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NMS Casebook > Preoperative Care > Flashcards

Preoperative Care Flashcards

1
Q

Age group that gets standard pre-op ECGs

A

Men over 40 and women over 50-55 years old

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2
Q

Major (>5% risk) clinical risk factors and operative risk factors for perioperative cardiac risk (MI, CHF and death)

A

CLINICAL: Unstable angina, MI in past 7-30 days, decompensated CHF, significant arrhythmias (AV block, symptomatic ventricular arrhythmias and uncontrolled supra ventricular arrhythmias) and severe valvular disease. OPERATIVE: emergent major operation in elderly, aortic reconstruction, major peripheral vascular procedures, major fluid shifts/blood loss.

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3
Q

Intermediate (1-5% risk) clinical risk factors and operative risk factors for perioperative cardiac risk (MI, CHF and death)

A

CLINICAL: Mild angina, previous MI, Q waves, compensated CHF and DM. OPERATIVE: carotid endarterectomy, major head/neck resections, laparotomy, thoracotomy, major orthopedic procedures and open prostatectomy.

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4
Q

Minor (

A

CLINICAL: Elderly, abnormal ECG (LVH, LBB, ST-T wave abnormalities and a-fib), poor exercise tolerance, history of stroke and uncontrolled HTN. OPERATIVE: endoscopy, breast procedures and cataract extraction.

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5
Q

Pros and cons of spinal anesthesia

A

Pros: fewer pulmonary complications. Cons: inability to vasoconstrict or increase CO when needed (higher risk for CAD, CHF, valvular heart disease and diabetic peripheral vascular disease)

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6
Q

Pros and cons of general anesthesia

A

Pros: excellent analgesia/amnesia w/good physiologic control. Cons: pulmonary complications and mild cardiodepression.

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7
Q

Pros and cons of general anesthesia

A

Pros: excellent analgesia/amnesia w/good physiologic control. Cons: pulmonary complications and mild cardiodepression.

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8
Q

Who should get a CBC pre-operatively?

A

Pts w/hx of anemia/polycythemia, procedures w/predictable blood loss and surgery for malignancy.

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9
Q

Who should get a BMP (basic metabolic panel) pre-operatively?

A

> 50 years old or hx of fluid/electrolyte disorders (diarrhea, CKD, diuretics, DM, steroids, chronic liver disease)

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10
Q

Who should get liver enzymes tested pre-operatively?

A

Pts w/hepatobiliary disease or malignancy

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11
Q

Who should get coags pre-operatively?

A

Hx of bleeding, anticoagulant therapy and hx of liver disease.

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12
Q

Who should get a UA pre-operatively?

A

Procedures that involve the urinary tract

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13
Q

Who should get ECGs pre-operatively?

A

Men > 40 and women > 55 years old, known cardiac disorders, serious operations, systemic conditions that cause heart disease (DM, HTN), therapy w/cardiac medications and therapy w/cardiotoxic drugs like doxorubicin.

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14
Q

Who should get CXR pre-operatively?

A

Pts with active or hx of pulmonary disease or pts having a serious operation.

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15
Q

ASA classification of perioperative mortality

A

1) Normal healthy pt (.06-.08% risk) 2) Mild systemic disease, no functional limitations (.27-.4%) 3) Moderate to severe systemic disease w/some functional limitation (1.8-4.3%) 4) Pt w/severe systemic disease that is a constant threat to life and functionally incapacitating (7.8-23%) 5) Moribund pt who is not expected to survive 24 hrs w/or w/o surgery (9.4-51%)

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16
Q

ASA classification of perioperative mortality

A

1) Normal healthy pt (.06-.08% risk) 2) Mild systemic disease, no functional limitations (.27-.4%) 3) Moderate to severe systemic disease w/some functional limitation (1.8-4.3%) 4) Pt w/severe systemic disease that is a constant threat to life and functionally incapacitating (7.8-23%) 5) Moribund pt who is not expected to survive 24 hrs w/or w/o surgery (9.4-51%) 6) Brain dead and organs being harvested. Tag each classification with an E if the procedure is an emergency.

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17
Q

A patient presents for an elective surgery. ECG shows evidence of a previous inferior MI, but he does not recall an MI or symptoms. How should you proceed?

A

Cardiology consult w/possible exercise stress test to identify stress-induced ischemia. Cardiac cath may be required prior to proceeding with elective surgery.

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18
Q

Pre-operative management of patients with diabetes that have to be “NPO after midnight”.

A

IVFs w/dextrose. No hypoglycemic agents the morning of surgery. Check sugars in the morning, if > 250 mg/dL, give 2/3 the morning dose NPH/regular. If

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19
Q

A patient presents for elective surgery with a Hct of 34%. How do you proceed?

A

Find the cause of anemia prior to proceeding with surgery. Note that the most common cause of anemia is colorectal cancer.

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20
Q

A patient presents for elective surgery with a Hct of 55%. How do you proceed?

A

Find the cause of polycythemia prior to proceeding with surgery. The most common cause is dehydration, hydrate the patient then proceed. Less common cause is polycythemia vera due to COPD or EPO-secreting tumors. Diagnose and treat these conditions prior to surgery. If hydration doesn’t do the trick, phlebotomy can be considered.

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21
Q

A patient presents for elective surgery with a Hct of 55%. How do you proceed?

A

Find the cause of polycythemia prior to proceeding with surgery. The most common cause is dehydration, hydrate the patient then proceed. Less common cause is polycythemia vera due to COPD or EPO-secreting tumors. Diagnose and treat these conditions prior to surgery. If hydration doesn’t do the trick, phlebotomy can be considered.

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22
Q

A patient presents for elective surgery with a BMI of 44. What tests should you run before proceeding with surgery?

A

PULMONARY: ABGs to evaluate pulmonary status. If abnormal do PFTs and encourage weight loss. If you must proceed with surgery you can use bronchodilators, epidural anesthesia and aggressive post-op pulmonary care to avoid atelectasis. CARDIOVASCULAR: SCDs and prophylactic subQ heparin for DVT prevention.

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23
Q

A patient presents for elective surgery with blood glucose of 320mg/dL. How should you proceed?

A

Perioperative blood glucose should be 100-250mg/dL and surgery should be delayed until blood glucose is under control with subQ/IV insulin + IV dextrose to prevent hypoglycemia.

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24
Q

Why might patients with poorly controlled DM have more post-op wound infections?

A

Poor circulation = decreased leukocytes to wound. High blood sugar = increased food for bacteria.

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25
Q

A patient presents for elective surgery with cellulitis from an infected hair follicle in his axilla. How do you proceed?

A

Cancel the surgery until there is no longer any active infection.

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26
Q

A patient presents for elective surgery with BP 180/100mmHg. He is normally in the 140s/80s range. How should you proceed?

A

Don’t postpone the surgery because studies have shown that it will not reduce perioperative risk if the pt is mildly hypertensive (DBP

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27
Q

Which anti-hypertensive medications have a high rebound hypertension rate if withheld?

A

Beta-blockers

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28
Q

Which anti-hypertensive medications have a high rebound hypertension rate if withheld?

A

Beta-blockers

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29
Q

A patient presents needing elective surgery with a 20-pack-year smoking history and significant chronic bronchitis. How would you counsel this patient?

A

Counsel the patient to abstain from smoking for 6-8 weeks because perioperative mortality risk is 2-6x higher than non-smokers. This will give his body time to regain bronchial ciliary function (normal after 2 days) and decrease sputum volume (normal after 2 weeks).

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30
Q

A patient presents for elective surgery with a 3 week hx of green sputum and no fever. How do you proceed?

A

Prescribe oral abx and reschedule surgery for when tx is complete.

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31
Q

A patient presents for elective surgery with 3 week hx of blood-tinged sputum. How do you proceed?

A

CXR to r/o infection vs. malignancy. This will also likely include a CT of the chest and bronchoscopy.

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32
Q

ABGs that are concerning for a patient that needs to go under general anesthesia

A

PO2 45.

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33
Q

A patient with sepsis secondary to acute cholecystitis presents to the ED. He has a PMHx significant for advanced COPD. How should you proceed?

A

1st try IVF and antibiotics, if his septic picture worsens go to the OR. If it gets better, spirometry and bronchodilators can help to improve pulmonary function before taking him to the OR.

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34
Q

A patient with sepsis secondary to acute cholecystitis presents to the ED. He has a PMHx significant for advanced COPD. How should you proceed?

A

1st try IVF and antibiotics, if his septic picture worsens go to the OR. If it gets better, spirometry and bronchodilators can help to improve pulmonary function. Pre-op CXR should be taken to r/o underlying pneumonia. Open cholecystectomy should be done to avoid excess CO2 from abdominal insufflation. You can also try to minimize the duration of general anesthesia and encourage early ambulation to prevent atelectasis.

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35
Q

Pulmonary function values that correlate with high risk of perioperative pulmonary complications (atelectasis, pneumonia, PTX, vent dependence, right heart failure and death).

A

FEV1

36
Q

Pulmonary function values that correlate with moderate risk of perioperative pulmonary complications (atelectasis, pneumonia, PTX, vent dependence, right heart failure and death).

A

FEV1 45mmHg.

37
Q

A patient presents for evaluation of peripheral arterial disease and rest pain. He has no other cardiovascular symptoms. How should you proceed?

A

In all vascular patients you should assess 5 factors to predict cardiac complications after vascular surgery: 1) Q waves 2) Hx of ventricular ecotopy 3) Hx of angina 4) DM requiring more than dietary modification 5) Age > 70.

38
Q

Persantine thallium stress test

A

Persantine vasodilator healthy blood vessels and thallium isotope lets you see them.

39
Q

Dobutamine echocardiogram

A

Dobutamine is a beta-1 agonist that increases cardiac contractility, allowing you to assess for ischemia.

40
Q

Most common cause of early post-op death following LE revascularization surgery.

A

MI. Reinfarction rates are as high as 15% in patients undergoing revascularization. Rates can be as high as 37% if the MI was recent.

41
Q

A patient presents for LE revascularization. He has a hx of prior MI. How should you proceed?

A

Stress test him. If reversible ischemia, cardiac catheterization is necessary. If non-reversible ischemia, then it is most likely due to old MI and cardiac cath is not necessary.

42
Q

How do you determine if patients should have further cardiac evaluation prior to surgery?

A

ACC/AHA guidelines: 20 pts for unstable angina and suspect critical aortic stenosis. 10 pts for MI

43
Q

How do you determine if patients should have further cardiac evaluation prior to surgery?

A

ACC/AHA guidelines: 20 pts for unstable angina and suspect critical aortic stenosis. 10 pts for MI 6 months ago, hx of pulmonary edema ever, non-sinus rhythm, premature arterial beats, more that 5 PVCs, age > 70 and poor medical conditions ( P02 45, K+ 50, Cr > 2.6). Score > 20 (10-15% risk for cardiac complications) = cardiology consult and stress test. Score 70, hx of angina, DM, Q waves, hx of MI, ST abnormalities, HTN w/LVH and hx of CHF). Pts with no more than 1 risk variable may proceed with surgery. If surgery is nonvascular and pt has > 1 variable they may proceed with surgery. If surgery is vascular and they have > 1 variable, they need a cardiology consult + stress test because risk for cardiac complications is 3-15%.

44
Q

A patient presents for elective surgery with a hx of non-Q wave MI 9 months ago. How do you proceed?

A

Non-Q-wave MI = non-transmural MI and more myocardium is at risk for ischemia and necrosis. This patient should undergo stress test for reversible ischemia and cardiac cath if + for reversible ischemia.

45
Q

A patient presents for elective surgery. ECG reveals a bundle branch block. What conditions are in your differential depending on which side the bundle branch block is on?

A

LBBB is highly suggestive of underlying ischemia and is never normal. RBBB can be a normal variant 10% of the time, but is more frequently seen in patients with significant pulmonary disease.

46
Q

A patient presents for elective surgery. ECG reveals a bundle branch block. What conditions are in your differential depending on which side the bundle branch block is on?

A

LBBB is highly suggestive of underlying ischemia and is never normal. RBBB can be a normal variant 10% of the time, but is more frequently seen in patients with significant pulmonary disease.

47
Q

How does prior CABG affect cardiac complication risk in patients undergoing non-cardiac surgery?

A

Reduced risk if cardiac surgery occurred 6 months to 5 years from pending surgery.

48
Q

Why stress test a patient who had saphenous vein CABG 10 years ago?

A

Saphenous graft occlusion rates are 12-20% at 1 year. 20-30% at 5 years and 40-50% at 10 years.

49
Q

Why stress test a patient who had percutaneous transluminal coronary angioplasty (PTCA) 2 years ago?

A

Coronary restenosis rates with PTCA are 25-35% at 6 months

50
Q

A patient presents for elective surgery and complains of moderate angina relieved by nitroglycerin. How should you proceed?

A

Coronary angiography to determine extent of CAD +/- PTCA or coronary artery revascularization.

51
Q

A patient presents for elective surgery and ECG shows 6 PVCs per minute. How should you proceed?

A

Stress test and echo to check for underlying ventricular dysfunction

52
Q

A patient presents for elective surgery and ECG shows new a-fib. How should you proceed?

A

Check for and if necessary treat CAD, CHF or valvular heart disease. Cardioversion or beta-blockers to control heart rate. Anti-coagulation to prevent emboli.

53
Q

A patient presents for LE vascular surgery and physical exam reveals a right carotid bruit. How should you proceed?

A

Duplex u/s to assess for stenosis. If high grade (70-99%) carotid endarterectomy is indicated prior to LE revascularization.

54
Q

Child’s Classification of Liver Failure

A

A, operative mortality 0-5%) Bili 3.5, no ascites, no encephalopathy and excellent nutrition. B, operative mortality 10-15%) Bili 2-3, albumin 3-3.5, easily controlled ascites, minimal encephalopathy and good nutrition. C, operative mortality > 25%) Bili > 3, albumin

55
Q

A patient presents with chronic liver failure with ascites and an umbilical hernia he wants to get fixed. How should you proceed?

A

Counsel the patient to stop drinking for 6-12 weeks. Control ascites with K-sparing diuretics (amiloride, triamterine, spironolactone and eplerenone) and Na/H2O restriction. Improve nutrition status. Give vitamin K to normalize PT. These should all increase his Child’s score and decrease poor outcomes.

56
Q

Child’s Classification of Liver Failure

A

A, operative mortality 0-5%) Bili 3.5, no ascites, no encephalopathy and excellent nutrition. B, operative mortality 10-15%) Bili 2-3, albumin 3-3.5, easily controlled ascites, minimal encephalopathy and good nutrition. C, operative mortality > 25%) Bili > 3, albumin

57
Q

A patient presents with chronic liver failure with ascites and an umbilical hernia he wants to get fixed. How should you proceed?

A

Counsel the patient to stop drinking for 6-12 weeks. Control ascites with K-sparing diuretics (amiloride, triamterine, spironolactone and eplerenone) and Na/H2O restriction. Improve nutrition status. Give vitamin K to normalize PT. These should all increase his Child’s score and decrease poor outcomes.

58
Q

A patient presents with a hernia that has a small ulcerated area above it. How should you proceed if the patient is Child’s class C?

A

Promptly try to manage the ascites first, then fix the hernia immediately because ulcerated hernias have a risk of rupture that comes with a mortality of 11-43%.

59
Q

A patient with previously diagnosed liver failure and ascites presents with acute changes in mental status. How should you proceed?

A

Tap the ascites fluid to check for spontaneous bacterial peritonitis and give abx if > 250 WBCs/mm^3. Also make sure you r/o electrolyte abnormalities, GI bleeding, sepsis and encephalopathy.

60
Q

If a patient has liver failure and agrees to quit drinking alcohol so he can have his hernia repaired, when exactly can you do the repair?

A

Once the patient has quit and already gone through withdrawals. Post-op alcohol withdrawal has high rates of morbidity and mortality.

61
Q

Pts who are at very high risk for uncontrollable hemorrhage during surgical repair of hemorrhoids.

A

Pts with cirrhosis and possible portal HTN

62
Q

Why wait for a patient with ESRD to get a kidney transplant prior to undergoing an elective “easy” operation? What if that is not an option because there is no donor?

A

ESRD can cause uremia which leads to platelet dysfunction, risk of bleeding and poor wound healing. If you must operate on a patient with poor renal function, dialysis prior to surgery allows for normal platelet function, BP, electrolytes and hydration status.

63
Q

Management of a patient schedule for surgery with PMHx significant for renal transplant and chronic prednisone use.

A

Post-op methylprednisone 125mg IV q8 hrs for 3 days.

64
Q

You take a patient with a hx of ESRD to the OR for hernia repair. After your incision the patient continues to have capillary oozing. What can you do to combat the effects of uremia on this patient’s platelets?

A

Platelet transfusion will not work because the uric acid will continue to inhibit the new platelets. You can give desmopressin (ddAVP) acutely to release vWF from endothelium and increase spreading/aggregation of platelets. FFP can temporarily correct defects. Conjugated estrogens act slow but can last up to 2 weeks. Post-op hemodialysis may be required to correct platelet function.

65
Q

Management of a patient schedule for surgery with PMHx significant for renal transplant and chronic prednisone use.

A

Post-op methylprednisone 125mg IV q8 hrs for 3 days. If hypotension occurs intraoperatively, give 25mg hydrocortisone followed by 100mg over next 24 hours.

66
Q

You take a patient with a hx of ESRD to the OR for hernia repair. After your incision the patient continues to have capillary oozing. What can you do to combat the effects of uremia on this patient’s platelets?

A

Platelet transfusion will not work because the uric acid will continue to inhibit the new platelets. You can give desmopressin (ddAVP) acutely to release vWF from endothelium and increase spreading/aggregation of platelets. FFP can temporarily correct defects. Conjugated estrogens act slow but can last up to 2 weeks. Post-op hemodialysis may be required to correct platelet function.

67
Q

You take a patient with a hx of ESRD to the OR for hernia repair. After your incision the patient continues to have capillary oozing. What can you do to combat the effects of uremia on this patient’s platelets?

A

Platelet transfusion will not work because the uric acid will continue to inhibit the new platelets. You can give desmopressin (ddAVP) acutely to release vWF from endothelium and increase spreading/aggregation of platelets. FFP can temporarily correct defects. Conjugated estrogens act slow but can last up to 2 weeks. Post-op hemodialysis may be required to correct platelet function.

68
Q

Next step in a patient with peaked T waves on ECG and 10mL of urine/hour.

A

He has oliguria and hyperkalemia. Correct hyperkalemia 1st with calcium gluconate to stabilize cardiac membranes. Give IV insulin and glucose to drive potassium intracellularly. Hemodialysis may also be necessary.

69
Q

Complications associated with mitral valve stenosis. What should you do pre-operatively if your pt has severe mitral valve stenosis?

A

Increased left atrial pressure causes pulmonary HTN and right head failure. This leads to symptoms of fatigue, dyspnea w/exertion and hemoptysis. The distended atrium also predisposes pts to a-fib. Pre-op these pts need a cardiology consult and an echo because mortality can be as high as 5%.

70
Q

Operative management of a patient with mitral valve stenosis.

A

Avoid hypercapnia, acidosis and hypoxia because these can cause increased pulmonary vascular resistance. Tachycardia should be avoided because it decreases diastolic filling time. Pt should be given prophylactic abx to prevent subacute bacterial endocarditis.

71
Q

Perioperative mortality in patients with mitral valve stenosis + underlying CHF. How do you manage these patients?

A

20%. Pts need extensive cardiac work up. If procedure is urgent get ECG, echo and monitor intraoperatively with a-line and transesophageal echocardiography. Note that PCWP will not be accurate with this condition because the mitral valve distorts the relationship between the PCWP and the left ventricular end-diastolic pressure.

72
Q

Perioperative mortality in patients with mitral valve stenosis + underlying CHF. How do you manage these patients?

A

20%. Pts need extensive cardiac work up. If procedure is urgent get ECG, echo and monitor intraoperatively with a-line and transesophageal echocardiography. Note that PCWP will not be accurate with this condition because the mitral valve distorts the relationship between the PCWP and the left ventricular end-diastolic pressure.

73
Q

Aortic stenosis in a patient being worked up for an elective surgical procedure.

A

Valve replacement takes priority, in urgent surgical situations, pulmonary artery catheter, a-line and transesophageal echocardiography should be considered.

74
Q

Cardiac conditions with high risk for bacterial endocarditis that merit abx prophylaxis

A

Prosthetic heart valves, previous endocarditis, complex congenital heart defects and prosthetic vascular grafts

75
Q

Cardiac conditions with moderate risk for bacterial endocarditis that merit abx prophylaxis

A

Rheumatic valvular disease, mitral valve prolapse w/regurg, hypertrophic cardiomyopathy

76
Q

Cardiac conditions with negligible risk for bacterial endocarditis that do not merit abx prophylaxis

A

Previous CABG, repair of ASD/VSD, mitral valve prolapse w/o regurg, physiologic murmurs and cardiac pacemakers

77
Q

Non-cardiac procedures with recommended abx prophylaxis for patients with moderate and high risk for bacterial endocarditis

A

Dental work (extractions, periodontal, cleanings), respiratory tract (tonsillectomy, rigid bronch, procedures involving tracheobronchial tree/lungs), GI tract (esophageal variceal banding, dilation of strictures, ERCP, biliary tract surgery, surgery involving intestines) and GU tract (prostate surgery, cystoscopy, dilation of strictures and major open procedures).

78
Q

Recommended abx prophylaxis for dental, oral, respiratory tract and esophageal procedures.

A

Amox 1 hr prior. Clinda/cephalosporin/clarithro 1 hr prior if PCN allergic

79
Q

Recommended abx prophylaxis for GI/GU procedures in high risk patients

A

Amp/gent 30 min prior and amp 6 hrs after. Vanc/gent 30 min prior and no following dose if PCN allergic.

80
Q

Recommended abx prophylaxis for GI/GU procedures in moderate risk patients.

A

Amox or amp 1 hr prior w/no f/u dose. Vanc 1-2 hrs prior w/no f/u dose if PCN allergic.

81
Q

What is a bowel prep?

A

Day b/f surgery pt is on a clear liquid diet to clear stool from the bowel. Cathartics (Golytely, Fleets Phospho-Soda and Mg Citrate) and enemas can also aid in mechanical clearance of stool, which is the most important aspect of bowel prep. Oral non-absorbable abx like neomycin and erythromycin can be used to decrease bacterial load in the bowel.

82
Q

What is a bowel prep?

A

Day b/f surgery pt is on a clear liquid diet to clear stool from the bowel. Cathartics (Golytely, Fleets Phospho-Soda and Mg Citrate) and enemas can also aid in mechanical clearance of stool, which is the most important aspect of bowel prep. Oral non-absorbable abx like neomycin and erythromycin can be used to decrease bacterial load in the bowel.

83
Q

Fluid/electrolyte changes w/Golytely cathartic for bowel prep.

A

Formula contains KCl, NaHCO3, NaCl and NaSO4…no net absorption or section of ions and normal fluid/electrolytes. Drinking 4L is equivalent to enema…just look out for dehydration in elderly.

84
Q

Fluid/electrolyte changes w/Fleets Phospho-Soda

A

It contains lots of sugar and salt and is thus contraindicated in diabetics and those on salt-restricted diets. It is hyper osmotic and draws lots of fluid into the stool. Since stool contains less Na/Cl and more K/HCO3, patients can have metabolic acidosis from losing so much HCO3. Loss of HCO3 exacerbates loss of K because the body tries to make more HCO3 by bringing more Na/H intracellularly at the expense of excreting more K. Patients can become confused, have arrhythmias, muscle cramping, weakness and fatigue. Patients must always be monitored for dehydration and given IVFs as needed.

85
Q

Fluid/electrolyte changes w/Mg citrate

A

Osmotic agent, watch for signs/symptoms of dehydration and metabolic acidosis. Contraindicated in patients with renal failure because decreased clearance of Mg can result in flushing, hypotension, respiratory depression, bradycardia, CNS depression, muscle paralysis, loss of DTRs and worsening renal failure.

86
Q

When do you give a patient calcium gluconate to alleviate hypermagnesemic symptoms?

A

When serum Mg levels > 5 mEq/L

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