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General Surgery 1 > Pre-Op Care and Morbidity > Flashcards

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.

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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
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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
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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
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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%
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6
Q

Goldman’s cardiac risk

A
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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
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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
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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
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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
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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
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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
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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
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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
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15
Q

OTC medications: complications and preop recommendation

A
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16
Q

Nutritional defects/malnutrition

A
  • Determinants:
    • Weight loss of 15% over last 3-4 months
    • Albumin less than 3.0 g/dl
    • Protein less than 6.0 g/dl
    • Serum transferrin level of less than 150 mg/dl
    • Increased RBC size (macrocytic)
    • Decreased B-12, Folic Acid
17
Q

Malnutrition

A
  • Malnourished patients have a higher complication rate
  • BMI LESS THAN 18
  • PREOP TREATMENT:
    • 25% ALBUMIN IN 100cc soln IV 120cc/h
18
Q

Immunocompromised

A
  • RISK OF INFECTION AND POOR WOUND HEALING
  • Elderly, malnourished and cancer patients have a high incidence of being immunocompromised
  • Determination by total lymphocyte count less than 800
  • Pt receiving corticosteroids within 3 days of surgery
    • Risk of poor wound healing
    • Steroids reduce inflammation, epithelialization and collagen synthesis
    • Leads to wound breakdown and infection
    • Pt will need additional dose of steroids on day of surgery if taking more than 5mg prednisone for 2 weeks
19
Q

GERD

A
  • Patients have a high incidence of postoperative nausea
  • Require aggressive antiemetic treatment preop and postop
  • Hx of H.pylori, PUD, hiatal hernia
  • Home meds will include all three:
  • H2 Blocker – “dines”
    • Cimetidine (Tagamet)
    • Ranitidine (Zantac)
  • Antacids – Gaviscon, Mylanta
  • PPIs (proton pump inhibitor) – “prazole”
    • Lansprazole (Prevacid)
    • Omeprazole (Prilosec)
20
Q

hypovolemia

A
  • Very common in the elderly!!
    • Bleeding
    • Vomiting/diarrhea
    • Bowel obstruction
    • Dehydration
  • Bowel obstruction can lead to shock which is why you have hypovolemia
  • Dizziness, weakness, anxiety
  • Cold skin, pallor, capillary refill > 2sec, diaphoretic
  • Orthostatic hypotension (fall in systolic pressure of more than 10mm Hg when patient sits up from lying position)
  • If patient is in pain – give analgesic to get true BP
  • Tachycardia is early sign
  • Fever
  • Low urine output
21
Q

hyponatremia hypovolemia

A
  • Loss of NA
  • Excess vomiting, diarrhea, sweating, diuretics
  • Preop Tx with NS with K
    • OR
  • Too much free water dilutes NA
  • CHF, cirrhosis, bowel obstruction, chronic renal failure
  • Preop Tx with diuretics (Lasix) with K
22
Q

Hypovolemia/Dehydration Labs

A
  • URINALYSIS
    • POSITIVE ketones
    • High specific gravity
    • High urine sodium
  • CBC is elevated unless due to bleeding/anemia
    • Increased glucose
    • Increased BUN
    • Increased Creatinine
    • Increased Albumin
    • BUN:CR >20:1
    • Decreased NA
    • Increased K
    • Decreased CL
    • Decreased Co2 (bicarb)
23
Q

Endocrine disorders

A
  • Hyperthyroidism
    • Risk of HTN
    • Risk of hyperthermia
    • Risk of cardiac arrhythmia
    • Risk of CHF
    • Treat with PPU (propylthiouracil) 1-6 weeks preop
    • If emergency, treat with propranolol, PPU and potassium iodide
  • Hypothyroidism
    • Risk of hypotension
    • Risk of shock
    • Risk of hypothermia
    • Preop treatment with levothyroxine until euthyroid
  • Adrenal Insufficiency
    • Risk of Addisonian crisis (salt wastage, hypotension, shock and death)
    • Risk of poor wound healing
    • Preop tx with cortisol and NS (normal saline)
24
Q

Allergies

A
  • Intraoperative anaphylaxis occur 1/4500 surgeries with 3%-6% mortality
  • Most allergies are to muscle relaxants, anesthesia drugs (etomidate/propofol) and narcotics
  • LATEX ALLERGIES second most common cause of anaphylactic allergies (first is muscle relaxants)
  • Chart all allergies provided in patient’s history even if it is actually a side-effect!
  • Sleepy with morphine….tachycardia with epinephrine
  • Treat anyphylaxis with epinephrine or Benadryl
25
Q

Anemia

A
  • Hemoglobin below 10
  • Hematocrit below 30 does not increase risk for surgery
  • Hemoglobin below 7 (or HCT below 21)will likely require blood transfusion of 1 unit
  • 1 unit of PRBC will raise HCT by approx 3
  • Check BP for orthostatic hypotension and s/sx of hypotension
  • Low Hemoglobin Determinants:
    • MCV (mean corpuscular volume)
    • MCHC (mean corpuscular hemoglobin conc)
  • Normocytic/normochromic
    • Acute blood loss
    • Early FE-deficiency
    • Chronic illness/cancer
    • Hemolytic anemia
  • Microcytic/hypochromic
    • Late FE-deficiency
    • Thalassemia
    • Lead poisoning
  • Microcytic/normochromic
    • Renal disease
  • Macrocytic/normochromic
    • Malnutrition
    • B-12 deficiency
    • Folic Acid deficiency
  • Preop treatment with Vitamin B12, FE and Folic Acid to correct any deficiencies
26
Q

Platelet Disorders

A
  • Platelets below 50,000 u/l does not increase risk for surgery
  • Platelets below 30,000, consider the need for blood transfusion
  • Platelets below 10,000 requires blood transfusion!
  • Replace with platelets (not PRBC!)
  • Only FFP and cryoprecipitate have clotting factors
  • Don’t replace with packed cells, replace with platelets
  • All patients should be asked if they had problems with bleeding after a surgical procedure
  • Surgery increases risk of DVT (deep vein thrombosis) 21 times! in the following patients
    • Severe obesity
    • Hx of DVT
    • Hx of prolonged immobilization
    • Hypercoagulable states such as
      • Factor V Leiden
      • TTP (thrombotic thrombocytopenic purpura)
      • SLE
      • Polycythemia Vera
27
Q

Preop treatment for DVT risk

A
  • WALK TO OPERATING ROOM
  • SEQUENTIAL COMPRESSION DEVICE (SCD)
  • ELASTIC STOCKINGS
  • HEPARIN 5000 units SUBQ q 8-12h
28
Q

Alcohol Abuse

A
  • Risk of malnutrition, seizures
  • Increased LFTs
  • Decreased albumin
  • Decreased FE/transferrin
  • Decreased B-12/Folic Acid
  • Increased Bilirubin
  • Check AFP
  • May have increased PT/INR/PTT
  • Preop tx with ativan, thiamine, B-12
  • Type and Screen for blood transfusion if needed
29
Q

Preop testing: EKG

A
  • MALE OVER 40
  • FEMALE OVER 50
  • HX OF CARDIAC DISEASE
  • HX OF HTN
  • HX OF DIABETES, RENAL DISEASE
  • HX OF COPD
30
Q

Preop testing: chest x-ray

A
  • AGE GREATER THAN 60
  • HX OF RESPIRATORY DISEASE
  • HX OF CARDIAC DISEASE
  • SMOKER
31
Q

Preop testing: coagulation studies

A
  • COAGULATION STUDIES – PT, PTT, INR
    • PT FOR COUMADIN (Warfarin)
      • Takes 2 days to change value
    • PTT FOR HEPARIN
    • INR (same as PT!)
      • Therapeutic value 2-3
    • Function test for Plavix - P2Y12
    • HX OF BLEEDING RISK
    • HX OF LIVER DISEASE/ALCOHOL ABUSE
    • PLAN FOR USE OF ANTICOAGULANTS
    • HX OF MEDICATIONS INCLUDING ASPIRIN, COUMADIN, WARFARIN, PLAVIX, NSAID
    • PT CHECKS FOR FACTOR 7 PTT FOR EVERYTHING , hemophiilia OTHER THAN FACTOR 7 AND 8 - IF PROLONGED COULD BE VON WILLEBRANDS OR HEMOPHILIA
    • INR – CONSIDERS BOTH
32
Q

Preop testing: albumin, FE, transferring, vitamin B-12, Folic acid

A
  • Albumin, FE, Transferrin, Vitamin B-12, Folic Acid
    • Hx of malnutrition
    • Hx of renal disease
    • Hx of anemia
    • Hx of alcohol abuse
    • Hx of liver disease

General Surgery 1 (9 decks)

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