PreSurgicalOptimization Flashcards
What should a history for preop consist of
- Review of physical health
- functional status and history of falls (frailty)
- Cognitive ability
- competency
- risk factors for postop delirium
- screen of alcohol or other abuse/dependence
- Availability of social support
- symptoms of depression
- cardiac eval
- risk factors for postop pulmonary complications
- nutritional status
- Medication assessments
- determine treatment goals and expectations
- appropriate preop diagnostic tests
How to do a minicog test
-say three words and have them remember and repeat
-have them draw a clock, starting with large circle, numbers and then hands at 11:10
(3 min)
-ask them to repeat the three words again
- 1 pt for ea word correct
- 2 for normal clock
- 0-2 pt is possible impairment
CAGE questions
- have you ever felt you should cut down on your drinking or drug use?
- have people annoyed you by crtizing you drinking or drug use>
- have you ever feld bad or Guilty about your drinking or drug use?
- have you ever had a drink or drug first thing in the morning to steady your nerves or to get rid of a hangover?
Criteria and score for frailty
- Shrinkage
- weakness
- exhaustion
- low physical activity
- slowe
Criteria and score for frailty
- Shrinkage (unintentional weight loss >10 lb in past year)
- weakness (decreased grip strength)
- exhaustion (self-reported poor energy and endurance)
- low physical activity (low weekly energy expenditure)
- slowness(slow walking)
4-5: frail
2-3: prefrail
Medications to discontinue before surgery
- nonessential that may inc surgical risk
- drugs with potential f interactions with anesthesia
- herbal medications 7 days b4
meds to consider periop
- those with withdrawal potential
- angiotensin-converting enzyme inhibitors
Recommended preop tests
Hemoglobin
Renal function test
Serum albumin
Tests for selected patients
- urinalysis
- chest radiograph
- electrocardiograms
- pulmonary function tests
- noninvasive stress testing
key questions when deciding to perform surgery of someone who is at risk or has CAD
- determine it is urgent
- determine acute coronary syndrome
- estimated perioperative risk of mobile acute care of elderly
- less than 1% (proceed)
- greater than 1% (dependent on functional capacity)
- functional capacity greater than 4 (proceed)
- less than 4 or unknown (will further testing/treatment imapact decision?)
- no (proceed or alternate)
- yes (stress test)
- abnormal (no surgery-intervention)
- normal (proceed or alternate)
algorithm for cardiac eval for noncardiac surgery
- emergency?
- active cardiac conditions?
- low risk?
- functional capaicty
- risk factors?
- risk rank of surgery
look at chart
patient related risk factors for postop pul complications
- advanced age
- presence of COPD
- american society of ane class
- fucntional dependence
- impaired sensorium
- frailty
- cigarette smoking
procedure-related factors for postop pul complications
- emergency surgery
- thoracic and upper ab procedures
- prolonged op
- type of ane and ane agent
- periop transfusion
risk factors for noncardiac surgical procedures
- history of ischemic heart disease
- history of compenstaed or prior heart failure
- history of cerebrovascular disease
- diabetes
- renal insufficiency
what are low risk procedures
-endoscopice, superficial procedures, cataract surgery, breast surgery, anbulatory
what are intermediate risk surgeries
intraperitoneal and intrathoracic, cardiac endarterectomy, head and neck, orthopedic, prostate
what are vascular surgies
aortic/other major vascular surgery, peripheral vascular surgery
1 MET
- take care of yourself?
- eat, dress, use toilet?
- walk indoors around the house
- walk a block or two at ground level at 2-3 mph
4 METs
- do light work around the house like dusting or washing dishes
- climb flight of stairs
- walk at ground level at 4 mph
- run short distance
- do heavy work around the house like scrubbing floors or lifting or moving
10 METs
participate in moderate rec acivity like golf, bowling, dancing, doubles tennis, or throwing baseball or football
-participate in strenuous sports like swimming, singles tennis, football, basketball or skiing
risk for post op venous thromboembolism (VTE)
- Hypercoagulability (congential hypercoag, cancer, cancer therapy, history of VTE, inflamm bowel disease, oral contraceptives, polycythemia, pregnancy, smoking, thrombocytosis)
- venous statsis (congestive heart failure, immobility, increasing age, obesity, varicose veins, venous compression or obstruction)
- endothelial injury (recent surgery, severe infection, trauma)
risk factors for postoperative delirium
- strongest: preexisting cognitive impairment and dementia
- untreated or inadequately controlled pain
- depression
- alcohol use
- sleep deprivation
- severe illness/comorbidities
- renal insufficiency
- anemia
- hypoxia
- poor nutrition
- dehydration
- electrolyte abnormalities
- poor funct status
- immobilization
- hearing or vision impairment
- over 70
- polypharm
- risk of urinary retention or constipation, presence of catheter
code of medical ethics on consent
- assess patients ability to understand
- present relevant information
- document the informed consent conversation
conditions that must be met for valid informed consent in presurgical patients
- patient must have the capacity to make health care decision
- patients receive adequate information
- patient consents freely
Living will
specifies medical treatments- including cardiopul resus- mechanical vent, enteral feeding, dialysis, antibiotics- that the patient would or would not want used to prolong their life, as well as other decisions regarding paiin management or organ/tissue/body donation
Durable power of attorney
a person (with or without alternatives) named to make decisions on behalf of the patient if ther are unable to
do not resus order (DNR)
specific medical order instructing providers not to perfrm CPR if the patient’s heart activity or breathing ceases
do not intubate (DNI) order
specific medical order instructing providers not to intubate the patient and/or place him or her on mechanical ventilation
considerations in patients at risk for postop delirium
- avoid starting new rxn for benzodiazepines and reduce them
- avoid using meperidine
- caution with rxning antihistamines antagonists and others with strong anticholinergic effects
when to initiated statin therapry
-preop as soon as possible with people who have known vascular disease, elevated LDL, or ischemia or thallium testing
indications of beta blockers
- people already on, especially with independent cardiac indications for beta blockers
- patients undergoing intermediate or vasular surgery with known coronary artery disease or mult risk factors for heart disease
intitation and titration of beta blockers
- started at least days to weeks b4 surgery
- titrated 60-80 beats/min in absence of hypotension
- should continue peri and post op
