Preoperative Care Flashcards
Goldman’s Index
Cardiac risk factors in surgery: 1) JVD 2) recent MI 3) PVCs and arrhythmias, age >70, aortic stenosis
JVD: indicates CHF, #1 CV risk factor overall
MI within 30 days: very high risk, delay surgery
PVCs: at risk of arrhythmia due to ventricular dysfunction, indicated for stress and echo
Ejection fraction: SV/EDV; normal EF >67%, an EF <35% increases risk of operative MI
Diabetes control before surgery
Should be NPO 8 hours before surgery, administer IVF with D5, check glucose morning of surgery; if glucose >250, 2/3 insulin, if glucose is <250, 1/2 insulin
Hyperglycemia preoperatively
ideal glucose is 100-250, delay surgery until glucose is under control
Diabetic coma preoperatively
absolute contraindication o surgery; give IVF, correct acidosis and glucose
Decreased hct preoperatively
important to determine underlying cause of anemia, consider possible colorectal cancer
Increased hct preoperatively
either hypervolemia or polycythemia; if hypovolemic, delay until hydrated, if polycythemic, important to determine underlying cause
Obesity preoperatively
Higher risk of hypertension, cardiovascular disease, post-op atelectasis, type 2 diabetes, DVTs; require DCTs prophylaxis and aggressive post-op pulmonary care for preventing atelectasis
HTN preoperatively
Diastolic BP >110 is high risk of CV complications, beta blockers reduce overall risk
LBBB indicates what?
Underlying ischemic heart disease
RBBB indicates what?
Indicates significant pulmonary disease, but can be normal in up to 10% of patients
Previous CABG and surgery?
Decreases cardiac risk if performed six months to five years before surgery
Previous coronary angioplasty and surgery?
High risk (35%) of coronary restenosis, so stress test is indicated; if angioplasty is recent, delay surgery for several weeks.
What is a cardiac bruit?
Indicates carotid stenosis; indicated for CEA if high grade (>70%) stenosis
Gangrenous toe and surgery?
Peripheral revascularization is more urgent than a full cardiac work-up
Smoking and surgery?
Up to 6+ risk for post-op complications due to compromised ventilation, must quit smoking for 2 months before surgery
COPD and surgery?
Give bronchodilators and try to improve pulmonary status as much as possible.
High risk for acute pulmonary failure with surgery; teach patient about incentive spirometry, give bronchodilators, and mobilize post-op to prevent atelectasis
Green sputum and surgery?
Give oral antibiotics, and schedule surgery after treatment is complete.
Bloody sputum and surgery?
Indicates active infection or lung cancer; requires a full work-up including CXR, CT scan, and bronchoscopy
What is acute cholecystits?
Prevents as fever, RUQ pain, WBC>15; get U/S–> IVF, abx, lap chole within 72 hours
What is Child’s classification?
Stratifies risk of surgery in patients with liver failure; measures three labs (albumin, bilirubin, PT) and three clinical findings (encephalopathy, ascites, nutrition).
Group A: 0-5% mortality
Group B: 10-15% mortality
Group C: >25% mortality; not good surgical candidates until Child’s status is improved
Alcohol use and surgery
Delay surgery until patient has undergone withdrawal, since post-op withdrawal syndrome has a high risk of morbidity/mortality
Liver failure and surgery
Make sure the patient is in a compensated state, abstain from alcohol 6-12 weeks, control ascites, normalize nutrition status and coagulation factors
What is pressure necrosis on hernia?
High risk of rupture with a high mortality rate, requires urgent repair
Delirium in liver failure causes?
CNS abnormality, electrolyte imbalance, GI bleeding, sepsis, or bacterial peritonitis; evaluate for mental status change, and tap the ascites
Ascitic leakage risks and management?
High risk of bacterial peritonitis; manage by sending fluid to lab, giving IV antibiotics, and urgent hernia repair
Signs of malnutrition and preoperative care
Recent weight loss (#1), albumin <3.0 (#2), give 7-10 days of pre-op nutritional support
Dysuria management
Get urinalysis and urine culture; if positive for UTI, delay surgery until resolved
Chronic renal failure (CRF) and surgery
Delay surgery until patient is stable, dialysis started, and any other problems resolved
CRF and K+ management
Needs to be obtained immediately before surgery since CRF can result in rapid electrolyte imbalances.
CRF and operative bleeding
Renal failure causes platelet dysfunction secondary to uremia; give desmopressin or FFP, but not platelets
CRF and operative hypotension
Many possible causes, consider glucocorticoid (aldosterone) deficiency in a patient who has taken steroids before
Kidney transplant patient preoperatively
Require perioperative steroids
Post-op hyperkalemia management
Check ECG for peaked T waves, Tx C BIG K Die (calcium gluconate, bicarb-insulin-glucose, kayexalate, and dialysis)
Mitral stenosis and surgery
Elevated LA pressure can lead to cor pulmonale (PH+RVH); management includes cards consult, prophylactic abx for endocarditis, can go to surgery if stable
Mitral stenosis and CHF and surgery
High risk of mortality; requires extensive cardiac work-up, ECG, echo, and operative monitoring of cardiac status
Aortic stenosis and surgery
Sx triad of angina, dyspnea, syncope, and high possibility of sudden death; requires cardiac workup and operative monitoring
Endocarditis prophylaxis for which procedures?
Recommended for GI procedures, GU procedures, and HEENT procedures
Cardiomyopathy and surgery
High risk of arrhythmias, CHF, heart failure, and sudden death, manage with cards consult and full cardiac workup
Bowel prep for surgery
Decreases fecal mass and bacterial content in the colon, prevents colon surgery complications; put patient on clears day before surgery, NPO at midnight, and give a cathartic agent
What is GoLYTELY?
An isotonic formula that causes no change in electrolyte or water balance; fluid remains in colon and causes a “volume washout”
What is Fleet’s Phospho-Soda?
A sugar-rich, hypertonic formula that works by drawing fluid into the GI tract; risks include dehydration, metabolic acidosis; avoid in diabetics
What is magnesium citrate?
An osmotic agent that draws fluid into the GI tract; risks include dehydration and hypermagnesemia; avoid in renal failure
Aspirin use preoperatively
Stop aspirin use 7-10 days prior to surgery, will affect platelet aggregation
NSAID use preoperatively
Stop NSAIDs 2 days prior to surgery, will affect platelet aggregation
Cellulitis and surgery?
Active infections are associated with higher risk of post-op wound infections; delay surgery until infection is resolved
