Gen Surg: Preoperative Evaluation

Consult dietitian

If any of the following criteria are met during the preoperative nutritional screening, what should be done?

-BMI <18.5 or < 20 in pts > 65 y/o

-Unintentional weight loss > 10% of body weight in last 6 months

-Greater than 50% decrease in dietary intake in last week

-Albumin < 3 g/dL

Cefazolin

What antibiotic is given 30-60 as a prophylactic for general surgeries?

Cefazolin + Metronidazole

What combination of antibiotics are given to a patient before having GI surgery?

Ciprofloxacin

What antibiotic is given to a patient prophylactically before having urologic surgery?

Clindamycin + Gentamicin

What two antibiotics can be given before head and neck surgery as a prophylactic?

8, 2

When should solids be discontinued before surgery? Liquids?

Continue

Should BBs, CCBs, nitrates, and statins be held or continue before surgery?

24 hours

How long should ACEi/ARBs be held before surgery?

Diuretics

What class of medication should be held the morning of surgery?

24 hours

How long should short-acting NSAIDs be held before surgery?

4 days

How long should intermediate-acting NSAIDs (like Naproxen) be held before surgery?

10 days

How long should long-acting NSAIds be held before surgery?

2-3 weeks

How long should MAOIs be discontinued before surgery?

7-10

How many days should aspirin be held before surgery, due to high bleeding risk?

5-7

How many days should P2Y12 inhibitors be held before surgery?q

1-2 days

How many days should DOACs be held before surgery?

5

How many days should warfarin be held before surgery?

Heparin

In the instance of a preoperative patient being on warfarin for a mechanical prosthetic valve, ATE/VTE within last 3 months, or severe thrombophilia, what should be used for bridging after discontinuing warfarin?

DKA

In regards to endocrine issues, what is an absolute contraindication for surgery?

8-9

You should consider delaying surgery if a diabetic patient’s current A1C is > __-__%

110-180

What is the glycemic target for a preop diabetic patient?

3-4

How many days should SGLT-2 inhibitors be held before surgery?

Day of

When should PO hypoglycemics and short acting insulin be stopped in a preop diabetic patient?

50%

How much of a preop diabetic patient’s intermediate-acting insulin dose be given the morning of surgery?

60-80

What percent of long acting / basal infusion should be given to a diabetic patient preoperatively the day of surgery?

B

Which of these patients would require steroid stress dosing before surgery?

A. Taking steroids for < 3 weeks, morning doses of prednisone <5mg or equivalent for any length of time, or being treated with prednisone 10mg or equivalent every other day

B. >20 mg/d of prednisone for >3 weeks or on steroids for Cushing Syndrome

No

Is additional steroid supplementation needed for minor procedures or surgery under local anesthesia, like an inguinal hernia repair?

50, 25

How much IV hydrocortisone should be given just before the procedure and after q8hr for 24 hrs, in the case of a moderate surgical stress procedure?

100, 50

How much IV hydrocortisone should be given before anesthesia induction and after q8hr for 24 hrs, in the case of major surgical stress?

Hyperkalemia

What is the most common complication for dialysis patients?

eGFR

In patients with CKD, what should be checked ~1 month before the surgery?

24hrs

In patients on dialysis, when should they receive dialysis before the surgery?

fluids, vasopressors

What can be done to optimize kidney perfusion for patients at risk of perioperative hypotension?

PT, aPTT, platelet count

What three tests should be ordered preoperatively in patients with an unknown history or one that is suggestive of bleeding disorders?

VTE

The following are risk factors for what?

-Cancer as reason for surgery

-Duration of procedure

-Obesity

-Previous VTE

-Advanced age

40

Thromboprophylaxis is recommended in patients older than ____ years or are undergoing major general procedures

Iron studies

What should be obtained in anemic patients, if the planned surgery is associated with significant blood loss?

8

In addition to symptomatic anemia in patients undergoing ortho/cardiac surgery, the AABB recommends preoperative transfusions for patients with hemoglobins of < _

MELD, Child-Pugh

What two scores can be calculated to determine hepatic risk in someone with chronic liver disease?

10, 16

A MELD score of < ___ is considered low risk, while one > ____ is considered high risk of mortality

100, 80, 45

-A patient with a Child-Pugh Score of 5-6 (Class A) has a ____% chance of 1 yr survival

-One with a score of 7-9 (Class B) has an ___% chance.

-A patient with a score of 10-15 (Class C) has a ___% chance

Alcoholic hepatitis, coagulopathy, cardiomyopathy

Hepatic Management Approach: Contraindications to Elective Surgery

-Acute _______ _______, acute liver failure, acute viral hepatitis, Child-Pugh class C cirrhosis, severe chronic hepatitis

-Severe _________ (PT prolongation > 3s despite vitamin K admin, platelets <50,000)

-Severe extrahepatic complications like acute renal failure, ____________, HF, and hypoxemia

LFTs

In acute hepatitis, surgery should be delayed until ____ improve

Delayed

In the case of a MELD score > 20 or Child-Pugh Class C, nonurgent surgery should be _________ until score/class improves

STOP-BANG

What screening tool is used for OSA? OSA is associated with double risk for postop pulmonary complications

RCRI

Predicts risk of major cardiac events, such as MI, cardiac arrest, and cardiac death

-All pts undergoing major surgery need to be screened

-Greater than 4 METs associated with increased risk of perioperative complication

2

An RCRI of greater than what indicates a functional capacity assessment?

Stress testing

In a patient with an RCRI of <4, what should be considered only if result will affect decision for surgery?

Resting EKG

What should be obtained in all patients with 1+ RCRI prior to major surgery?

P1

What is the ASA class of a normal healthy patient?

P2

What is the ASA class of a patient with mild systemic disease?

P3

What is the ASA class of a patient with severe systemic disease?

P4

What is the ASA class of a patient with severe systemic disease that is a constant threat to life?

P5

What is the ASA class of a moribund patient not expected to survive without the operation?

P6

What is the ASA class of a brain-dead patient whose organs are being removed for donor purposes?

Emergent

Is this surgery emergent, urgent, time-sensitive, or elective?

-Performed ASAP due to threat to life or limb

-3.7% mortality at 30 days

Urgent

Is this surgery emergent, urgent, time-sensitive, or elective?

-Performed within 24-48hrs due to threat to life or limb

-2.3% mortality at 30 days

Time-Sensitive

Is this surgery emergent, urgent, time-sensitive, or elective?

-Performed within 1-6 weeks to avoid negative outcomes

Elective

Is this surgery emergent, urgent, time-sensitive, or elective?

-Performed within 12 months