preop assessment

Question 1

CV, PULM, ENDO, COAG effects of anesthesia and surgery

Answer 1

CV: peripheral vasodilation causing hypotension (d/t blocking sympathetic system)
pulm: less TV and FRC bc it closes small airways & can cause atelectasis
Endocrine: Epi, NE, cortisol increases for up to 3 days after; serum ADH for up to 1 week (water retention & hyponatremia)
Coag: hypercoag & more inflammation

Question 2

6 parts of a pre-op assessment

Answer 2

1. h & P
2. RCRI, STS risk calculator or NSQUIP to assess risk
3. ACC/AHA– over 4 METS = no further cardiac testing if intermediiate or low risk procedure
4. preop testing specific to patient
5. modify risk factors if possible
6. convo w/ patient about risks

Question 3

what to do for high vs very high risk pts from RCRI assessment

Answer 3

• high: assess if further CV testing is needed if it’ll change tx or outcome
• v. high: treat and refer to cards

Question 4

• multivariate model which can help predict adverse cardiac events for patients.
• better predictor of preoperative risk than RCRI
• uses age, ASA class, surgery type, functional status, Cr over 1.5

Answer 4

NSQIP (national surgical quality improvement program)
- if over 1% and under 4 METS–> get pharm stress test if it would change tx

Question 5

what does 4, over 7 and over 10 METS mean?

Answer 5

4: can walk up flight of steps or on level ground at 3-4 mph
7+: 10min mile jogging, scrubbing floors
10+: basketball, football, swim, run

Question 6

what do you if someone is unable to complete 4 METS?

Answer 6

stress test!! exercise, if they cant exercise then pharm
- reversible perfusion defect= higher chance of postop MI

Question 7

5 C/I to surgery

Answer 7

• Recent myocardial infarction < 60 days
• Unstable angina
• Class III or IV angina– (3-climbing one flight of stairs, 4 is any physical activity or at rest)
• Decompensated heart failure.
• Symptomatic mod-sev. valvular heart dz

Question 8

who needs Plavix (clopidrogel) perioperatively? (2)

Answer 8

• bare metal stenting after PCI– need at least 4-6 wks
• drug eluting stents– at least 1 yr

Question 9

FEV under 1.5 means what? FEV under 1 means what? what is the best predictor of perioperative pulm complications?

Answer 9

• under 1.5 = increased pulm complications
• under 1= prolonged intubation
• serum albumin under 3.5 is best predictor!!

Question 10

what are pulm pre-op interventions – general vs for asthmatics

Answer 10

general: no smoking over 2 mo before, abx or bronchodilator therapy
steroid pretx for asthmatics

Question 11

how do you screen for OSA in preop eval? (3)

Answer 11

• SACS, STOP-BANG, Berlin score

Question 12

4 tests commonly ordered pre-operatively?

Answer 12

Hgb if over 65 or if there will be a lot of blood loss
Cr if over 50 or renal dz
pregnancy test
ECG if over 50 or vasc op or hx of cardiac or sig. resp disease, DM, RCRI over 1%

Question 13

5 meds to D/C prior to surgery & why

Answer 13

• For risk of bleeding: aspirin, plavix (hold for 7-10d), NSAIDs (for 1-3d), Warfarin (4d or INR over 1.5)
• For risk of thrombosis: Estrogen x 4 wks