Preoperative Risk Assessment

Question 1

high risk procedures/ surgeries (2 day risk 2-4%)

Answer 1

cardiac,

vascular,

neurosurgical,

intrabdominal,

urological (TURP)

Joint replacement,

laminectomy

renal biopsy,

endoscopy with FNA

Question 2

Low risk procedures/ surgeries (2 day risk <2%)

Answer 2

cataract surgery tooth extraction, CVC removal, pacemaker/ICD replacement LN biopsy, endoscopy without needle biopsy carpel tunnel repair

Question 3

When to interrupt anticoagulation while on warfarin?

Answer 3

high bleeding risk surgeries

Question 4

When to bridge anticoagulation while on warfarin if having a fib?

Answer 4

if CHADS2VASC >6 and bridge with heparin.

Question 5

What is desmopressin (DDAVP)?

Answer 5

anti diuretic hormone analogue that increases vWF and factor 8 levels and usually primary used for mild bleeding episodes prior to minor procedures. DDAVP is effective for mild to moderate type 1 vWD. Those with severe bleeding will need cauterization not DDAVP

Question 6

When do we use vWF preparations in surgery?

Answer 6

big gun drug

used in severe bleeding episodes in those who don’t respond to desmopressin (DDAVP) and perioperatively for invasive surgeries (like neurosurgery)

Question 7

What is Type 1 vWD?

Answer 7

von willebrand dx type 1 which is about 75% of all cases has a quantitive deficiency of vWF leading to low vWF antigen and vWF activity and factor 8 levels. Pts with type O have vWF levels that are up to 30% lower than those with A, B, or AB.

Question 8

is there a role in giving platelets for for vWF dx in perioperatively

Answer 8

no because it has a small proportion of total blood vWF. but it can be used in patients which have refractory bleeding with vWF concentrations.

Question 9

What is considered major surgery for vWD pts?

Answer 9

cardiothoracic,

craniotomy,

C section, hysterectomy,

open cholecystectomy

prostectomy

Question 10

What is consider MINOR surgery for vWD pts?

Answer 10

breast and cervical biopsy,

CVC placement,

complicated dental and gingival surgery

laproscopic procedures

Question 11

When do you treat mild subclinical hypothyroidism prior to surgery?

Answer 11

if TSH >10 and T4 normal treat with levothyroxine if TSH<10 but greater than upper limit of normal, check antithyroid peroxidase and if positive, treat with levothyroxine. generally subclinical hypothyroidism is not associated with significant adverse short term outcomes.

Question 12

What to do if patient has severe overt hypothyroidism

Answer 12

rule out comorbid adrenal insufficiency especially if they are going to surgery. severe overt hypothyroidism increases risk for afib perioperatively.

Question 13

what dosage of steroids is there little risk for adrenal insufficiency and therefore need no prior screening or work up prior to surgery

Answer 13

daily morning dose of prednisone<5 mg

or

its equivalent for any period any dose of steroids <3 weeks

or

prednisone 10 mg every other day

Question 14

what dosage of steroids lend themselves to being intermediate risk or unknown risk for adrenal insufficiency ?

As a result, these pts need to have a pre op evaluation of hypothalamic pituitary adrenal axis recommended

Answer 14

daily dose of prednisone 5-20 mg for >3 weeks

daily evening doses of prednisone <5 mg (may disrupt diurnal variation)

prior longer duration or higher doses of glucocorticoids in the past year inhaled glucocorticoids for >3 weeks

>3 intraarticular or spinal steroid injections within the past three months

Question 15

what dosage of steroids that is high risk for adrenal insufficiency in perioperative period and will need stress dose steroids

Answer 15

daily prednisone dose >20 mg daily for >3 weeks

OR

any pt with steroids who has a Cushing’s features (buffalo hump, central obesity, moon faces, weight gain)

Question 16

how long does it take for the HPA axis function to return to normal after stopping corticosteroid use?

Answer 16

up to 6-12 months after discontinuation. Interim pt may be asymptomatic unless stress (like surgery) and may need stress dose steroids perioperatively

Question 17

which test do you order to assess the need for intraoperative steroids / adrenal insufficiency ?

Answer 17

a ACTH (cosyntropin) stimulation test

Test where you measure cortisol before and after you give ACTH.

Basically ACTH will cause an increase in cortisol levels.

If cortisol after test is >18 = no adrenal insufficiency

If cortisol after ACTH is given <18 = then adrenal insufficiency is present.

Question 18

typical perioperative corticosteroid regimen is

Answer 18

hydrocortisone 100 mg IV followed by 50 mg every 8 hrs for 24 hrs with rapid taper (1-2 days) as stress resolves.

Question 19

active cardiac conditions that increase perioperative cardiovascular risk

Answer 19

UA or recent MI decompensated HF significant arrhythmia (symptomatic bradycardia, high grade AV block, SVT, symptomatic or new onset VT) severe valvular dx (severe aortic stenosis or symptomatic mitral stenosis)

Question 20

high risk surgeries are: >5%)

Answer 20

aortic or major vascular or peripheral vascular

Question 21

intermediate risk 1-5% surgeries are:

Answer 21

carotid endarterectomy

head and neck

intraperitoneal and intrathoracic

orthopedic

prostate

Question 22

low risk surgery <1%)

Answer 22

ambulatory or superficial procedure endoscopic procedure cataract breast

Question 23

for preoperative risk assessment first assess:

Answer 23

active high risk cardiac condition (if yes stabilize prior to surgery)

no then if surgery is low risk.

if yes, no further evaluation if intermediate or high risk surgery calculate their RCRI.

If <1% can proceed. If RCRI>1% then calculate their METS.

If unable to calculate METS then need cardiac evaluation.

Question 24

when to get TTE for preop evaluation?

Answer 24

new murmur prior CHF with last TTE >1 year ago known valvular disorder without any TTE in last year.

Question 25

any changes to someone who is on tamoxifene and getting surgery

Answer 25

needs to hold tamoxifen 2-4 weeks prior to surgery with moderate or high risk of VTE (hip replacement). Those on tamoxifen for cancer treatment need to discuss with oncologist. Low risk procedures for VTE don’t need to stop tamoxifene

Question 26

when to start beta blockers for surgery

Answer 26

really shouldn’t start beta blockers on the day of surgery consider starting it preoperatively if there’s someone who had prior MI or CHF.

Question 27

which herbal supplements can increase bleed risk?

Answer 27

ginkgo biloba, ginsing, saw palmetto can increase bleeding risk and needs to be stopped prior to surgery or dental procedures. Should stop 14 days before scheduled procedure

Question 28

after minimum duration of DAPT is completed (6 to 12 months) what to do in a CAD pt with the P2Y12 receptor blocker in someone going to get elective surgery? what about aspirin?

Answer 28

stop 3-7 days before surgery unless surgery has severe risk for bleeding complications, continue ASA is continued perioperatively as it reduces risk for thrombotic complications.

Question 29

what to do for someone on DAPT for dental procedure or skin biopsy?

Answer 29

they should continue DAPT in minor surgeries.

Question 30

what are high risk bleeding procedures

Answer 30

open heart surgery abdominal vascular surgery intracranial and spinal surgeries major cancer surgery urological surgery

Question 31

what are low bleeding risk procedures

Answer 31

arthrocentesis

coronary angiography outpatient

dental surgery

cataract surgery

minor outpatient procedures excisional skin biopsy

Question 32

people who have a mechanical mitral valve and are anticoagulation with warfarin should continue or hold AC in low bleed risk procedures?

Answer 32

continued anticoagulation with low risk bleeding procedures

Question 33

when to stop plavix prior to a CABG (stent in place has already been there for >1yr) ?

Answer 33

need to be off P2Y12 inhibitors for at least 5-7 days. There’s an increased bleeding risk Aspiring should be continued if they have history of CAD because decreases rate of early graft occlusion and improves overall cardiovascular morbidity and mortality

Question 34

When to stop DOAC prior to surgery?

Answer 34

hold DOAC 48 hrs prior

Question 35

how to do a preoperative risk assessment in geriatric pt?

Answer 35

use the cardiovascular health study index for FRAILTY

weight loss >5% over the past year

exhaustion with normal activity (measured by questionnaire)

physical weakness (grip strength, hand held dynomometer)

slow walking speed (walking 15 feet in 6-7 sec)

decreased physical activity (measured by total weekly calorie utilization <383 Kcals for males and <270 K cal for females)

4-5 pts is frail 2-3 intermediately frail 0-1 pt non frail

Progressive increase in length of stay and 30 day post operative complications with increasing points.

Question 36

presence of aortic stenosis is associated with

Answer 36

10-30% increased risk for perioperative cardiac complications undergoing non cardiac surgery like: developing hypotension, MI, CHF and arrhythmias and death in perioperative period.

Question 37

pts who have moderate to severe AS also have

Answer 37

increased risk for acquired von Willebrand syndrome

Question 38

how to have surgery with AS?

Answer 38

emergent surgeries for lifesaving procedures should proceed with invasive HDS monitoring to ensure adequate intravascular volume, preload, and systemic vascular resistance.

Question 39

how to preop risk assess someone based on cardiac recs

Answer 39

Remember low risk surgery depends on the pt’s surgery and then the pt’s RCRI.

If RCRI <1% or low risk surgery then can proceed without further testing or any evaluation of METs.

Question 40

when to start beta blockers prior to surgery?

Answer 40

only indicated for MI, angina, CHF with reduced EF and A fib.

Do not start one day of surgery.

Question 41

RCRI risk assessment is

Answer 41

Question 42

preoperative testing for someone who has CKD

Answer 42

get baseline BMP (Cr and electrolytes)

Depending on results, electrolytes should be corrected and volume status should be optimized.

Question 43

METS chart

Answer 43

Question 44

Why do we measure frailty prior to a surgery?

Answer 44

it is associated with greater post operative mortality and complications.

albumin and pre albumin do not accurately assess frailty. we use a combo of risk factors that predict future adverse events and based on pt’s history and physical appearance.

Question 45

when do we do perioperative bridging for someone who has a fib but never had a TIA or stroke?

Answer 45

use CHADSVASC to calculate risk for thrombosis.

if on warfarin and who do not have a mechanical valve or not a high risk for thromboembolism then can forego perioperative bridging.

can just stop warfarin 5 days before surgery.

Question 46

when to stop DOAC or NOAC prior to surgery?

Answer 46

stop 1-3 days before. generally don’t need to bridge

ok to resume after surgery usually 24-72 hrs but need to collaborate with the surgeon.