Pre-Operative Evaluation (Exam I) Flashcards
what is vancomycin used for
- distal ilium, colon and appendix surgeries
what is clindamycin alternative for?
- when allergic to cefazolin
-gram positive and negative bacteria - for surgeries located in the abdomen
What does cefazolin cover
most aerobic gram positive bacteria that cause SSI
what is the most common antibiotic for surgery
Cefazolin
What is the formula for BMI?
BMI = kg / m²
What mnemonic guides an emergent physical examination?
AMPLE
- Allergies
- Medications
- Past medical history
- Last meal
- Events leading up to need for surgery
What factors are worth one point on the Revised Cardiac Risk Index?
- High risk surgery
- Ischemic heart disease
- Hx of CHF
- Hx of CVA
- DM w/ insulin
- Creatinine > 2 mg/dL
What group of surgeries has the highest risk?
Vascular (Aortic, major, & peripheral vascular) > 5%
What sort of risk would be seen on the Revised Cardiac Risk Index with a score of 0?
What about with a score of 3 or greater?
- 0 = 0.4%
- 3 = 5.4%
What are METs?
What is one MET equal to?
- Metabolic Equivalent of Tasks (measurement of rate of energy consumption).
- 1 MET = 3.5 mLO₂ /kg/min
How would one assess functional capacity? What is the range of this assessment?
- Through METs
- 1 MET = eating, working at computer, etc
- 12 MET = running rapidly for long distances
What are the three levels of urgency of surgery?
- Emergent - Life or limb threatened, sx needed within 6 hours, no cardiac pre-op necessary.
- Urgent - Life or limb threatened, sx needed in 6-24 hours.
- Time-sensitive - delays exceeding 1-6 weeks would adversely affect patient.
What ASA level would an otherwise healthy 22 year old who got in a car wreck with massive trauma necessitating emergent surgery have?
- ASA V (won’t live without sx)
What ASA level would a healthy non-smoking 27 year old with diabetes have coming in for an EGD?
- ASA II (healthy but has well-controlled DM)
What ASA level would a 56 year old male who had an MI 2 months ago have for his follow up TEE today?
- ASA IV (MI less than 3 months ago)
What ASA level would a 12 year old girl with no hx have coming in for a routine tonscillectomy?
- ASA I (no hx, healthy, routine sx)
What ASA level would a 42 year old male with COPD and poorly controlled DM have?
- ASA III (COPD, poorly controlled DM)
What is the most common anaphylactic drug allergy?
What other two drugs have really common allergies?
- NMBs
- Antibiotics & chlorhexidine
What condition makes one more prone to latex allergy?
- Spina Bifida
What three things discussed in lecture would prompt you to order coagulation studies?
- Known or suspected coagulopathy
- Known bleeding disorder, hepatic disease, or anticoagulant use.
- ASA 3-4; undergoing moderate - major surgery
Is Lidocaine and amide or an ester?
How can you tell?
- Lidocaine = Amide
- Two “i’s” would indicate and amide (ex. bupivicaine)
What cross-reactivity allergies are possible for someone who has a known neuromuscular blocking agent allergy?
- Neostigmine & Morphine
What medications need to be discontinued for surgery?
- Aspirin & P2Y12 Inhibitors (Clopidogrel, ticagrelor dc 5-7 days, prasugrel & ticlopidine dc 7-10)
- Topical Medications (day of)
- Diuretics (day of, except Thiazide)
- Sildenafil dc 24 hr prior (unless for CHF, then continue)
- NSAIDs dc 48 hrs prior
- Warfarin dc 5 days prior
- Hormone Replacement Therapy (dc 4 weeks prior)
- Non-insulin DM meds (dc day of)
What insulin should a type 1 diabetic take (or not take) the day of their surgery?
- DC short-acting
- Continue basal rate if using a pump
- Take 1/3 of normal long-acting if no pump.
What insulin should a type 2 diabetic take (or not take) the day of their surgery?
- DC short-acting
- Continue basal rate if using a pump
- 0 - 50% of normal long-acting dose
What is a normal dosing regimen of stress-dose steroid for a major surgery?
Why is this necessary?
- 100mg Hydrocortisone Q8 for 24hrs
- Stress dose steroid regimen’s replace physiologic cortisol levels. (thus prevent adrenal crisis)
What is the HPA Axis?
- Hypothalamus, Pituitary, & Adrenal glands.
What herbs/supplements carry an increased risk of bleeding?
- Saw Palmetto
- Garlic
- Ginger
- Ginkgo
- Ginseng
- Green Tea
(essentially; saw palmetto & anything starting with a “g”)
Which herbs/supplements carry an increased risk of excessive sedation/anxiolysis?
- Kava
- St. John’s Wort
- Valerian
Which herbs/supplements carry an increased risk of hypoglycemia?
- Ginseng
Which herbs/supplements carry a cardiovascular risk (especially intraoperatively)? Why?
- Ephedra (ma huang)
- Basically ephedrine = ↑ HR & BP
- ventricular arrythmias with halothane
Which herbs/supplements boost immune system response?
- Echinacea
If a patient just ate a full, fatty meal, how long until they can have surgery?
- 8 hours
If an infant needs an anesthetic procedure in the morning at 8AM when can their last feeding prior to this occur?
- 4AM
If a patient has toast with coffee and milk in the morning, how long will it be until they can have surgery?
- 6 hours
If a patient had a gatorade at 6AM when are they clear for their anesthetic procedure?
- 8AM
What is Mendelson syndrome?
What two factors increase your risk for this?
prophylaxis for this?
- Increased risk of aspiration Pneumonitis
- Increased risk of aspiration due to > 25mL of gastric contents and a gastric pH < 2.5.
-decrease gastric volume and acidity - decrease volume ( D2 antagonists)
-H2 antagonists
-PPIs
What can be done to prevent aspiration pneumonitis?
- ↓gastric volume and ↑gastric pH
What drugs are given to help prevent aspiration pneumonitis?
- Antacids (↑pH)
- H2 Antagonists (ex. famotidine; ↑pH)
- PPI’s (ex. omeprazole; ↑pH)
- D2 Antagonist (ex. metaclopramide; reduces gastric volume)
What scoring tool is used to determine PONV risk?
- Simplified Apfel Score
What are the four risk factors of a Simplified Apfel Score?
- Female
- Hx of PONV/motion sickness
- Non-smoker
- Post-op opioids
What sort of risk is conferred by an Apfel score of 1-2?
What would be done with this score?
- Moderate-severe risk
- Prevention with 2-3 antiemetics & limiting opioids.
What sort of risk is conferred by an Apfel score of 3-4?
- Severe risk
- Avoid volatiles, use propofol. No opioids if possible, use 2-3 antiemetics.
What drugs are useful in prevention/treatment of PONV?
- Scopolamine (necessary well in advance)
- GABA analogs (lower opioid usage)
- Ondansetron (5HT3 antagonist)
- Promethazine (H1 Antagonist)
- Dexamethasone (may cause perineal burning)
What should be known about presurgical antibiotics?
- Prophylactic abx should be given within 1 hour before incision
- Vanc & fluoroquinolone should be given within 2 hours of incision.
What chance of cross-reactivity exists with cephalosporins and penicillin?
- 10%
