Pre Op Jill Flashcards
goals of prep assessment
- detect unrecognized disease and risk factors
2. optimize preoperative medical condition
ASA 1 health status
healthy, non smoking
no or minimal alcohol use
ASA 2 health status
mild systemic disease (well controlled HTN, DM, stable asthma)
w/o functional limitation
social drinker, prego, obese, current smoker
ASA 3 health status
severe systemic dz/functional limitation
hx of cardiac complication COPD active hepatitis, alcohol dependence/abuse ESRD + dialysis premature infant BMI >40
ASA 4 health status
severe systemic disease w/constant threat to life
recent MI, CVA, TIA, CAD Ongoing ischemia or valve dysfunction sepsis dic ards esrd - dialysis
ASA 5 health status
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
ASA 6 health status
brain dead, just going in to harvest organs
risk assessment - RCRI
6 primary indicators of cardiac complications
- high risk surgery (vascular, open peritoneal, intrathoracic procedure)
- hx of heart disease (MI, postive stress Tess, pathologic Q waves, nitrate use)
- Hx of compensated or prior HF
- hx of CVA
- DM tx with insulin
- CKD w. Cr >2 mg/dl
factors to take into account preoperative risk assessment
- exercise capacity
- age
- medications used
- obesity
- obstructive sleep apnea
- alcohol misuse
- smoking
- personal/fh of anesthetic complications
exercise functional capacity to consider pre op
poor exercise capacity = inability to perform >4 METS
strong predictor of all cause mortality, more than RCRI
age pre-op
not a significant risk factor for cardiac complications
should not be a SOLE eliminator of surgery
obstructive sleep apnea pre-op
OSA increases risk for post-operative pulmonary applications
most pts are undiagnosed
STOP BANG, high obese pts
alcohol use in pre op considerations
misuse increases risk of post op complications (esp. surgical site infection, cardiopulmonary infection)
also at risk for seizure and delirium tremens
assessing alcohol use pre op
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
smoking use pre op
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
when is ideal time to stop smoking prior to sx?
ideally cessation should be done months prior to surgery and not within a few weeks of tx
rare complication of anesthesia
malignant hyperthermia
must asses for family hx
occurs when pts are exposed to succinylcholine or volatile anesthetic
malignant hyperthermia epidemiology
autosomal dominant
2x more common in males (half of rxns are <19 yrs of age)
malignant hyperthermia patho
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
malignant hyperthermia Clinical Presentation:
- 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
malignant hyperthermia management
Optimize oxygenation, end surgery
Dantrolene
ICU management, Pt counseling
Dantrolene
blocks accumulation of calcium
tx malignant hyperthermia
Indications of Preoperative Diagnostic Testing
HgB/Hct
pts age >65 undergoing major surgery
younger patients going for surgery where large blood loss is expected
Indications of Preoperative Diagnostic Testing
Cr/Chem Panel
Pts > 50, undergoing intermediate or high risk surgery
Young patients with suspected renal disease or nephrotoxic drug use
Indications of Preoperative Diagnostic Testing
Urine Pregnancy Test/beta HCG
All females of child bearing age
Indications of Preoperative Diagnostic Testing
CXR
Pts > 50 who are undergoing:
- AAA
- Upper abdominal surgery (GB, liver, stomach, pancreas)
- Thoracic surgery
+/- obese pts
Indications of Preoperative Diagnostic Testing
EKG
Preexisting cardiovascular dz
Pt undergoing any
Severely obese pts with poor exercise tolerance and 1 addition CVD/RCRI risk actor
Indications of Preoperative Diagnostic Testing
PFTs
Pts w/symptoms of unexplained dyspnea
Exercise intolerance
COPD or asthma pts without optimal tx
Abnormal pulm exam
Pts undergoing pulm resection surgery
Pulm Complications MC
atelectasis
bronchospasm
pneumonia
risk of pulm complications and FEV1
risk increases with FEV1 <1.5 L
high risk of prolonged ventilation/mortality FEV1 <1
NSQUIP calculator
online calculation of risk
Takes into account type of surgery, functional status of pt, increased ages, abnormal Cr, ASA class
ex. of 1 MET
take care of self
eat/dress/use toilet
walk indoors
walk on level @2 mph
washing dishes
ex of > 4 MET
climb 1 flight of stairs
walk on level @ 4mph
run a short distance
scrubbing floors
golf, bowl, dance
> 10 MET s
singles tennis
football
basketball
skiing
when to do further cardiac tests?
Less than 4 Mets
Greater than 4 METs + high risk surgery
low risk surgeries
endoscopic procedures
superficial procedures
cataract sx
breast sx
ambulatory sx
intermediate risk surgeries
carotid endarterectomy
endovascular abdominal aortic aneurysm repair
head and neck
intraperitonela sx
intrathoracic sx
orthopedic sx
prostate sx
high risk vascular surgery
peripheral vascular surgery
aortic/major vessel sx
emergency surgery
what anti-hypertensives can’t be taken day of surgery
diuretics (hydrochlorothiazide, furosemide)
ACE Inhibitors
ARBs (HoTN, CV, renal outcomes)
who gets beta blockers as pre op management
CAD or 2+ cardiac risk factors
titrated to HR 60-80
why are BB continued to surgical patients
decreased oxygen demand
acute withdrawal, may cause ischemia
alpha 2 agonistis and surgery
continue to day of surgery but dont initiate
abrupt withdrawal can cause rebound HTN
CCB and surgery
continue, can initiate if needed
Digoxin
continue preoperatively
H2 Blockers/PPI:
considered safe, continue if pt is already taking, may be used empirically
Inhaled Beta Agonists/Anti Cholinergics:
continue use, reduce periop pulmonary complications
Theophylline:
may cause serious arrhythmias and neurotoxicity = hold evening prior
Statin:
continue perioperatively, initiate if prior to cardiac surgery
Niacin and fibric acid derivatives:
hold 24hrs prior, rhabdo and myopathy risk
estrogen and surgery OC
continue if low risk surgery
may choose to stop 4-6 weeks prior to surgery due to increased VTE risk
HRT and surgery
stop 4-6 weeks if having procedure with high risk of VTE
low risk is ok to conintue
SSRI’s/SNRIs:
increased bleeding risk, hold 3 weeks pre op
Psych Med management
continue with caution
Lithium, antipsychotics, anxiolytics
diabetes surgery
pro op eval
EKG, A1C, serum Cr, fasting glucose (goal b/t 110-180)
PTS should have surgery in the morning
DM
control is diet alone
no therapy, SSI possible/avoid D5W fluids
DM control is oral agent/non insulin injectable
continue meds,
hold morning of surgery
DM long acting insulin
take 1/3 to ½ normal dose day of up until pt resumes full diet post op
surgery risk with DM
Sulfonylureas:
increase hypoglycemia
surgery risk with DM
Metformin:
contraindicated if increased risk of renal hypoperfusion, lactate accumulation, tissue hypoxia
surgery risk with DM
TZD:
may worsen fluid retention/ peripheral edema = HF risk
surgery risk with DM
DDP-IV/GLP-1:
decrease GI motility, worsening post op ileus
surgery risk with DM
SGLT2:
increase risk of hypoglycemia, reports of AKI and DKA
thyroid disease surgical management
Subclinical Hypothyroidism:
(elevated TSH, normal T4) continue surgery
thyroid disease surgical management
Overt Hypothyroidism:
urgent/emergent sx is ok, postpone elective surgeries until patient is euthyroid
thyroid disease surgical management
Severe Hypothyroidism:
risk of myxedema coma, ok for emergent surgeries (high risk), hold other surgeries
consider stress dose steroid, tx with IV levothyroxine
thyroid disease surgical management
Overt Hyperthyroidism:
increased risk of thyroid storm, ok for emergent surgeries, hold others
Adrenal insufficiency surgical risk
(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
who needs stress dose management
adrenal insufficiency
chronic disease
stress dose management
minor surgical procedure
(hernia repair, colonoscopy, bx)
usual steroid dose morning of
stress dose management
Moderate surgery:
(joint replacement, vascular surgery)
usual morning dose + 50mg Hydrocortisone IV prior to procedure, 25 mg IV q8/24hrs until normal regimen resumed
stress dose management
Major surgery:
(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
when do you stop heparin prior to procedure
5hrs prior
when do you stop LMWH prior to surgery
24hrs prior
goal INR before surgery
< 1.5
stop Coumadin 5 days prior or give vitamin K for urgent sx
bleeding character of vWF dz
delayed bleeding, unstable clot forms following procedure but the will break open/not heal
vWF dz surgical management
DDAVP or vWF infusions
who gets endocarditis prophylaxis? what meds?
high risk cardiac condition AND high risk procedure
Either Amox, Cephalexin or Clinda/Azithromycin
High Risk Procedures:
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
High Risk Conditions:
Prosthetic heart valve
Prosthetic material in valve repair
Prior hx of infective endocarditis
Pulmonary conduit
Valve regurgitation in transplanted heart
