Preoperative Risk Assessment Flashcards
high risk procedures/ surgeries (2 day risk 2-4%)
cardiac,
vascular,
neurosurgical,
intrabdominal,
urological (TURP)
Joint replacement,
laminectomy
renal biopsy,
endoscopy with FNA
Low risk procedures/ surgeries (2 day risk <2%)
cataract surgery tooth extraction, CVC removal, pacemaker/ICD replacement LN biopsy, endoscopy without needle biopsy carpel tunnel repair
When to interrupt anticoagulation while on warfarin?
high bleeding risk surgeries
When to bridge anticoagulation while on warfarin if having a fib?
if CHADS2VASC >6 and bridge with heparin.
What is desmopressin (DDAVP)?
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
When do we use vWF preparations in surgery?
big gun drug
used in severe bleeding episodes in those who don’t respond to desmopressin (DDAVP) and perioperatively for invasive surgeries (like neurosurgery)
What is Type 1 vWD?
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.
is there a role in giving platelets for for vWF dx in perioperatively
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.
What is considered major surgery for vWD pts?
cardiothoracic,
craniotomy,
C section, hysterectomy,
open cholecystectomy
prostectomy
What is consider MINOR surgery for vWD pts?
breast and cervical biopsy,
CVC placement,
complicated dental and gingival surgery
laproscopic procedures
When do you treat mild subclinical hypothyroidism prior to surgery?
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.
What to do if patient has severe overt hypothyroidism
rule out comorbid adrenal insufficiency especially if they are going to surgery. severe overt hypothyroidism increases risk for afib perioperatively.
what dosage of steroids is there little risk for adrenal insufficiency and therefore need no prior screening or work up prior to surgery
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
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
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
what dosage of steroids that is high risk for adrenal insufficiency in perioperative period and will need stress dose steroids
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)
how long does it take for the HPA axis function to return to normal after stopping corticosteroid use?
up to 6-12 months after discontinuation. Interim pt may be asymptomatic unless stress (like surgery) and may need stress dose steroids perioperatively
which test do you order to assess the need for intraoperative steroids / adrenal insufficiency ?
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.
typical perioperative corticosteroid regimen is
hydrocortisone 100 mg IV followed by 50 mg every 8 hrs for 24 hrs with rapid taper (1-2 days) as stress resolves.
active cardiac conditions that increase perioperative cardiovascular risk
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)
high risk surgeries are: >5%)
aortic or major vascular or peripheral vascular
intermediate risk 1-5% surgeries are:
carotid endarterectomy
head and neck
intraperitoneal and intrathoracic
orthopedic
prostate
low risk surgery <1%)
ambulatory or superficial procedure endoscopic procedure cataract breast
for preoperative risk assessment first assess:
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.
when to get TTE for preop evaluation?
new murmur prior CHF with last TTE >1 year ago known valvular disorder without any TTE in last year.
any changes to someone who is on tamoxifene and getting surgery
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
when to start beta blockers for surgery
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.
which herbal supplements can increase bleed risk?
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
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?
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.
what to do for someone on DAPT for dental procedure or skin biopsy?
they should continue DAPT in minor surgeries.
what are high risk bleeding procedures
open heart surgery abdominal vascular surgery intracranial and spinal surgeries major cancer surgery urological surgery
what are low bleeding risk procedures
arthrocentesis
coronary angiography outpatient
dental surgery
cataract surgery
minor outpatient procedures excisional skin biopsy
people who have a mechanical mitral valve and are anticoagulation with warfarin should continue or hold AC in low bleed risk procedures?
continued anticoagulation with low risk bleeding procedures
when to stop plavix prior to a CABG (stent in place has already been there for >1yr) ?
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
When to stop DOAC prior to surgery?
hold DOAC 48 hrs prior
how to do a preoperative risk assessment in geriatric pt?
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.
presence of aortic stenosis is associated with
10-30% increased risk for perioperative cardiac complications undergoing non cardiac surgery like: developing hypotension, MI, CHF and arrhythmias and death in perioperative period.
pts who have moderate to severe AS also have
increased risk for acquired von Willebrand syndrome
how to have surgery with AS?
emergent surgeries for lifesaving procedures should proceed with invasive HDS monitoring to ensure adequate intravascular volume, preload, and systemic vascular resistance.
how to preop risk assess someone based on cardiac recs
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.
when to start beta blockers prior to surgery?
only indicated for MI, angina, CHF with reduced EF and A fib.
Do not start one day of surgery.
RCRI risk assessment is
preoperative testing for someone who has CKD
get baseline BMP (Cr and electrolytes)
Depending on results, electrolytes should be corrected and volume status should be optimized.
METS chart
Why do we measure frailty prior to a surgery?
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.
when do we do perioperative bridging for someone who has a fib but never had a TIA or stroke?
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.
when to stop DOAC or NOAC prior to surgery?
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.
