Pre-operative Evaluation And Risk Flashcards
Emergent surgery time frame
6 hours
Urgent surgery time frame
24 hours
Time sensitive surgery time frame
Negatively affected outcome if not within 1-6 weeks
Elective surgery time frame
Delay for up to 1 yr
RCRI
Revised Cardiac Risk Index
Risk of cardiac complications after surgery
Takes risk category of procedure, pt hx and insulin/Cr levels into consideration
NSQIP
National Surgical Quality Improvement Program
21 patient predictors and planned procedure into account
Predicts 9 different outcomes in the 30 days post op
DASI
Duke Activity Status Index
Self assessment questionnaire to estimate functional capacity of 12 activities, measured by METs
If patient exceeds 4 METs - go for surgery!
How is anesthesia risk assessed?
ASA classification. Subjective. Higher scores equate to higher operative blood transfused units, delirium, morb/mort
What is the most common reason for postponing surgery?
Pre-op hypertension management
Policy on BP meds morning of surgery?
Okay to take except:
ACE/ARB (hypotension risk)
Diuretic (fluid shift risk)
Prophylactic B blockers
Start high cardiac risk stratification (3+ RCRI) in the weeks/months before, continue until POD #30
Dec risk of cardiac arrest, MI
Inc risk of stroke/mortality if started close to surgery
Statin therapy in surgery
High effective in preventing cardiac events, continue if taking
Can initiate in those undergoing vascular or high risk surgeries
Increased outcomes with stopping smoking how long before surgery?
4 weeks
Pre-op pulmonary risk modifications
Stop smoking, bronchodilator tx, control infxn, weight control
Intra-op risk modifications for pulmonary
Limit anesthesia, prevent aspiration, limit paralytic, optimize tidal volume and bronchodilation
Post-op risk modification for pulmonary risk
Inspiration excersizes, early mobilization, adequate pain control
Pre/peri management of diabetic meds
Fast acting oral antihyperglycemics are held morning of surgery unless >200 in pre-op
NPH (intermediate acting) - 1/2 dose morning of surgery
Insulin gtt for 300+, cancel if 400+
Post op: use SQ sliding scale insulin, reintroduce meds once PO
Which bridge therapy should be used for pts with renal insufficiency or on hemodialysis?
unfractionated heparin
How long should you hold OTC/HRTs before surgery?
4-6 weeks
How long do you hold warfarin pre-op?
5 days
How long do you hold plavix pre op?
5 days
How long do you hold ASA pre op?
7-10 days
How long to hold NSAIDs before surgery?
3 days
Ibuprofen can be 24 hours
When is anticoagulation bridging indicated?
warfarin
NOACs should be d/c when before surgery?
2-3 days
What is the reversal agent for Pradaxa>
Praxbind
Protocol for Factor Xa inhib and direct thrombin inhibitors?
hold 2-3 days pre-op, restart 1-3 days post op depending on bleeding risk
Factor Xa: Rivaroxaban, Apixaban
Direct thrombiN: dabigatran
Why is LMWH preferred over UFH for bridge therapy?
Longer half life -> less injections
More bioavailability
No monitoring needed
Common indications for surgery on pregnant women?
Appendicitis
Biliary Disease
Ovarian d/o
Trauma
When do you do continuous fetal monitoring during surgery?
> 23 weeks
Medication for pregnant women
Opioids okay
No NSAIDS > 32 wks
Thromboprophylaxis post-op until full ambulation
