Preoperative Evaluation

Question 1

What equates to 4 METs of activity

Answer 1

Climb Stairs

Walk up Incline

Question 2

Major risk factors in Elective Vascular Surgery

Answer 2

CAD
HF
CVA
Diabetes
Cr> 2.0
Age > 70

Question 3

Indications for pre-op stress test

Answer 3

Elective vascular surgery
Patient unable to perform 4 METs
High risk patient
Abnormal result with change management

Question 4

Therapy after Coronary Stents

Answer 4

Dual Antiplatelet Therapy (DAPT): aspirin plus P2Y12-R blocker

Question 5

Duration of DAPT after coronary stent implantation

Answer 5

6 to 12 months DAPT
-after that lifelong Aspirin

Question 6

CV Assessment for recent (<6 months) Coronary Drug-eluting stent implantation

Answer 6

DAPT for 6 months

Consider delay of surgery or perform on DAPT

Question 7

CV assessment for remote (>6 months) coronary DES implantation

Answer 7

discontinue antiplatelet therapy prior to surgery
-restart after surgery

Special case** Bare metal stents: dc DAPT after 1 month

Question 8

CV assessment: Recent Acute Coronary Syndrome

Answer 8

Delay surgery until 60 days

Question 9

Pulmonary Evaluation Pre-op: Smokers

Answer 9

quitting before surgery may reduce risk

Question 10

Child Pugh Class

Answer 10

Points for Encephalopathy, Ascites, Bilirubin, Albumin, PT
-Class A and B = lowest risk
-Highest risk = class C

Question 11

MELD Score

Answer 11

point system for: Bilirubin, creatinine, INR
-Estimates 3 month mortality
-MELD Score >15 = higher risk

Question 12

Pro-op Eval: Hematology

Answer 12

Goal Platelets: >50,000
Goal INR <1.5
Goal Hgb >7g/dL (Hct >21)

Question 13

Indications for Urgent Surgery

Answer 13

Risk of prolonged delay is high
hip fracture/malignancy

Question 14

Elective surgery Indications

Answer 14

Delay of surgery acceptable
Time to optimize patient
Extensive pre-op testing possible

Question 15

Warfarin

Answer 15

Hold 4-5 days before surgery

Goal INR <1.5

Question 16

Heparin Drip

Answer 16

half life 60-90 minutes

Dc hours before surgery

Question 17

LMWH

Answer 17

Last dose 24 hours before surgery
-last dose 50% normal

Question 18

Aspirin, Clopidogrel, Ticagrelor, Prasugrel

Answer 18

Discontinue 5 to 7 days before surgery

Question 19

ACE-I and ARBs

Answer 19

may cause hypotension: via decrease of RAAS
-usually held morning of surgery

Question 20

NSAIDS

Answer 20

inhibit platelet function
-avoid 1 week prior to surgery

Question 21

Oral Contraceptive Pills

Answer 21

May increase risk of post-op thrombosis
-hold if surgery high risk for post-op DVT/PE

Question 22

Beta-blockers and Statins

Answer 22

Continue

Question 23

Oral Hypoglycemic Agents

Answer 23

Sulfonylureas, Thiazolidinediones
-hold morning of surgery

Question 24

Metformin

Answer 24

Associated with lactic acidosis with renal hypoperfusion
-hold morning of surgery

Question 25

Insulin

Answer 25

continue but decrease dose morning of surgery -due to NPO