Pre-Op, Operative, and Post-Op Care (CMPP)

What is the appropriate attire in the OR

Cap is covering your hair, & mask is covering your mouth & nose

Hospital-provided scrubs

Booties covering your shoes

As a general rule of thumb, things that are blue in the OR are

Sterile

(T/F) You cannot wear nail polish or fake nails in the OR

True

Scrubbing in

Specific process of washing hands and arms to decontaminate prior to surgery

Typically, what is the active ingreident in soap for scrubbing in

Chlorhexidine

Steps to Scrubbing In

Preparation

Pre-Wash

Scrub

Rinsing

Drying and Gowning

What goes into the preparation of scrubbing in

Remove all jewelry

Nails < 2 mm

Put on surgical mask, eye protection, and cap

What is the pre-wash in scrubbin in

Wet hands and arms, then use a nail pick to thoroughly clean under your fingernails

How long does the actual scrubbing take for scrub in

3-5 min

How do you scrub

Use an impregnated sponge or brush and scrub every surface of your fingertips, between your fingers, palms, and back of hands

Work way down your forearms to just above elbows

How do you rinse during scrub in

Rinse your hands and arms thoroughly, making sure to keep hands higher than your elbows so that water flows from the cleanest area to the less clean area

What should a student do if they contaminate themselves during surgery

step back from the sterile field and turn to the scrub tech circulator for assistance

What should you do if you feel faint in the OR

Step back from the field immediately

Ask the circulating nurse to help you sit down

What members of the surgical team are scrubbed in

Surgeon

First assist

Scrub Tech/ Scrub Nurse/surgical technologist

Second assist if needed

Observer (scrubbed)

Role of the Surgeon in the OR

Leads the operation, makes critical decisions during the procedure, and performs the surgical procedure

Role of the First Assist in the OR

Works directly with surgeon - retraction, suturing, controlling bleeding

Who can fill the role of first assist

Surgeon

Resident

PA

CSFA

Role of the Scrub Tech/ Scrub Nurse/surgical technologist in the OR

Prepares sterile field, sets up tools & equipment, passes instruments during procedure

What memebers of the OR team are not scrubbed in

Anesthesiologist/Nurse Anesthetist (CRNA)

Circulating nurse

Perfusionist

Medical device representative (not always present)

Observer (not scrubbed)

When is a perfusionist present in the OR

Open hear surgery

Role of Anesthesiologist/Nurse Anesthetist (CRNA)

Manages sedation, administers pain medication and other medical

Monitors vital signs and breathing (airway)

Role of Circulating nurse

Nurse who moves around OR to coordinate care, manage documentation, open sterile packages, ensures surgical team has needed materials

Role of Perfusionist

Operates cardiopulmonary bypass machine

Role of Medical device representative

Guides surgeon on using specific implants or devices

What does the role and responsibilities of the surgical PA depend on

Employer

What does the PA do in pre-op

Pre-op H&P

Labs and imaging interpretation

Optimization of patient prior to surgery (managing comorbidities)

Informed consent +/-

Who is the best person to obtain consent for any OR procedure

Surgeron

What roles does the PA fill in the OR

First or second assist

Positioning and prepping patient

Harvesting grafts or vessels (saphenous in cardiac surgery)

Closing incision

What roles does the PA fill in the post-op care

Writing postop orders and progress notes

Pain control

Wound care

Drains/tubes

Rounding on patients daily and Adjusting care plans as needed

Recognizing and responding to complications

Suture/staple removal and wound checks in office

What roles does the PA fill in the administrative side of surgery

Communicating between surgical team, nursing staff, anesthesia, and other consulting services

Documentation and billing-related paperwork

Patient and family education

What are the phases of operative care

Preoperative

Operative

Postoperative

Perioperative Care

the medical support a patient receives before, during, and after surgery

What is critical goals of perioperative care

Minimizes complications (infections, DVTs)

Decreases hospital stay

Speeds up physical recovery

Potential to reduce healthcare costs

What is considered pre-operative care

ER consult

Admission

Rounds/evaluation

Patient transfer

What is the timeframe of preoperative care

Begins when the decision for surgery is made and ends when the patient is transferred to the operating room

What does pre-op care focus on

Health assessments

Managing existing medications,

Risk screening

Patient education

Intraoperative

The time spent inside the operating room

What is involved in intraoperative care

Actual surgical procedure

Anesthesia management

Continuous vital sign monitoring

Maintaining a sterile, safe surgical environment

What is considered post-op care

Patient transfer

Post-anesthesia Care Unit (PACU)

Post-op rounds

Discharge from hospital or surgical center

Postoperative Care

Starts immediately after surgery in the Post Anesthesia Care Unit (PACU)

Extends through recovery

How long do patients tend to spend in PACU

1-3 hours

What does post-op care focus on

Pain management

Wound care

Preventing complications

Physical rehabilitation

What is the purpose of pre-op evaluations

optimize the patient’s medical condition and prepare for the stress of surgery

What is the most important part of pre-op eval

History

What are the components of pre-op evaluation

AMPLE History

HPI

PMH / PSH

Medications Allergies

Most Common Cause of SBO

Adhesions

What are special history questions that should be asked in pre-op eval

Prior anesthesia, problems, reactions?

Prior bleeding problems, anticoagulant medications?

History of DVT or PE?

History of infection, immunosuppressant conditions or medications?

History of wound healing problems, keloids?

Family history of problems with surgery or anesthesia?

Who tends to control the protocols in pre-op testing

Anesthesia Service / ASA

What patients should get a CBC are part of perioperative tests

Neonates

Age > 75

Malignancy

Renal Disease

Anticoagulant

Bleeding / Hematologic Diseases

What patients should get a Coag study are part of perioperative tests

Chemo patients

Liver Disease

Anticoagulant

Bleeding / Hematologic Diseases

What patients should get a BMP are part of perioperative tests

Age > 75

CV Disease

Diabetes

Diuretics, Digoxin, or Steroid Use

CNS Disease

Endocrine Disorders

What patients should get a LFTs are part of perioperative tests

Liver disease (including hepatitis)

Malnutrition

What patients should get a CXR are part of perioperative tests

Cardiovascular disease

COPD

Malignancy

What patients should get a EKG are part of perioperative tests

Age >75

Cardiovascular disease

Pulmonary disease

Diabetes

Digoxin use

CNS disease

What patients should get a Pregnancy test are part of perioperative tests

If they can get pregnant

What patients should get a Type and Screen are part of perioperative tests

Hematologic/bleeding disorders

Coagulopathy

Provider anticipated need for blood transfusion

Generally, what is the only reason a surgery should be delayed

if the condition of the patient can be significantly improved with medical care

What should be done before surgery

Risk / Benefits

Consults

Who does clearance for surgery

Hospitalists

Primary Care Provider

Specialists depending on patient’s medical condition

Anesthesiologists

Dripps- American Society of Anesthesiologists (ASA) Physical Status Calculation

A risk assessment tool that predicts 48 hour mortality for surgery

What does an “E” signify after an ASA Class

emergency surgery → delaying treatment of the patient will result in a significantly increased threat to life or body part

What factors should be considered along side ASA class

Age

Comorbidities

Home Medications

Duration and Extent of Operation

Anesthesia Choice

Surgerical Team Skills

Blood Products Needed

Implants Needed

Expected Post-Op Care

According to ASA classes, an emergency surgery does what to the risk?

Doubles

Who is considered an ASA Class I patient

Normal healthy

Non-smoker

Non or minimal drinker

ASA Class II

Patient with mild systemic disease without functional limitation or end-organ involvement

What are some conditions that make a patient ASA Class II

Active smoking

Social ETOH consumption

Pregnancy

Obesity BMI >30 but <49

Controlled DM or HTN

Mild lung disease

NYHA class 1 CHF

Mild cognitive dysfunction

Mild-to-moderate OSA with CPAP compliance

ASA Class III

Patient with 1 or more severe systemic diseases causing substantive functional limitation

What conditions can make a patient an ASA Class III

COPD

BMI >40

Active hepatitis

Compensated cirrhosis

ETOH dependence or abuse

Functional implanted pacemaker

Moderate reduction of EF or NYHA class 2 or 3

ESRD (regular dialysis)

History (> 3 mo.) of MI, CVA, TIA, pulmonary embolism, or CAD/stents

Significant cognitive dysfunction

Isolated severe OSA regardless of CPAP compliance

Poorly controlled DM or HTN

ASA Class IV

Patient with severe systemic disease that poses constant threat to life

What conditions can make a patient ASA Class IV

Recent (<3 mo.) MI, CVA, TAI, or CAD/stents

Ongoing cardiac ischemia or severe valve dysfunction

Severed reduction of EF or NYHA class 4 CHF

Shock

Sepsis

DIC,

ARDS

ESRD (not scheduled dialysis)

Uncompensated cirrhosis

Severe cognitive dysfunction

ASA Class V

Moribund patient not expected to survive without operation

What conditions can make a patient ASA V

Ruptured thoracic or AAA

Massive trauma

Intracranial bleeding with mass effect

Ischemic bowel with significant cardiac pathology

Multiple organ or system dysfunction

ASA Class VI

Declared brain-dead patient whose organs are to be removed for donation

Most widely used tool for noncardiac surgery risk assessment

Revised Cardiac Risk Index (RCRI/Lee Index)

Revised Cardiac Risk Index (RCRI/Lee Index)

A simple bedside tool that Estimates risk of cardiac complications after noncardiac surgery

How is RCR / Lee Index Scored

Predictor = 1

• High-risk surgery

• Ischemia heart disease

• Heart failure history

• Cerebrovascular disease

• Insulin-dependent diabetes

• Renal insufficiency (creatinine>2.0)

Classes

• 0 points = Class I

• 1 point = Class II

• 2 points = Class III

• 3+ = Class IV

NSQIP Myocardial Infarction and Cardiac Arrest (MICA) calculator

A procedure specific tool that Estimated 30-day risk of perioperative myocardial infarction or cardiac arrest (MICA) using ACS-NSQIP-derived Gupta model

What variables are considered in the NSQIP MICA calculator

Age in years

Functional status – independent, partially independent, totally dependent

ASA class (I-V)

Serum creatinine- normal (<= 1.5 mg/dL) or abnormal (>1.5 mg/dL)

Procedure category/type

Complications from Anesthesia

Corneal abrasions/dental injury

Spinal/epidural hematoma

Vascular catheter injury

Positioning injury

Infection

Local anesthetic toxicity

Aspiration

What is the most costly complication of srugery

Pulmonary

Types of Pulmonary Complications from Surgery

Atelectasis

Pulmonary infection

Prolonged mechanical ventilation

Respiratory failure

Chronic lung disease exacerbation

Bronchospasm

Patient Related Risk Factors for Pulmonary Complications for Surgery

Age

ASA Class

Smoking

Obesity

Impaired Sensorium

Functionally dependent

Chronic lung disease

Sleep apnea

CHF

What is the only modifiable risk factor for pulmonary complications from surgery

Smoking

What is the current recommendation with smoking and surgery

quit at least 1 month prior to surgery

Why is smoking a big risk factor for surgery

Smoking damages the cilia in the trachea and bronchioles

• Prevents clearance of fluids, which accumulate during anesthesia, putting patients at risk for atelectasis and pneumonia

Smoking causes vasoconstriction in the heart and periphery

• Increased chances of MI and problems with wound healing

Procedure Related Risk Factors for Pulmonary Complications for Surgery

Surgical site

Emergency surgery

Prolonged surgery

General anesthesia

Transfusion > 4units

What surgical sites have higher risk for pulmonary complications

Open aortic surgery– Highest risk

Thoracic

Upper abdominal

Neurosurgery

Head and Neck

Vascular

How do we asssess for pulmonary risk for surgery

History and Physical Exam

Identify Pulmonary Risk Factors

ASA - Global Assessment of Pulmonary Risk

Arozullah Multifactorial Risk Index for Postoperative Respiratory Failure

What is the scoring of Arozullah Respiratory Failure Risk Index

Predictors

• AAA → 27 pts

• Thoracic → 21 pts

• Neurosurgery, Upper Abdominal Peripheral Vascular, Neck → 14 pts

• Emergency Surgery → 11 pts

• Albumin < 3.0 g/dL → 9

• BUN > 30 mg/dL → 8

• Partial/Full Dependence → 7

• History of COPD → 6

• Age > 70 → 6

• Age 60 - 69 → 5

Score

• < 10 → Class I

• 11-19 → Class II

• 20-27 → Class III

• 28-40 → Class IV

• > 40 → Class V

Arozullah Respiratory Failure Risk Index classess tend to follow the same general structure as

ASA Classes

What are predictors for MI, HF, or Cardiac Death from Surgery

Unstable Coronary Syndrome

Angina, acute or recent MI

Decompensated Heart Failure

New onset, worsening HF, NYHA Class IV

Significant Arrhythmias

High-grade AV block

Symptomatic or new ventricular arrhythmia

Tachycardia > 100

Symptomatic bradycardia

Severe Valvular Disease

What procedures are considered high cardiac risk

Aortic,

Major vascular,

Cardiothoracic,

Emergent,

along with large blood loss/fluid shifts

What procedures are considered intermediate cardiac risk

Head, Neck,

Intraperitoneal,

Intrathoracic,

Orthopedic,

Prostate

What procedures are considered low cardiac risk

Ambulatory surgery,

Endoscopy,

Superficial Procedure,

Cataract surgery,

Breast surgery

What is the current preferred agent for anticoagulation for surgery

Thrombin Inhibitors

Factor X inhibtors

Dabigatran (Pradaxa)

Thrombin Inhibitors

Argatroban

Thrombin Inhibitors

Bivalirudin (Angiomax)

Thrombin Inhibitors

Desirudin (Iprivask)

Thrombin Inhibitors

Apixaban (Eliquis)

Direct factor Xa inbitors