Pre & Post Op Care - Johns Flashcards
What is the role of a primary care physician in the medical evaluation of surgery?
- Estimate surgical risk from H&P, appropriate lab and x-ray
- Diagnose and manage medical problems that contribute to morbidity and mortality
What is the risk of Interoperate and Postoperative Death?
First 48 hours – 0.3% mortality
10% - induction of anesthesia
35% - operatively
55% - postop in first 48 hours
What are the causes of Interoperative and Postop Death in the first 48 hours?
Causes – 15% each
Failure to maintain adequate ventilation
Aspiration
Arrhythmia
Drug induced myocardial depression
Hypotension from blood lossHow are the surgical risks associated with the Physical Status of the Patient evaluated/classified?
ASA Physical Status Scale
Developed in 1940’s, modified since
Relies on accurate H & P
Estimates surgical risk
More recent studies show good correlation
with non-cardiac mortalityWhat are the three general categories of surgical risk?
- Physical status of patient
- Surgical factors
- Anesthesia factors
What are the 6 classes of the ASA Physical Status Scale?
Class 1: A normally healthy individual
Class 2: Patient with mild systemic disease
Class 3: Patient with severe systemic disease that is not incapacitating
Class 4: Patient with incapacitating systemic disease that is a constant threat to life.
Class 5: A moribund patient
E: Added to any class patient with emergency surgery (doubles any class 1-5)
What are the two major cardiologic effects of anesthetic agents?
1) Myocardial depression (all)
2) Arrhythmogenic properties
-Pre-op arrhythmia (PVC, a-fib)- 0.4% risk of serious
arrhythmia operatively
-Known pre-op heart disease- 3.9% risk
of serious arrhythmia operatively
-Therefore: Serious operative arrhythmias more
closely associated with underlying heart
disease than pre-op arrhythmias alone
What are the two cardiac risk factors in patients undergoing non-cardiac surgery?
1) Physiology of peri-operative period
2) Disturbance of cardiac performance
Increased cardiac 02 demand (tachycardia)
Diminished O2 supply (hypoxemia)
What are the surgical factors that affect surgical risk?
- Organ involved
- Extent of disease
- Skill of surgeon
- Length of surgical procedures
- Facilities
What are the anesthesia factors that affect surgical risk?
Spinal vs. general
-Risk of intraoperative hypotension same
-CHF may be worsened by general
anesthesia
-Gauthier (1983)- elderly patients with
hip surgery showed similar mortality
According to Gloldstein, what are the surgical AND anesthesia factors that affect surgical risk?
Poor physical status Poor physical fitness Cardiac disease (angina, CHF) Extremes of age The adult male Depression or anxiety Race (non-whites) Long duration of anesthesia and surgery Surgery of vital organs Complex surgery Emergency surgery Lack of skill, infrequent performance and excessive aggressiveness of surgeon
When do the majority of post-op MI’s occur?
Post-op MI’s
60% occur in first 3 days
70% occur by days 4-6
50% are silent
The mortality overall is 50-70%What are the treatment goals for hypokalemia for patients going into surgery?
Hypokalemia
Serum K should be over 3.0
If on digitalis should be over 3.5
What is an acceptable hemoglobin for a patient going into surgery?
Normal blood volume is more important than the actual hemoglobin value.
The hemoglobin should be over 10 if significant blood loss is expected during surgery.
What are the basic rules of elective surgery?
Hint: 9 rules
1) No surgery within 6 months of a M.I.
2) No surgery in the patient has active
CHF or its’ signs (crackles, S3).
3) Stable angina does not carry an increased
risk, unstable angina does.
4) Hypertension with a diastolic under 110
does not carry an increased risk.
5) Pre-op arrhythmias are more significant if
associated with underlying heart disease.
6) Potassium over 3.5 if on digitalis, 3.0 if not.
7) The hemoglobin should be over 10.0 in a
patient with coronary artery disease,
over 8.5 in other patients.
8) From a medical standpoint, spinal
anesthesia is not significantly safer than
general anesthesia. They are both safe.
9) In emergency surgery you have to weigh the
benefits and the risks, there are no firm rules!
