Pre-Op evaluation

Question 1

at what METS level do pts have higher risk of surgery?

Answer 1

pts who can’t do 4-5 METS (walking 4 blocks or climbing 2 flights of stairs)

Question 2

what is an ASA 1 pt

Answer 2

healthy pt (no chronic or psych)

Question 3

what is an ASA 2 pt

Answer 3

pt with mild systemic dz (mild asthma/well-controlled htn); no impact on daily activity

Question 4

what is an ASA 3 pt

Answer 4

signif/severe systemic dz that limits normal activity (renal failure on HD, CHF class 2)… likely impact on anesthesia & surgery

Question 5

what is an ASA 4 pt?

Answer 5

severe dz that is a threat to life or requires ICU…eg acute MI, RF with mech vent. serious limitation of daily activity. major impact on surgery/anesthesia

Question 6

what is an ASA 5 pt?

Answer 6

moribund pt likely to die in next 24 hrs without surgery

Question 7

what is an ASA 6 pt?

Answer 7

brain-dead organ donor

Question 8

what kind of cardiac murmurs should I worry about?

Answer 8

diastolic always pathologic - need to be worked up
systolic depends - could be high output 2/2 hyperthyroid, pregnancy, anemia
regurg tolerated better than stenosis

Question 9

at what point would htn delay a case?

Answer 9

if > 200/115 & its elective surgery…delay until < 180/110. Hypo is worse than Hyper

Question 10

EKG - when should i order it preop?

Answer 10

order if Class 1 risk (either 1+ risk factor like IHD, CHF, CVD, DM, RI + vasc surg OR pt has mentioned risk factors with int risk surgery). also reasonable if pt having vasc surgery

Question 11

which drugs should i continue b4 surgery?

Answer 11

statins, beta-blockers, cardiac & anti-htnsives (with ACE or ARB may need to have vasopressin ready)

Question 12

what about ASA?

Answer 12

d/c if taking primary prevention

cont if taking secondary prevention unless surg has risk of bleeding into small spaces - crani/eye

Question 13

what about a type 1 diabetic?

Answer 13

d/c short-acting insulin
if on pump, use lowest basal rate
if PO meds, take 1/3-1/2 of int/long acting morning insulin (lente or NPH) to avoid dka

Question 14

what about a type 2 diabetic?

Answer 14

d/c short-acting insulin
cont metformin
take 0-1/2 or morning long-acting insulin
NO PO hypoglycemics

Question 15

what should I consider re: steroids

Answer 15

cont usual dose on the day of… beware if have been on steroids > 3 wks, HPA may be suppressed for up to one yr if high-dose

Question 16

herbals or supplements?

Answer 16

d/c 7-14 days…except Valerian which is like a Benzo

Question 17

also continue… (6)

Answer 17

MAOI's,
narcotics
inhalers
anxiolytics
methodone or NRT's
meds for COPD/asthma

Question 18

how long must a pt be fasting?

Answer 18

> 6 hrs solid & non-human milk

> 2 hrs clear liquid if no inc GERD risk, hiatal hernia, pregnancy, DM, SBO/LBO

Question 19

at a minimum what must informed consent contain?

Answer 19

indications for treatment & alternatives

Question 20

what needs to be considered esp with kids getting their tonsils out?

Answer 20

if they had recent URI - min 2 wks ago but prefer that it be 4-6 wks ago. overall look at kid - how sick r they acting, ask parents what their activity level is - how r they eating/playing etc

Question 21

what factors need to be considered before d/cing anticoagulation?

Answer 21

why they’re on the med - eg if for a stent, what type of stent and how long have they had it, how long have they been on anticoags, have they had problems with their stent in the past?