preop highlights Flashcards
who do you do troponin post op ?
basically patient who undergo urgent or emergency surgery above hte age of 65 or above the age of 45-64 with cvd
what does the trops timing post op look like and what else ?
trops 48-72
PACU EKG
major/significant CVD in preop context means what
CAD
PAD
CHF
CVD
obst cardiac
pulmo htn ( sevee)
bnp threshold
300
the RCRI elements ( 6 )
- high risk surgery
- ischemic heart diseasE
- CHF HX
- HX stroke
- t2dm ( on insulin)
- preop creat >177
what is bnp predictive of ?
postop adverse cardiac events
MINS & asymptomatic MIs vs other symptomatic myocardial infarction - what are they associated with
basically a similar increased irks of 30 day mortality as symptomatic myocardidac infarction.
in what cardiac surgery do you hold p2yi . timeline to hold
if patient going on pump
- clopido 2-7
- tica 2-3 ( vs 5-7 for others)
class 1 indication for AVR
severe AS w/ sx
severen AS, asx, ef<50%
severe AS going for other cardiac sx ( i.e. CABG)
so let’s say, echo shows moderate AS. but you are symptomatic and ef is less than 50 .. what do you do next ?
dobutamine stress echo
okay now same .. modeterate AS on echo , but you;’re symptomatic . now ef >50% . what do you do ?
AVR if teh expert things this is AS causing the symptoms.
POAF thought to be what type of afib. valve or nonvalv
nonvalv
what dd the poise 1 say about metoprolol study . why is problematic ?
starting 100 mg metoprolol xr 2-4 hrs preop led to more dea th, more stroke, less mi ( most of which were mins)
- bcs blunts adrenergic response to stress= more adv reaction
what did the poise 2 trial say about ASA
equal rate of death and MI for those we stopped aspirin
but those who continued had more bleeding
- long story short.. no benefit on MI rate, but more bleeding
but then what did poise 2 subgroup ASA analysis show
those with prior PCI who continued their ASA had less post op MI
what’s recent stent that would propt you to continue ASA ?
- DES : 3-12M
- BMS : 6 weeks
p2y12i timeline to hold for periop
tica & clopi : 5-7 d
prasu : 7-10d
per acc/aha 2024, when do you consider continuing acei ?
in hfref
poise 3 says what about acei to be held
continung acei to avoid hypertesnion vs holding it to avoid hypotension -= no divffference in vasc outcomes OR AKI !!!!
what does the bridge trial state ( nejm 2015)
bridging with warfarin was non inferior to preventing art thromboembolism with out briging and decreased risk of bleeding
high risk bleeding with which anticoagulant?
dabigatran
in elective surgery : doacs including dabigatran , what’s the holding time and when do you resume it
- doacs ( apix, edox, rivarox) : hold it 24hrs pre surgery and resume 24hrs post sugery
- dabigatran : hold 48hrs pre surugery and resume 48-72hours post
what about warfarin, when do you hold pre surgery given you will not be bridiging. do you test for inr
hold it 5 days pre . day -1 you test for INR
when do you resume warfarin post op
resume 12 hrs post op
with bridging, when do you stop warfarin ?
-5 days
with briding, when do you resume warfarin and lmwh
- warfarin 12H
- LMWH : 24H
if CrCL <50, when do you stop dabigatran if high risk bleed
at -d4
how many days before neuroaxial anesthesia do you hold dabigatran and do you resume it post puncture/kt manipulation/removal
- 3-5 days
- 6h
how many days before neuroaxial anesthesia do you hold doacs other than dabigran and do you resume it post puncture/kt manipulation/removal
- 3D
- 4-6H
how many days before neuroaxial anesthesia do you hold LMWH therapeutic and do you resume it post puncture/kt manipulation/removal
- 24H
- 4H
how many days before neuroaxial anesthesia do you hold LMWH ppx and do you resume it post puncture/kt manipulation/removal
- 12H
- 4H
how many days before neuroaxial anesthesia do you hold IV heparin and do you resume it post puncture/kt manipulation/removal
- 2-4H
- 1H
how many days before neuroaxial anesthesia do you hold warfarin and do you resume it post puncture/kt manipulation/removal
- 5 days
- immediately
how many days before neuroaxial anesthesia do you hold fondaparinuyx and do you resume it post puncture/kt manipulation/removal
- 36-42H
- 6-12 H
how many days before neuroaxial anesthesia do you hold prasugrel and do you resume it post puncture/kt manipulation/removal
-7-10 days
- 6H
how many days before neuroaxial anesthesia do you hold ASA and do you resume it post puncture/kt manipulation/removal
can continue
For orthopedic vte ppx : what’s prefered for THA-TKA and duration
DOACs
13-35D ( prefer >3 weeks)
For orthopedic vte ppx : what’s prefered for THA-TKA and duration , especially if want to give something with ASA ? what’s the study about ASA alone ? Was it better ?
- rivaroxaban 5 d + ASA 9-30days
- cristal trial JAma 2022 : ASA 100 inferior to enoxaparin
For orthopedic vte ppx : what’s prefered for hip fracture and duration
LMWH/LUDH
14-35days
NOT DOACS !!!!!
For orthopedic vte ppx : what’s prefered for major trauma and duration . what if risk of bleeding
LMWH /LUDH
until d/c (inlcuding rehab)
if risk of bleeding –> IPC up front
Lower leg below knee surgery and arthroscopy of the knee, do they need ppx ?
no UNLESS inpatient !!!
give them until d/ced
what are surgeries you would avoid using pharmaco ppx
- neuro sx
- uro surgery
- lap chole
- trauma with high risk bleeding
why avoid pharma ppx in lap chole ?
bcs it’s a day surgery
cardiac surgery or major vasc surgery : pharma or non pharma ppx
YOU COULD DO EITHER ( paucity of evidence !!!)
per gaps study, what’s not helpful to add to compression stockings
lmwh
graduated compression stocking are useless
what surgery can you use doac ppx
tha
tka
what is one doac that cannot be used as ppx
edoxaban
whch type of cautery causes eletromagnetic interferences regarding ppm/ICD ?
monopolar cautery
if put magnet on ICD
- what does it inhibit
- what does it allow to have
- arrythmia detection
- pacing function preserved
which surgery would you recommend delaying to improve glycemic control
total joint arthroplasty
who should have IV insulin during surgery
- major surgery
- CABG
- insulin dep pt w/ prolonged or
- t1DM if >1-2H
-intrapartum in gest db
hold glp1 how long before sx ?
1 week
hold sglt2 how long before sx
72H
dose of insulin LA the morning of the surgery
1/2 dose
dose of insulin LA the night before the surgery
70-100%
dose of NPH ( BID) the morning of the surgery
1/2
dose of insulin SA pre surgery
omit
anemia : hgb level to optimize for women and men ?
- <115
- <130
target hgb before major joint arthroplasty ?
130
TXA increase risk of thrombosis ? improves what ?
no.
reduce periop blood loss, #transfusion, #pttransfused
other than glycemic control, what other reason can you delay arthroplasty per 2023 ACR guideline ?
for nicotine use reduction/cessation
ideal time to stop smoking before surgery ?
4 weeks
what are some resp risk assessment that put someone more at risk ( pt related risk)
- copd
- older than 60
- underlying disease ( ASA >II)
- general health ( fct class)
- HF
- alb <35
- obese
- asthma
- pulmo htn
pulmo htn are more at risk of what
- mortality
- MACA
- ICU
- prolonged vent
- arrythmia
if have pulmonary htn and noted preop, what to do
- do not go forward w/ elective OR
- investigate why and refer ( work up !!)
what’s the def amount of corticosteroids that causes HPA suppression
pred >20 mg /d for 3+ weeks or cushingoid
major surgery stress dose
Majorsurgery–UsualAMdose+HC100mgIVX1pre-op,then50mgq8hX3doses,then25 mg q8h X 3 doses then back to usual dose
Moderate surgery stress dose
Usual AM dose + HC 50mgX1pre-op, 25mgq8hX3,then usual dose
if it’s a minor surgery, what dose of corticosteroid
usual dose
how many days that IV iron take to have effect
minimum 3-4 days
if low surgery, how long after covid ?
2 weeks
if high risk surgery, how long after covid
7 weeks
