preop management Flashcards
Continue antihypertensive meds until
day of surgery and resume postoperatively UNLESS PATIENT IS TAKING ACE INHIBITORS OR ARBS.
Why don’t you want to follow the same rules with ACE or ARBS
Renally excreted. Don’t want them to take it on the day of surgery bc these drugs tend to lower BP a lot and anesthesia lowers BP as well. So in some cases we can’t control this low BP and have to get pressors involved
pts with DM usually present in this manner PreOp
Usually hyperglycemic preop due to stress (increase of cortisol and epinephrine) or unrecognized infection
what do we do to manage pts with DM in surgery
need tight glucose control
usually book very early in the morning
usually not on PO because need insulin to monitor very carefully
Fasting Glucose above 200 may be treated with insulin by anesthesiologist
usually put them on a sliding scale of insulin depending on BG
when should pts with DM discontinue there medications before surgery
Patients with well-controlled diabetes taking oral agents should continue meds until day BEFORE surgery – will manage with insulin if needed during surgery
how should analgesics be managed in pts with DM why?
Preoperative sedatives or analgesics should be as low dose as possible due to increased sensitivity
cortisol, catecholamines and glucagon oppose
Patients with non-insulin dependent diabetes should stop taking long-acting sulfonylureas (Glyburide) due to
what would you recommend they take instead
should stop taking a couple days before due to risk of intraoperative hypoglycemia
Use short-acting (Repaglinide) or sliding scale insulin (preferred during hospitalization).
pts taking metformin have a risk of
lactic acidosis (increased lactic acid and low ph)
with renal insufficiency
need to watch out for this
how do you test a pt pre op to insure good glycemic control
FBS= less than 100
random blood sugar < 200
or hemoglobin A1C <6.5
what if you don’t have good glycemic control in a DM pt scheduled for surgery
refer back to PCP or endocrinologist for stabalization
Preoperative HTN increases risk of perioperative complicationsi.
increase Incidence of stroke
increase Incidence of arrhythmia
increase Incidence of myocardial ischemia/myocardial infarction
Complications related to heart disease is the major cause of perioperative deaths sometimes you can monitor with
arterial line
Should be monitored with arterial line or subclavian if significant heart disease
how should pts with valvular dz be monitored preop
Antibiotic prophylaxis for patients with valvular disease
Up to a week to 5 days before surgery
when would we stop heparin presurg
Heparin stopped 5 days prior to surgery – resumed 12 hours post op
Serious cardiac event or death during procedure is based on the
Goldman’s Index
concerns with renal disease
Risk of dehydration
Risk of infection
medications that can be nephrotoxic
. Gentamycin (aminoglycosides)
Methicillin (PCNs)
Toradol (NSAIDS)
what should we always check before a surgery scheduled for renal pt
when would a pt need dialysis before surgery
Look at potassium -if high needs dialysis before surgery
Consult with nephrologist to order dialysis day before surgery
If alcohol intake is high or history of alcohol abuse in pt awaiting surgery
patient will need medical intervention for withdrawal symptoms
Management – Give ETOH to pt’s pre-op
Alternative –>Ativan
Presence of umbilical hernia may indicate
ascites
when would we test PT/PTT/INR
done for longer cases where you might need to transfuse patients)
LFT cause for concern in preop liver pt when
- AST (aspartate aminotransferase)
- ALT (alanine aminotransferase)
- Alkaline phosphatase
preop testing for pt with liver dz
A BEAP P L
A albumin <3.5
B bili direct >.3 total>1.0
E encephalopathy
A acities
P Pt/INR
PTT used to monitor heparin therapy
LDH (lactate dehyrogenase) >90 elevated with cell injury/death
AFP (alpha fetoprotein)–>CA/cirrhosis
Also elevated in testicular cancers, particularly seminomas
LDH when elevated indicated
Indicates poor perfusion of one of the organs
obese pts are at risk for
poor wound healing
BMI>30 obese
BMI>40 morbid obese
how do you prevent DVT in obese pt (meds)
TX with 5000 units Heparin subq perioperatively
Perioperative timeline = ~ 90 days around surgery
i
Continue heparin 5k subq q 12hr while hospitalized
modifications to help prevent DVT in obese pt
Get up to bathroom before surgery/walk to operating room
Early ambulation after surgery helps prevent DVT’s as well
co-morbidities often seen in obese pts
Comorbidities of HTN, Diabetes, Obstructive Sleep Apnea, GERD Stress Incontinence
Consider each comorbidity as a separate underlying disease
Lung compromise including patients with
COPD
Emphysema
have increased risk of
pneumonia
atelectasis
and hypoxia
atelectasis is a complication of what
partial or complete collapse (pulling at)
that can result from being on a ventilator
pre-op tx for pts with productive cough
Preop tx with bronchodilators and antibiotics for productive cough
what are the recommendations around smoking preop
Don’t cut back or quit smoking 2-3 days before surgery b/c there is increased mucus production which makes it harder to manage the airway
Asthma patients should get what before surgery
Asthma patients should get steroids/bronchodilator treatment before surgery
Example: Albuterol MDI (patient can use their own home inhaler)
when should you recommend a pt stop smoking before surgery
SMOKING cessation 8 weeks before surgery will decrease sputum production
risk of bleeding with these 6 meds
NSAIDS Plavix ASA Cuomadin Warfarin OTC
when should NSAIDS be stopped
i. Should be discontinued 5 days preop
when should plavix and ASA be stopped
i. Should be discontinued 10 days preop
when should coumadin and warfarin be stopped***
i. Should be discontinued 5 days preop
ii. Switch to Heparin if necessary
when should OTC meds be stopped
should be discontinued 10 days preop
Determinants of malnourished pt
Weight loss of 15% over last 3-4 months
Albumin less than 3.0 g/dl
Protein less than 6.0 g/dl
Serum transferrin level of less than 150 mg/dl
Increased RBC size (macrocytic)
Decreased B-12, Folic Acid
malnutrition bMI
And preop tx
<18
PREOP TREATMENT:
25% ALBUMIN IN 100cc soln IV 120cc/h
who is at risk of poor wound healing
Elderly, malnourished and cancer patients have a high incidence of being immunocompromised
pts on corticosteroids -usually if chronic use will try to get them off 2 week sbefore
Pt receiving corticosteroids within 3 days of surgery is at risk of
Risk of poor wound healing
Steroids reduce inflammation, epithelialization and collagen synthesis
Leads to wound breakdown and infection
Pt will need additional dose of steroids on day of surgery if taking more than 5mg prednisone for 2 weeks
GERD complications
Patients have a high incidence of postoperative nausea
TX considerations for a pt with GERD
Require aggressive antiemetic treatment preop and postop
Workup for pt with GERD
Hx of H.pylori, PUD, hiatal hernia
Meds to consider for pt with GERD
i. H2 Blocker – “dines” Cimetidine (Tagamet) Ranitidine (Zantac) ii. Antacids – Gaviscon, Mylanta iii. PPIs (proton pump inhibitor) – “prazole” Lansprazole (Prevacid) Omeprazole (Prilosec)
hypovolemia
b. Bleeding
c. Vomiting/diarrhea
d. Bowel obstruction-Shock
e. Dehydration
Hypovolemia sxs and PE
Symptoms –>Dizziness, weakness, anxiety
PE –> Cold skin, pallor, capillary refill > 2sec, diaphoretic
Orthostatic hypotension definition
fall in systolic pressure of more than 10mm Hg when patient sits up from lying position)
this is an early sign of hypovolemia
Tachycardia is early sign of
Fever
Low urine output
also seen
you really want to control this to prevent hypovolemia
PAIN
will allow for assessment of true blood pressure
Hyponatremia hypovolemia commonly caused by
diuretics
loss of NA
excess vomiting diarrhea, sweating, diuretics all cause this
hyperthyroid pt at risk of
i. Risk of HTN
ii. Risk of hyperthermia
iii. Risk of cardiac arrhythmia
iv. Risk of CHF
Tx for pt with hyperthyroid prop (how many weeks pre op)
Treat with PPU/PTU (propylthiouracil) 1-6 weeks preop
If emergency, treat with propranolol, PPU and
potassium iodide
propranolol lowers BP
hypothyroidism
i. Risk of hypotension
ii. Risk of shock
iii. Risk of hypothermia
preop tx for adrenal insufficiency
Preop tx with cortisol and NS (normal saline)
ADD cortisol
what are we considered about with allergies in surgery
Intraoperative anaphylaxis occur 1/4500 surgeries with 3%-6% mortality
Most allergies are to
Most allergies are to muscle relaxants, anesthesia drugs
(etomidate/propofol) and narcotics
LATEX ALLERGIES second most common cause of anaphylactic allergies (first is muscle relaxants)
when would you need to consider a transfusion in a pt with anemia awaiting surgery
Hemoglobin below 7 (or HCT below 21) will likely require blood transfusion of 1 unit
1 unit of PRBC will raise HCT by
by approx 3 points
anemia is of concerned with hemoglobin below
i. Hemoglobin below 10
ii. Hematocrit below 30 does not increase risk for surgery
vi. Low Hemoglobin Determinants:
- MCV (mean corpuscular volume)
2. MCHC (mean corpuscular hemoglobin conc)
Normocytic/normochromic concerned about
- Acute blood loss
- Early FE-deficiency
- Chronic illness/cancer
- Hemolytic anemia
viii. Microcytic/hypochromic concerned for
- Late FE-deficiency
- Thalassemia
- Lead poisoning
Macrocytic/normochromic concerned for
- Malnutrition
- B-12 deficiency
- Folic Acid deficiency
Platelets below _____does not increase risk for surgery
50,000 u/l
Platelets below _____consider the need for blood transfusion
30,000,
Platelets below _____ require blood transfusion
10,000
platelets are usually this low because of chemo
platelet counts needing a transfusion (<10,000) would replace with
Replace with platelets (not PRBC!)
e. Surgery increases risk of DVT (deep vein thrombosis) 21 times! In the following patients –
ii. Hx of DVT
iii. Hx of prolonged immobilization
iv. Hypercoagulable states such as
Hypercoagulable states such as
- Factor V Leiden
- TTP (thrombotic thrombocytopenic purpura)
- SLE
- Polycythemia Vera
f. PREOP TREATMENT FOR DVT RISK:
i. WALK TO OPERATING ROOM
ii. SEQUENTIAL COMPRESSION DEVICE (SCD)
iii. ELASTIC STOCKINGS
iv. HEPARIN 5000 units SUBQ q 8-12h
risks witH the alcoholic pt
a. Risk of malnutrition b/c ETOH is empty calories, can cause seizures & delirium tremens (rapid onset confusion caused by withdarawal from alcohol)
LABS WITH alcoholic pt
increase LFTs decrease Albumin decrease FE/transferrin decrease B-12/Folic Acid increase Bilirubin
may have ____ PT/INR/PTT
h. May have increased PT/INR/PTT
treatment for alcoholic pt
Type and Screen for blood transfusion if needed
i. Preop tx with ativan, thiamine, B-12
goldman criteria
age of 70
MI in the last 6 months
S3 gallop or JVD
valvular aortic stenosis
rhythm other than sinus on last pre-op exam
> 5PVC on any EKG
know the lab values
abdominal thoracic or aortic
surgery planned
emergency operation
DM more sensitive to anesthesia because
increased cortisol
increased sensitivity because surgery evokes a stress response that release of growth hormone and glucagon
these hormones oppose glucose hemostasis
more sedated more easily
More important than the BP is the
EKG
managed by the anesthesiologist
if you have an EKG that is diufferent than the prior consider a cardiology consult
intraoperative HTN is associated
stokes MI death
how to we manage the pain meds of DM pts
usally lower the amount of analgesics because they are more sensitive to them and it can mess with their blood sugar
what would be the benefits of an arterial line to avoid complications from heart disease
Arterial line – can check blood gases and can also check very accurate BP’s manage fluid
why would you use a subclavian line to monitor over an arterial line
Subclavian line has more ports so can check blood
what is the total score with goldman’s index
Total score is 53
what is this risk of having a cardiac event with goldman’s index
Risk of serious cardiac event or mortality is from .9% to 63.6%
what are the lab values on goldman cardiac index
K
K<3
what are the lab values on goldman cardiac index HCO3
<20
what are the lab values on goldman cardiac index bun
> 50
what are the lab values on goldman cardiac index Cr
Cr>30
what are the lab values on goldman cardiac index PO2
<60`
what are the lab values on goldman cardiac index pc02
> 50
what, other than the lab values would add to the cardiac risk index with regards to liver and disease
increased liver enzymes or bedridden wiht chronic disease
stop NSAIDS
a week before surgery
ok to take Tylenol with codeine
NORCO
preop testing for a pt with renal disease
labs and nml ranges
BUN >20 (>100 CRITICAL!)
Creatinine >1.2
Albumin < 3.5
LDH (lactate
dehyrogenase) > 90 U/L
LDH is an enzyme released by cells with injured or destroyed
Urinanalysis
Proteinuria
CASTS
most common cause of prolonged PTT
most common cause of prolonged PTT
use to asses pts with chronic liver disease
Child–Pugh score
what OTC meds cause complications
echinachea -allergy and immunocompremis ephredra-MI HTN STOKRE GARLIC-bleeind ginko- bleeding ginseng-hypoglcemia and risk of bleeding Kava-increase effet of aneshesia St. John's -alter effects valerian-increase risk of anesthesia fish oil- bleeding
risk of bleeding with these OTC
garlic and ginseing (hypoglycemia as well)
stop 7 days before
when should you stop ephredra and Kava
24 hours before
st johns wart should be stopped
5 days before
immunocompromised pts have a lymphocyte count
Determination by total lymphocyte count less than 800
hypovolemia labs
glucose BUN Creatinine Albumin BUN:CR >20:1
NA
K
CL
Co2 (bicarb)