Pre-Operative Testing

Question 1

Joint Commission for the Accreditation of Hospitals requires all surgical patients to have a documented H&P in the medical record within _______ before surgery

Answer 1

30 days

Question 2

GOALS OF PREOP EVALUATION

5

Answer 2

1. Clearly defining the patients medical conditions
2. Evaluating the severity and stability of these conditions
3. Identifying unrecognized comorbid disease and risk factors for medical complications of surgery
4. Optimizing all medical conditions
5. Recommending perioperative measures to reduce the risk

Key is careful history and physical ~ 90% and 10%

Question 3

Routine testing often leads to what complications? 4

Answer 3

1. false positive results,
2. extra cost,
3. possible delay of surgery,
4. and medico-legal liability

Question 4

When laboratory tests are felt to be necessary, it is reasonable to use test results that were performed and were normal within the past what amount of time, unless there has been an change in clinical status?

Answer 4

4 months

Question 5

For healthy patients what should we accomplish before surgery? 2

Answer 5

1. Screening questionnaire and complete H and P***

2. Pregancy test for all women of reproductive age

Question 6

When are the following needed?

1. H&H?
2. Serum Cr? 2
3. Which labs should you not order? 5
4. ECG?
5. CXR and PFTs?

Answer 6

1. H&H not indicated unless major surgery if >65 or in younger patients if significant blood loss is expected
2. Serum creatinine only needed if:
   - Over 50 with intermediate or high risk surgery
   - Younger with anticipated hypotension or nephrotoxic drugs
3. • Electrolytes,
   • blood glucose,
   • liver enzymes,
   • hemostasis,
   • UA – not needed
4. ECGs not needed for patients with low risk procedures
5. CXR and PFTs not needed unless >50 with upper abdominal or thoracic surgery

Question 7

CBC
1. Anemia seen in only 1% of _________ patients

2. Unanticipated abnormalities in what are quite rare?
3. _______ where major blood loss expected?
4. All >___YO having major surgery

Answer 7

1. asymptomatic
2. WBC and platelet
3. Hb & Hct
4. 65

Question 8

KIDNEY FUNCTION TESTS

1. Renal insufficiency is an independant risk factor for?
2. And a major predictor of what?
3. What is the most senstive test for kidney function?
4. At what point do you have an increased cardiac risk with this pt?

Answer 8

1. Renal insufficiency is an independent risk factor for postop pulmonary complications and a
2. major predictor of postoperative mortality
3. Serum creatinine most sensitive test for kidney function
4. Increased cardiac risk if creatinine > 2 mg/dL
   -Rarely elevated in the asymptomatic patient (0.2%)
   Prevalence increases with age (9.8% ages 46-60)

Question 9

Order serum creatinine for who? 4

Answer 9

1. Order for patients >50 with:
2. moderate risk surgery
3. anticipated hypotension
4. possible use of nephrotoxic medication

Question 10

Unexpected abnormalities for electrolytes in what percent of patients?

Answer 10

Unexpected abnormalities in

Question 11

____________ is associated with an increase in perioperative 30-day morbidity and mortality, although the relationship between most electrolyte derangements and operative morbidity is not clear.

Answer 11

Hypernatremia

Question 12

Since clinicians can predict most abnormalities based on history… electrolytes are NOT routinely recommended unless:

4

Answer 12

1. on diuretics,
2. ACE inhibitor,
3. ARB or
4. has known renal disease

Question 13

Blood Glucose
1. ___% of patients over 60 have abnormal values

2. Asymptomatic __________ does not increase complications
3. The revised cardiac risk index identified diabetes as a risk factor for postop cardiac complications, however only patients with _________ diabetes were at risk
4. Surgical patients with diabetes do better if what is well controlled?

Answer 13

1. 25
2. hyperglycemia
3. insulin-treated
4. glucose

Question 14

LIVER FUNCTION TESTS

1. Patients with what have more M/M? 2
   - Patient will have signs and symptoms picked up on in H & P

Patients with mild abnormals and no known liver disease do fine

Answer 14

1. • cirrhosis and
   • acute liver failure

Question 15

HEMOSTASIS
1. What not recommended if the history, PE and family history do not suggest the presence of a bleeding disorder? 3

2. Incidence of bleeding disorders quite rare, even so, _______ is more sensitive then PT or PTT in predicting complications
3. Required for patients on what? 2
4. What is higher in hepatitis, ALT or AST?
5. Cirrhosis?

Answer 15

1. • Routine Platelet count,
   • PT/INR,
   • PTT
2. History
3. • anticoagulants and
   • neurosurgery
4. ALT >AST
5. AST>ALT

Question 16

1. PTT is associated with what pathway?
2. Screens all coagulation factors besides what? 2
3. PT/INR?
4. Factors?
5. INR normal?

Answer 16

1. Intrinsic pathway
2. VII and TF
3. Intrinsic pathway
4. FII, FVII, FV, FX, fibrinogen
5. 1

Question 17

URINALYSIS

1. What are we looking for? 2
2. UTI have potential to cause what complications? 2

Answer 17

1. Looking for renal disease or infection
   - Serum creatinine levels more sensitive for renal disease
2. UTI’s have the potential to
   - cause bacteremia and
   - post-surgical wound infections, particularly with prosthetic surgery.

Question 18

UA
1. Patients with positive UA and culture are managed how?

-However, it is unclear whether a positive preoperative urinalysis and culture with subsequent antibiotic treatment prevent post-surgical infection

Answer 18

1. are treated with antibiotics and proceed with surgery without delay

Question 19

ELECTROCARDIOGRAM
1. Abnormalities increase with what?

2. Detecting recent _____ important, increased M/M
3. Required for patients with what? 7
4. Can be considered for asymptomatic patients undergoing surgery with what?

Answer 19

1. age, rare under 45
2. MI’s
3. • CAD,
   • congestive heart disease,
   • arrhythmias,
   • structural heart disease
   • Peripheral artery disease or
   • cerebrovascular disease
   • Diabetes
4. elevated risk (risk of major adverse cardiac event ≥1%). ProfoudlyObesity*

Question 20

What is the leading cause of perioperative mortality?

Answer 20

CV events

Question 21

Revised cardiac risk index - Lee index (1 point each)

6

Answer 21

1. High risk surgery
2. Hx ischemic heart disease
3. Heart failure
4. Cerebrovascular disease
5. Insulin dependent diabetes 6. Creatinine > 2

Question 22

Resting ECG – increased risk with what? 2

Answer 22

presence of

• Q waves or
• significant ST segment elevation or depression

Question 23

SERIOUS CONCERNS? REFER TO CARDIOLOGIST. May need what? 3

Answer 23

may need

• stress testing,
• echo,
• revascularization

Question 24

CHEST X-RAYS
1. Not recommended unless what?

2. Recommended for patients with what? 2
3. Consider them for what? 2

Answer 24

1. Not recommended unless suspected cardiopulmonary disease
2. Recommended for patients with:
   - Known/suspected cardiopulmonary disease
   - > 50 undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery
3. Consider CXR for patients
   - AP and Lat for the morbidly obese (BMI >40)
   - Patients over 70 without risk factors

Question 25

PFTs
Pulmonary complications important source of morbidity/mortality

Risk factors? 5

Occult findings? 3

Answer 25

1. Age >50,
2. COPD,
3. CHF,
4. obstructive sleep apnea,
5. pulmonary hypertension

Occult:

1. exercise intolerance,
2. cough,
3. unexplained dyspnea

Question 26

PFT’s – spirometry, flow loops

necessary for who?

Answer 26

1. A must for patients having a lung resection
2. Unexplained dyspnea or exercise intolerance
3. COPD or asthma… has airflow been optimized?

Question 27

Look at slide 22 to review flow volume loops

Answer 27

22

Question 28

OBSTRUCTIVE SLEEP APNEA
Patients with OSA have an increased risk of complications

1. Which patients are OK to go to surgery without a new sleep study? 3
2. Who needs a sleep study? 3
   Start treatment prior to surgery

Answer 28

1. • Asymptomatic patients who
   • follow their treatment and
   • have not had weight changes since last sleep study
2. • Patients who have persistent symptoms,
   • who do not follow treatment and
   • have had changes in weight…

Question 29

Smokers:

1. Less likely to do what? 2
2. Test for abstinence?
3. Normal when?

Answer 29

1. Less likely to
   - heal fusions and
   - skin grafts
2. Test for abstinence - serum continine levels (Nicotine metabolite)
3. normal after 2 weeks of abstinence

Question 30

IMMUNOCOMPROMISED
are less likely to heal. Examples? 4

More likely to develop what?

Answer 30

1. HIV,
2. chemotherapy,
3. RA/psoriasis on biologics,
4. leukemias

More likely to develop an infection

Question 31

1. baseline hemoglobin measurement for all pts ____ years of age or older who are undergoing major surgery and for younger patients undergoing surgery that is expected to result in what?
2. serum creatinine in patients > ___ undergoing intermediate or high risk surgery,
3. and younger pts suspected of having what? 3
4. ECG should be part of the evaluation in patients with known what? 5
5. except for those undergoing ________ surgery.
6. chest x-ray in patients with what or undergoing what? 2

Answer 31

1. 65, significant blood loss
2. 50,
3. • renal disease,
   • when hypotension is likely during surgery, or
   • when nephrotoxic medications will be used.
4. • coronary artery disease,
   • significant arrhythmias,
   • peripheral arterial disease,
   • cerebrovascular disease, or
   • other significant structural heart disease
5. low-risk
6. • cardiopulmonary disease and
   • those older than 50 years of age who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery.