Preoperative Care

Question 1

Goldman’s Index

Answer 1

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

Question 2

Diabetes control before surgery

Answer 2

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

Question 3

Hyperglycemia preoperatively

Answer 3

ideal glucose is 100-250, delay surgery until glucose is under control

Question 4

Diabetic coma preoperatively

Answer 4

absolute contraindication o surgery; give IVF, correct acidosis and glucose

Question 5

Decreased hct preoperatively

Answer 5

important to determine underlying cause of anemia, consider possible colorectal cancer

Question 6

Increased hct preoperatively

Answer 6

either hypervolemia or polycythemia; if hypovolemic, delay until hydrated, if polycythemic, important to determine underlying cause

Question 7

Obesity preoperatively

Answer 7

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

Question 8

HTN preoperatively

Answer 8

Diastolic BP >110 is high risk of CV complications, beta blockers reduce overall risk

Question 9

LBBB indicates what?

Answer 9

Underlying ischemic heart disease

Question 10

RBBB indicates what?

Answer 10

Indicates significant pulmonary disease, but can be normal in up to 10% of patients

Question 11

Previous CABG and surgery?

Answer 11

Decreases cardiac risk if performed six months to five years before surgery

Question 12

Previous coronary angioplasty and surgery?

Answer 12

High risk (35%) of coronary restenosis, so stress test is indicated; if angioplasty is recent, delay surgery for several weeks.

Question 13

What is a cardiac bruit?

Answer 13

Indicates carotid stenosis; indicated for CEA if high grade (>70%) stenosis

Question 14

Gangrenous toe and surgery?

Answer 14

Peripheral revascularization is more urgent than a full cardiac work-up

Question 15

Smoking and surgery?

Answer 15

Up to 6+ risk for post-op complications due to compromised ventilation, must quit smoking for 2 months before surgery

Question 16

COPD and surgery?

Answer 16

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

Question 17

Green sputum and surgery?

Answer 17

Give oral antibiotics, and schedule surgery after treatment is complete.

Question 18

Bloody sputum and surgery?

Answer 18

Indicates active infection or lung cancer; requires a full work-up including CXR, CT scan, and bronchoscopy

Question 19

What is acute cholecystits?

Answer 19

Prevents as fever, RUQ pain, WBC>15; get U/S–> IVF, abx, lap chole within 72 hours

Question 20

What is Child’s classification?

Answer 20

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

Question 21

Alcohol use and surgery

Answer 21

Delay surgery until patient has undergone withdrawal, since post-op withdrawal syndrome has a high risk of morbidity/mortality

Question 22

Liver failure and surgery

Answer 22

Make sure the patient is in a compensated state, abstain from alcohol 6-12 weeks, control ascites, normalize nutrition status and coagulation factors

Question 23

What is pressure necrosis on hernia?

Answer 23

High risk of rupture with a high mortality rate, requires urgent repair

Question 24

Delirium in liver failure causes?

Answer 24

CNS abnormality, electrolyte imbalance, GI bleeding, sepsis, or bacterial peritonitis; evaluate for mental status change, and tap the ascites

Question 25

Ascitic leakage risks and management?

Answer 25

High risk of bacterial peritonitis; manage by sending fluid to lab, giving IV antibiotics, and urgent hernia repair

Question 26

Signs of malnutrition and preoperative care

Answer 26

Recent weight loss (#1), albumin <3.0 (#2), give 7-10 days of pre-op nutritional support

Question 27

Dysuria management

Answer 27

Get urinalysis and urine culture; if positive for UTI, delay surgery until resolved

Question 28

Chronic renal failure (CRF) and surgery

Answer 28

Delay surgery until patient is stable, dialysis started, and any other problems resolved

Question 29

CRF and K+ management

Answer 29

Needs to be obtained immediately before surgery since CRF can result in rapid electrolyte imbalances.

Question 30

CRF and operative bleeding

Answer 30

Renal failure causes platelet dysfunction secondary to uremia; give desmopressin or FFP, but not platelets

Question 31

CRF and operative hypotension

Answer 31

Many possible causes, consider glucocorticoid (aldosterone) deficiency in a patient who has taken steroids before

Question 32

Kidney transplant patient preoperatively

Answer 32

Require perioperative steroids

Question 33

Post-op hyperkalemia management

Answer 33

Check ECG for peaked T waves, Tx C BIG K Die (calcium gluconate, bicarb-insulin-glucose, kayexalate, and dialysis)

Question 34

Mitral stenosis and surgery

Answer 34

Elevated LA pressure can lead to cor pulmonale (PH+RVH); management includes cards consult, prophylactic abx for endocarditis, can go to surgery if stable

Question 35

Mitral stenosis and CHF and surgery

Answer 35

High risk of mortality; requires extensive cardiac work-up, ECG, echo, and operative monitoring of cardiac status

Question 36

Aortic stenosis and surgery

Answer 36

Sx triad of angina, dyspnea, syncope, and high possibility of sudden death; requires cardiac workup and operative monitoring

Question 37

Endocarditis prophylaxis for which procedures?

Answer 37

Recommended for GI procedures, GU procedures, and HEENT procedures

Question 38

Cardiomyopathy and surgery

Answer 38

High risk of arrhythmias, CHF, heart failure, and sudden death, manage with cards consult and full cardiac workup

Question 39

Bowel prep for surgery

Answer 39

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

Question 40

What is GoLYTELY?

Answer 40

An isotonic formula that causes no change in electrolyte or water balance; fluid remains in colon and causes a “volume washout”

Question 41

What is Fleet’s Phospho-Soda?

Answer 41

A sugar-rich, hypertonic formula that works by drawing fluid into the GI tract; risks include dehydration, metabolic acidosis; avoid in diabetics

Question 42

What is magnesium citrate?

Answer 42

An osmotic agent that draws fluid into the GI tract; risks include dehydration and hypermagnesemia; avoid in renal failure

Question 43

Aspirin use preoperatively

Answer 43

Stop aspirin use 7-10 days prior to surgery, will affect platelet aggregation

Question 44

NSAID use preoperatively

Answer 44

Stop NSAIDs 2 days prior to surgery, will affect platelet aggregation

Question 45

Cellulitis and surgery?

Answer 45

Active infections are associated with higher risk of post-op wound infections; delay surgery until infection is resolved