TCP Week 5 - Surgery Pre and Post-Op Complications

Pre-op consultation | What is the main purpose of evaluating a surgical patient?

To identify and treat problems that may increase operative risk and to optimize the patient before surgery.

Pre-op consultation | What are the major goals of the preoperative medical consultation?

Detect and treat problems that increase surgical risk; improve quality of care; decrease morbidity, mortality, cost, hospital stay, and recovery time.

Pre-op principle | What is one of the strongest indicators of a patient's postoperative status?

The patient's preoperative status.

Pre-op H&P | Why is a thorough history and physical examination emphasized?

It is often the best predictor of future events and can reduce unnecessary preoperative testing.

Pre-op H&P | What can the history and physical establish before surgery?

Baseline health, known comorbidities, undiagnosed disease, disease control, and likely perioperative risks.

Pre-op checklist | What items are included in the lecture's preoperative checklist?

History and physical; laboratory testing; imaging; ECG; antibiotic order; NPO order; and informed consent.

Pre-op checklist | What testing is listed for patients age 40 years or younger?

Hemoglobin and a urine pregnancy test for females.

Pre-op checklist | What additional studies are listed for patients age 40 years or older?

Add an ECG and serum glucose.

Pre-op testing | When should laboratory or imaging studies be ordered?

When the information will be used and may affect perioperative management.

Pre-op testing | Why should tests not be ordered routinely for medicolegal reasons?

False-positive results can trigger more testing, increase costs, and delay the perioperative course.

Pre-op testing | What is the key rule for ordering a preoperative test?

Do not order it unless the result may change management.

Pre-op checklist | Why is an antibiotic order included?

To ensure indicated prophylaxis is selected and administered at the proper time before incision.

Pre-op checklist | Why is an NPO order included?

To document and enforce preoperative fasting instructions.

Pre-op checklist | Why must informed consent be confirmed?

Because the patient must understand and authorize the procedure before surgery.

Pre-op assessment | What broad factors determine whether surgery should proceed or be delayed?

Baseline health, comorbidities, expected physiologic stress, modifiable risks, and urgency of the procedure.

Anesthesia and surgery | What common physiologic effects are listed?

Hypotension, tachycardia, hypoxemia, hypothermia, anemia, and pain.

Anesthesia | Why can common physiologic effects be more dangerous in some patients?

They may be poorly tolerated by patients with limited cardiopulmonary reserve, malnutrition, anemia, or major comorbidities.

Cardiac pre-op assessment | Which conditions should be evaluated?

Coronary artery disease, myocardial infarction, congestive heart failure, hypertension, peripheral vascular disease, valvular disease, and previous endocarditis.

Cardiac pre-op assessment | Which two prior conditions are specifically said to significantly increase perioperative complications?

Previous endocarditis and previous myocardial infarction.

Pulmonary pre-op assessment | Which risk factors or diseases are listed?

Smoking, asthma, COPD, and sleep apnea.

Pulmonary pre-op assessment | What postoperative complications may be associated with pulmonary disease?

Hypoxemia, atelectasis, pneumonia, aspiration, and other respiratory complications.

Nutritional pre-op assessment | Which laboratory markers are emphasized?

Albumin and prealbumin.

Nutritional pre-op assessment | What do albumin and prealbumin indicate in the lecture?

They are markers of a negative catabolic state and strong predictors of poor outcomes.

Nutrition and healing | How is protein status related to surgery?

Protein status is directly related to the stages of wound healing.

Hematologic pre-op assessment | Which studies are listed?

PT, PTT, INR, hemoglobin, hematocrit, and platelet count.

Hematologic testing | Should coagulation and blood studies be ordered automatically?

No. They should be guided by history, medications, findings, and the planned procedure.

ASA classification | What does ASA I mean?

A normal, healthy patient.

ASA I | What examples are listed?

Healthy; no smoking; and no or very minimal alcohol use.

ASA classification | What does ASA II mean?

A patient with mild systemic disease.

ASA II | What examples are listed?

Smoking; more than minimal alcohol use; pregnancy; obesity; well-controlled diabetes; well-controlled hypertension; or mild lung disease.

ASA classification | What does ASA III mean?

A patient with severe systemic disease that is not incapacitating.

ASA III | What examples are listed?

Diabetes; poorly controlled hypertension; distant MI, CVA, TIA, or cardiac stent; COPD; ESRD or dialysis; active hepatitis; pacemaker; EF below 40%; or congenital metabolic abnormalities.

ASA classification | What does ASA IV mean?

A patient with severe systemic disease that is a constant threat to life.

ASA IV | What examples are listed?

Recent MI, CVA, TIA, or cardiac stent; ongoing ischemia; severe valvular dysfunction; implanted ICD; or EF below 25%.

ASA classification | What does ASA V mean?

A moribund patient who is not expected to survive without the operation.

ASA V | What examples are listed?

Ruptured abdominal or thoracic aneurysm; intracranial bleed with mass effect; or ischemic bowel with significant cardiac pathology.

ASA classification | What does ASA VI mean?

A declared brain-dead patient whose organs are being removed for transplantation.

ASA emergency designation | What does adding an E indicate?

The surgery is an emergency.

ASA example | What does ASA IIIE mean?

Severe systemic disease in a patient undergoing emergency surgery.

Cardiac risk assessment | What is its purpose?

To identify predictors of perioperative cardiac complications and guide treatment of cardiac disease and risk factors.

Operative risk | What basic factors affect operative risk?

Age under 1 or over 70; overall physical status; class and physiologic extent of the procedure; comorbidities; and urgency.

Age and operative risk | Why are older patients at greater risk?

Age-related complications are usually due to a higher burden of underlying disease.

Emergency surgery | How does urgency affect preoperative optimization?

Urgency may limit the measures that can be taken before surgery.

Goldman Index | What is it?

The original cardiac risk index used to predict cardiac events in noncardiac surgery.

Goldman Index | How many factors does it use?

Nine factors.

Goldman Index | How many points are assigned for age over 70 years?

5 points.

Goldman Index | How many points are assigned for MI within 6 months?

10 points.

Goldman Index | How many points are assigned for signs of CHF such as a ventricular gallop or JVD?

11 points.

Goldman Index | How many points are assigned for significant aortic stenosis?

3 points.

Goldman Index | How many points are assigned for an arrhythmia other than sinus rhythm or PACs?

7 points.

Goldman Index | How many points are assigned for 5 or more PVCs per minute?

7 points.

Goldman Index | Which major laboratory or medical abnormalities count for 3 points?

PaO2 below 60; PaCO2 above 50; potassium below 3; bicarbonate below 20; BUN above 50; creatinine above 3; elevated SGOT; chronic liver disease; or bedridden status.

Goldman Index | How many points are assigned for emergency surgery?

4 points.

Goldman Index | How many points are assigned for intraperitoneal, intrathoracic, or aortic surgery?

3 points.

Goldman scoring | What score is Class I?

0 to 5 points.

Goldman scoring | What is the complication rate for Class I?

1%.

Goldman scoring | What score is Class II?

6 to 12 points.

Goldman scoring | What is the complication rate for Class II?

7%.

Goldman scoring | What score is Class III?

13 to 25 points.

Goldman scoring | What is the complication rate for Class III?

14%.

Goldman scoring | What score is Class IV?

26 to 53 points.

Goldman scoring | What is the complication rate for Class IV?

78%.

RCRI | What does RCRI stand for?

Revised Cardiac Risk Index.

RCRI | When was it introduced?

1999.

RCRI | How is it described relative to the Goldman Index?

Simpler and more accurate.

RCRI | What is its purpose?

To estimate a patient's risk of perioperative cardiac complications.

RCRI | How many factors does it use?

Six factors.

RCRI factors | What are the six factors?

Ischemic heart disease; CHF; CVA or TIA; creatinine at least 2.0 mg/dL; insulin-dependent diabetes; and high-risk surgery.

RCRI renal criterion | What creatinine threshold counts as a risk factor?

Serum creatinine greater than or equal to 2.0 mg/dL.

RCRI scoring | What does 0 risk factors indicate?

Class I; very low risk; 0.4% complications.

RCRI scoring | What does 1 risk factor indicate?

Class II; low risk; 0.9% complications.

RCRI scoring | What does 2 risk factors indicate?

Class III; moderate risk; 6.6% complications.

RCRI scoring | What does 3 risk factors indicate in the lecture?

Class IV; high risk; greater than 11% complications.

Goldman versus RCRI | What is the major structural difference?

Goldman uses weighted point values across 9 factors; RCRI counts 6 listed risk factors.

Goldman versus RCRI | Which is described as simpler?

The RCRI.

Goldman versus RCRI | Which lecture-listed highest class has a 78% complication rate?

Goldman Class IV.

Malnutrition | Why is it important in surgical patients?

It directly affects surgical outcomes.

Malnutrition | What complications are listed?

Poor wound healing; bacterial overgrowth in the GI tract; abnormal nutrient loss through stool; and increased infection risk.

Severe malnutrition | What may be considered before surgery?

Postponing surgery until the malnutrition is resolved or improved.

Albumin | What normal range is listed?

3.5 to 5 g/dL.

Albumin | What value increases surgical risk?

Below 3.2 g/dL.

Prealbumin | What normal range is listed?

16 to 40 mg/dL.

Prealbumin | What value increases surgical risk?

Below 18 mg/dL.

Total lymphocyte count | What threshold is listed as increased risk?

Below 3,000 per microliter.

Nutritional intervention | What are the two approaches discussed?

Total enteral nutrition and total parenteral nutrition.

TEN | What does TEN stand for?

Total Enteral Nutrition.

TEN | What is the central principle?

Use the gastrointestinal tract whenever possible.

TEN | What forms can it take?

A normal oral diet, liquid supplements, or tube delivery of daily requirements.

TEN | What system does it feed directly?

The gastrointestinal tract.

TEN | What major risk is listed?

Aspiration.

TPN | What does TPN stand for?

Total Parenteral Nutrition.

TPN | How does it deliver nutrition?

It bypasses the digestive system and delivers nutrition directly into the bloodstream.

TPN | What type of access is required?

A dedicated central line.

TPN | What infection risk is listed?

Catheter-site infection.

TPN | What cost-related disadvantage is listed?

It is expensive.

TEN versus TPN | Which uses the GI tract?

TEN.

TEN versus TPN | Which bypasses the GI tract?

TPN.

TEN versus TPN | Which carries aspiration risk?

TEN.

TEN versus TPN | Which carries central catheter infection risk?

TPN.

Coagulation studies | Are they routinely indicated preoperatively?

No.