Preoperative Care

Question 1

According to ACC/AHA, what conditions are considered clinical predictors of increased perioperative cardiovascular risk?

Answer 1

• unstable coronary syndromes (unstable/sever angina or recent MI)
• decompensated HF (NYHA class IV; worsening or new onset HF)
• significant arrythmias (high grade AV block, mobitz II AV block, symptomatic ventricular arrythmias, supraventricular arrythmias)

Question 2

How should peroperative testing be determined for a patient?

Answer 2

Based on history (assessment of risk factors) and physical…there is no STANDARD preop testing protocol

Question 3

How to categorize patient’s anesthetic risk?

Answer 3

ASA class 1-5 based on perioperative morbidity and mortality
1 = you good fam
5 = u already dead nigguh

Question 4

How to decide between local, general, and spinal anesthesia?

Answer 4

local has less physiologic consequences than local or general….but sometimes if not done effectively can increase pain and need for IV meds which can increase risk
spinal anesthesia may lead to fewer pulmonary complications than general, however do not use in patients with CAD, low cardiac reserve and low EF or peripheral neuropathy….because loss of peripheral vasoconstricto ability or ability to increase CO when necessary
general anesthesia allows excellent analgesa and amnesia while maintaining good physiologic control

IN THE END JUST CONSULT ANESTHESIOLOGIST

Question 5

When to d/c NSAIDs and aspirin for elective procedure?

Answer 5

NSAIDS - 2 days before procedure

aspirin - 7-10 days before procedure

Question 6

Preop management for relatively healthy patient with fmaily history of early MI

Answer 6

ECG and possible stress test, ask for symptoms of angina or SOB

Question 7

preop management for patient with cholesterol of 320

Answer 7

chronically treat with lifestyle modification and possible management, but don’t postpone surgery just for this

Question 8

Preop management of patient with previous inferior MI

Answer 8

re do ECG, consult cards, possible exercise stress test….if ischemia present, may need to do cardiac cath to see if revascularizaiton is needed before surgery

Question 9

preop management for patient with DM

Answer 9

since NPO after midnight, patient needs IV dextrose to prevent hypoglycemia
- check blood glucose morning tightly morning of procedure (should be around 100-250)…if greater than 250, give 2/3rds morning dose if insulin NPH…if less than 250, give 1/2 morning dose in IDDM

Question 10

preop management of patient with anemia

Answer 10

WORK UP ANEMIA first!, usually will be GI bleed or colorectal cancer but other causes should be worked up too

Question 11

preop management of patient with Hct 55%

Answer 11

see if they are dehdydrated (give fluids) or if polycythemia vera (rare but impotant)
cuases of polycythemia vera 0 COPD or EPO secretingtumor like renal cell carcinoma or hepatocellular carcinoma)

Question 12

What complications are obese patients more predisposed to?

Answer 12

• pulmonary hypoventilation, hypercapnia, and pulmonary HTN

- DVT

Question 13

Perioperative managemnt of obese patient

Answer 13

• ABGs and PFTs to evaluate pulmonary function]
• consider postponing elective procedure if patient is willing to do weight loss program
• aggressive pulmonary support during procedure and epidural anesthesia and prophylaxis for atelectasis post op
• SCDs and heparin to prevent DVT post op

Question 14

DM are more predisposed to what complication after procedure?

Answer 14

postoperative wound infection

Question 15

Preop patient has cellulitis form infected hair follicle…

Answer 15

resolve any active infection before operating! REGARDLESS OF LOCATION

Question 16

Preop patient burns on urination

Answer 16

get UA and culture…if UA positive or infection, surgery should be postponed until UTI resolved

Question 17

Preop patient BP is 180/110…

Answer 17

keep using their Bblocker to avoid rebound HTN….diastolic greater than 110 is at risk for malignant HTN, acute MI, or CHF…but if less than or at 110, don’t delay procedure…

HTN patients are at higher chance to have their BP go up right before procedure

Question 18

Operating on smoker…

Answer 18

STOP SMOKING 6-8 weeks before procedure and encourage smoking cessation!

Question 19

Operating on patient with change in sputum to green

Answer 19

probably bronchitis…so treat with antibiotics and operate after procedure complete

Question 20

Operating on blood streaked sputum (bloody for 3 weeks)

Answer 20

indicates active infection or malignancy!….do full work up including CXR and chest CT…bronchoscopy is also necessary to cehck for endobronchial lesions and obstain cytology samples

Question 21

How to manage patient with urgent need for procedure (septic from acute cholecystitis) with advanced COPD…

Answer 21

• ABGs to determine pulmonary status (o2 should be greater than 60 and CO2 less than 45)
• pulmonary toilet and preoperative bronchodilators to improve pulmonary condition
• get info about patient’s preop pulmonary status
• if acute chole…give IVF, antibiotics and see if patient’s conditions improves…if it does you can postpone surgery, if not go ahead
• post op incentive spirometry

Question 22

How to manage patient with urgent need for procedure….with SEVERE COPD..

Answer 22

these patients are high risk for pulmonary failure…
ask if patient is at baseline and if patient uses O2 at home
consider adjusting what procedure is performed (favorable open cholecystectomy becasue lapcholes are associated with increased CO2 absoprtion)

Question 23

Why should patients undergoing revascularizations procedures have a thorogh cardiac risk assessment?

Answer 23

vascular surgery has a high risk for cardiac complications

do thorough workup!

Question 24

Most common cause of early postop death following lower extremity revascularization?

Answer 24

MI!
patients with prior hx of MI risk is 15%
patients with recent mi risk is 37%

do stress test to see if need for cardiac cath before procedure!

Question 25

MI within _____ days of a vascular procedure is a major risk factor for perioperative cardiac complications and surgery should be delayed.

Answer 25

30

anything greater than 30 days is an intermediate risk factor and cards should be consulted

Question 26

What to do if you see greater than 6 PVCs preop?

Answer 26

stress test and echo, but antiarrythmics prophylactically have not been shown to be beneficial

Question 27

What to do preop of patient shows afib

Answer 27

determine if new or chronic..if new look for underlying CAD, CHF, or valvular heart disease….treatment lies around cardioversion to NSR or betablockers to conrol rate….anticoagulation may also be used…coordinate with cards for surgery

Question 28

Preop patient has loud right carotid bruit or previous stroke…

Answer 28

carotid duplex study should be performed…if more than 80% occlusion, may need to do carotid endarterectomy before revascularization

Question 29

ABI of 0.2 vs ABI of 0.4

Answer 29

0.2 is more urgent and vascularization should be favored more than ABI of 0.4

Question 30

How to stratify risk in patient’s with liver failure?

Answer 30

MELD or Child Pugh score

Question 31

What 3 things does the MELD look at?

Answer 31

INR, creatinine, and bilirubin

scored 0-40

Question 32

What does the Child Pugh score look at?

Answer 32

ascites, encephalopathy, albumin, total bilirubin, nutrition

graded A, B, C, with C being the worst

Question 33

How to approach patients with liver failure preop?

Answer 33

Try to optimize and see if they are compensated
try to control ascites with K sparing diuretics or sodium/water restriction
try to normalize prothrombin time with Vit K
abstain from alcohol for 6-12 weeks before surgery

Question 34

What to watch out for in patient with liver failure and umbilical hernia?

Answer 34

ascites can lead to SBP!!!!….try to control ascites as best you can or repair hernia urgently

Question 35

What to do if patient smells of alcohol preop?

Answer 35

DELAY SURGERY

they might go into withdrawal…stop alcohol 6-12 weeks before procedure

Question 36

How to manage patient with CKD preop?

Answer 36

correct any correctable problems (aka DIALYSIS RIGHT BEFORE SURGERY)…keep patients hydrated with good BP control…check electrolytes frequently esp K

Question 37

What intraoperative complication is a CKD patient predisposed to?

Answer 37

ooozing and bleeding from platelet dysfunction secondary to uremia…use DDAVP acutely, FFP, or conjugated estrogen

Question 38

Patient’s K rises to 7.1 post op and is oliguric..what to do

Answer 38

IV calcium cluconate, IV insulin and glucose…hemodialysis probably necessary.

Question 39

Which high risk cardiac conditions warrant antibiotic prophylaxis preop

Answer 39

prosthetic cardiac valve
hx of infective endocarditis
some congentical heart disesae
cardiac transplant recipients with cardiac valvular disease
esp for dental procedures and invasive respiratory tract procedures (protects from strep viridans) ..penicillin or cephalosporin

Question 40

How to intraoperatively monitor patients cardiac status in patients with high risk cardiac conditions like aortic stenosis?

Answer 40

pulmonary artery catheterization or TEE or arterial line