Preoperative Care 2 Flashcards
Cholecystitis patient presents with PO2 of 49 and PCO2 of 65. Cannot speak without gasping for air – management if surgery is absolutely necessary?
Patient is at high-risk for acute pulmonary failure with surgery
- CXR to rule out pneumonia
- Determine baseline respiratory status
- Before surgery – Teach incentive spirometry and use bronchodilators
- During surgery – Minimize duration of anesthesia
- Postoperatively – mobilize ASAP to prevent atelectasis
Surgical management of a patient needing urgent surgery but with hx of severe pulmonary function problems?
- ABG – PaO2 under 60 suggests pulmonary hypertension, PaCO2 over 45 increases perioperative morbidity
- If surgery not immediately necessary, try spirometry, bronchodilator therapy and other efforts to improve pulmonary status before surgery
Patient with severe acute pulmonary problems – type of surgery that is contraindicated?
Laparoscopy – may lead to increased CO2 absorption, increasing work of lungs
Pulmonary function values (FVC, PAP, PaCO2) and their implications on surgery?
- Forced vital capacity was than 50-75% of predicted – moderate risk
- Pulmonary arterial pressure less than 25 – moderate/high risk
- PaCO2 over 45 – moderate risk
FEV1 value and its implication for surgery?
<35% predicted – high-risk
0.6 L – can only tolerate pulmonary wedge resection
1 L – can tolerate up to lobectomy
2 L – can tolerate up to pneumonectomy
Surgical patient with peripheral vascular disease – factors used to predict risk for cardiac complications after vascular surgery?
- Q waves on EKG
- History of ventricular ectopy
- History of angina
- Diabetes controlled by more than just diet
- 70 years and older
Patient with peripheral vascular disease – tests before vascular surgery?
- Current EKG to compare with previous EKG
- Exercise Stress test
- If cannot tolerate exercise stress test, nuclear stress test or dobutamine EKG
- If reversible ischemia is present, may need cardiac catheterization and possible coronary revascularization before surgery
Most common cause of early postoperative death following lower extremity revascularization? How common?
MI; 15% if previous history of MI, 37% if recent history of MI
Surgical patient for vascular surgery reports an MI three years ago – management? If MI was three months ago? If 3 weeks ago?
Stress test (if reversible ischemia, do cardiac cath)
MI is an intermediate risk – Use guidelines to estimate coronary risk
Major risk factor – delay surgery
Patient for vascular surgery reports a non-Q-wave MI nine months ago – management?
Non-trams mural infarct – peri-infarct myocardium and risk for further infarction.
Thallium stress test to determine reversible ischemia. If positive, coronary bypass necessary
Patient for vascular surgery – EKG shows left bundle branch block – management?
LBBB is never normal and is highly suggestive of ischemic heart disease – Evaluate for underlying
Disease
Patient for vascular surgery had CABG two years ago – risk of complications?
If CABG was 10 years ago?
Prior coronary artery revascularization 0.5-5 years previously reduces risk for cardiac complications
No longer has benefit – perform stress testing to evaluate for reversible ischemia
Patient for surgery had angioplasty two years ago – management? If angioplasty was two days ago?
25-35% chance of restenosis at six months, so need stress test
Increased risk of coronary thrombosis in the first month post surgery. Delay surgery for several weeks
Surgical patient has angina on moderate exertion and uses nitroglycerin – management?
Coronary angiography to determine extent of disease
Surgical patient – EKG shows six PVCs Per minute – management?
Increased risk of ventricular dysfunction – form stress test and go to evaluate LV function
