Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery > Preop H&P > Flashcards

Preop H&P Flashcards

1
Q

What is the most impt thing about the preop hx and physical?

A
  • assessing cardiac risk

- CV events are leading cause of perioperative death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Joint commission for accreditation of hospitals requrires what for all surgical pts?

A
  • reqrs all surgical pts to have a H and P documented in the medical record w/in 30 days b/f surgery
  • the goal is to reduce complications and health care costs
  • a standard preop eval hasn’t been defined
  • routine lab, cv and pulm tests are often performed w/o justification
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Serious morbidity during surgical procedures usually is a result of what? What is the role of the medical consultant b/f surgery?

A
  • 3-10% of pts undergoing surgical procedures experience serious morbidity, most of which results from cardiac, pulmonary or infectious complications

Role of medical consultant b/f surgery is:

  • clearly defining the pt’s medical conditions
  • eval severity and stability of these conditions, -optimizing all medical conditions
  • providing a surgical risk assessment
  • recommending perioperative measures to reduce the risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Physiologic changes during aneshesia and surgery?

A
  • physiologic effects of anesthesia: peripheral vasodilation leading to hypotension, most of the anesthetic agents also lead to reduced myocardial contractility
  • the decrease in tidal volume caused by general and spinal epidural anesthesia can cause atelectasis
  • epi and NE levels are elevated during surgery and the 1st and 2nd postop days
  • the serum cortisol is generally elevated for 1-3 days (increases sugar, suppresses immune system)
  • serum ADH may be elevated for up to 1 wk postop
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the most impt aspect of the preop eval?

A

a thorough hx including:

  • thorough ROS
  • extensive med hx, OTC
  • allergies
  • surgical and anesthetic hx
  • fxnl status
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What should you pay attention to in the ROS?

A
  • undx or inadequately controlled chronic disease
  • cardiac and pulm (recent chest pain or exertional SOB esp impt)
  • bleeding disorders (hemophilia, von willebrands)
  • hx of DVT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What do you need to ask about in medication hx?

A
  • not just Rx meds that are impt
  • recent use of anticoagulants, aspirin, and nonselective NSAIDs
  • don’t forget supplements, herbs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Potential effects of preop use of common herbal therapies?

A
  • echinacea: hepatotoxicity
  • ginseng: PLT inhibitor, hypoglycemia
  • garlic: PLT inhibitor, preload reduction
  • gingko: PLT inhibitor, alters vasoregulation
  • St. John’s wort: upregulates P450, drug-drug rxns
  • kava: potentiates sedation, drug-drug rxns
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are impt allergies to ask about?

A
  • allergies to rubber product? Latex?

- allergies to any foods assoc w/ latex rxns such as bananas, avocados, kiwis, apricots, melons, and chestnuts?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Impt surgical and anesthetic hx ?s to ask about?

A
  • hx of bleeding complications during surgery

- personal or family hx of major rxns to anesthetics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Impt fxnl status eval of pt?

A
  • what is pt’s self reported exercise tolerance?
  • what is pt’s activity level?
  • a great tool to use for assessing fxnl status is the duke activity status index (ability to perform greater than 4 metabolic equivalents has been assoc w/ a lower CV risk)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Preop eval of cardiac risk?

A
  • cardiac complications of noncardiac surgey are perhaps major cause of perioperative morbidity and demise
  • approx 1 mill pts undergoing surgery each year suffer a cardiac complication, 50,000 pts have MI
  • pts w/o a hx of CAD are at extremely low risk (less than 0.5%) for perioperative ischemic complications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the RFs for major cardiac complications (lee index)?

A

1 pt for each of the following:

  • high risk surgery
  • hx of ischemic heart disease
  • hx of CHF
  • hx of stroke or TIA
  • insulin-dependent DM
  • serum Cr over 2 mg/dL

pts and complication rate:

  • 0 pts, 0.4% complication rate
  • 1 pt, 1% complication rate
  • 2 pts, 7% complication rate
  • greater or equal to 3 pts, 11% complication rate
  • complications include MI, pulmonary edema, Vfib or primary cardiac arrest, complete heart block
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Is there a routine noninvasive cardiac test done preop?

A
  • no, there is no convincing evidence that routine noninvasive cardiac stress testing improves periop care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

When is noninvasive cardiac testing preop indicated?

A

if 2 of the following factors are present:

1) intermediate clinical predictor
- class 1 or 2 angina
- prior MI based on hx or pathologic Q waves
- compensated or prior herat failure
- diabetes
2) poor fxnl capacity (less than 4 metabolic equivalents)
3) procedure w/ high surgical risk (emergency surgery, aortic repair or peripheral vascular surgery, prolonged procedure w/ large fluid shifts or blood loss)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management of low risk pt w/ CAD perioperatively?

A
  • these pts have 4-5% risk of major cardiac complication
  • they should be considered for prophylactic revascularization only if indications for revascularizaiton exist independent of noncardiac surgery
  • preop anti-anginal meds should be continued preop and in post op period
  • prophylactic IV nitro may reduce ischemia but hasn’t been shown to reduce the rate of postop complications
17
Q

Management of high risk pts w/ CAD for surgery?

A
  • in these pts surgery should be delayed until CAD is tx, if possible
  • for pts w/ recent MI, delaying the surgery for 3-6 months may be useful
18
Q

Preop eval for CHF pts?

A
  • decompensated CHF as indicated by elevated JVP, an audible 3rd heart sound or evidence of pulmonary edema on exam or CxR significantly increases risk of perioperative pulmonary edema (15%) and death (2-10%)
  • preop control of CHF w/ diuretics and afterload reducing agents decreases the risk but diuretics can increase risk of intraop hypotension
  • electrolytes and digoxin level should be checked
  • the anesthesiologist and surgeon should be made aware of presence and severity of CHF
19
Q

What would you do if you heard a murmur in a pt who has come in for a routine preop history and physical?

A
  • get an echo
20
Q

Preop eval for pt w/ valvular heart disease?

A
  • pts w/ heart murmurs should have echos to define the nature and severity of valvular lesions. Pts w/ sig lesions may need abx prophylaxis and appropriate fluid management and consideration of invasive intraop monitoring
  • pts w/ severe sx aoritc stenosisare at especially high risk for complications
21
Q

Preop eval of arrhythmias?

A
  • finding of a rhythm disturbance during preop eval should prompt consideration of further cardiac eval, especially if the finding of structural heart disease would alter perioperative management. Pts found to have a rhythm disturbance w/o structural heart disease are at very low risk for perioperative complications
  • in pts w/ a fib, rate should be controlled and they should be covered w/ lovenox window
  • sx supraventricular and ventricular tachycardia should be controlled b/f surgery
  • pts who have indications for permanent pacemaker should have these placed b/f surgery
22
Q

Preop eval of HTN?

A
  • severe HTN (greater tahn 180/110) has been assoc w/ higher risk of cardiac complications
  • therefore BP should be controlled b/f surgery if possible
23
Q

Preop eval for pulm complications?

A
  • risk of developing pulm complications is highest in pts undergoing cardiac, thoracic, and upper abdominal surgery
  • the 3 pt specific factors assoc w/ increased risk of postop pulmonary complications are: chronic lung disease, morbid obesity and tobacco use
  • pts w/ chronic lung disease, esp those w/ FEV1 less than 500ml or an arterial pCO2 greater tahn 45mmHg are at highest risk
  • CXR for pts older than 60 good preop eval
  • pts w/ asthma at optimal pulm fxn at time of surgery don’t appear to be at increased risk
  • smoking cessation for at least 8 wks has been show to reduce risk of pulm complications in pts undergoing CABG
  • the use of incentive spirometry and deep breathing exercises begun preop and continued for 3-5 days in postop period reduces the incidence of postop atelectasis
24
Q

Periop management of pts w/ lung disease?

A
  • DVT prophylaxis is impt, esp in pt undergoing or hip surgery
  • abx may be useful in pts coughing purulent sputum
  • pts who take theophylline should be maintained on IV theophylline when necessary (narrow therapeutic window)
25
Q

Preop heme eval- what if blood work shows that the pt has some anemia?

A
  • does this pt need preop eval for anemia: certain types of pts (with immune hemolytic anemia and sickle cell disease need to be eval b/f surgery) are at high risk
  • does this pt need transfusions: usually pts w/ hemoglobin of 8-9 g/dL do well though in some situations like pts w/ CAD, CHF and PVD we like to see a higher hemoglobin
26
Q

Bleeding risk assessment preop?

A
  • hx is most impt part of eval
  • when the hx is unavailable a formal eval should be done and should consist of PT, PTT, platelet count and bleeding time
27
Q

What ?s should you ask to eval risk of bleeding?

A
  • have you ever bled a long time or developed a swollen tongue or mouth after cutting or biting your tongue, cheek or lip?
  • do you develop bruses larger than a silver dollar w/o being able to remember how you injured yourself?
  • has bleeding ever started again the day after a tooth extraction?
  • was bleeding after surgery ever hard to stop? Have you had unusual bruising around an area of surgery or injury?
  • has any 1st degree blood relative had a problem w/ unusual bleeding or bleedin after surgery?
28
Q

Neuro eval - preop?

A
  • 2 MC serious SEs of surgery in the area are acute delirium and stroke
  • it is impt to avoid meds that can cause delirium. Meperidine, anticholinergics, and benzos have all been assoc w/ delirium
  • postop stroke is a relatively infrequent complication. Older age, sx carotid stenosis and the occurence of postop afib and RFs for development of stroke
29
Q

Preop eval for DM?

A
  • pts w/ diabetes are at increased risk for postop infections and MIs
  • regulation of blood sugar can also be difficult in these pts: generally, the goal should be to keep the sugar b/t 100-250 mg/dL
  • all pts w/ diabetes should have their renal fxn, and electrolytes measured and corrected b/f surgery.
30
Q

When should glucocorticoid replacement be considered?

A
  • in any pt who has been on 7.5 mg of prednisone for 3 wks or 20 mg prednisone for a wk
  • if there is evidence of adrenocortical insufficiency, these pts should receive 100mg of hydrocortisone every 8 hrs beginning on morning of surgery and continuing for 48-72 hrs. Tapering the dose is not necessary
31
Q

Preop eval of hypothyroidism?

A
  • severe sx hypothyroidism should be corrected b/f surgery

- pts w/ mild or asx hypothyroidism generally tolerated surgery well

32
Q

Preop eval for renal disease?

A
  • these pts are at high risk for periop comlications such as postop hyperkalemia, pneumonia and fluid overload
  • dialysis dependent pts should be dialyzed 24 hrs b/f surgery. Their electrolytes should be carefully monitored in periop period
  • pts w/ renal insufficiency, defined as elevated serum Cr or BUN should have their volume status monitored as hypovolemia can increase the risk of postop deterioration in renal fxn
33
Q

Physical exam preop?

A
  • ensure thorough CV and pulm exam

- unexpected abnormal findings on physical exam should be fully characterized and investigated b/f elective surgery

34
Q

What are the med recommendations perioperatively?

A
  • most Rx meds should be continued on morning of surgery w/ small sips of water ,unless CI
  • ACEI and diuretics usually withheld day of surgery (increases risk for renal failure and hypotension)
  • pts w/ diabetes: no metformin or oral hypoglycemics day of surgery, whether or not and how much insulin a diabetic takes largely dependent on pt
  • d/c herbal supplements 2 wks prior to surgery
  • pts whose risk of bleeding from preop use of ASA for 7-10 days, nonselective NSAIDs for 3-5 days, and thienopyridine (such as plavix) for 2 wks
  • although much more complicated, as a general rule, a pt taking warfarin may have surgery as long as INR is less than 1.5
  • all pts w/ CV RFs should receive bbs perioperatively unless strongly CI
35
Q

Best tool to use when performing preop eval?

A
  • hx

Surgery (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions