Preop/Postop Flashcards
A 74-year-old male with hypertension, diabetes mellitus, and stage 3 chronic renal insufficiency presents to your office with a request from a consulting ophthalmologist for risk assessment prior to cataract surgery. His medications include lisinopril (Prinivil, Zestril), 20 mg daily; amlodipine (Norvasc), 5 mg daily; aspirin, 81 mg daily; pravastatin (Pravachol), 20 mg daily; and glipizide (Glucotrol), 5 mg daily. His blood pressure is 126/72 mm Hg. His most recent laboratory tests from 2 months ago show a hemoglobin A1c of 7.2% (N 4.0–5.6) and a serum creatinine level of 1.8 mg/dL (N 0.6–1.3). He is in his normal state of health, and is able to walk 1–2 blocks before having to stop to rest.
Which one of the following would be most appropriate with regard to preoperative medical testing for this patient? (check one)
No preoperative medical testing
A CBC
An EKG and cardiac stress testing
An EKG, and if results are abnormal, stress testing or echocardiography
No preoperative medical testing
In general, recommended preoperative testing is based on the patient’s medical history and risk factors, the risk associated with the planned surgery, and the patient’s functional capacity. In the case of cataract surgery, however, randomized, controlled trials have established a lack of benefit from preoperative testing for patients in their normal state of health (SOR A).
In a patient without allergies who is admitted to the hospital for hip joint replacement, which one of the following is the recommended prophylactic antibiotic? (check one)
Ampicillin
Ampicillin/sulbactam (Unasyn)
Cefazolin
Clindamycin (Cleocin)
Vancomycin (Vancocin)
Cefazolin
Cefazolin is the recommended prophylactic antibiotic for most patients undergoing orthopedic procedures such as total joint replacement, unless the patient has a β-lactam allergy (SOR A).
A 78-year-old male is on dual antiplatelet therapy (aspirin and clopidogrel) as a result of a stroke 6 months ago. He recently underwent coronary angiography, and his cardiologist has scheduled coronary artery bypass surgery for a week from today.
Which one of the following is recommended with regard to his antiplatelet therapy? (check one)
Stopping only aspirin 5 days before surgery
Stopping only clopidogrel 5 days before surgery
Stopping both aspirin and clopidogrel 5 days before surgery
Continuing both aspirin and clopidogrel
Stopping only clopidogrel 5 days before surgery
Patients receiving dual antiplatelet therapy who require bypass surgery should continue taking aspirin. Clopidogrel or prasugrel should be stopped 5 days before the surgery due to the increased risk of major bleeding during surgery.
Which one of the following is the recommended duration of thromboprophylaxis following total hip arthroplasty, starting from the day of surgery and including outpatient prophylaxis?
(check one)
7 days
14 days
35 days
60 days
90 days
35 days
For patients undergoing major orthopedic surgery, the American College of Chest Physicians recommends outpatient thromboprophylaxis for a duration of up to 35 days. Older recommendations for 10–14 days of prophylaxis were based on studies performed when this was the usual hospital stay. This is still recommended as the minimum length for prophylaxis, but a longer period of time is preferred.
A 40-year-old female is scheduled for a cholecystectomy and you wish to estimate her risk for postoperative bleeding. Which one of the following provides the most sensitive method for identifying her risk? (check one)
Bleeding time
Prothrombin time (PT)
Activated partial thromboplastin time (aPTT)
Bleeding history
Bleeding history
Bleeding time, activated partial thromboplastin time (aPTT), and prothrombin time (PT) are relatively poor predictors of bleeding risk. Studies have shown that baseline coagulation assays do not predict postoperative bleeding in patients undergoing general or vascular surgery who have no history that suggests a bleeding disorder. Obtaining a history for evidence of prior bleeding problems is the most sensitive and accurate method of determining a patient’s risk.
An 88-year-old female is admitted to the hospital with a hip fracture after tripping and falling, and her orthopedist recommends surgery. You are consulted for co-management and risk stratification prior to surgery.
The patient has a history of controlled blood pressure and had a coronary artery bypass graft 10 years earlier. She is not experiencing any cardiac symptoms or syncope.
The most appropriate intervention would be operative management within how many hours? (check one)
48
60
72
84
96
48
The American Academy of Orthopaedic Surgeons’ clinical practice guideline recommends operative management of a hip fracture within 24–48 hours of injury unless a delay is needed to stabilize comorbidities (SOR C). Early intervention reduces complications, improves pain control, and reduces the duration of hospitalization.
A 72-year-old male who underwent total left knee arthroplasty 3 months ago is scheduled for a routine 6-month dental visit next week. His dentist contacts you for advice regarding antibiotic prophylaxis to prevent joint infection.
Which one of the following should you recommend? (check one)
No antibiotic prophylaxis
Amoxicillin, 2 g orally, 1 hour before the procedure
Ceftriaxone, 1 g parenterally, 1 hour before the procedure
Delaying the dental visit for 3 months
Contacting the orthopedic surgeon who performed the arthroplasty
No antibiotic prophylaxis
One of the most potentially devastating late complications of joint replacement surgery is infection of the prosthetic joint. Because dental procedures are known to induce transient bacteremia, the use of prophylactic antibiotics prior to dental procedures for patients with prosthetic joints was considered orthopedic dogma for many years. Current evidence to support this practice is limited and antibiotic use is known to increase cost, bacterial resistance, and the risk of adverse drug reactions, and in most cases the risks of antibiotic prophylaxis outweigh the likelihood of benefit. Therefore, prophylaxis with antibiotics is not recommended for routine outpatient dental procedures in patients with joint replacements. Amoxicillin, 2 g orally, 1 hour prior to a dental procedure such as a cleaning would be recommended for patients with congenital heart disease and valve replacement to prevent subacute bacterial endocarditis. Prophylaxis with parenteral ceftriaxone, delaying the dental visit for 3 months, and contacting the orthopedic surgeon who performed the arthroplasty would not be appropriate in this scenario.
A local dentist contacts you for a prescription for the appropriate antibiotic dosage for one of
your patients who has an appointment for dental cleaning to eliminate a significant plaque
buildup. The patient is a 55-year-old male who has controlled hypertension and mitral valve
prolapse with mitral regurgitation. He is allergic to sulfonamides.
Which one of the following would be the most appropriate prophylaxis for this patient?
(check one)
Amoxicillin, 2 g orally 1 hour prior to the procedure
Amoxicillin, 3 g orally 1 hour prior to the procedure and 1.5 g orally 6 hours after the procedure
Ceftriaxone (Rocephin), 1 g intramuscularly 1 hour prior to the procedure
Clindamycin (Cleocin), 600 mg orally 1 hour prior to the procedure
No antibiotic prophylaxis
No antibiotic prophylaxis
According to the American Heart Association’s 2007 guidelines, prophylaxis to prevent bacterial
endocarditis associated with dental, gastrointestinal, or genitourinary procedures is now indicated only for
high-risk patients with prosthetic valves, a previous history of endocarditis, unrepaired cyanotic congenital
heart disease (CHD), or CHD repaired with prosthetic material, and for cardiac transplant recipients who
develop valvular disease.
Based on a risk-benefit analysis in light of available evidence for and against antibiotic prophylaxis, these
recommendations specifically exclude mitral valve prolapse and acquired valvular disease, even if they are
associated with mitral regurgitation. The American Dental Association has endorsed this guideline.
According to the recommendations of the American Heart Association, which one of the following patients requires endocarditis prophylaxis? (check one)
A 10-year-old female with a previous history of Kawasaki disease without valvular dysfunction
A 22-year-old female who underwent surgical repair of a ventricular septal defect 1 year ago
A 28-year-old female with mitral valve prolapse without regurgitation
A 35-year-old female with a history of infectious endocarditis in her 20s that was related to intravenous drug use
A 42-year-old female with a history of rheumatic fever with chorea who has normal cardiovascular findings
A 35-year-old female with a history of infectious endocarditis in her 20s that was related to intravenous drug use
The American Heart Association and the American College of Cardiology have decreased the number of indications for antibiotic prophylaxis prior to dental procedures. Currently antibiotics are indicated for prosthetic cardiac valves, previous infective endocarditis, unrepaired cyanotic congenital heart disease or a repaired congenital defect with a residual shunt, and a cardiac transplant with valve regurgitation due to a structurally abnormal valve. Amoxicillin, 2 g, is the antibiotic prophylaxis of choice.
A 68-year-old female sees you for a routine health maintenance visit. She feels well and says she has been eating more carefully and exercising for 45 minutes 4 days a week for the past 6 months. Her past medical history includes controlled hypertension and osteoarthritis of the knee. Her family history is notable for a myocardial infarction in her mother at 48 years of age. Her only medication is lisinopril (Prinivil, Zestril).
The physical examination is notable only for a BMI of 36 kg/m2. Laboratory findings are notable for significant hyperlipidemia and you recommend starting a statin. She reports that she will undergo an elective total knee replacement next month and asks about the safety of starting a new medication before this surgery.
You recommend that she (check one)
start a statin immediately to decrease her risk of cardiovascular disease and perioperative mortality
start a statin immediately to decrease her risk of cardiovascular disease, although her risk of perioperative mortality will not be affected
start a statin immediately to decrease her risk of cardiovascular disease, stop the statin 1 week before surgery, and resume taking it after the surgery, to decrease her risk of perioperative mortality
start a statin immediately after the surgery to decrease her risk of cardiovascular disease and perioperative mortality
start a statin after she is released postoperatively by her surgeon to decrease her risk of cardiovascular disease and perioperative mortality
start a statin immediately to decrease her risk of cardiovascular disease and perioperative mortality
Family physicians are often consulted for perioperative medical management. Studies have shown decreased perioperative mortality in patients who continue statins and in patients with clinical indications for statin therapy who start statins prior to undergoing vascular or high-risk surgeries such as joint replacement. A meta-analysis of 223,000 patients showed a significant reduction in perioperative mortality in patients receiving statin therapy versus placebo who underwent noncardiac surgical procedures. This patient has a clinical indication (multiple risk factors) to start statin therapy now.
A 55-year-old female sees you for a preoperative evaluation prior to having cataract surgery. The patient has a previous history of type 1 diabetes mellitus. She reports that she takes a brisk daily walk and has no angina or other cardiac symptoms. The cardiovascular and pulmonary examinations are unremarkable.
Which one of the following would be most appropriate for the preoperative cardiac evaluation of this patient?
(check one)
No further evaluation
An EKG
A treadmill stress test
Pharmacologic stress testing
A chest radiograph
No further evaluation
This 55-year-old patient is undergoing a low-risk procedure. While her diabetes mellitus is a cardiovascular risk factor, she is asymptomatic, her age lowers her risk, and her functional status is good. She should be allowed to undergo cataract surgery with no further evaluation. Guidelines from the American College of Cardiology and the American Heart Association recommend that the patient be allowed to undergo surgery with no further testing.
A 46-year-old male with a prosthetic heart valve requests your advice regarding antibiotic prophylaxis for an upcoming dental procedure. The patient is allergic to penicillin.
Which one of the following would be most appropriate? (check one)
Ciprofloxacin (Cipro)
Clindamycin (Cleocin)
Doxycycline
Rifampin (Rifadin)
Trimethoprim/sulfamethoxazole (Bactrim)
Clindamycin (Cleocin)
Patients with an artificial heart valve should be given antibiotic prophylaxis prior to dental procedures to prevent infectious endocarditis. The organisms that most frequently cause infectious endocarditis include Staphylococcus aureus (31%), Streptococcus viridans (17%), coagulase-negative staphylococci (11%), Enterococcus (11%), Streptococcus bovis (7%), and other streptococci (5%). Amoxicillin is the preferred medication for prophylaxis. Clindamycin or azithromycin can be used in patients with a penicillin allergy. If the penicillin allergy is not associated with anaphylaxis, angioedema, or urticaria, then cephalexin would be an appropriate antibiotic choice. Ciprofloxacin, doxycycline, rifampin, and trimethoprim/sulfamethoxazole are not used for bacterial endocarditis prophylaxis.
