SESAP Peri-Op

Question 1

Pacemaker-dependent patients w/ surgery above umbilicus – what do you do?

Answer 1

Reprogram pacemaker to asynchronous mode with magnet.

Question 2

What energy device can you use in patients with pacemaker dependecy?

Answer 2

DO NOT want to have it cross the path of the pacemaker.
Ultrasonic device –> energy passes within the device with vibration. NOT via patient like in monopolar or within tong of bipolar. No dispersion.

Question 3

Clean-contaminated wounds - to decrease SSI

Answer 3

Do not need Abx continued past skin closure.

Question 4

SSI control -
BG?
Temperature?
Prep?

Answer 4

peri-op BG < 200
Normothermia
Alcohol-based solutions

Question 5

Clean case
definition
example
Abx

Answer 5

1. No inflammation. No entry into GI, resp, GU
2. Fundoplication. Hernia
3. Ancef for high risk patients (morbid obestiy, cancer) or implant placement (valves, mesh, VP shunt)

Question 6

Clean-contaminated
definition
example
Abx

Answer 6

1. Entry into GI, GU, biliary tract, respiratory
2. Lap appy, colon cases, lap chole for cholecystitis
3. Cefoxitin (gram negative). Ancef/Flagyl

Question 7

CHADS-VASC

What is it?

Answer 7

1. CHF
2. HTN
3. Age > 75
4. DM
5. History of stroke.or TIA
6. Vascular conditions
7. Female gender

Anything greater than > 5-6 = heparin bridge.

Question 8

Apixaban -
MOA
How long do you hold peri-operatively

Answer 8

Factor XA inhibitor.
Normal creatinine clearance - 2 days. Abnormal creatinine clearance 4-5 days.
USED IN RENAL PATIENTS.

Rivaroxaban (has a 1/2 life of 6 hours versus Apixaban 12 hrs)

Question 9

Steroids

Describe physiologic impact of chronic glucocorticoid admin

Answer 9

supresses HPA axis leading to adrenal atrophy and decreased ability to make glucocorticoids during stress

Question 10

Steroids around surgery

what do you do?

Answer 10

Normal adrenal - 10-15 mg/d
Laparotomy - 50 mg/d. Laparoscopuc maybe less.
If you are on low dose 5-10 mg/d, just continue around surgery. No reason for stress dosing.

Question 11

Wound healing -
Impact of smoking
Impact of BG
Impact of Vitamin C and Zinc

Answer 11

Smoking - micorvascular vasoconstriction –> skin necrosis and impact woundhealing. QUITTING HELPS
BG –> Hyperglycemia impairs neutrophils which delays inflammatory response and wound healing along with increasing infection risk
Vitamin A and C are important for collagen crosslinking
Zinc assits with RNA/DNA synthesis and collagenase function.

Question 12

Dabigatran
MOA
1/2 life
how long to hold pre-op

Answer 12

Direct thrombin inhibitor.
12-17 hours (onset is like 1-3 hrs)
Hold for 2 days.

Question 13

Rapid Sequence intubation

Answer 13

1. Pre-oxygenate.
2. Induction agent - ketamine, etomadiate, propofol, midazalom
3. Paralytic - succhinylcholine 1-1.5 mg/kg or rocuronium 1.2 mg/kg

Question 14

3-3-2 RULE

Answer 14

Interincisor - 3 fingers (open mouth)
hyoomental - 3 fingers
hyothyroid (larynx with respect to oral airway)