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GI2 > Pre Op Jill > Flashcards

Pre Op Jill Flashcards

1
Q

goals of prep assessment

A
  1. detect unrecognized disease and risk factors

2. optimize preoperative medical condition

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2
Q

ASA 1 health status

A

healthy, non smoking

no or minimal alcohol use

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3
Q

ASA 2 health status

A

mild systemic disease (well controlled HTN, DM, stable asthma)

w/o functional limitation

social drinker, prego, obese, current smoker

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4
Q

ASA 3 health status

A

severe systemic dz/functional limitation

hx of cardiac complication 
COPD 
active hepatitis, alcohol dependence/abuse
ESRD + dialysis 
premature infant 
BMI >40
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5
Q

ASA 4 health status

A

severe systemic disease w/constant threat to life

recent MI, CVA, TIA, CAD 
Ongoing ischemia or valve dysfunction
sepsis 
dic 
ards
esrd - dialysis
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6
Q

ASA 5 health status

A

moribund, not expected to survive w.o operation

ruptured aortic aneurysm
massive trauma
intracranial bleed w/mass effect
ischemic bowel in face of significant pathology

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7
Q

ASA 6 health status

A

brain dead, just going in to harvest organs

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8
Q

risk assessment - RCRI

6 primary indicators of cardiac complications

A
  1. high risk surgery (vascular, open peritoneal, intrathoracic procedure)
  2. hx of heart disease (MI, postive stress Tess, pathologic Q waves, nitrate use)
  3. Hx of compensated or prior HF
  4. hx of CVA
  5. DM tx with insulin
  6. CKD w. Cr >2 mg/dl
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9
Q

factors to take into account preoperative risk assessment

A
  1. exercise capacity
  2. age
  3. medications used
  4. obesity
  5. obstructive sleep apnea
  6. alcohol misuse
  7. smoking
  8. personal/fh of anesthetic complications
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10
Q

exercise functional capacity to consider pre op

A

poor exercise capacity = inability to perform >4 METS

strong predictor of all cause mortality, more than RCRI

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11
Q

age pre-op

A

not a significant risk factor for cardiac complications

should not be a SOLE eliminator of surgery

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12
Q

obstructive sleep apnea pre-op

A

OSA increases risk for post-operative pulmonary applications

most pts are undiagnosed

STOP BANG, high obese pts

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13
Q

alcohol use in pre op considerations

A

misuse increases risk of post op complications (esp. surgical site infection, cardiopulmonary infection)

also at risk for seizure and delirium tremens

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14
Q

assessing alcohol use pre op

A

emergent or urgent surgery will req. treatment to prevent symptoms of withdrawal

should stop drinking at least 4 weeks before physiologic abnormalities occur

AUDIT-C, CAGE, SBIRT

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15
Q

smoking use pre op

A

increased risk of ICU admission and mortality

cessation preoperatively should reduce post op issues BUT increased risk if stop <8 weeks prior to surgery

if they are current smokers at time of sx, nicotine patch should be given

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16
Q

when is ideal time to stop smoking prior to sx?

A

ideally cessation should be done months prior to surgery and not within a few weeks of tx

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17
Q

rare complication of anesthesia

A

malignant hyperthermia

must asses for family hx

occurs when pts are exposed to succinylcholine or volatile anesthetic

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18
Q

malignant hyperthermia epidemiology

A

autosomal dominant

2x more common in males (half of rxns are <19 yrs of age)

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19
Q

malignant hyperthermia patho

A

calcium accumulation occurs causing sustained muscle contraction (generates heat, consuming O2, depleting ATP)

once energy stores depleted = rhabdomyolysis of muscle = hyperkalemia and spilling myoglobin in blood

leads to CO2 production and DIC

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20
Q

malignant hyperthermia Clinical Presentation:

A
  • Sustained muscular contraction, rhabdomyolysis, anaerobic metabolism and mixed metabolic and respiratory acidosis
  • Early hypercarbia not amenable to increased minute volume
  • Sinus tachycardia
  • Masseter or generalized muscle rigidity
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21
Q

malignant hyperthermia management

A

Optimize oxygenation, end surgery

Dantrolene

ICU management, Pt counseling

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22
Q

Dantrolene

A

blocks accumulation of calcium

tx malignant hyperthermia

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23
Q

Indications of Preoperative Diagnostic Testing

HgB/Hct

A

pts age >65 undergoing major surgery

younger patients going for surgery where large blood loss is expected

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24
Q

Indications of Preoperative Diagnostic Testing

Cr/Chem Panel

A

Pts > 50, undergoing intermediate or high risk surgery

Young patients with suspected renal disease or nephrotoxic drug use

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25
Q

Indications of Preoperative Diagnostic Testing

Urine Pregnancy Test/beta HCG

A

All females of child bearing age

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26
Q

Indications of Preoperative Diagnostic Testing

CXR

A

Pts > 50 who are undergoing:

  • AAA
  • Upper abdominal surgery (GB, liver, stomach, pancreas)
  • Thoracic surgery

+/- obese pts

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27
Q

Indications of Preoperative Diagnostic Testing

EKG

A

Preexisting cardiovascular dz

Pt undergoing any

Severely obese pts with poor exercise tolerance and 1 addition CVD/RCRI risk actor

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28
Q

Indications of Preoperative Diagnostic Testing

PFTs

A

Pts w/symptoms of unexplained dyspnea

Exercise intolerance

COPD or asthma pts without optimal tx

Abnormal pulm exam

Pts undergoing pulm resection surgery

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29
Q

Pulm Complications MC

A

atelectasis
bronchospasm
pneumonia

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30
Q

risk of pulm complications and FEV1

A

risk increases with FEV1 <1.5 L

high risk of prolonged ventilation/mortality FEV1 <1

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31
Q

NSQUIP calculator

A

online calculation of risk

Takes into account type of surgery, functional status of pt, increased ages, abnormal Cr, ASA class

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32
Q

ex. of 1 MET

A

take care of self

eat/dress/use toilet

walk indoors

walk on level @2 mph

washing dishes

33
Q

ex of > 4 MET

A

climb 1 flight of stairs

walk on level @ 4mph

run a short distance

scrubbing floors

golf, bowl, dance

34
Q

> 10 MET s

A

singles tennis
football
basketball
skiing

35
Q

when to do further cardiac tests?

A

Less than 4 Mets

Greater than 4 METs + high risk surgery

36
Q

low risk surgeries

A

endoscopic procedures

superficial procedures

cataract sx

breast sx

ambulatory sx

37
Q

intermediate risk surgeries

A

carotid endarterectomy

endovascular abdominal aortic aneurysm repair

head and neck

intraperitonela sx

intrathoracic sx

orthopedic sx

prostate sx

38
Q

high risk vascular surgery

A

peripheral vascular surgery

aortic/major vessel sx

emergency surgery

39
Q

what anti-hypertensives can’t be taken day of surgery

A

diuretics (hydrochlorothiazide, furosemide)

ACE Inhibitors

ARBs (HoTN, CV, renal outcomes)

40
Q

who gets beta blockers as pre op management

A

CAD or 2+ cardiac risk factors

titrated to HR 60-80

41
Q

why are BB continued to surgical patients

A

decreased oxygen demand

acute withdrawal, may cause ischemia

42
Q

alpha 2 agonistis and surgery

A

continue to day of surgery but dont initiate

abrupt withdrawal can cause rebound HTN

43
Q

CCB and surgery

A

continue, can initiate if needed

44
Q

Digoxin

A

continue preoperatively

45
Q

H2 Blockers/PPI:

A

considered safe, continue if pt is already taking, may be used empirically

46
Q

Inhaled Beta Agonists/Anti Cholinergics:

A

continue use, reduce periop pulmonary complications

47
Q

Theophylline:

A

may cause serious arrhythmias and neurotoxicity = hold evening prior

48
Q

Statin:

A

continue perioperatively, initiate if prior to cardiac surgery

49
Q

Niacin and fibric acid derivatives:

A

hold 24hrs prior, rhabdo and myopathy risk

50
Q

estrogen and surgery OC

A

continue if low risk surgery

may choose to stop 4-6 weeks prior to surgery due to increased VTE risk

51
Q

HRT and surgery

A

stop 4-6 weeks if having procedure with high risk of VTE

low risk is ok to conintue

52
Q

SSRI’s/SNRIs:

A

increased bleeding risk, hold 3 weeks pre op

53
Q

Psych Med management

A

continue with caution

Lithium, antipsychotics, anxiolytics

54
Q

diabetes surgery

pro op eval

A

EKG, A1C, serum Cr, fasting glucose (goal b/t 110-180)

PTS should have surgery in the morning

55
Q

DM

control is diet alone

A

no therapy, SSI possible/avoid D5W fluids

56
Q

DM control is oral agent/non insulin injectable

A

continue meds,

hold morning of surgery

57
Q

DM long acting insulin

A

take 1/3 to ½ normal dose day of up until pt resumes full diet post op

58
Q

surgery risk with DM

Sulfonylureas:

A

increase hypoglycemia

59
Q

surgery risk with DM

Metformin:

A

contraindicated if increased risk of renal hypoperfusion, lactate accumulation, tissue hypoxia

60
Q

surgery risk with DM

TZD:

A

may worsen fluid retention/ peripheral edema = HF risk

61
Q

surgery risk with DM

DDP-IV/GLP-1:

A

decrease GI motility, worsening post op ileus

62
Q

surgery risk with DM

SGLT2:

A

increase risk of hypoglycemia, reports of AKI and DKA

63
Q

thyroid disease surgical management

Subclinical Hypothyroidism:

A

(elevated TSH, normal T4) continue surgery

64
Q

thyroid disease surgical management

Overt Hypothyroidism:

A

urgent/emergent sx is ok, postpone elective surgeries until patient is euthyroid

65
Q

thyroid disease surgical management

Severe Hypothyroidism:

A

risk of myxedema coma, ok for emergent surgeries (high risk), hold other surgeries

consider stress dose steroid, tx with IV levothyroxine

66
Q

thyroid disease surgical management

Overt Hyperthyroidism:

A

increased risk of thyroid storm, ok for emergent surgeries, hold others

67
Q

Adrenal insufficiency surgical risk

A

(inadequate mineral corticoid and cortisol) are at risk for adrenal crisis (HoTN, HoGlycemia, shock)

inability to increase production of adrenal hormones in response to stress

68
Q

who needs stress dose management

A

adrenal insufficiency

chronic disease

69
Q

stress dose management

minor surgical procedure

A

(hernia repair, colonoscopy, bx)

usual steroid dose morning of

70
Q

stress dose management

Moderate surgery:

A

(joint replacement, vascular surgery)

usual morning dose + 50mg Hydrocortisone IV prior to procedure, 25 mg IV q8/24hrs until normal regimen resumed

71
Q

stress dose management

Major surgery:

A

(CABG, emergency)

usual morning dose, 100 mg IV prior, 50 mg IV q8/24 hrs then taper dose 1/2 per day until maintenance dose is reached

72
Q

when do you stop heparin prior to procedure

A

5hrs prior

73
Q

when do you stop LMWH prior to surgery

A

24hrs prior

74
Q

goal INR before surgery

A

< 1.5

stop Coumadin 5 days prior or give vitamin K for urgent sx

75
Q

bleeding character of vWF dz

A

delayed bleeding, unstable clot forms following procedure but the will break open/not heal

76
Q

vWF dz surgical management

A

DDAVP or vWF infusions

77
Q

who gets endocarditis prophylaxis? what meds?

A

high risk cardiac condition AND high risk procedure

Either Amox, Cephalexin or Clinda/Azithromycin

78
Q

High Risk Procedures:

A

Dental procedures that manipulate gingiva (routine cleaning, tooth extraction, drainage of abscess)

Invasive procedures of respiratory tract (incision or biopsy of mucosa, bronchoscopy w/bx, tonsillectomy, adenoidectomy)

Invasive procedures of infected skin or soft tissue

79
Q

High Risk Conditions:

A

Prosthetic heart valve

Prosthetic material in valve repair

Prior hx of infective endocarditis

Pulmonary conduit

Valve regurgitation in transplanted heart

GI2 (6 decks)

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