Pre-op Hx PE Flashcards
Indications for carotid endarterectomy?
Symptomatic dz + 50% or greater stenosis
asymptomatic + 80% or greater stenosis
What is the leading cause of perioperative death?
Cardiovascular events.
*This is the most important thing about the preoperative hx and PE is assessing cardiac risk.
Are there routine preoperative labs/tests that all patients should undergo?
No, there arent any tests/labs that are right for every pt and every surgery
Within what time frame should all pts who undergo surgery need a complete H&P?
within 30 days before surgery.
Physiologic effects of anesthesia?
Peripheral vasodilation leading to hypotension b/c you cant compensate well.
Most of anesthetic agents also lead to reduced myocardial contractility.
The decrease in tidal volume cause by general and spinal/epidural anesthesia can cause what?
May cause atelectasis.
What is the most important aspect of the preoperative evaluation?
-what are some key questions to ask?
A thorough history.
- ROS
- extensive med hx, OTC meds
- allergies
- surgial and anesthetic hx
- functional status
Key:
- Cardiac and pulm hx
- bleeding disorders
- Hx of DVT
What are the effects of these herbal therapies?
- echinacea
- ginseng
- garlic
- ginkgo
- St. Johns Wort
- Kava
Echinacea: hepatotoxicity
Ginseng: PLT inhibitor; hypoglycemia
Garlic: PLT, inhibitor; preload reduction
Ginko: PLT inhibitor; alters vasoregulation
St, Jonhs Wort: Upregulates P450; drug-drug reactions
Kava: potentiates sedation; drug-drug reactions
What are some specific allergies you want to be aware of in your pre-op patient?
Latex allergy!
- allergies to foods associated with latex rxns such as:
- -banana
- -avocados
- -kiwi
- -apricot
- -melons
- -chestnuts
Which test is great for assessing functional status?
Duke Activity Status Index.
-ability to perform greater than 4 metabolic equivalents has been associated with a lower cardiovascular risk.
What is the LEE index used for?? Describe its scoring and the implications associated.
Lee index assesses risk factors for major cardiac complications.
- one point for each of the following:
- -high risk surgery
- -hx of ischemic heart dz
- -hx of congestive heart failure
- -hx of stroke or TIA
- -Insulin-dependent DM
- -Serum Cr greater tahn 2mg/dL
Scoring:
- 0 points =0.4% complication rate
- 1 = 1% comp rate
- 2 = 7% comp rate
- greater than/= 3 = 11% complication rate.
Complications include:
-MI, pulm edema, V-fib, primary cardiac arrest, complete heart block.
T/F, there is no convincing evidence that routine noninvaasive cardiac stress testing improve perioperative care.
True.
Indications for stress testing are:
- intermediate clinical predictor:
- -class 1 or 2 angina
- -prior MI based on hx or pathologic Q waves
- -compensated or prior heart failure
- DM
- poor functional capacity
- procedure with high surgical risk (emergency surgery, aortic repair or peripheral vascular dz)
Preoperative Evaluation of CHF pt:
-what are some PE findings that may indicate a significant risk of perioperative pulmonary edema and death?
-Preoperative control of CHF with which medications?
Signs of decompensated CHF as indicated by elevated JVP, an audible third heart sound, or evidence of pulmonary edema on CXR.
Preoperative control of CHF with diuretics and afterload reducing agents such as Calcium channel blockers (vasodilators).
What would you do if you heard a murmur in the patient who has come in for a routine preoperative hx and PE?
Patients found to have a rhythm disturbance without structural heart dz are at _____ risk for perioperative complications?
T/F, BP should be controlled before surgery?
get an echo.
VERY LOW RISK.
True.
What three specific factors are associated with increased risk of postoperative pulmonary complications?
Chronic lung dz, morbid obesity, and tobacco use.
Perioperative management of patients with lung dz?
DVT prophylaxis, esp in those undergoing pelvic, or hip surgery
- abx may be useful in pts coughing up purulent sputum
- pts on theophylline should be maintained on IV theophylline when necessary
It is important to avoid medications that cause delirium, what are some of these?
Delirium meds:
-meperidine (demerol [opioid]), anticholinergics, and benzos.
What is goal blood sugar peri/post-operatively for pts with DM?
All pts with DM should have what two labs checked and corrected before surgery?
between 100 -250mg/dL.
Renal function and electrolytes measured and corrected before surgery.
When do we give glucocorticoid replacement to pts going to surgery?
Glucocorticoid replacement should be considered in any pt who has been on 7.5mg of prednisone for 3wks or 20mg for 1wk AND if they have adrenocortical insuffficiency (addisons).
If adrenocortical insufficiency these pts should receive 100mg of hydrocortisone every 8hrs the AM of surgery and continuing for 48-72hrs
Pts with renal dz are at high risk for what perioperative complications?
Complications: postop hyperkalemia, pneumonia and fluid overload.
D/C herbal supplememnts how far in advance of surgery?
When to D/C ASA, NSAIDS, and plavix before surgery?
Pt taking warfarin may have surgery as long as the INR is less than ___?
D/c herbal supplements 2 wks prior to surgery
D/C ASA 7-10days prior, NSAIDS 3-5days prior, Plavix 2wks prior
INR needs to be less than 1.5
