PreOp Flashcards
1
Q
- What is the purpose of preoperative evaluation?
A
The purpose of preoperative evaluation is to gather information to formulate an anesthetic plan, assess the risk of perioperative complications, implement risk‐reduction strategies to improve postoperative recovery, and order any indicated tests or consultations. (189)
2
Q
- What are the essential components of a complete preoperative evaluation?
A
It includes a detailed medical and anesthetic history, review of medications, assessment of the patient’s functional capacity (in METs), physical examination (with special emphasis on the airway, cardiovascular and pulmonary systems, and neurologic status), and review of prior tests and consultations with additional testing ordered as indicated. (189)
3
Q
- How does the anesthesiologist classify a patient’s physical status?
A
The anesthesiologist uses the ASA Physical Status Classification system, ranging from ASA 1 (healthy) to ASA 6 (brain‐dead organ donor), with an “E” added for emergency surgery. (190)
4
Q
- How is the patient’s functional status determined?
A
Functional status is determined by assessing the patient’s ability to perform activities measured in metabolic equivalents (METs); for example, walking one to two blocks corresponds to about 3 METs, while climbing one to two flights of stairs equals about 5 METs. (190)
5
Q
- Why is it important to assess the patient’s functional status?
A
Because functional capacity is predictive of perioperative risk; patients who can achieve at least moderate activity (MET ≥ 4) generally have a lower risk of perioperative complications. (190)
6
Q
- How much oxygen is consumed when performing one metabolic equivalent of task (MET) of activity?
A
One MET is equivalent to an oxygen consumption of 3.5 mL O2/min per kilogram of body weight. (191)
7
Q
- Why is evaluation of the airway important?
A
Airway evaluation is critical to predict difficult endotracheal intubation or mask ventilation, ensuring that necessary equipment and skilled personnel are available for safe airway management. (191)
8
Q
- What are the components of the airway examination?
A
The airway exam assesses the condition of the teeth, the ability to advance or protrude the mandible, tongue size, visibility of structures (using Mallampati classification), mandibular compliance, presence of facial hair, thyromental distance, and neck mobility. (191)
9
Q
- Is “screening” preoperative testing indicated for every patient?
A
No. Routine screening tests without specific clinical indications rarely alter management and are not cost‐effective. (191)
10
Q
- When should preoperative tests be ordered?
A
Tests should be ordered when they are indicated by the patient’s clinical history, comorbidities, or physical findings – particularly if the results may influence the decision to proceed or modify the anesthetic plan. (191)
11
Q
- Should all patients of a certain age receive a preoperative electrocardiogram (ECG)?
A
Age alone is not an indication; a preoperative ECG is obtained based on clinical risk factors and specific indications rather than age alone. (192)
12
Q
- What are the recommendations for obtaining a preoperative ECG?
A
A 12‐lead ECG is indicated in patients with suspected electrolyte abnormalities, arrhythmias, active cardiac conditions, pulmonary hypertension, or on digoxin; it is not routinely indicated for low-risk surgery. (192)
13
Q
- How effective are ECG findings for predicting a major adverse cardiac event (MACE)?
A
ECG findings have not been shown to predict MACE beyond what is indicated by clinical risk factors. (192)
14
Q
- Do all females of childbearing years require a β-human chorionic gonadotropin (β-hCG) assay prior to surgery?
A
Pregnancy testing should be offered to women of childbearing age; policies vary by institution, but it is not mandatory in every case. (192)
15
Q
- Why might preoperative tests be useful when evaluating patients with severe comorbid conditions and undergoing intermediate- or high-risk procedures?
A
They help establish a diagnosis, predict risk, and guide therapy, ensuring that any significant abnormalities are addressed or optimized before surgery. (192-193)
16
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative albumin level testing useful?
A
Conditions such as anasarca, liver disease, malnutrition, or malabsorption may warrant albumin testing. (192-193)
17
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative complete blood count (CBC) with platelets testing useful?
A
A history of alcohol abuse, anemia, dyspnea, hepatic or renal disease, malignancy, poor exercise tolerance, or recent chemotherapy/radiation may indicate the need for CBC with platelets. (192-193)
18
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative creatinine level testing useful?
A
Patients with renal disease or those at risk for kidney disease should have creatinine testing. (192-193)
19
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make obtaining a preoperative chest radiograph useful?
A
Patients with active or chronic pulmonary symptoms, unexplained abnormal chest findings, decompensated heart failure, thoracic malignancy, or history of chest radiation. (192-193)
20
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make obtaining a preoperative ECG useful?
A
Patients with a history of alcohol abuse, active cardiac conditions, arrhythmias, implanted devices, obstructive sleep apnea, severe obesity, syncope, or on digoxin/amiodarone may benefit from a preoperative ECG. (192-193)
21
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative electrolyte testing useful?
A
Those with histories of alcohol abuse; cardiovascular, hepatic, renal, or thyroid disease; diabetes; malnutrition; or on digoxin/diuretics. (192-193)
22
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative glucose level testing useful?
A
Patients with diabetes, severe obesity, or those on steroids. (192-193)
23
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative liver function tests (LFTs) useful?
A
Patients with a history of alcohol abuse, hepatic disease, recent hepatitis exposure, or an undiagnosed bleeding disorder. (192-193)
24
Q
- Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative platelet count testing useful?
A
Those with a history of alcohol abuse, hepatic disease, bleeding disorders, hematologic malignancies, recent chemotherapy/radiation, or known thrombocytopenia. (192-193)
25
25. Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative prothrombin time (PT) testing useful?
Patients with alcohol abuse, hepatic disease, malnutrition, bleeding disorders, or on anticoagulants may require PT testing. (192-193)
26
26. Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative partial thromboplastin time (PTT) testing useful?
Those with personal or familial bleeding disorders, undiagnosed hypercoagulable states, or on unfractionated heparin. (192-193)
27
27. Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative thyroid function testing (TFT) useful?
Patients with goiter, thyroid disease, unexplained dyspnea, fatigue, palpitations, or tachycardia. (192-193)
28
28. Which patient comorbid conditions when undergoing intermediate- or high-risk procedures may make preoperative urinalysis useful?
When a urinary tract infection is suspected. (192-193)
29
29. Are any patient-specific baseline tests indicated before anesthesia?
Yes; for example, creatinine levels (if contrast is planned), hemoglobin/hematocrit for blood loss risk, type and screen for transfusion likelihood, and targeted tests based on clinical findings. (192-193)
30
30. What is the purpose of a preoperative consultation?
Its purpose is to diagnose, evaluate, or optimize new or poorly controlled conditions, and to create a detailed clinical risk profile to guide safe anesthetic planning. (192-193)
31
31. Is a consultation letter stating 'cleared for surgery' or 'low risk' adequate?
No; a comprehensive consultation should include a summary of the patient’s medical issues, test results, and specific therapeutic recommendations to ensure safe anesthetic management. (192-193)
32
32. For which comorbid conditions are hypertensive patients at risk?
Hypertensive patients are at risk for end-organ damage including ischemic heart disease, heart failure, renal insufficiency, and cerebrovascular disease. (193)
33
33. Should surgery be delayed because of elevated blood pressure (BP)? What is severe hypertension?
Surgery is generally not delayed if BP is below 180/110 mm Hg; severe hypertension (systolic >200 mm Hg or diastolic >110 mm Hg) is an independent risk factor for MI and may warrant delay and optimization. (193)
34
34. Is there a risk in normalizing BP in hypertensive patients?
Yes; aggressive BP reduction can cause cerebral or coronary ischemia. Intraoperative BP should be maintained within 20% of the patient’s baseline. (194)
35
35. How is a patient with known or risk factors for coronary artery disease evaluated prior to noncardiac surgery?
Evaluation is guided by a stepwise algorithm using risk stratification tools such as the Revised Cardiac Risk Index (RCRI) and assessment of functional capacity, with further testing as indicated by clinical status. (194)
36
36. What is the Revised Cardiac Risk Index (RCRI)?
The RCRI is a tool that assesses the risk of major adverse cardiac events (MACE) based on specific clinical criteria. (194)
37
37. What are the six criteria that are incorporated in the RCRI?
They include: presence of ischemic heart disease, history of heart failure, history of cerebrovascular disease, insulin-dependent diabetes mellitus, creatinine ≥2 mg/dL, and undergoing high-risk surgery (intrathoracic, intra-abdominal, or suprainguinal vascular procedures). (194)
38
38. How long should a patient wait after coronary revascularization before undergoing elective noncardiac surgery?
The waiting period depends on the revascularization type and duration of dual antiplatelet therapy: typically 1 month after a bare metal stent and 6-12 months after a drug-eluting stent, with careful risk assessment if surgery is urgent. (196)
39
39. What are the current recommendations for use of perioperative β-blockade and statins for cardiovascular risk reduction?
Patients on chronic β-blockers should continue them, and perioperative statin therapy should be continued—and may be initiated in patients with appropriate indications, especially in vascular surgery. (196)
40
40. What are the main types of heart failure? What are common causes of each type?
The two main types are systolic dysfunction (often due to ischemic heart disease) and diastolic dysfunction (commonly associated with hypertension and advanced age); many patients may have a mixed picture. (196)
41
41. Should patients with advanced or decompensated heart failure undergo anesthesia?
Elective surgery should be postponed in patients with decompensated heart failure; patients with class IV heart failure face high perioperative risk and require careful evaluation and planning. (196)
42
42. When is a preoperative echocardiogram indicated in patients with heart failure?
It is indicated when there are new or worsening symptoms, recent changes in clinical status, or unexplained dyspnea. (196)
43
43. Are all cardiac murmurs associated with valvular disease?
No; functional murmurs due to high-output states (e.g., in hyperthyroidism, pregnancy, or anemia) are not necessarily indicative of valvular pathology. (196)
44
44. Which cardiac murmurs are always pathologic?
Diastolic murmurs are always considered pathologic. (196)
45
45. What are some clinical clues that suggest a patient may have valvular disease?
Clues include advanced age, a history of coronary artery disease or rheumatic fever, signs of volume overload, pulmonary disease, cardiomegaly, and abnormal ECG findings. (196)
46
46. When is a preoperative echocardiogram indicated in a patient with a cardiac murmur?
It is indicated if moderate or greater valvular abnormalities are suspected, if the patient is to undergo general or spinal anesthesia, or if there has been a significant change in clinical status. (196)
47
47. Should patients with valvular disease undergo elective surgery?
Patients with stable valvular disease may proceed with surgery if appropriate monitoring and management are planned; if intervention is indicated, it should precede elective noncardiac surgery. (196)
48
48. For which patients is prophylaxis for infective endocarditis indicated? For which procedures?
Prophylaxis is recommended for patients with prosthetic cardiac valves, previous infective endocarditis, certain congenital heart diseases, and cardiac transplant recipients with abnormal valves; it is primarily indicated for dental procedures involving gingival manipulation. (198)
49
49. What conditions typically prompt placement of a pacemaker or implantable cardioverter-defibrillator (ICD)?
Patients with heart failure, cardiomyopathies, or potentially life-threatening arrhythmias may require pacemakers or ICDs. (198)
50
50. What challenges does a cardiac implantable electronic device (CIED) present perioperatively? What are the potential risks to the patient?
CIEDs can be affected by electromagnetic interference (EMI) from surgical equipment (e.g., monopolar cautery), potentially causing inappropriate pacing or ICD discharges; proper reprogramming or use of magnets is required to minimize risk. (198)
51
51. What is the typical response to a magnet for an ICD? For a pacemaker? For an ICD in a patient who is also pacemaker dependent?
A magnet usually suspends the antitachycardia function of an ICD and sets a pacemaker to asynchronous mode at a manufacturer-determined rate; however, in pacemaker-dependent patients with dual-function devices, reprogramming is recommended rather than relying solely on a magnet. (198-199)
52
52. Are there any procedures for which electromagnetic interference (EMI) of a CIED is not a concern?
EMI is rarely a concern for procedures below the umbilicus, especially when bipolar cautery is used. (199)
53
53. What clinical conditions are predictors of postoperative pulmonary complications (PPCs)?
Advanced age, heart failure, COPD, smoking, impaired sensorium or functional dependency, and obstructive sleep apnea are predictors of PPCs. (199)
54
54. What methods are effective at reducing the rate of PPCs?
Optimizing treatment for obstructive disease, treating infections, managing heart failure, and postoperative use of incentive spirometry, deep breathing exercises, PEEP, and CPAP are effective methods. (200)
55
55. Are specific tests predictive of PPC risk?
No; routine pulmonary function tests, chest radiographs, or arterial blood gas analyses do not reliably predict or lower PPC risk. (200)
56
56. What is obstructive sleep apnea (OSA)?
OSA is characterized by intermittent airway obstruction or significant oxygen desaturation during sleep. (200)
57
57. Which comorbid conditions are associated with OSA?
OSA is associated with diabetes, hypertension, atrial fibrillation, arrhythmias, stroke, heart failure, pulmonary hypertension, and dilated cardiomyopathy. (200)
58
58. What components of the patient’s history or physical examination can identify those at risk of OSA? Is there a questionnaire that predicts the diagnosis of OSA?
The STOP-BANG questionnaire—covering snoring, tiredness, observed apneas, high blood pressure, BMI ≥35, age ≥50, neck circumference >40 cm, and male gender—is used; three or more affirmative answers indicate high risk. (201)
59
59. What impact does OSA have for anesthesia?
OSA increases the risk of perioperative airway obstruction, hypoxemia, atelectasis, ischemia, pneumonia, reintubation, and prolonged hospital stays. (201)
60
60. Should patients having anesthesia bring their continuous positive airway pressure (CPAP) devices to the hospital?
Yes, patients who use CPAP at home should bring their device for perioperative use. (201)
61
61. What are the ASA recommendations for perioperative care of patients with OSA?
The ASA recommends that patients with OSA be diagnosed and treated preoperatively and that the risk of ambulatory surgery be carefully considered due to higher rates of complications. (201)
62
62. What body mass index (BMI) defines extreme obesity?
A BMI greater than 40 defines extreme obesity. (201)
63
63. Which comorbid conditions are associated with obesity?
Obesity is associated with OSA, heart failure, diabetes, hypertension, pulmonary hypertension, difficult airway management, and decreased arterial oxygenation. (201)
64
64. What physiologic effects can chronic hyperglycemia have on the organs?
Chronic hyperglycemia can lead to renal insufficiency, strokes, peripheral neuropathies, visual impairment, and cardiovascular disease. (201)
65
65. What perioperative complications can result from chronic hyperglycemia?
Impaired wound healing, increased surgical site infections, and bloodstream infections are possible complications. (201)
66
66. If a diabetic patient has preoperative hyperglycemia, should the surgery be canceled? Is there benefit to acutely lowering the blood glucose?
Surgery should not be canceled solely for hyperglycemia if there is no ketosis or dehydration; acutely lowering blood glucose is unlikely to alter outcomes significantly, though optimal control is desirable for elective high-risk surgery. (201)
67
67. What is the clinical significance of renal disease in the preoperative patient?
Renal disease can lead to hypertension, cardiovascular disease, volume overload, electrolyte disturbances, and metabolic acidosis, which may affect anesthetic drug selection and management. (201)
68
68. Is renal insufficiency a risk factor for perioperative complications?
Yes, renal insufficiency increases perioperative risk. (201)
69
69. When should a patient with end-stage renal disease receive dialysis before surgery?
Dialysis should be performed within 24 hours of surgery but not immediately prior, to avoid acute volume depletion and electrolyte imbalances. (201)
70
70. Should surgery be canceled if a dialysis patient has a preoperative potassium level of 5.8 mEq/dL?
No; if the potassium is less than 6 mEq/dL and consistent with the patient’s baseline, surgery can proceed. (201)
71
71. Does radiocontrast medium worsen renal function in normal patients?
It transiently decreases GFR in most patients; those with diabetes or preexisting renal insufficiency are at highest risk. (201)
72
72. Can the risk of renal injury be reduced in patients receiving radiocontrast medium?
Yes; adequate hydration and maintaining appropriate mean arterial pressure can reduce the risk, particularly in patients with GFR <60 mL/min. (201)
73
73. Does anemia predict perioperative morbidity and mortality risks?
Yes; anemia is associated with increased perioperative morbidity and mortality. (202)
74
74. Does a patient with anemia require further evaluation to identify its cause before elective surgery?
Yes; evaluating and correcting anemia preoperatively is important, particularly for elective high-risk procedures, to reduce transfusion needs and improve outcomes. (202)
75
75. What is the clinical significance of advanced age in the preoperative patient?
Advanced age is associated with a higher likelihood of comorbid conditions and altered pharmacodynamics, necessitating careful evaluation and possible dose adjustments. (202)
76
76. Are elderly patients at a higher risk for hospital admission after ambulatory surgery?
Yes; patients over 85 years with recent hospital admissions are at higher risk for postoperative hospital admission following ambulatory surgery. (202)
77
77. How does a patient’s do-not-resuscitate (DNR) status transfer from the hospital ward to the operating room?
DNR policies should be reviewed and discussed with the patient or surrogate preoperatively; options include full suspension of directives or modification of resuscitative efforts tailored to the patient’s goals. (202)
78
78. What are some patient, procedural, and logistical factors the anesthesiologist considers when choosing an anesthetic technique?
Factors include patient comorbidities, aspiration risk, age, airway management, coagulation status, previous anesthetic history, surgical site and duration, positioning, postoperative disposition, and equipment/analgesia availability. (202)
79
79. What side effects of general anesthesia are commonly disclosed to patients?
Common side effects include dental injury, sore throat, hoarseness, postoperative nausea/vomiting, drowsiness, confusion, and urinary retention; severe but rare risks include awareness, vision loss, aspiration, organ failure, malignant hyperthermia, and death. (202)
80
80. What side effects of regional anesthesia are commonly disclosed to patients?
Regional anesthesia may cause prolonged numbness/weakness, post-dural puncture headache, and block failure; rare but severe complications include bleeding, infection, nerve damage, seizures, and, in extreme cases, permanent deficits. (202)
81
81. Why is an accurate assessment of risk important?
It ensures effective communication with the patient and surgeon, aids in making informed decisions about delaying or canceling surgery, and is essential for obtaining informed consent. (202)
82
82. What risk assessment tools are available?
Tools include the ASA Physical Status Classification and the ACS NSQIP risk calculator available online. (202)
83
83. How is informed consent obtained?
Informed consent is obtained after discussing the indications, risks, benefits, and alternatives with the patient in clear language, ensuring that the patient understands and agrees to the proposed plan. (202)
84
84. Should all medications be continued perioperatively?
Medications should be evaluated individually; generally, essential medications like cardiac drugs and non-loop diuretics are continued, while others may be withheld as clinically indicated. (202)
85
85. Should β-adrenergic blockers be continued preoperatively?
Yes, they should be continued in patients already taking them for angina, arrhythmias, or hypertension. (202)
86
86. Should statins be continued preoperatively?
Yes, statins should be continued because they reduce the risk of adverse events such as stroke, MI, and renal dysfunction. (202)
87
87. Should ACE inhibitors or ARBs be continued preoperatively?
ACEIs or ARBs may be discontinued 12–24 hours before surgery if used solely for hypertension, especially if significant blood loss or fluid shifts are anticipated, but should be continued in patients with heart failure or CAD. (202)
88
88. How is aspirin managed perioperatively?
Aspirin is managed based on the risk of bleeding versus thrombotic risk; for primary prevention, it may be stopped 5–7 days before surgery, whereas in high-risk patients (e.g., those with stents), low-dose aspirin is usually continued. (204)
89
89. How are antiplatelet agents managed for regional/neuraxial anesthesia?
Management follows ASRA guidelines, with agents such as clopidogrel being withheld for 7 days in intermediate- and high-risk procedures; aspirin may be withheld for 6 days in low-risk settings if used for primary prevention. (204-206)
90
90. How are anticoagulants managed for regional/neuraxial anesthesia?
Anticoagulants are managed per ASRA guidelines: IV heparin is held for 4 hours, subcutaneous heparin for 8–10 hours, LMWH for 12 hours (prophylactic) or 24 hours (therapeutic), and warfarin is stopped for 5 days prior to surgery. (207-209)
91
91. For which patients is bridging anticoagulation indicated?
Bridging is indicated for high-risk patients (e.g., those with mechanical heart valves, recent stroke/TIA, high CHADS2 scores, or severe thrombophilia) with an annual thrombotic risk >10%. (207-209)
92
92. If warfarin is being withheld before surgery, for how many days should it be stopped?
Warfarin is typically stopped 5 days before surgery to allow the INR to fall to less than 1.5. (207-209)
93
93. When should LMWH be discontinued before surgery?
LMWH should be discontinued 12 hours before surgery for prophylactic dosing and 24 hours for therapeutic dosing. (207-209)
94
94. What should be done if the INR is elevated near the day of surgery?
A small dose of vitamin K (1–5 mg orally or subcutaneously) can be administered to reverse anticoagulation if the INR is elevated. (207-209)
95
95. In which patients is LMWH contraindicated?
LMWH is contraindicated in patients with creatinine clearance <40 mL/min, body weight >150 kg, porcine allergy, heparin-induced thrombocytopenia, or a history of bleeding complications on LMWH. (207-209)
96
96. How should insulin dosing for type 1 and type 2 diabetics be managed preoperatively?
Type 1 diabetics should take half of their usual intermediate- to long-acting insulin on the day of surgery, while type 2 diabetics may take none or up to a half-dose; adjustments should be made to avoid hypoglycemia. (207-209)
97
97. Should ultra-long-acting insulin such as glargine be continued on the day of surgery?
Yes, ultra-long-acting insulin should be continued, but the dose should not exceed 1 unit/kg on the day of surgery. (207-209)
98
98. Does metformin need to be withheld on the day of surgery? Should surgery be canceled if a patient has taken metformin?
Metformin is held on the day of surgery; however, it does not cause hypoglycemia during fasting and surgery does not need to be canceled if a patient has taken it. (207-209)
99
99. Should oral hypoglycemic drugs be withheld on the day of surgery?
Yes, oral hypoglycemics are generally withheld on the day of surgery to avoid hypoglycemia in fasting patients. (209)
100
100. Which medications should be continued on the day of surgery?
Essential medications such as asthma drugs, cardiac medications, birth control pills, seizure medications, steroids, thyroid medications, and certain autoimmune medications should be continued. (209)
101
101. Which medications should be discontinued for surgery?
Medications like entanercept, infliximab, and adalimumab are generally discontinued, but this should be confirmed with the prescribing physician and surgeon. (209)
102
102. Which herbal medication should not be discontinued abruptly before surgery?
Valerian should not be abruptly discontinued due to the risk of withdrawal. (209)
103
103. Is neuraxial anesthesia contraindicated in patients taking herbal medications?
No, herbal medications are not an absolute contraindication to neuraxial or regional anesthesia, although in high-risk procedures with bleeding concerns, discontinuation may be recommended. (209)
104
104. Should psychiatric medications be continued preoperatively?
Yes, psychiatric medications are typically continued to avoid exacerbation of psychiatric conditions. (209)
105
105. Should monoamine oxidase inhibitors (MAOIs) be discontinued before surgery?
No, MAOIs should be continued because discontinuation can cause severe depression or withdrawal; the anesthetic plan should be adjusted instead. (209)
106
106. Should narcotics, anxiolytics, or nicotine replacement be discontinued before surgery?
No, these medications should generally be continued to prevent withdrawal symptoms and maintain patient comfort. (209)
107
107. Should patients taking oral steroids take the steroid on the day of surgery?
Yes, patients should take their usual dose of oral steroids on the day of surgery. (209)
108
108. How much cortisol does a patient typically produce a day?
A patient typically produces about 30 mg of cortisol daily, which is equivalent to 5–7.5 mg of prednisone. (209)
109
109. Which patients are at risk for adrenal insufficiency?
Patients taking more than 5–20 mg/day of prednisone (or equivalent) for over 3 weeks are at risk for HPA suppression and adrenal insufficiency. (209)
110
110. What risks are associated with high-dose steroids?
High-dose steroids are associated with increased risk of infections, psychosis, poor wound healing, and hyperglycemia. (209)
111
111. How should perioperative glucocorticoids (stress-dose steroids) be dosed for a patient on chronic steroids?
Dosing should be tailored to the surgical stress: for minor procedures about 25 mg/day hydrocortisone equivalent, for moderate stress 50–75 mg/day for 1–2 days, and for major surgery 100–150 mg/day for 2–3 days, then resume the usual dose. (209)
112
112. What medications can be offered preoperatively to patients with a history of severe postoperative nausea and vomiting (PONV)?
A scopolamine patch, applied 2–4 hours preoperatively, can be used (noting that it is contraindicated in patients with angle-closure glaucoma). (209)
113
113. Who is at risk for pulmonary aspiration, and how should these patients be premedicated?
Patients at risk include laboring parturients, those with intra-abdominal masses, nonfasting patients, or those with gastroesophageal reflux; premedication with H2 antagonists, proton pump inhibitors, nonparticulate antacids, and prokinetic agents may help. (209)
114
114. What are the guidelines for food and fluid intake for adult patients before elective surgery?
For patients without aspiration risk: a light meal and clear liquids up to 6 hours before surgery, breast milk up to 4 hours before, and clear liquids up to 2 hours before; no solids or liquids within 2 hours. For high-risk patients, no intake within 8 hours is recommended. (209)
