Pre-operative Assessment

Question 1

Stepwise approach

Answer 1

Emergent surgery?
ACS?
Calculate clinical / surgical risk

Question 2

4 METs

Answer 2

Climb 2 flights of stairs
Walk 4 blocks on level ground
Rake leaves or push lawn mower

Question 3

Not emergent surgery or ACS, then

Answer 3

Estimate risk
Low risk <1% -> go to OR
Elevated risk >=1% -> estimate functional status

Question 4

RCRI

Answer 4

Coronary artery disease
CHF
Cr >= 2 
Prior stroke or TIA
IDDM
>=2 predictors = elevated risk

Question 5

Examples of high risk surgery

Answer 5

Vascular
Thoracic
Transplant

Question 6

Examples of low risk surgery

Answer 6

Eye
Breast
Asymptomatic carotid

Question 7

Pre-op stress testing indications

Answer 7

Elevated surgical risk
Poor functional capacity
Will change management (need for surgery, timing of surgery, medications)

Question 8

Pre-op coronary angiogram indications

Answer 8

Unstable sx
High risk stress test
Severe CAD +/- LV dysfunction

Question 9

Pre-op revascularization indications

Answer 9

Follow other revasc guidelines

Question 10

Asymptomatic severe AS guideline

Answer 10

Elective surgery reasonable with appropriate monitoring

Question 11

Asymptomatic severe MS guideline

Answer 11

Elective surgery reasonable with appropriate monitoring if valve morphology not amenable to percutaneous balloon

Question 12

Appropriate monitoring for stenotic valve lesions

Answer 12

Team approach, cardiac anesthesia
Arterial line +/- swan
Maintain afterload

Question 13

Regurgitant lesion monitoring

Answer 13

Maintain preload, avoid excessive afterload

Question 14

Guideline for regurgitant lesions

Answer 14

Elective non-cardiac surgery reasonable in asymptomaitc severe MR and AR, particularly if EF is normal

Question 15

Pre-op beta blockers

Answer 15

Continue if on
If high risk, can start low and go slow
Do not start day of surgery

Question 16

Holding P2Y12 after PCI before non-cardiac surgery

Answer 16

BMS, wait 30 days
DES, wait at least 3 months, ideally 6 months
Continue ASA

Question 17

Pathway for anticoagulation

Answer 17

Is a/c appropriate to begin with?
Can procedure be performed on a/c?
When should patient hold a/c?
Is bridging indicated?

Question 18

Pre-op holding warfarin for INR 2-3

Answer 18

5 days before

Question 19

Pre-op holding warfarin for INR <2

Answer 19

3-4 days

Question 20

Pre-op holding warfarin for INR >3

Answer 20

5+ days before

Question 21

Neuraxial procedure holding DOAC

Answer 21

Dabigatran 4-5 days

Apixaban / rivaroxaban 3-5 days

Question 22

Bridging for AF CV2 <= 4, no prior stroke or TIa

Answer 22

No bridging

Question 23

Bridging for AF CV2 >= 7, stroke or TIA in last 3 months

Answer 23

Bridge

Question 24

Bridging for AF CV2 5-6 or remote stroke / TIA

Answer 24

Assess bleeding risk
High -> no bridging
Low -> bridge

Question 25

Bleeding risk assessment for bridging anticoagulation

Answer 25

Major bleed in last 3 mo
ICH in last 3 mo
PLT abnormality or ASA use
Prior bleed during previous bridgin

Question 26

Restarting warfarin after surgery

Answer 26

Day of surgery

Question 27

Bridging with LMWH / restarting DOAC after surgery

Answer 27

When hemostasis achieved
Low bleeding risk -> 24 hours after
Higher bleeding risk -> 48-72 hours after (if at all)