Preoperative/Postoperative Care Flashcards
1
Q
allergies and meds not to give
A
- egg: dont use propofol
- shellfish: do not use IV iodinated contrast
2
Q
risk assessment for cardiac disease
A
- hx of MI, unstable angina, valvular dz, HTN, arrhythmias, and heart failure
- if previous infarction there is a 5-10% risk of postop MI
- if current unstable angina avoid elective surgeries
- if stage III HTN control prior to surgery
- if hx of rheumatic heart dz provide prophylactic abx tx
- cardio clearance: 12 lead EKG, noninvasive stress testing
- coronary revasc before noncardiac ops in pts with: significant left main coronary artery stenosis, stable angina with 3 vessel coronary dz, stable angina with 2 vessel dz, significant proximal left anterior descending coronary artery stenosis with either an ejection fraction <50% or ischemia on noninvasive testing, high-risk unstable angina or non-ST-segment elevation MI, or acute ST-elevation MI
3
Q
risk assessment for pulmonary disease
A
- hx of asthma, COPD
- established risk factor for postop pulm complications (PPC): advanced age, elevated ASA class, congestive heart failure, fnal dependence, known COPD, malnutrition, alc abuse, and altered mental status, sleep apnea is an independent risk factor for PPC
- smoking cessation also confers favorable effects on wound healing - stop smoking at least 1 mo before operations, ideally with programmatic support through formal counseling programs and possibly smoking cessation aids such as varenicline or transderm nicotine
- postop pulm complications: hypoxia, atelectasis, PNA
- aggressive postoperative pain management to promote ealry ambulation
- incentive spirometry - insp mm training, deep insp, coughing, good oral hygiene
4
Q
risk assessment for metabolic disease
A
- hx of DM, adrenal insuff
- blood gluc elevated preop in DM pts especially if physical trauma present with emotional and physiologic stress
- elevated postop blood glucose levels in DM pts translate to progressively greater chances of SSI (surg site infxn) following cardiac ops, as well as a greater likelihood of post op infxn and prolonged hosp stays in pts with noncardiac ops
- risk of SSI incrementally increase in a linear pattern with the degree of hyperglycemia, with levels greater than 140 being sole predictor of SSI
- intravenous insulin is best for periop gluc control dt its rapid onset of action, short half-life, and immediate availability (as opposed to subcut absorption)
- periop hyperlyc should be treated with IV short acting insulin or SQ sliding scale insulin
- glycemic control: normal = 90-100 preferred, control with IV insulin; moderate = 120-200
- postop monitoring for: hyperglyc or hypoglyc, infxn, poor healing and wound issues, CVD (double the risk for men, quad the risk, for women
- obesity: contrary to popular belief, this is not a risk factor for most major adverse postop outcomes, except pulm embolism
5
Q
functional capacity
A
- Excellent (activities requiring >7 METs): carry 24lbs up 8 steps, carry objects that weigh 80lbs, outdoor work, recreation (ski, basketball, squash, handball, jog or walk 5mph)
- moderate (>4 - <7 METs): sexual intercourse without stopping, walk at 4mph on level ground, outdoor work (garden, rake, pull weeds), recreation (roller skate, dance)
- poor (<4 METs): shower or dress without stopping, make bed, dust, or wash dishes, walk at 2.5 mph on level ground, outdoor work (eg clean windows), recreation (golf or bowl)
6
Q
risk stratification for periop thromboembolism
A
- high: (>10%/y risk of ATE or >10%/mo risk of VTE)
- mech hrt valve: any mech mitral valve, other aortic valve, recent (<6mo) stroke or TIA
- afib: CHADs2 score of 5-6, recent (<3mo) stroke or TIA, rheumatic valvular dz
- venous thromboembolism: recent (<3mo) VTE, severe thrombophilia
- intervention: bridging anticoag w/ therapeutic dose SQ heparin or IV enoxaparin sodium (lovenox) - IPC + LMWH or low-dose SQ hep
- pearls: if pt already on warf, hold 1 wk prior, place on lovenox, remain lovenox 1wk postop before returning to warf
- moderate: (4-10%/y risk of ATE or 4-10%/mo risk of VTE)
- mech hrt valve: bileaflet aortic valve and 1 of following - afib, prior stroke or TIA, HTN, DM, HF, age >75
- afib: CHADs2 score of 3-4
- VTE: within past 3-12mo, recurrent VTE, nonsevere thrombophilic conditions, active malig
- intervention: bridge anticoag with tx dose SQ hep OR tx dose IV lovenox OR intermittent pneumatic compression devices
- low: (<4%/y risk ATE or <2%/mo risk VTE)
- mech hrt valve: bileaflet aortic valve without afib and no other risk factors for stroke
- afib: CHADs2 score of 0-2 (and no prior stroke or TIA)
- VTE: single VTE within past 12mo and no other RF
- intervention: mech prophylaxis with intermittent pneumatic compression (IPC) devices
- pearls: bridging anticoag with low-dose hep or no bridging
- very low: intervention = early ambulation alone
7
Q
risk assessment for renal dz
A
- dialysis-dependent CKD - risk of complications (postop hyperK, PNA, fluid overload, bleeding) significantly increased - pts should undergo dialysis within 24 hrs before surg and lytes monitored immediately before and during postop period, monitor weight, I&Os, renal fn
8
Q
risk assessment for hepatic dz
A
- liver dz complications: hemorrhage, infxn, renal failure, encephalopathy, substantial mortality rate
- elevated LFTs after major surg is common; transient, not associated with hepatic dysfn
- ascites leads to wound dehiscence or hernias, hepatic encephalopathy is worsened by sedatives and analgesics, coagulopathy (give pts vitK +/- plasma transfusion)
- postop: check plt number and fn (inc bleeding risk with low PLTs), check for lyte disturbs (especially hyperNa), risk for upper GI hemorrhage (esophageal or gastric varices), alcoholics (malnut potential for vit def (be aggressive with refeeding to prevent abnl in gluc metabolism and cardiac arrhythmia - alc withdrawal (1-5d, peak at 3d), prevent with benzos)
9
Q
tobacco use or dependence
A
- can dec fnal capacity and inc risk of bleeding, infxns, and wound dehiscence, hernia recurrence rate inc with tobacco use
10
Q
substance abuse
A
- in general, pts should be advised to refrain from taking illicit drugs for at least a couple weeks before an op
- similarly, a hx of heavy alc consumption raises possibility of postop withdrawal syndrome (can be associated with significant morbidity and death)
- ideally, pts should cease drinking alc for at least one wk before op
11
Q
When to discontinue certain meds
A
- Aspirin: continue if mod to high risk for coronary artery dz
- oral anticoags: stopped 3-5d before (hep administered until 6hrs before surg - resume 36-48h postop)
- cox-2: hold 2-3d before
- DM meds: hold 1d prior
- estrogen: hold 4-6wks prior dt inc risk postop DVT
- HTN meds: continue or risk of periop MI
- GI meds (H2, PPI): continue unchanged including day of surg
- pulm meds: continue including day of surg
- DC all herbs and vitamins
12
Q
American Society of Anesthesiologists classification system
A
- ASA 1: normal healthy pt
- no organic, physiologic, or psych disturbs; excludes very young and very old; healthy with good exercise tolerance
- ASA 2: pts with mild systemic dz
- no fnal limitations; has well controlled dz of one body system; controlled HTN or DM without systemic effects, cigarette smoking without chronic obstructive pulm dz; mild obesity, pregnancy
- ASA 3: pts with severe systemic dz
- some fnal limitation; has a controlled dz of more than one body system or one major system; no immediate danger of death; controlled congestive heart failure (CHF), stable angina, former heart attack, poorly controlled HTN, morbid obesity, chronic renal failure; bronchospastic dz with intermittent sxs
- ASA 4: pts with severe systemic dz that is a constant threat to life
- has at least one severe dz that is poorly controlled or at end-stage; possible risk of death; unstable angina, system COPD, sxatic CHF, hepatorenal failure
- ASA 5: moribund pts who are not expected to survive without the operation
- not expected to survive >24h without surg; imminent risk of death; multiorgan failure, sepsis syndrome with hemodynamic instability, hypotherm, poorly controlled coagulopathy
- ASA 6: declared brain-dead pt whose organs are being removed for donor purposes
13
Q
Preop abx: GI
A
- GI: involving entry into lumen of GI tract
- pathogens: G- bacilli, G+ cocci
- abx: cefazolin
- Biliary:
- open or lap: enteric G- bacilli, enterococci, clostridia
- abx: cefazolin, cefotetan, cefoxitin, amp-sulbactam
- lap: none
- open or lap: enteric G- bacilli, enterococci, clostridia
- appendectomy: enteric G- bacilli, anaerobes, enterococci
- abx: flagyl plus one of the following - cefoxitin, cefotetan, cefazolin
14
Q
Preop abx: cardiac
A
- Cardiac: coronary artery bypass, cardiac device insertion procedures (eg, pacemaker implantation), placement of ventricular assist devices
- pathogens: staph aureus, staph epidermidis
- abx: cefazolin, cefuroxime, vancomycin, clindamycin
15
Q
preop abx: small intestine
A
- nonobstructed: enteric G- bacilli, G+ cocci
- abx: cefazolin
- obstructed: enterig G- bacilli, anaerobes, enterococci
- abx: flagyl plus one of the following - cefoxitin, cefotetan, cefazolin
16
Q
preop abx: hernia repair
A
- pathogens: aerobic G- organisms
- 1st line abx: cefazolin
