Pre-op Risk Assessment Flashcards
Endoscopy, cataract, plastics, breast.
What is the risk of these procedures? - low/mod/high
Low
Head and neck, abdominal, orthopedic, prostate
What is the risk of these procedures? - low/mod/high
Moderate
Aortic and vascular, peripheral vascular, cardiothoracic, emergent
What is the risk of these procedures? - low/mod/high
High
How long should you wait to do non-cardiac surgery on someone who recently had an MI
> 60 days should elapse before non-cardiac surgery
In heart failure, what has the strongest association with MACE (major advserse cardiac events)?
3rd heart sound and JVD
Risk is greatest with diastolic dysfunction
A patient for preop eval has mod-severe valvular stenosis or regurgitation. What evaluation should you ensure they have complete?
Echo if:
- no echo within last year
- clinical changes
- unknown cause of dyspnea
What is the definition of 1 MET (metabolic equivalent)
1 MET = resting or basal O2 consumption of 40-year-old, 70 kg man
Definition of < 4 METs
poor function capacity (slow ballroom dancing, golfing with cart, playing musical instrument)
Definition of 4-6 METs
moderate functional capacity (climbing flight of stairs, walking up hill, heavy housework)
Definition of 7-10 METs
good functional capacity (mod-vigorous exercise)
Definition of > 10 METs
excellent functional capacity (vigorous exercise)
What does the ACC/AHA perioperative guidline recommend in the following case:
Known CAD and emergency situation
Proceed to surgery with appropriate monitoring
What does the ACC/AHA perioperative guidline recommend in the following case:
Urgent or elective surgery
Refer to cardiology
What does the ACC/AHA perioperative guidline recommend in the following case:
stable CAD
low risk surgery
no further testing required
What does the ACC/AHA perioperative guidline recommend in the following case:
stable CAD
Moderate-risk surgery
METs > 4
no further testing required
What does the ACC/AHA perioperative guidline recommend in the following case:
stable CAD
moderate risk surgery
METs < 4
increased risk of MACE and further testing indicated
What does the ACC/AHA perioperative guidline recommend in the following case:
stable CAD
high risk surgery
proceed to further testing
In which situations should stress testing be considered in pre-op eval?
- high risk procedures
- pts with elevated risk and poor or unknown functional capacity
What are risk factors for pulm complications that might indicate need for pre-op CXR?
- COPD
- CHF
- functional dependence
- hypoalbuminemia
- emergency or prolonged procedure
- surgical sites close to diaphragm: involving thorax, upper abd, AAA
How long should pts quit smoking prior to surgery?
2 months
8 weeks
When should you get pre-op UA?
only for implantation fo foreign material (hip replacement, heart valve) or urologic procedures
What preop eval should is a specific consideration for pts with rheumatoid arthritis?
C spine XR for atlanto-axial sublucation prior to intubations
- prevent spinal cord injury during intubation
Goal blood sugar level for perioperative time period
140-180 mg/dL
Should statins be continued in peri-op period?
ABSOLUTELY YES
may be reasonable to start them 4 weeks prior in pts who will have vascular surgery
Should Beta blockers be continued in peri-op period?
Yes continue them
careful with initiation 1 week prior to surgery
How long should you hold aspirin prior to surgery?
POISE-2 trial
- stop 5-7 days prior to surgery
- safety fo stoping in pts with prior MI still questionable so may continue in these pts
Should DAPT be held prior to surgery?
DAPT should be continued if possible when
- <4-6 wks after bare metal stent
- < 1 year after DES
If must be stopped continue aspirin
How should you manage pre-op warfarin in pt with lower thromboembolic risk?
- Stop warfarin 5 days pre-op
- If INR 1.5-1.9 can stop 3-4 days prior
- restart postop when taking PO
Lower risk =
- A fib with no CVA or embolism in last 12 months
- biologic heart valve > 3 months out
- vascular gract
- DVT > 3 months out and not hypercoagulable
- no current systemic arterial embolism
How should you manage pre-op warfarin in pt with higher thromboembolic risk?
- stop warfarin 4 days preop and start LMWH
- stop LMWH 12-18 hrs preop
- restart LMWH 6 hours postop
- restart warfarin when able to take PO
- stop LMWH when INR = 2.0
