Pre-operative Evaluation And Risk

Question 1

Emergent surgery time frame

Answer 1

6 hours

Question 2

Urgent surgery time frame

Answer 2

24 hours

Question 3

Time sensitive surgery time frame

Answer 3

Negatively affected outcome if not within 1-6 weeks

Question 4

Elective surgery time frame

Answer 4

Delay for up to 1 yr

Question 5

RCRI

Answer 5

Revised Cardiac Risk Index
Risk of cardiac complications after surgery
Takes risk category of procedure, pt hx and insulin/Cr levels into consideration

Question 6

NSQIP

Answer 6

National Surgical Quality Improvement Program
21 patient predictors and planned procedure into account
Predicts 9 different outcomes in the 30 days post op

Question 7

DASI

Answer 7

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!

Question 8

How is anesthesia risk assessed?

Answer 8

ASA classification. Subjective. Higher scores equate to higher operative blood transfused units, delirium, morb/mort

Question 9

What is the most common reason for postponing surgery?

Answer 9

Pre-op hypertension management

Question 10

Policy on BP meds morning of surgery?

Answer 10

Okay to take except:
ACE/ARB (hypotension risk)
Diuretic (fluid shift risk)

Question 11

Prophylactic B blockers

Answer 11

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

Question 12

Statin therapy in surgery

Answer 12

High effective in preventing cardiac events, continue if taking
Can initiate in those undergoing vascular or high risk surgeries

Question 13

Increased outcomes with stopping smoking how long before surgery?

Answer 13

4 weeks

Question 14

Pre-op pulmonary risk modifications

Answer 14

Stop smoking, bronchodilator tx, control infxn, weight control

Question 15

Intra-op risk modifications for pulmonary

Answer 15

Limit anesthesia, prevent aspiration, limit paralytic, optimize tidal volume and bronchodilation

Question 16

Post-op risk modification for pulmonary risk

Answer 16

Inspiration excersizes, early mobilization, adequate pain control

Question 17

Pre/peri management of diabetic meds

Answer 17

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

Question 18

Which bridge therapy should be used for pts with renal insufficiency or on hemodialysis?

Answer 18

unfractionated heparin

Question 19

How long should you hold OTC/HRTs before surgery?

Answer 19

4-6 weeks

Question 20

How long do you hold warfarin pre-op?

Answer 20

5 days

Question 21

How long do you hold plavix pre op?

Answer 21

5 days

Question 22

How long do you hold ASA pre op?

Answer 22

7-10 days

Question 23

How long to hold NSAIDs before surgery?

Answer 23

3 days

Ibuprofen can be 24 hours

Question 24

When is anticoagulation bridging indicated?

Answer 24

warfarin

Question 25

NOACs should be d/c when before surgery?

Answer 25

2-3 days

Question 26

What is the reversal agent for Pradaxa>

Answer 26

Praxbind

Question 27

Protocol for Factor Xa inhib and direct thrombin inhibitors?

Answer 27

hold 2-3 days pre-op, restart 1-3 days post op depending on bleeding risk

Factor Xa: Rivaroxaban, Apixaban
Direct thrombiN: dabigatran

Question 28

Why is LMWH preferred over UFH for bridge therapy?

Answer 28

Longer half life -> less injections
More bioavailability
No monitoring needed

Question 29

Common indications for surgery on pregnant women?

Answer 29

Appendicitis
Biliary Disease
Ovarian d/o
Trauma

Question 30

When do you do continuous fetal monitoring during surgery?

Answer 30

> 23 weeks

Question 31

Medication for pregnant women

Answer 31

Opioids okay
No NSAIDS > 32 wks
Thromboprophylaxis post-op until full ambulation