Surgery Flashcards
What are the typical features of varicoceles ? When is referral appropriate?
Most varicoceles appear in adolescence, occur on the left side, and are asymptomatic. Anout 10% are bilateral. Surgical repair of large varicoceles can reverse testicular growth arrest with catch-up growth occurring within 1 to 2 years. Varicoceles are the most common surgically correctable cause of subfertility in men and the goal of surgery is to maximize chances for fertility. Varicoceles in men are common with an incidence of approximately 15%. The appearance of a varicocele on the right side only, or in a child less than 10 years of age, is abnormal and may indicate an abdominal retroperitoneal mass. The child should be referred for further evaluation.
What is the most helpful test to diagnosis acute appendicitis?
An abdominal/pelvic CT
List the high, intermediate and low risk surgeries for perioperative cardiac complications.
High risk are emergency surgeries, surgeries with anticipated heavy blood loss, aortic surgery, or peripheral vascular surgery.
Intermediate risk include abdominal or thoracic, head/neck, carotid endarterectomy, orthopedic, and prostate.
Low risk include breast, cataract, superficial, endoscopy, and ambulatory procedures.
What are high, intermediate and low risk patient related predictors for perioperative cardiac complications?
High-risk patients include those who had an MI less than or equal to six weeks previously, unstable angina, decompensated CHF, hemodynamically unstable arrhythmias, severe valvular disease (AS or MS valve area less than 1 cm²)
Intermediate risk patients include those with mild angina pectoris, MI greater than six weeks and less than five years ago, compensated CHF, and diabetes mellitus.
Minor risk patients include those of advanced age, those with abnormal EKGs such as LVH, LBBB, and ST T-wave abnormalities; non-sinus rhythm, low functional capacity, history of a previous stroke or CVA, and uncontrolled hypertension.
When is cardiac assessment not necessary in a patient with history of heart disease?
No cardiac assessment is necessary if the patient has had a normal cardiac stress test within two years, CABG with no symptoms within five years, angioplasty and no symptoms six months to five years previously.
Cardiac reevaluation testing is indicated if these patients are symptomatic or have had angioplasty within the past six months or more than five years ago.
How are clinical and surgery specific risk factors used to determine preoperative evaluation?
If there are no risk factors, proceed to surgery without additional evaluation. If there are greater than or equal to 3 risk factors plus vascular surgery, consider non-invasive testing if it will change management and consider beta blockade in appropriate patients. If there are greater than or equal to three risk factors and intermediate risk surgery; or 1 to 2 risk factors – and vascular surgery proceed to surgery with beta blockade or consider testing if management would change.
The patient is taking ASA what should they do prior to surgery?
Stop it 5 to 7 days prior to surgery.
If the patient is taking clopidogrel or ticlopidine what should they do prior to surgery?
Stop at the drug 5 to 7 days before surgery.
The patient is taking NSAIDs what should they do prior to surgery?
Stop them 1 to 3 days prior to surgery.
If the patient is taking a COX-2 agent what should they do prior to surgery?
Stop it to 2 to 3 days prior to surgery. These drugs do not affect platelets but they do affect renal function.
If a patient is on insulin or oral diabetic agents, what should they do prior to surgery?
They should take one half the usual insulin dose on the morning of surgery and hold oral hypoglycemics.
The patient is taking steroids prior to surgery what should they do before and during surgery?
If they have no signs of hypothalamic pituitary axis suppression, they should continue their usual daily dose of steroids.
If they have positive signs of HPA suppression or if they are on more than 20 mg per day of prednisone for three or more weeks, they should be given 50 mg IV hydrocortisone and then 25 mg Q8 hours for 24 to 48 hours at the time of surgery, for low risk surgery.
For high-risk surgery they should be given 100 mg IV then 50 mg every eight hours for 24 to 48 hours.
How is warfarin managed perioperatively?
If they are at low thromboembolic risk, that warfarin should be stopped five days preop and restarted postop as soon as they are taking PO.
If they are at high thromboembolic risk, warfarin should be stopped 4 days preop and low molecular weight heparin or unfractionated heparin should be started. Stop low molecular weight heparin 12 to 18 hours preop, unfractionated heparin six hours preop. Restart Low molecular weight heparin six hours postop assuming hemostasis has been achieved. Restart warfarin when tolerating PO. Stop low molecular weight heparin when INR equals 2.0.
What patients are at low risk for a thromboembolic event?
Those with atrial fibrillation with no CVA or systemic embolism within the past 12 months, those with biological heartvalves greater than three months out, those with vascular grafts, those with history of venous thrombosis more than three months out with no confirmed hypercoagulable state, those with systemic arterial embolism in the past but not currently.
What patients are at high thromboembolic risk?
Those with a mechanical heart valve, those with a history of DVT/PE with documented hypercoagulable state, those with history of DVT/PE less than three months ago.
What should patients do with herbal medications prior to surgery?
It is prudent to stop them about two weeks before surgery.
What should patients do about low-dose aspirin if they’re going to have surgery?
They should continue it if they are at high risk for a cardiac or embolic event.
What should patients on statins do about them if they’re going to have surgery?
They should continue them. There is some evidence that it is a good idea to start patients on statins before surgery especially if you can do so at two weeks before surgery.
What is the revised cardiac risk index?
it is calculated by giving a patient one point each for each of the following: high-risk surgery, ischemic heart disease, cerebrovascular disease, renal insufficiency, and diabetes mellitus.
A patient with a score of two or more will benefit from a perioperative beta blocker.
