S&P Lecture 1: Pre-op

Which OR team member is NOT sterile and obtains supplies as needed?

Circulating nurse

Which OR team member sets up the sterile field and passes instruments (may first assist)?

Scrub tech or scrub nurse

Who must perform the pre-anesthesia evaluation?

A member of the anesthesia team (MD or DO or CRNA)

Postop complications most often result from failure to do what preoperatively?

Identify comorbidities and assess operative risk

What are the three goals of the preoperative evaluation?

1. Diagnosis of surgical disease

2. Determine comorbidities and severity

3. Assess operative risk and ability to respond to surgical stress

What does the AMPLE emergency history include?

1. Allergies

2. Medications

3. Past medical history

4. Last meal

5. Events leading up to the emergency

A last meal within how many hours requires rapid sequence intubation?

Less than 6 hours

What are the steps of rapid sequence intubation?

1. Sedate

2. Paralyze,

3. Intubate with cricoid pressure (Sellick maneuver)

Why do emergency surgeries carry higher anesthetic risk?

1. Inadequate preparation

2. Cardiopulmonary and renal function not fully evaluated

3. Undesirable meds or substances may still be on board

Preop management of LONG-acting insulin?

Reduce dose by 20%

Preop management of INTERMEDIATE-acting insulin?

Give half the AM dose

Preop management of mixed or short- or rapid-acting insulin?

Do not take on the day of surgery

Preop management of an insulin pump?

Reduce basal rate by 20% the night before surgery

Preop management of oral diabetes medications (general rule)?

Hold on the day of surgery

How long may metformin need to be held before surgery?

24-48 hours

Why is metformin held before surgery?

Renal function complications, Lactic acidosis

When are DOACs (rivaroxaban or apixaban) stopped before surgery?

24-48 hours prior

When is enoxaparin stopped before surgery?

12-24 hours prior (dose dependent)

When is warfarin stopped before surgery?

3-5 days prior with bridging

When can heparin be stopped before surgery?

A few hours prior

Whose OK is usually needed before stopping a blood thinner?

Cardiology, Hematology

Which medications are CONTINUED on the day of surgery?

1. Anticonvulsants

2. Antidepressants

3. Antipsychotics

4. Most antihypertensives

5. Rhythm control medications

6. Thyroid medications

Which cardiovascular medication class is HELD on the day of surgery?

Diuretics

How long before surgery is phentermine stopped?

2 weeks

Which herbals can cause coagulopathy or bleeding and are stopped 2 weeks prior?

Ginseng, Ginkgo, Garlic

Steroid plan for a MINOR or ambulatory operation (e.g. inguinal hernia repair)?

Take usual morning dose with no supplemental steroids

Which operations are MODERATE surgical stress for steroid dosing?

Lower extremity revascularization, Total joint replacement

Moderate surgical stress: steroid dose just before induction?

Hydrocortisone 50 mg IV then 25 mg IV q8h x 6 doses

Moderate surgical stress: when is the prior outpatient steroid dose resumed?

Postoperative day 2 if stable

Which are MAJOR surgical stress for steroid dosing?

1. Major cardiac surgery

2. Brain surgery

3. Major abdominal surgery

4. Thoracic surgery

5. Inflammatory bowel disease

Major surgical stress: steroid dose just before induction?

Hydrocortisone 100 mg IV then 50 mg q8h x 6 doses

Major surgical stress: steroid plan on postoperative day 2?

Hydrocortisone 25 mg q8h if fasting OR oral prednisone 15 mg daily

Major surgical stress: when is the preop steroid dose resumed?

Postoperative day 3 or 4 if stable

Aspirin monotherapy for PRIMARY prevention: preop plan?

Stop aspirin preoperatively as needed (7 days)

Aspirin for secondary prevention + prior PCI + HIGH risk of injury if bleeding: plan?

Consult cardiology

Aspirin for secondary prevention + prior PCI + NOT high bleeding-injury risk: plan?

Continue aspirin

Aspirin for secondary prevention with NO prior PCI: plan?

Risk-benefit analysis

What is the example of a high risk of injury from a bleeding complication in the antiplatelet algorithms?

Intracranial surgery

DAPT patient NOT at high cardiovascular risk: plan?

Continue aspirin only

What is the example of HIGH cardiovascular complication risk in the DAPT algorithm?

Recent cardiac event or intervention

DAPT + high CV risk + operation does NOT need to urgently proceed: plan?

Postpone surgery

DAPT + high CV risk + urgent surgery + HIGH bleeding-injury risk: plan?

Continue aspirin only

DAPT + high CV risk + urgent surgery + NOT high bleeding-injury risk: plan?

Continue dual antiplatelet therapy

What are standard pre-op orders?

1. Obtain consent

2. NPO

3. SCDs

4. Place IV

5. Antibiotics for OR

6. Chlorhexidine wipes

7. Labs based on risk and procedure

Is there a standard battery of preop labs for all patients?

No — testing is based on risk and comorbidities found on H&P

Do consultants 'clear' patients for surgery?

No — they provide risk stratification and recommendations to optimize the patient

Indications for a preop HEMOGLOBIN?

History of anemia, Malignancy, Renal insufficiency, Cardiac diagnosis, Diabetes, Pregnancy, Surgery with expected blood loss

Indications for preop ELECTROLYTES?

Diabetes, Hypertension, Cardiovascular disease, Renal or hepatic disease, Potential fluid loss (dehydration or vomiting), Elderly

Indications for a preop URINALYSIS?

Urinary symptoms, Chronic disease, Urinary procedure

When is preop PT and aPTT indicated?

Bleeding history, Anticoagulant use, Bleeding disorder, Liver failure, Malnutrition, Brain or spine surgery

Causes of coagulopathy to look for in the H&P?

Liver failure, Malnutrition, Hypothermia, Acidosis, Dilution, Medications, Herbals, Sepsis

Indications for a preop chest X-ray?

Intrathoracic procedure, Active pulmonary disease

Who gets a preop pregnancy test?

Women of childbearing age (up to around 55)

What degree of recent weight loss signals poor nutrition and higher operative risk?

More than 10-20%

Standard prophylactic antibiotic for most clean and clean-contaminated surgery?

Cefazolin

Prophylaxis choice with a beta-lactam (penicillin) allergy?

Clindamycin with or without gentamicin

Antibiotic typically added or substituted for MRSA colonization?

Vancomycin

Which clean operations get NO antibiotic prophylaxis?

Thyroid surgery, Parathyroid surgery

Which operations use cefazolin PLUS metronidazole as standard prophylaxis?

Elective colorectal surgery, Head and neck through oral or pharyngeal mucosa, Whipple resection

Standard prophylaxis for urology WITH entry into the urinary tract or intestine?

Cefoxitin with or without metronidazole

Standard prophylaxis for EMERGENCY gastrointestinal (contaminated or dirty) surgery?

Ceftriaxone plus metronidazole

Common target pathogens in CLEAN surgery?

Staphylococcus aureus, Coagulase-negative staphylococci

Which extra pathogen is targeted in CARDIAC surgery prophylaxis?

Corynebacterium spp.

Common target pathogens in COLORECTAL surgery?

Enteric gram-negative bacilli, Anaerobes (Bacteroides fragilis)

When must an intraoperative REPEAT antibiotic dose be given?

Surgery longer than 2 half-lives of the drug (generally over 4 hours), Blood loss over 1500 mL

Which prophylactic antibiotic timing had the LOWEST SSI rate?

Preoperative (0-2 hours before incision)

Which prophylactic antibiotic timing had the HIGHEST odds of SSI?

Postoperative (more than 3 hours after incision)

What defines a CLEAN wound?

Uninfected with no inflammation and closed primarily — no viscus entered

What defines a CLEAN-CONTAMINATED wound?

Viscus entered under controlled conditions without unusual contamination

What qualifies as a CONTAMINATED wound?

Open fresh accidental wound, Major break in sterile technique, Gross spillage from a viscus, Acute nonpurulent inflammation

What qualifies as a DIRTY wound?

Old traumatic wound with devitalized tissue, Retained foreign body, Fecal contamination, Existing clinical infection, Perforated viscus

ASA I?

Healthy patient with a limited procedure

ASA II (e.g. well-controlled HTN or mild obesity)?

Mild to moderate systemic disturbance

ASA III (e.g. poorly controlled DM or morbid obesity or stable COPD)?

Severe systemic disturbance

ASA IV (e.g. recent MI or CVA or ongoing cardiac ischemia)?

Life-threatening disturbance

ASA V (e.g. massive trauma or ruptured AAA)?

Not expected to survive without surgery

ASA VI?

Brain-dead patient whose organs are being harvested

Which ACS tool estimates procedure-specific perioperative complication risk?

NSQIP risk calculator

Why does surgery stress the heart?

Catecholamine surge, Increased HR and contractility, Increased myocardial oxygen demand, Decreased myocardial blood flow

How long after an MI is perioperative risk significantly higher (delay elective surgery)?

First 6 months

Cardiac algorithm: surgery is urgent (6-24 h) or emergent (under 6 h). Next step?

Proceed to surgery

Which ACTIVE cardiac conditions require delaying surgery and multidisciplinary consult?

Cardiac arrhythmias, Severe valvular heart disease, Acute heart failure, Acute coronary syndrome

Cardiac algorithm: patient has a prior coronary stent. Next step?

Consider specialty consultation

What does MACE stand for?

Major adverse cardiac events

Cardiac algorithm: perioperative MACE risk under 1%. Next step?

Proceed to surgery

Cardiac algorithm: MACE risk 1% or greater. Next step?

Optimize medical therapy and evaluate functional capacity (METs)

What functional capacity allows proceeding to surgery despite MACE ≥1%?

More than 4 METs

Poor functional capacity: when is noninvasive stress testing done?

Only if it will change decision-making or perioperative care

Stress test shows intermediate or high-risk findings. Next step?

Cardiovascular consultation

What are the RCRI criteria?

High-risk surgery (intraperitoneal or intrathoracic or suprainguinal vascular), Ischemic heart disease, Congestive heart failure, Cerebrovascular disease, Preop insulin, Creatinine over 2 mg per dL

Maximum MACE risk on the RCRI (all criteria yes)?

10%

Which tool is used with the RCRI to estimate METs?

Duke Activity Status Index (DASI)

Who needs an ECG if none in the last year?

Diabetes, Hypertension, Chest pain, CHF, Smoking, PVD, Inability to exercise, Morbid obesity

Which age group needs an ECG within 1 year regardless?

All patients over 65

Gold standard test for CAD?

Cardiac catheterization

Patient-related pulmonary risk factors (ACP guideline)?

COPD, Age over 60, ASA 2 or higher, Functionally dependent, CHF, Hypoalbuminemia

Surgery-related pulmonary risk factors (ACP guideline)?

Surgery over 3 hours, Abdominal or thoracic surgery, Neurosurgery, Head and neck surgery, Vascular surgery, General anesthesia, Emergent surgery

Are chest X-ray and spirometry routinely used to predict postop pulmonary complications?

No

When may PFTs be appropriate preop?

Select patients with a history of COPD or asthma

Which postop pulmonary risk reduction strategies ARE recommended?

Deep breathing and incentive spirometry, Limited use of NG tube