Pre/Post Op

Question 1

What factors independently predict cardiac risk factors for surgery? Revised Goldman Cardiac Risk Index

Answer 1

• • High Risk Surgery itself
• • Hx ischemic heart disease
• • CHF
• • CVD
• • DM requiring insulin
• • Creatinine 2.0+

Question 2

Factoring the cardiac risk factors for perioperative cardiac complications, how do you calculate risk for surgery?

Answer 2

Zero Factors – 0.4%
One Factor – 1.0%
Two Factors – 2.4%
Three or more – 5.4%

Question 3

What patients with how many cardiac risk factors can be considered low risk?

Answer 3

Low Risk is considered Score of 0 or 1 – RCRI

– No further cardiac testing is required or risk stratification

Question 4

What is the index used to gauge cardiac risk factor for surgery?

Answer 4

Revised Goldman Cardiac Risk Index (RCRI)

Question 5

What kind of patients require further risk stratification for surgery?

Answer 5

• • 2 or more RCRI factors

- - Considered elevated risk for major adverse event

Question 6

What has been found to be an accurate predictor of perioperative or long term events from surgery?

Answer 6

Functional Status

– Metabolic Equivalents

Question 7

What are metabolic equivalents that can be used to stratify risk for surgery and not require any further evaluation?

Answer 7

• – Climbing a flight of stairs
• – Walking up a hill
• – Performing heavy household work
• – Rigorous Sports activities

Question 8

When should a patient undergo a cardiac stress test or echocardiogram before surgery?

Answer 8

A patient who already needs one.

• • Unstable Angina
• • Arrhythmia
• • Uncompensated CHF
• • Severe valvular disease

Question 9

If a patient has recently had an MI and recovering, but was scheduled for a cholecystectomy, when should it be rescheduled?

Answer 9

8 weeks after the MI at the minimum

Question 10

Who should receive a EKG prior to surgery?

Answer 10

– Any patient undergoing intermediate-risk procedures with at least 1x RCRI risk factor, this is in order to compare it to an EKG afterward to know if any events occurred during the procedure.

Question 11

If a patient with CHF and DM is undergoing cataracts removal, what needs to be done prior to that procedure?

Answer 11

No EKG needs to be performed for any patients undergoing an low-risk surgery.

Question 12

What hepatic functions are measured to assess the hepatic risk for surgery using the Child-Pugh score?

Answer 12

• Albumin
• Bilirubin
• Encephalopathy
• Ascites
• PT (INR)

Question 13

What is a hepatic risk factor that is an absolute contraindication for elective surgery?

Answer 13

Acute Hepatitis

Question 14

What should be evaluated and corrected in a patient with liver disease before they undergo surgery?

Answer 14

• • Renal Function
• • Electolytes
• • Bleeding Time (PT/PTT)
• • Encephalopathy
• • Nutritional status

Question 15

If a patient has prolonged bleeding time, what can be used to correct it for surgery?

Answer 15

Bleeding Time –> Desmopressin
If INR Elevated
– Vitamin K
– Fresh Frozen Plasma

Question 16

If a patient has Afib and is going to undergo an elective cholecystectomy, what should you instruct the patient to do before surgery?

Answer 16

Discontinue taking Warfarin 3-4 days before surgery and to check INR to ensure it is below 1.5 before proceeding with surgery.

Question 17

If a patient has a history of PE after surgery before in the past and is on Warfarin, how should you manage the patient differently?

Answer 17

The patient should be bridged with Heparin after stopping Warfarin (LMWH) before surgery, then resuming warfarin immediately post-op and Heparin is resumed 12 hours after surgery.

Question 18

What are the increased surgical complications associated with diabetes mellitus?

Answer 18

• Increased risk of infection
• Delay in wound healing
• Increased cardiac complications
• Increased mortality post-operatively

Question 19

What might need to be adjusted in diabetic patients post operatively?

Answer 19

Insulin dose should go up. This is due to the body being under stress and elevated cortisol that releases more glucose

Question 20

What should be done with a patient who has renal insufficiency preoperatively and will be receiving intraoperative contrast?

Answer 20

• • Ensure proper hydration and give Isotonic fluids prior to surgery to prevent volume loss
• • Acetylcysteine can be used to limit contrast induced nephropathy

Question 21

What are indicators of severe nutritional depletion?

Answer 21

• • Anergy to skin antigens
• • Albumin less than 3g/dL
• • Serum transferrin less than 200 mg/dL
• • Significant weight loss (more than 20% body weight) over the span of several months

Question 22

If patient has signs of severe nutritional depletion how should surgeries be handled?

Answer 22

Should be postponed until patient is optimized nutritionally in order for them to heal properly

Question 23

What is the best indicator of nutritional status?

Answer 23

Prealbumin, malnutrition indicated by less than 16 mg/dL

– Short half-life 2-3, so can be a good snapshot of nutritional status

Question 24

What are conditions that can cause prealbumin to be decreased, despite normal nutrition?

Answer 24

Physiologic Stressors
Infections
Liver Dysfunction
Over-hydration

Question 25

What are the best predictors of post-operative pulmonary complications?

Answer 25

Abnormal Pulmonary Function Test

Question 26

How should receive a pulmonary function test prior to undergoing surgery?

Answer 26

Patients who have underlying pulmonary disease and clinical evaluation is unclear whether they are at their baseline airflow and airways are optimally reduced

Question 27

What is the best way to reduce post-operative respiratory complications?

Answer 27

Smoking Cessation at least 4 weeks prior to surgery

Question 28

What is the FEV1 requirement for a patient in order to have a lobectomy undergone?

Answer 28

Greater than 1.5L

Question 29

What is the FEV1 requirement for a patient to undergo a pneumonectomy?

Answer 29

Greater than 2L