Preoperative Evaluation and Testing Flashcards
Pre-op H&P - Important meds to screen for
Anticoagulation meds
ASA
NSAIDs
Pre-op H&P - Herbal remedies to screen for
Echinacea - hepatotoxic
Ginseng - Platelet inhibitor, hypoglycemia
Garlic - platelet inhibitor, decreased preload
Gingko - platelet inhibitor, vasoregulation altered
St. John’s Wort - P450 upregulation, drug interactions
Kara - sedation, drug interactions
Latex allergy association
Banana
Avocado
Kiwi
Apricot
Melon
Chestnut
-allergy to any above
CAD and CHF risk
Low-risk CAD: revascularize only if independently indicated, give pre-op anti-anginal and IV nitro post-op
High-risk CAD: treat CAD before surgery, get stress test and echo
-delay surgery for 3-6 months w/ recent MI
CHF: have to know current ejection fraction before anesthesia - peripheral vasodilators decrease afterload
Valvular Heart Disease and Hypertension
Valve: echo w/ heart murmur for valve lesions, Abx prophylaxis and fluid management if significant
-Severe symptomatic aortic stenosis is high risk
HTN: Severe (>150/>110) is a higher risk cardiac complication - control before surgery
Arrhythmias
Patients with rhythm disturbances w/o structural disease are low risk
Control symptomatic supravent/ventricular tachycardia pre-op
Lovenox window to bridge anticoagulation peri-operatively
Pulmonary Evaluation
Highest risk of complications w/ cardiac, thoracic, upper abdominal surgery
Highest risk: Chronic lung disease, morbid obesity, tobacco
-Chronic lung dx = FEV1<500 or pCO2 >45
Smoking cessation for >8 weeks w/ CABG
PFTs in all pts with lung resection or unexplained dyspnea, exercise intolerance
Hematologic Evaluation and Test
CBC for all patients >65 years old
Asx anemia is rare, only check if symptomatic
Need transfusion w/ Hbg <8-9 to prevent stress on heart
Get PT, PTT, platelet count, bleeding time is formal Hx unavailable
- Otherwise only get when on anticoagulants or w/ neurosurgery
- aPTT = intrinsic pathway, PT = extrinsic pathway
Neurologic Evaluation
Delirium and stroke are the most common serious side effects of surgery
Avoid delirium drugs: Meperidine, anticholinergics, benzos
Diabetes Evaluation
Increased risk infection and MI
Blood glucose goal 100-250 before surgery
Correct fluids and electrolytes during surgery
Asx hyperglycemia doesn’t increase complications
Chronic Glucocorticoid Evaluation
Maintain with previous supplementation
May have to increase 2-3X dose during surgery
Renal Disease Evaluation
High-risk post-op hyperkalemia, pneumonia, and fluid overload
Dialyze patient 24 hours pre-op and monitor volume status w/ renal insufficiency (increased Creat/BUN)
Creatinine is most sensitive for function - increased CV risk if >2
-Screen in >50 yo w/ moderate risk, HOTN planned, or nephrotoxic meds
Medication Recommendations
Withhold ACEI, diuretics, metformin, oral hypoglycemia
DC all herbal supplements 2 wks prior
With Warfarin, use Lovenox window and operate when INR <1.5
All CV risk patients receive beta blockers unless strongly contraindicated
Electrolyte and LFT Screening Indications
Electrolytes: only with diuretics, ACEI/ARBs or renal disease
-Hypernatremia does increase 30 day peri-op M/M
LFTs: Cirrhosis and acute failure have more M/M - should detect on H&P
-ALT>AST = hepatitis; AST>ALT = cirrhosis
Urinalysis and Pregnancy Screening Indications
UA: Not routine; UTI may cause bacteremia and infection with prosthetics - H&P to detect
Pregnancy test: All women of reproductive age get one
