Surgery E1: Pre-op Care

What is the peri-operative period?

pre-op phase up to 48 hrs post-op

AMPLE:

(H&P)

Allergies

Meds (+OTC)

PMH & surgical hx

Last meal -what/when?

Events preceding

What supplements inhibit clotting?

Chamomile & Dandelion root

What is the Match Test?

*done to evaluate exercise tolerance

can the patient blow out a match 8 inches from the mouth without pursing the lips

When is the Stair Test?

*done to evaluate exercise tolerance

can the patient climb 1 flight of steps without dyspnea

When should patients cease smoking prior to surgery?

6 weeks

*pts have greater risk of complications

What helps determine whether surgery should proceed as scheduled or if further testing is needed?

risk stratification

Which risk level:

estimated risk of periop major cardiac events is < 2%

low risk

Which risk level:

pts w/ known or suspected heart disease; recommended to do further cardiac workup

high risk

Which risk level:

pts w/ recent MI (w/in 60 days) or unstable angina, decompensated HF, high grade arrhythmias, or valvular heart disease → refer to cardio

very high risk

What predicts major cardiac events in adults undergoing non-cardiac surgery?

Revised Cardiac Risk Index (RCRI)

What are the RF listed in RCRI?
*each worth 1 pt

high risk surgery

hx of IHD

hx CHF

hx cerebrovascular dz

insulin tx pre-op

preop serum Cr > 2

RCRI RF scores:

0 → 3.9% risk of major cardiac event

1 → 6% risk of major cardiac event

2 → 6.5-10% risk of major cardiac event

3+ → 11-15% risk of major cardiac event

Which pts should receive abx prophylaxis to prevent infective endocarditis?

prosthetic valve, previous endocarditis infxn, post-transplant valvulopathy, CHD: unrepaired cyanotic condition, repaired but w/ residual defects, prosthetic material used to repair w/in 6 months

How long should elective non-cardiac surgery be delayed in pts w/ drug eluting stents?

minimum of 6 months-1 yr

How long should surgery be delayed for pts w/ bare metal stents?

30 days

How long should surgery be delayed for pts s/p balloon angioplasty?

14 days

Who should receives BBs perioperatively?

those taking them for cardiac indication, those undergoing vascular operations or at high cardiac risk (2-7 days preop), known CAD or presence of ischemia

What can intermediate/high risk pts start prior to surgery?

Atenolol or Bisoprolol

What is a strong marker of adverse surgical outcomes and increases morbidity and mortality risks?

hyperglycemia during periop period

Patient taking oral hypoglycemic agents should hold their doses who many days before surgery?

only on the day of surgery

What changes in insulin dose should be made the day of surgery?

dec AM dose by 1/2

What insulin should be used for postop?

Regular insulin on a sliding scale

What pts is surgery CI in?

acute hepatitis, acute liver failure, alcoholic hepatitis

*use Child Pugh criteria to determine severity of dz

What should be administered in an alcoholic patient prior to surgery?

"Banana bag" (IV vitamin cocktail)

*if malnourished + IV Thiamine

What pts require a stress dose of steroids preoperatively?

pts taking 20+ mg/day of prednisone for > 3 weeks w/in the past year

What factors are used when screening pts for frailty?

wt loss >5% of BW w/in the past yr, exhaustion, weakness (poor grip strength), slow gait speed, dec physical activity

What is one of the strongest predictors of poor surgical outcomes?

malnutrition

What labs can be drawn to help identify malnutrition?

*check 2 wks prior to surgery

acute: Prealbumin

chronic: Albumin

What is one of the most powerful predictors of post-op pulmonary complications?

Serum albumin level < 3 g/dL

In patients with renal disease, what should be avoided?

K+ in IVFs & NSAIDS

When should Coumadin be d/c prior to surgery?

5 days before

When should Plavix be d/c prior to surgery?

5 days before

When should ASA be d/c prior to surgery?

1 week before

When should NSAIDs be d/c prior to surgery?

1 week before

When should Xarelto/Eliquis be d/c prior to surgery?

2-3 days before

When should Pradaxa be d/c prior to surgery?

1-2 days before

When should Pradaxa be d/c prior to surgery in a pt w/ CrCl < 50?

3-5 days before

Risk of spontaneous bleeding occurs at what platelet count?

< 10,000-20,000/mm3

What is bridge therapy?

substitutes short acting anticoagulants (LMWH) in place of long acting for surgery purposes

What is the reversal agent for Warfarin?

PCC (must administer w/ Vit K)

*FFP in CI or unavailable

What is a contract made between the surgeon and the patient (shared decision making)?

Informed consent (CANNOT proceed w/o)

What needs to be covered during informed consent?

nature of procedure, risks/benefits, reasonable alternatives, risks/benefits of alternatives, assessment of pt understanding

Who can make decisions when a patient cannot speak for themselves?

Surrogate decision makers (usually family)

What are Advanced directives?

legal documents that inform health care providers about the pt's wishes regarding the level of care to be delivered when the pt is unable to do so

What is Durable Power of Attorney (medical proxy)?

type of advanced directive in which an individual designates another person as an agent to make health care decisions on the individual’s behalf

What are the exceptions of to informed consent?

pt incapacitated, life-threatening emergency w/o time to obtain consent, voluntary waived consent

*if ability to make decisions is questionable → psych consult

What ASA classification:

normal healthy patient, non-smoking, no or minimal alcohol use

ASA I

What ASA classification:

• Pt with mild systemic disease, w/o substantive functional limitations

• current smoker, social alcohol drinker, pregnancy, obesity (BMI 30-40), well-controlled DM/HTN, mild lung disease

ASA II

What ASA classification:

• Pt with severe systemic disease, substantive functional limitations, 1+ moderate-severe diseases

• poorly controlled DM/HTN, COPD, morbid obesity, hepatitis, EtOH abuse, pacemaker, slightly reduced EF, ESRD w/ dialysis, premature infant, PCA < 6 weeks, hx MI, CVA, TIA, or CAD/stents

ASA III

What ASA classification:

• Pt with severe systemic disease that is a constant threat to life

• recent MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia, severe valve dysfunction, low EF, sepsis, DIC, ARD, ESRD not on dialysis

ASA IV

What ASA classification:

• Moribund patient not expected to survive w/o the operation

• ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel, significant cardiac pathology, multiple organ/system dysfunction

ASA V

What ASA classification:

Declared brain-dead patient whose organs are being removed for donor purposes

ASA VI

What does the addition of an “E” to and ASA classification indicate?

denotes emergency surgery = delay in tx would lead to significant inc in threat to life or body part

What are the NPO ASA guidelines?

d/c solid food 8 hrs prior, nonhuman milk 6 hrs prior, breast milk 4 hrs prior, clear liquids 2 hrs prior

Which IV fluids are hypotonic?

½ NS, D5W

When is a type & cross needed?

transfusion is planned

*usually 2 units held x 72 hours

When should prophylactic abx be administered prior to surgery?

30-60 min before skin incision

Which surgeries require prophylactic abx?

high risk GI, cardiac, vascular, gyn, head/neck, any implant, any procedure considered contaminated or dirty