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Surgery > preop management > Flashcards

preop management Flashcards

1
Q

Continue antihypertensive meds until

A

day of surgery and resume postoperatively UNLESS PATIENT IS TAKING ACE INHIBITORS OR ARBS.

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2
Q

Why don’t you want to follow the same rules with ACE or ARBS

A

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

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3
Q

pts with DM usually present in this manner PreOp

A

Usually hyperglycemic preop due to stress (increase of cortisol and epinephrine) or unrecognized infection

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4
Q

what do we do to manage pts with DM in surgery

A

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

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5
Q

when should pts with DM discontinue there medications before surgery

A

Patients with well-controlled diabetes taking oral agents should continue meds until day BEFORE surgery – will manage with insulin if needed during surgery

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6
Q

how should analgesics be managed in pts with DM why?

A

Preoperative sedatives or analgesics should be as low dose as possible due to increased sensitivity

cortisol, catecholamines and glucagon oppose

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7
Q

Patients with non-insulin dependent diabetes should stop taking long-acting sulfonylureas (Glyburide) due to

what would you recommend they take instead

A

should stop taking a couple days before due to risk of intraoperative hypoglycemia

Use short-acting (Repaglinide) or sliding scale insulin (preferred during hospitalization).

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8
Q

pts taking metformin have a risk of

A

lactic acidosis (increased lactic acid and low ph)

with renal insufficiency

need to watch out for this

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9
Q

how do you test a pt pre op to insure good glycemic control

A

FBS= less than 100
random blood sugar < 200
or hemoglobin A1C <6.5

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10
Q

what if you don’t have good glycemic control in a DM pt scheduled for surgery

A

refer back to PCP or endocrinologist for stabalization

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11
Q

Preoperative HTN increases risk of perioperative complicationsi.

A

increase Incidence of stroke

increase Incidence of arrhythmia

increase Incidence of myocardial ischemia/myocardial infarction

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12
Q

Complications related to heart disease is the major cause of perioperative deaths sometimes you can monitor with

A

arterial line

Should be monitored with arterial line or subclavian if significant heart disease

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13
Q

how should pts with valvular dz be monitored preop

A

Antibiotic prophylaxis for patients with valvular disease

Up to a week to 5 days before surgery

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14
Q

when would we stop heparin presurg

A

Heparin stopped 5 days prior to surgery – resumed 12 hours post op

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15
Q

Serious cardiac event or death during procedure is based on the

A

Goldman’s Index

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16
Q

concerns with renal disease

A

Risk of dehydration

Risk of infection

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17
Q

medications that can be nephrotoxic

A

. Gentamycin (aminoglycosides)
Methicillin (PCNs)
Toradol (NSAIDS)

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18
Q

what should we always check before a surgery scheduled for renal pt

when would a pt need dialysis before surgery

A

Look at potassium -if high needs dialysis before surgery

Consult with nephrologist to order dialysis day before surgery

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19
Q

If alcohol intake is high or history of alcohol abuse in pt awaiting surgery

A

patient will need medical intervention for withdrawal symptoms

Management – Give ETOH to pt’s pre-op
Alternative –>Ativan

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20
Q

Presence of umbilical hernia may indicate

A

ascites

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21
Q

when would we test PT/PTT/INR

A

done for longer cases where you might need to transfuse patients)

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22
Q

LFT cause for concern in preop liver pt when

A
  1. AST (aspartate aminotransferase)
  2. ALT (alanine aminotransferase)
  3. Alkaline phosphatase
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23
Q

preop testing for pt with liver dz

A

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

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24
Q

LDH when elevated indicated

A

Indicates poor perfusion of one of the organs

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25
Q

obese pts are at risk for

A

poor wound healing

BMI>30 obese
BMI>40 morbid obese

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26
Q

how do you prevent DVT in obese pt (meds)

A

TX with 5000 units Heparin subq perioperatively
Perioperative timeline = ~ 90 days around surgery
i
Continue heparin 5k subq q 12hr while hospitalized

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27
Q

modifications to help prevent DVT in obese pt

A

Get up to bathroom before surgery/walk to operating room

Early ambulation after surgery helps prevent DVT’s as well

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28
Q

co-morbidities often seen in obese pts

A 
Comorbidities of 
HTN, 
Diabetes,
Obstructive Sleep Apnea, GERD
Stress Incontinence

Consider each comorbidity as a separate underlying disease

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29
Q

Lung compromise including patients with

A

COPD

Emphysema

have increased risk of

pneumonia
atelectasis
and hypoxia

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30
Q

atelectasis is a complication of what

A

partial or complete collapse (pulling at)

that can result from being on a ventilator

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31
Q

pre-op tx for pts with productive cough

A

Preop tx with bronchodilators and antibiotics for productive cough

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32
Q

what are the recommendations around smoking preop

A

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

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33
Q

Asthma patients should get what before surgery

A

Asthma patients should get steroids/bronchodilator treatment before surgery

Example: Albuterol MDI (patient can use their own home inhaler)

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34
Q

when should you recommend a pt stop smoking before surgery

A

SMOKING cessation 8 weeks before surgery will decrease sputum production

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35
Q

risk of bleeding with these 6 meds

A 
NSAIDS
Plavix
ASA
Cuomadin
Warfarin 
OTC
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36
Q

when should NSAIDS be stopped

A

i. Should be discontinued 5 days preop

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37
Q

when should plavix and ASA be stopped

A

i. Should be discontinued 10 days preop

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38
Q

when should coumadin and warfarin be stopped***

A

i. Should be discontinued 5 days preop

ii. Switch to Heparin if necessary

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39
Q

when should OTC meds be stopped

A

should be discontinued 10 days preop

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40
Q

Determinants of malnourished pt

A

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

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41
Q

malnutrition bMI

And preop tx

A

<18

PREOP TREATMENT:
25% ALBUMIN IN 100cc soln IV 120cc/h

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42
Q

who is at risk of poor wound healing

A

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

43
Q

Pt receiving corticosteroids within 3 days of surgery is at risk of

A

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

44
Q

GERD complications

A

Patients have a high incidence of postoperative nausea

45
Q

TX considerations for a pt with GERD

A

Require aggressive antiemetic treatment preop and postop

46
Q

Workup for pt with GERD

A

Hx of H.pylori, PUD, hiatal hernia

47
Q

Meds to consider for pt with GERD

A 
i.	H2 Blocker – “dines”
Cimetidine (Tagamet)
Ranitidine (Zantac)
ii.	Antacids – Gaviscon, Mylanta
iii.	PPIs (proton pump inhibitor) – “prazole”
Lansprazole (Prevacid)
Omeprazole (Prilosec)
48
Q

hypovolemia

A

b. Bleeding
c. Vomiting/diarrhea
d. Bowel obstruction-Shock
e. Dehydration

49
Q

Hypovolemia sxs and PE

A

Symptoms –>Dizziness, weakness, anxiety

PE –> Cold skin, pallor, capillary refill > 2sec, diaphoretic

50
Q

Orthostatic hypotension definition

A

fall in systolic pressure of more than 10mm Hg when patient sits up from lying position)

51
Q

this is an early sign of hypovolemia

A

Tachycardia is early sign of

Fever
Low urine output
also seen

52
Q

you really want to control this to prevent hypovolemia

A

PAIN

will allow for assessment of true blood pressure

53
Q

Hyponatremia hypovolemia commonly caused by

A

diuretics

loss of NA
excess vomiting diarrhea, sweating, diuretics all cause this

54
Q

hyperthyroid pt at risk of

A

i. Risk of HTN
ii. Risk of hyperthermia
iii. Risk of cardiac arrhythmia
iv. Risk of CHF

55
Q

Tx for pt with hyperthyroid prop (how many weeks pre op)

A

Treat with PPU/PTU (propylthiouracil) 1-6 weeks preop

If emergency, treat with propranolol, PPU and
potassium iodide

propranolol lowers BP

56
Q

hypothyroidism

A

i. Risk of hypotension
ii. Risk of shock
iii. Risk of hypothermia

57
Q

preop tx for adrenal insufficiency

A

Preop tx with cortisol and NS (normal saline)

ADD cortisol

58
Q

what are we considered about with allergies in surgery

A

Intraoperative anaphylaxis occur 1/4500 surgeries with 3%-6% mortality

59
Q

Most allergies are to

A

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)

60
Q

when would you need to consider a transfusion in a pt with anemia awaiting surgery

A

Hemoglobin below 7 (or HCT below 21) will likely require blood transfusion of 1 unit

61
Q

1 unit of PRBC will raise HCT by

A

by approx 3 points

62
Q

anemia is of concerned with hemoglobin below

A

i. Hemoglobin below 10

ii. Hematocrit below 30 does not increase risk for surgery

63
Q

vi. Low Hemoglobin Determinants:

A
  1. MCV (mean corpuscular volume)

2. MCHC (mean corpuscular hemoglobin conc)

64
Q

Normocytic/normochromic concerned about

A
  1. Acute blood loss
  2. Early FE-deficiency
  3. Chronic illness/cancer
  4. Hemolytic anemia
65
Q

viii. Microcytic/hypochromic concerned for

A
  1. Late FE-deficiency
  2. Thalassemia
  3. Lead poisoning
66
Q

Macrocytic/normochromic concerned for

A
  1. Malnutrition
  2. B-12 deficiency
  3. Folic Acid deficiency
67
Q

Platelets below _____does not increase risk for surgery

A

50,000 u/l

68
Q

Platelets below _____consider the need for blood transfusion

69
Q

Platelets below _____ require blood transfusion

A

10,000

platelets are usually this low because of chemo

70
Q

platelet counts needing a transfusion (<10,000) would replace with

A

Replace with platelets (not PRBC!)

71
Q

e. Surgery increases risk of DVT (deep vein thrombosis) 21 times! In the following patients –

A

ii. Hx of DVT
iii. Hx of prolonged immobilization
iv. Hypercoagulable states such as

72
Q

Hypercoagulable states such as

A
  1. Factor V Leiden
  2. TTP (thrombotic thrombocytopenic purpura)
  3. SLE
  4. Polycythemia Vera
73
Q

f. PREOP TREATMENT FOR DVT RISK:

A

i. WALK TO OPERATING ROOM
ii. SEQUENTIAL COMPRESSION DEVICE (SCD)
iii. ELASTIC STOCKINGS
iv. HEPARIN 5000 units SUBQ q 8-12h

74
Q

risks witH the alcoholic pt

A

a. Risk of malnutrition b/c ETOH is empty calories, can cause seizures & delirium tremens (rapid onset confusion caused by withdarawal from alcohol)

75
Q

LABS WITH alcoholic pt

A 
increase LFTs
decrease  Albumin
decrease FE/transferrin
decrease  B-12/Folic Acid
increase Bilirubin
76
Q

may have ____ PT/INR/PTT

A

h. May have increased PT/INR/PTT

77
Q

treatment for alcoholic pt

A

Type and Screen for blood transfusion if needed

i. Preop tx with ativan, thiamine, B-12

78
Q

goldman criteria

A

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

79
Q

DM more sensitive to anesthesia because

A

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

80
Q

More important than the BP is the

A

EKG

managed by the anesthesiologist

if you have an EKG that is diufferent than the prior consider a cardiology consult

81
Q

intraoperative HTN is associated

A

stokes MI death

82
Q

how to we manage the pain meds of DM pts

A

usally lower the amount of analgesics because they are more sensitive to them and it can mess with their blood sugar

83
Q

what would be the benefits of an arterial line to avoid complications from heart disease

A

Arterial line – can check blood gases and can also check very accurate BP’s manage fluid

84
Q

why would you use a subclavian line to monitor over an arterial line

A

Subclavian line has more ports so can check blood

85
Q

what is the total score with goldman’s index

A

Total score is 53

86
Q

what is this risk of having a cardiac event with goldman’s index

A

Risk of serious cardiac event or mortality is from .9% to 63.6%

87
Q

what are the lab values on goldman cardiac index

K

88
Q

what are the lab values on goldman cardiac index HCO3

89
Q

what are the lab values on goldman cardiac index bun

90
Q

what are the lab values on goldman cardiac index Cr

91
Q

what are the lab values on goldman cardiac index PO2

92
Q

what are the lab values on goldman cardiac index pc02

93
Q

what, other than the lab values would add to the cardiac risk index with regards to liver and disease

A

increased liver enzymes or bedridden wiht chronic disease

94
Q

stop NSAIDS

A

a week before surgery
ok to take Tylenol with codeine

NORCO

95
Q

preop testing for a pt with renal disease

labs and nml ranges

A

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

96
Q

most common cause of prolonged PTT

A

most common cause of prolonged PTT

97
Q

use to asses pts with chronic liver disease

A

Child–Pugh score

98
Q

what OTC meds cause complications

A 
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
99
Q

risk of bleeding with these OTC

A

garlic and ginseing (hypoglycemia as well)

stop 7 days before

100
Q

when should you stop ephredra and Kava

A

24 hours before

101
Q

st johns wart should be stopped

A

5 days before

102
Q

immunocompromised pts have a lymphocyte count

A

Determination by total lymphocyte count less than 800

103
Q

hypovolemia labs

A 
 glucose
 BUN
 Creatinine
Albumin
BUN:CR   >20:1

 NA
 K
 CL
 Co2 (bicarb)

Surgery (18 decks)

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