Pre-operative Management

Question 1

What is included in Pre-Op Clearance?

This is generalized to fit across specialities

Answer 1

• Determination of surgical risk
• Pre-op H&P
• Pre-op labs
• Management of specific conditions
• Peri-op medication management
• Pre-procedure prophylaxis
• Surgical documentation

Question 2

What mortality/MI risk qualifies the procedure as high risk?

Answer 2

> 5% risk for mortality/MI

Question 3

What are some high risk procedures?

Answer 3

• > 5% risk for mortality/MI
• Emergent procedures
• Aortic/major vascular procedure
• Peripheral vascular procedures

Question 4

What are considered intermediate risk procedures?

Answer 4

• 1-5% risk
• Head/neck procedures
• Carotid endarterectomy
• Most orthopedic procedures
• Prostatectomy
• Intraperitoneal/intrathoracic surgery

Question 5

Laparoscopic procedures fall under what procedure risk catagory?

Answer 5

Low Risk

< 1% risk for mortality/MI

Question 6

What should be included in the pre-op H&P

Answer 6

HPI, Vitals, ROS, Exam
* Include last oral intake
* Highlight previous episodes/treatment
* Clarify acute/sudden onset for emergent patients
* At least heart, lung and applicable systems; ideally full physical

PMH
* Medical co-morbidities
* Past surgical procedures/anesthesia

FH, SH

Allergies, Medications

Where you need to document appropriately so that insurance covers

Question 7

What is malignant hyperthermia?

Where should it be documented in the pre-op H&P?

Answer 7

Anesthesia complication –> allergic reaction to anesthesia!

Family History or Allergies

Question 8

What are some specific allergies to include in the allergy section of the pre-op H&P?

Answer 8

• Latex
• Betadine/iodine
• Antibiotics

Question 9

Do you ask about herbal meds/supplements during the pre-op H&P?

Answer 9

Yes, this is pertinent information for the pre-op H&P because some can interact with meds/anesthesia, or increase bleeding risk

Kava Kava can prolong anesthesia

Question 10

Initial surgical consent should be done by whom?

Who can act as a proxy?

Answer 10

The surgeon

Residents in an emergency

PAs as a proxy is much more of a grayer area

Question 11

What surgery complications are associated or at higher risk due to obesity?

What is the goal BMI

Answer 11

Thromboembolism and infection

< 40

Question 12

OSA increases what surgical complication risks?

Answer 12

Respiratory/cardiovascular complications

Question 13

What is the STOPBANG questionnaire?

Answer 13

OSA screening questionnaire

Question 14

What medication can be considered for alcohol withdrawal prophylaxis to avoid post-op complications (withdrawal)?

Answer 14

Benzodiazepines PRN

Question 15

Is MAT designed for pain control?

Answer 15

NO! Doesn’t work for pain, pain medication post-op must go beyond current dose of opioids for pain relief

Question 16

When using spinal/epidural anesthesia what lab value should be collected as part of pre-op labs?

Answer 16

Platelets

Order CBC

Question 17

Hyperglycemia increases post-op complications in what procedures?

Answer 17

Cardiac, Vascular, and Ortho procedures

Question 18

Cotinine is a by product of what?

When should it be ordered pre-op?

Answer 18

Nicotine

In smokers, nicotine users

Question 19

How long can cotinine be measured in the system after quitting nicotine products?

Answer 19

Up to 6 weeks

Question 20

When should a PT/INR be drawn during pre-op labs?

Answer 20

• Occassionally get as baseline
• Patients on Coumadin or with liver disease
• Neet to repeat screen day of surgery (fingerstick)

Question 21

What nutrition marker can be drawn prior to surgery to evaluate nutritional status?

Is it specific?

Answer 21

Albumin/Pre-albumin

No, but the best we got

Question 22

For patients that are MRSA or MSSA carriers what can be used to decolonize pre-operatively to reduce risk?

Answer 22

Mupirocin ointment and hibiclens pre-op

Question 23

Who should have a pregnancy test prior to surgery?

When should a pregnancy test be ordered prior to surgery?

Answer 23

All women of childbearing age unless documented hysterectomy or tubal ligation

Morning of surgery

Question 24

What patients should receive an EKG prior to surgery?

Answer 24

• Routine screening for patients age 45+
• High risk for cardiac event

Question 25

When should anti-platelet therapy be discontinued prior to surgery?

What about Coumadin?

Answer 25

7- days

5- days

Question 26

When should newer anticoagulants (Xa inhibitors) be discontinued prior to surgery?

As with other anticoagulant therapies, when should they be resumed?

Answer 26

2-3 days

Resume according to surgeons preference

Question 27

For patients on Coumadin, how do you determine if they need Lovenox bridging prior to surgery?

Answer 27

CHADS-VASc Score >/= 5

Question 28

What is the target peri-op glucose level?

Answer 28

110-180 mg/dL

Question 29

The presence of rheumatologic disorders increases what surgical risks?

Answer 29

Surgical site infection and increased cardiovascular complication risk

Question 30

Is it considered safe to continue methotrexate or hydroxychloroquine for surgery?

Answer 30

Despite risk of increase SSI and poor wound healing it is considered safe to continue because the risks of the disease are worse than risk of maintaining drug

Question 31

Should psych medications be held for surgery?

What is a risk associated?

Answer 31

No

Be aware of increased bleeding risk for some agents