their own home inhaler)
- SMOKING cessation 8 weeks before surgery will decrease sputum production
- Don’t stop 2 or 3 days before surgery – they will start coughing and all the phlem will produce a productive gunk in the lungs during surgery
14
Q
Review of medications
A
- RISK OF BLEEDING!!!
- NSAIDS
- Should be discontinued 5 days preop
- Plavix/Aspirin
- Should be discontinued 10 days preop
- Coumadin/Warfarin
- Should be discontinued 5 days preop
- Switch to Heparin if necessary
- Look at medications – do they match medical conditions? Patient has high b/p on any meds? – you can catch diseases this way – refer to specialist after surgery
15
Q
OTC medications: complications and preop recommendation
A
