Pre-operative evaluation review

Question 1

What baseline functional status deems a patient able to undergo major abdominal/vascular surgery?

Answer 1

patient can maintain 4 mets (walking up a flight of stairs unassisted)

Question 2

When would you get further cardiac testing for a patient before major surgery?

Answer 2

1. cannot muster 4 METs (cannot walk up a flight of stairs

2. has at least 3 of the following: CAD, CHF, occlusive cerebrovascular disease, DM, CKD

Question 3

When should you refer a patient to a cardiologist before major surgery?

Answer 3

Active heart disease

• unstable coronary disease
• decompensated heart failure
• significant cardiac arrhythmia
• significant valvular disease

Question 4

What additional tests would you order for a patient with COPD prior to major surgery?

Answer 4

think about the following:

1. ABG
2. PFTs

Question 5

Which are the branched amino acids?

Answer 5

• valine
• leucine
• isoleucine

Question 6

What would PFTs look like on a morbidly obese patient

Answer 6

• decreased functional residual capacity
• decreased vital capacity
• decreased total lung capacity

Question 7

Components of CHADS2 score

Answer 7

• CHF
• hypertension
• Age > 75
• Diabetes
• previous stroke (worth 2 points)

Question 8

When would you bridge patient with AF prior to surgery?

Answer 8

CHADS2 score > 3-4

Question 9

best pre-op nutritional marker

Answer 9

serum albumin (want it > 3.5)

Question 10

Patient is going for an elective surgery, but is on dabigatran, when do you stop it?

Answer 10

• if Cr/CL > 50 2 days before, if < 50 then 3-5 days before surgery

Question 11

Physiologic changes with CO2 insufflation

Answer 11

• decrease in venous return
• increase in SVR
• increase in MAP with decrease in CO/CI

Question 12

who does not need stress dose steroids before surgery, if they are taking steroids?

Answer 12

• if amount is < 5 mg/day

- if they have been on the steroids for < 3 weeks

Question 13

Perioperative steroid supplementation for chronic steroid users

Answer 13

• routine abdominal, peripheral vascular, orthopedic
  50 mg IV hydrocortisone -> 25 mg IV hydrocortisone q8h for 24 hours -> continue home dose
• Major surgery (resection of solid organ, central vascular surgery, cardiac surgery)
  100 mg IV hydrocortisone -> 50 mg IV hydrocortisone q8h for 24 hours -> taper till you reach home dose (down by half every day)

Question 14

What does Renin do?

Answer 14

cleaves angiotensin I from antiogenisnogen

Question 15

how do you treat malignant hyperthermia?

Answer 15

stop the anesthetic
give dantrolene (ryanodine antagonist)

Question 16

What is succinylcholine metabolized by?

Answer 16

plasma pseudocholinesterase

Question 17

patient on oral hypoglycemic agent, short acting insulin, and long acting insulin…on day of surgery what do they take?

Answer 17

• stop oral agent
• stop short acting insulin
• half dose of long acting insulin

Question 18

what causes the classic sign of peri-umbilical pain then right lower quadrant pain of appendicitis?

Answer 18

• luminal dissension of appendix causes diffuse visceral pain
• once appendix touches peritoneum you get RLQ pain

Question 19

another name for omega-3 fatty acids

Answer 19

alpha-linolenic acid

Question 20

decision making ladder for patient with phimosis and difficulty placing foley

Answer 20

• if there is swelling use ice
• dilation of foreskin with kelly clamp
• dorsal slit circumcision

Question 21

two kinds of local anesthetic used in small procedures?:

Answer 21

amino esters

amino amides

Question 22

with which kind of local anesthetic are anaphylactic reactions more common?

Answer 22

amino esters

Question 23

what is the proposed mechanism for allergic reaction with amino esters?

Answer 23

build up of para-aminobenzoic acid

Question 24

which type of heparin do we use in vascular surgery?

Answer 24

typically unfractionated heparin because its quick on an off…in case you need to go back to the OR, among other benefits

Question 25

how do you monitor UFH levels?

Answer 25

through aPTT of anti-Xa activity

Question 26

how do you reverse heparin

Answer 26

protamine infusion

Question 27

Sheehan syndrome

Answer 27

hypopituitarism secondary to gland necrosis in the setting of previous hypotension

Question 28

most common electrolyte abnormality in Sheehan syndrome

Answer 28

hyponatremia

Question 29

how does adding epinephrine help with local anesthesia?

Answer 29

epinephrine causes vasoconstriction which reduces absorption of anesthetic increasing the duration