preop mgmt

Question 1

major cardiac risk factors

Answer 1

MI <6 weeks
unstable angina
decompensated HF
significant dysrhythmia (AVB, ventricular dysrhythmias, tachyarrhythmias)
severe valvular disease

cards consult!!!

Question 2

purpose or preop examination

Answer 2

mitigate risk for surgery
risk stratification

Question 3

age significance

Answer 3

not overall predictor of cardiac mortality

is risk factor for pulmonary complications

Question 4

important med recs

Answer 4

aspirin, NSAIDs, DOACs, warfarin, steroids

Question 5

approach to preop diagnostics

Answer 5

screen for asymptomatic disease that may affect surgical risk

appraisal of disease that require tx before surgery

everyone needs age & condition appropriate labs

very selective approach!!! no routine testing w/o clinical indications

-CBC/BMP reasonable for most
- BMP not evidence based, unless renal dysfunction
-H&H 65+ major surg, or sig blood loss
- WBC/plt if spinal or epidural anesthesia
- UA maybe for ortho

no EKG/CXR/PFTs in low risk unless s/s

Question 6

major risk factors

Answer 6

ischemic heart disease
known HF
hx of TIA or CVA
renal insufficiency
DM on insulin
high risk surgeryi

Question 7

risk predictors

Answer 7

RCRI (revised cardiac risk index)
ACS NSQIP
METS

Question 8

METS

Answer 8

metabolic equivalents
exercise tolerance is a risk predictor for surgery risk

METS <4 - high risk (>5%) - MI, HF, arrhythmia
METS 4-10 int risk (1-5%)
METS >10 low risk (<1%)

Question 9

nitrogen balance

Answer 9

gold standard of adequate protein intake

Question 10

periop endocarditis - who, what, how?

Answer 10

hx: prosthetic valves, previous endocarditis, CHD, transplant

procedures: dental, skin/soft tissue, respiratory tract

tx: amoxicillin

Question 11

CAD meds

Answer 11

aspirin - continue unless concerns about hemorrhage

dual antiplatelets - coordinate w surgeon

B-blocker - continue if already taking, no need to start

other anticoagulants - coordinate w surgeon

Question 12

CHF mgmt

Answer 12

optimize fluid status
consider BNP trend
inotropes PRN periop
pulm support

Question 13

A fib meds

Answer 13

warfarin - low risk stop 5 days preop/high risk stop 5 days preop then bridge with heparin 2 days after stopping,

NOACs - hold 2-6 doses depending on agent and CrCl

Question 14

transfusion goals

Answer 14

asymptomatic anemia - hgb 7
symptomatic anemia - hgb 8

Question 15

DM mgmt

Answer 15

not on insulin - hold short acting meds day of, hold long acting (metformin, sulfonylureas) one day preop/2postop, consider SSI periop

insulin - hold/reduce HS short acting, continue long acting

Question 16

renal disease

Answer 16

optimize fluid status - diuresis as needed

on dialysis - consult renal, HD within 24 hours of procedure preop

PD - continue as needed, if abd surgery consider HD

Question 17

liver disease

Answer 17

risk for morbidity/mortality!!!

child-pugh & MELD

optimize lytes/coags (vit K, cryo, FFP, then DDAVP/plt)

ascites - diuretics, albumin

encephalopathy - lactulose, rifaximin

pulm - pleurocentesis

Question 18

pulm

Answer 18

smoking cessation 4 weeks preop
abx if purulent secretions
IS

COPD - bronchodilators, CPT, steroids,

asthma - steroids if FEV1<80, if previous steroids (<6mo) need stress dose coverage

Question 19

arenal insufficiency

Answer 19

continue steroids if taking

stress dose steroids w taper